Psychiatric Disorders and Treatments, Exams of Nursing

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PMHNP CERTIFICATION FINAL EXAM

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2024 GRADED A+

Which patient is at highest risk for SI A. 30y/o married AA female with previous SI attempt *1 risk factor B. 35 y/o single Asian male with previous SI attempt *3 risk factors C. 38 y/o single AA male who is a manager of a bank *2 risk factors D. 68 y/o single white male with depression *5 risk factors (age, male, white, depression) - D. 68 y/o single white male with depression *5 risk factors (age, male, white, depression) Count the risk factors When interview teenagers (16 y/o) that arrive with their parents what should you do? - interview them separately from parents.

• This helps Build therapeutic rapport with teens by telling them the info is confidential. Parents may be upset but remember you are advocating for the child. Which Ethnic group has the highest rate of suicide? - Native Americans Example A patient is being treated for schizophrenia with olanzapine. Which of the following is the most common side effect of olanzapine? A. Increased waist circumference B. EPS (not as common in atypical antipsychotics d/t 5HT2A)-receptor antagonism C. Increased Lipids D. Metabolic Syndrome - D. Metabolic Syndrome (UMBRELLA ANSWER) Which antipsychotics have the least weight gain? - Latuda, Abilify, (also least sedating), Geodon-if patient has metabolic syndrome consider switching to one of the medications above. Or if the patient is overly sedated try switching to ABILIFY Which mood stabilizer have the least weight gain? - Lamictal
• But remember all mood stabilizers cause some weight gain When presented with a question about typical vs atypical antipsychotic the answer is usually to start of a - atypical A client presents with complains of changes in appetite, feeling fatigued, problems with sleep-rest cycle, and changes in libido. What is the neuroanatomical area of the brain that is responsible for the normal regulation of these functions? A. Thalamus B. Hypothalamus C. Limbic System D. Hippocampus - Hypothalamus A, B, & D are all part of the limbic system so you can rule that out

When a patient is hesitant to participate in treatment you should encourage? - Bring a support person like a husband Thyroid-Stimulating hormone normal level - 0.5-5.0 Mu/L When T4 and T3 are high and TSH is low what is the diagnosis - HYPERTHYROIDISM, TSH secretion decreases: TSH LOW à key symptoms HEAT INTOLERANCE Key symptoms of Heat Intolerance - Hyperthyroidism When T4 and T3 are Low and TSH is high what is the diagnosis - (HYPOTHYROIDISM) TSH secretion increased: TSH HIGH à COLD INTERANCE Key symptoms of Cold Intolerance - Hypothyroidism Hyperthyroid can mimic - Mania Hypothyroid can mimic - Depression A patient on depakote complains of RUQ pain and has reddish/brown urine - Hepatoxicity

• Check LFTs Signs of Depakote toxicity - Disorientation, confusion, lethargy You suspect depakote toxicity what do you do? - Check
• LFT
• Ammonia
• Depakote Level What herbal supplement can cause hepatoxicity? - Kava Kava When taking Kava Kava in combinations with other medications you should caution about - Risk of Hepatoxicity and Sedation TCAs carry a risk of - Hepatotoxicity Signs of Stevens-Johnson Syndrome - - fever, mouth pain, swelling, burning eyes, blisters, skin pain two psychotropics known to cause steven johnson syndrome - lamictal and tegretol What nationality is most suseptible of getting steven johnson? - Asians When treating asians with tegretal screen for? - HLAB- 1502 Allele What two medications cause agranulocytosis? - Clozaril & Tegretal

Agranulocytosis when to discontinue medication - Less than 1000 When monitoring for agranulocytosis in patients look for s/s of what? - Infection

• Fever, sore throat, fatigue, chills Before starting any mood stabilizer in a female of childbearing age be sure to check? - HCG Which two medications may decrease the risk of suicide? - clozaril and lithium Medications that increase lithium level - NSAID-ibuprofen, INDOCIN THIAZIDES-hydrochlorithiazide ACE INHIBITORS-lisinopril Ace inhibitors are treatment of choice for? - Heart Failure Certain medications are known to increase lithium level, but HOW? - by reducing renal clearance When educating a patient about lithium teach them about - Hyponatremia Dehydration-hot days, exercise Normal Lithium Level - 0.6-1. Lithium Toxicity - 1.5 or above Discontinue and re-order lithium level Lithium level of 1.4 - Monitor for toxicity Labs before starting lithium - TSH, BUN, CREATININE, HCG, U/A to check for presence of protein in the urine (4+ protein is concerning for renal impairment)à4+ protein in urine=MONITOR FOR TOXICITY 4+ protein in the urine of a patient on lithium - 4+ protein is concerning for renal impairment 4+ protein in urine=MONITOR FOR TOXICITY Lithium side effects - hypothyroid, leukocytosis, maculopapular rash, t-wave inversion, Coarse Hand Tremor, GI upset (nausea, vomiting, anorexia)
• Some of these are also signs of toxicity Signs of lithium toxicity - confusion, ataxia, GI upset, palpitation, tremor NMS - muscle rigidity, mutism (because of muscle rigidity), increased CPK (caused by muscle contraction and muscle destruction), increase WBC, increased WBC, myoglobinuria (also from muscle destruction)

Cherry colored urine in a patient that exercises a lot - test for myoglobinuria may be a sign of rhabdo Serotonin Syndrome - With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures.

• Treatment: cyproheptadine (5-HT2 receptor antagonist). Treatment for NMS - Stop Offending Medication
• Dantrolene (muscle relaxer)
• Bromocriptine (Dopamine D2 agonist). *In question focus on what they are asking for ... dopamine agonist vs muscle rela xer Treatment for Serotonin Syndrome - Stop Med (1 or more SSRI, SSNRI, TCA, MOAI)
• Cyproheptadine Triptans - Used for MIGRAINES
• These meds increase serotonin example SUMATRIPTAN patient taking Prozac and started on sumatriptan - - call PCP to ask them to switch the migraine med if patient already on SUMATRIPTAN do not start antidepressant without talking to PCP How long do you wait when switching between an SSRI to an MAOI? - 2 weeks How long do you wait when switching between Prozac and MAOI? - 5 - 6 weeks wash out period What is the first line treatment for depression and why? - SSRI-First line treatment for depression due to less risk of injury from OVERDOSE If a cancer patient has depression what should you consider? - Treating with a medication with minimal drug/drug side effects like Lexapro Patient with depression worries about sexual dysfunction what would be the medication of choice? - Wellbutrin Primary symptoms of depression include fatigue and low energy what med would you chose? - Wellbutrin Wellbutrin is contraindicated in patients with - Seizures and anorexia Which medications are best for neuropathic pain? - SNRI Gabapentin

TCA

Secondary to the black box warning providers caring for patients on antidepressants should assess for? - Suicidality, frequency, and severity at EVERY appointment Which meds have the worse serotonin discontinuation syndrome - Those with short half lives such as zoloft Symptoms of serotonin withdrawal syndrome - Fever, achiness, soreness, lethargy, fatigue, impaired memory, decreased concentration, GI UPSET Shits and Shivers Ages of onset for schizophrenia in males vs females - - MALES 18 - 25 years

• FEMALE 25 - 35 years Schizophrenia increases the risk for - SUICIDE HIGH RISK OF SI in SCHIZOPHRENIA Just having schizophrenia increases your risk of suicide. MUST ASK ABOUT SI, EVERYTIME (frequency, severity of thoughts) What increases the causes or increases the risk or schizophrenia - excessive pruning of synapses
• inadequate synapse formation,
• intrauterine insults such as maternal exposure to toxins, viral agents, maternal substance use, maternal illness, maternal malnutrition, fetal oxygen deprivation,
• first order relative (mom/dad) MRI or PET scan what is seen in schizophrenia - EVERYTHING DECREASES EXCEPT VENTRICLES
• You will see VENTRICULAR ENLARGEMENT Stimulants can potentiate the release of what neurotransmitter? - Dopamine which can worsen symptoms of schizophrenia Assertive Community Treatment (ACT) - a form of rehabilitation post hospitalization, in home treatment What level of prevention is ACT? - Tertiary What adjunctive treatment is important in schizophrenia - - social skills training
• Exercise

Exercise for mental health patients can promote - Cognition Quality of Life Long-term health ACT is ideal for patients with a history of - Treatment non-compliance

• Think about making the treatment convenient for them-->bringing it to their home What diagnosis has the highest risk of Homicidality - Antisocial In the MMSE how do you test for abstraction? - proverb interpretation (everyone that lives in glass houses shouldn't throw stones) Are they able to think abstractly Thought Process-Tangential - means that their response has nothing to do with the question Circumstantial - means that their response goes in circles instead of getting to the point of the question Mental Status-Thought Content includes - SI/HI/AH/VH Another name for MMSE - Folstein Scale How to assess concentration on MMSE - Serial 7s or perform an activity backwards i.e list the days of the week backwards Assess ability to learn new material - repeat 3 words after me Assess ability to recall - repeat 3 words after 5 minutes Assess fund of knowledge - Who is the president What is a quick and easy way to assess for neurological issues - Clock drawing test If patient is unable to draw a clock this indicates - Problem with the right hemisphere, cerebrum, or parietal lobe mesolimbic pathway - Hyperactivity of dopamine in the this pathway mediates positive psychotic symptoms
• Antagonism of D2 receptors in this pathway treats positive psychotic symptoms mesocortical pathway - - Decreased dopamine in the this projection to the dorsolateral prefrontal cortex is postulated to be responsible for negative and depressive symptoms of schizophrenia

Nigrostriatal Pathway - - This pathway mediates motor movements

• Dopamine blockade in this pathway can lead to increase acetylcholine levels
• Blockade of dopamine (D2) receptors in this pathway can lead to EPS, i.e dystonia, parkinsonian symptoms and akathisia Low Dopamine in the nigrostriatal pathway increases which neurotransmitter - - Dopamine has a reciprocal relationship with acetylcholine (Ach) (LOW DOPAMINE INCREASE Ach) Long-standing D2 blockade in the nigrostriatal pathway can lead to - tardrive dyskinesia Tuberoinfundibular pathway - - Blockade of D2 receptors in this pathway can lead to increase prolactin levels leading to hyperprolactinemia which clinically manifests as amenorrhea, galactorrhea, and sexual dysfunction, gynecomastia
• DECREASE DOPAMINE INCREASED PROLACTIN Long-term hyperprolactinemia can be associated with what condition - osteoporosis Normal Prolactin Level in Men - level less than 20ng/ml Normal Prolactin Level in Women - less than 25ng/ml Which medication is the highest offender for increasing prolactin - Risperdal Acute Dystonia + Treatment - neck stiffness, muscle spasm of upper body especially neck/face/tongue
• Treatment is IM COGENTIN + continue PO COGENTIN for several days Akathisia + Treatment - may mimic anxiety, restlessness, can't sit still, rocking, pacing
• First line Treatment is BETA-BLOCKERS like PROPANOLOL (Inderal)
• Second line treatment is COGENTIN
• Third line treatment is benzos Beta-Blockers such as Inderal are contraindicated with what type of asthma medication - - DO NOT GIVE WITH BROCHODIALATOR such as ALBUTERAL this combination can cause bronchospasm akinesia/bradykinesia + treatment - A. difficulty initiating movement; slowness of movement
• Treatment Cogentin

PSEUDOPARKINSON or PARKINSONIAN + Treatment - caused by dopamine blockade, results in muscle rigidity, mask like facial expression, may look blunted, pill rolling tremors in fingers, shuffling gait, motor slowing

• Treatment COGENTIN tardive dyskinesia + Treatment - abnormal facial movements, grinding teeth, lip smacking, protruding tongue
• Treatment DECREASE DOSE OF MED, DISCONTINUE MED, Switch to CLOZARIL, Switch to different med, VINPAT Does Cogentin Treat TD - COGENTIN MAKES TD WORSE Typical onset of TD - OCCURS 1 - 2 years TYPICALLY, but can be ACUTE ONSET ALSO What non-psych med can cause TD? - REGLAN (Metoclopramide) can CAUSE Tardive Dyskinesia must educate patient that this med or the combination of this PLUS antipsychotic can increase risk of TD*** encourage them to discontinue reglan if TD develops InDucers CYP450 - DECREASE Carbamazepine Rifampin Alcoholics (chronic) Phenytoin Grisiofulvin Phenobarb Sulphonylureas Crap GPS Induces me to Madness! InhIbitors of CYP450 - INCREASE Ciprofloxacin Ritonavir Amiodarone Cimetidine Ketoconazole Acute Etoh Macrolides INH Grapefruit Juice Omeprazole

Crack Amigos Erythromycin and Clarithromycin can cause - Increased tegretol levels Patient started on Clozaril or Zyprexa and two months later starts smoking - as a provider you know that the smoking can decrease the medication effectiveness

• Increase medication dose Patient has been a chronic smoker and has been stable on Zyrexa but tells you that he recently quit smoking cold turkey - as a provider you know that you must now decrease the dose of the antipyshcotic Medications that cause mania - Steroids, Disulfiram (Antabuse), Isoniazid (INH), Antidepressants in persons with bipolar
• If a patient must take steroids, the provider should increase the mood stabilizer Medications that cause depression - steroids, beta blockers, interferon, Accutane (isotrentinoin), some retroviral drugs, antineoplastic drugs, benzodiazepines, progesterone
• may need to increase antidepressant Accutane (isotretinoin) - Can cause depression and birth defects Flonase - As a provider you know that flonase is a STEROID so it may exacerbate mood symptoms Increase mood stabilizer to maintain stability, steroids can also trigger depression Flonase can trigger mood instability but it can also cause an increase in - Psychosis patient is taking flonase while on antipsychotic but you find that the antipsychotic is ineffective it is likely because the flonase is exacerbating psychosis
• increase the dose of antipsychotic Neurotransmitters involved in Addiction - Dopamine and GABA Symptoms of Stimulant Abuse - 1. agitation/aggression

2. impaired judgment
3. euphoria
4. elevated BP
5. tachycardia
6. dilated pupils
7. hallucinations
8. TREMORS
9. IMSOMNIA

If an anorexic patient complains of pain or bloating after eating this may indicate - delayed gastric emptying Medications that delay gastric emptying - Omeprazole, ranitidine, famotidine Proton Pump Inhibitors (omeprazole & Protonix) - Decrease absorption of antipsychotics & SSRI

• MUST WAIT TWO HOURS BEFORE TAKING ANTIPSYCHOTIC OR SSRI When initiating an SSRI on an elderly patient you should advise about - increased anxiety Paradoxical effect - when meds cause the opposite effect than expected Apoptosis - programmed cell death/neuronal loss At age 45 and above the patient displays mania for first time what should be ruled out - MEDICAL CONDITION Patient with bipolar disorder presents with depressed mood & emotional lability - Give Depakote Hallmark sx of Borderline Personality - Recurrent self harm Treatment for Borderline Personality - DBT Creator of DBT - Marsha Linehan What activity is helpful in making a diagnosis of borderline personality - Journaling or diary keeping Conversion Disorder - STRESS leads to neurological symptoms such as seizures, paresthesia, blindness, mutism Adjustment Disorder - adjusting to a situation resulting in depression or anxiety or both or mixed disturbance of emotions and conduct (this type is more common in children: insomnia, peer conflict, verbal altercations, truancy, crying)
• Symptoms occur within 3 months of the stressor If question states recently moved, recent death ... THINK ADJUSTMENT factitious disorder - when patients introduce foreign substances into their body or contaminate their food
• Faking illness but NO MOTIVE BEHIND IT

Malingering - Faking illness for financial gain Reactive Attachment - common in children in foster care, abuse from parents

• Withdrawn and shows no emotion towards caregiver ODD - They deliberately annoy others, no aggression, defiance of authority
• Family Therapy is mainstay
• Child management /Parent management skills is the focus in therapy
• Positive reinforcement
• Boundary Setting Conduct Disorder - violence, criminal, fire setting, killing animals, gang activity, +AGGRESSION, NO REMORSE
• May need meds and therapy
• Goal of therapy is to target MOOD & AGGRESSSION (mood stabilizers, antipsychotics, alpha agonists/alpha 2 adrenergic receptor blockers such as guanfacine and clonidine)
• Monitor BP with guanfacine and clonidine Acute Stress Disorder - similar to PTSD but the timeline differs
• heightened arousal, nightmares, flashbacks
• LESS THAN ONE MONTH PTSD - - OVER ONE MONTH
• 3 HALLMARK SXS: intrusive re-experiencing of trauma, increased arousal, avoidance
• May also have NIGHTMARESà GIVE PRAZOSIN
• Non-pharm tx of PTSD- EMDR, CBT Panic attack vs Panic disorder (treatment) - Panic attack = BZ Panic disorder = SSRI Panic Attack is ACUTE Panic Disorder is CHRONIC Feels like impending doom Tourette's Syndrome - Criteria for diagnosis
• TWO moto tics and ONE vocal tics
• LASTS more than ONE YEAR
• By age 18 CHILDREN MAY NORMALLY HAVE TICS so if they have one tic only THIS IS NORMAL Child presents with one tic and the parent is worried - CHILDREN MAY NORMALLY HAVE TICS so if they have one tic only THIS IS NORMAL Neurotransmitters involved in Tourettes - DNS: Dopamine, Norepinephrine, Serotonin

Treatment for tourettes - Treatment: Haldol, Pimozide, Abilify, Guanfacine, clonidine What type of medication can cause tics or exacerbate them - Stimulants Neurotransmitters involved in mood disorders - DNS: Dopamine, Norepinephrine, Serotonin + GABA Neurotransmitters involved in ADHD - DNS: Dopamine, Norepinephrine, Serotonin part of brain implicated in ADHD - prefrontal cortex basal ganglia reticular activating system ADHD inattentive type is caused in what part of the brain - Prefrontal Cortex which is known to regulate ATTENTION and EXECUTIVE FUNCTION dorsolateral prefrontal cortex - Attention Executive Function Cognition Processing Working Memory Problem Solving Deficit in the can lead to ADHD inattentive type - Prefrontal Cortex Teacher reports that the stimulant only works for first few hours of class - medication has worn off too fast. Order multiple dosing throughout the day When does the aftercare plan start - on admission If parents become anxious while you are educating about a new diagnosis what should you do - - Provide patient and parents information immediately don't wait till discharge

• Parents may become anxious after a diagnosis of mental illness such as ADHD, stop teaching offer support because they will not absorb the education. Provide supportive therapy Neurotransmitters involved in OCD - serotonin, dopamine, glutamate & GABA A tic may also be a _ - Compulsion Facts about OCD - Obsession/Compulsion
• A tic may be a compulsion
• If first order relative has OCD the child's risk of developing OCD is increased
• Streptococcal infections increase risk of OCD
• Treatment SSRI-prozac, Zoloft, if adult you may also use TCA such as clomipramine

If question asks if the patient has Tourette's vs OCD listen for mention of streptococcal treatment this will trigger you to think OCD - DMDD - 6 - 17 years ONLY

• Irritability for no reason, sad, depressed mood, tantrums, crying, moody, always mad If patient presents with irritability or labile mood and you need help further delineating symptoms - Administer MOOD QUESTIONAIRE 7/13 Bipolar Diagnosis Likely Sleep Disorders are often So what should you assess if a parent reports that a child is having nightmares - GENETIC ask if someone in the family has a similar issue with sleep...look for family patterns of sleep problems GAD - Worry, apprehension, fear must LAST ATLEAST 6 MONTHS Delirium - - ACUTE (within hours to days) onset of disturbance of LOC, COGNITION, inattention
• Urinary Tract Infections are common cause for DELIRIUM always check UA
• Treatment is antipsychotics like HALDOL Dementia - - Chronic and slow onset (months to years to develop)
• Mental decline in cognition, irritability, personality changes
• When asked questions they may try to answer or MAKE UP ANSWERS (confabulate) Low levels of what labs may mimic dementia - Vit B12 and Folic Acid Cortical Dementia - Language and memory (aphasia and amnesia) Subcortical Dementia - Motor abnormalities/Mood issues like apathy, depression, irritability HIV Dementia is a type of subcortical dementia Early signs of HIV dementia - subcortical form of dementia COGNITIVE, MOTOR, BEHEAVIOR for example a patient with lack of coordination, unsteady gait Treatment for HIV dementia - Antivirals Pseudo Dementia - Depression causes the memory issues, common in older adults
• Also assess onset of symptoms, pseudo dementia is more acute onset
• When asked questions they often say "I DON'T KNOW"

Instruments to use to differentiate between dementia and pseudo dementia - - Use instrument to further screen out cognitive issues such as SLUMS, MOCHA, MMSE

• Older individuals with depression may present with irritability and agitation If question is asking you to differentiate between depression and dementia look at the amount of time that the symptoms have been present - hallmark of lewy body dementia - visual hallucinations Frontotemporal lobe Dementia - PICKs Disease
• Hallmark is personality changes, language difficulties, poor impulse control, and behavioral changes
• May see slurred speech or difficulty getting words out What lobe is associated with ability to understand what others are saying (comprehending speech) - Temporal Lobe Neurotransmitters involved in Autism - GABA, Glutamate, Serotonin Autism - a disorder that appears in childhood and is marked by deficient communication, social interaction, Poor eye contact, May not respond when you call their name, Stereotypical movement When play they often like to line up their toys, stack them in tidy rows Broken Mirror Theory of Autism - Explains that the child's presentation is caused by the mirror neuron i.e dysfunction in the mirror neuron Risk Factors for Autism - Male gender, genetic loading, intellectual disability, parents ages, preterm Screening tools for Autism - ADOS-G (autism diagnostic observation schedule-genetic) ASQ (ages and stages questionnaire) M-CHAT (modified-checklist for autism-toddler) Where is Norepinephrine produced? - locus coeruleus and medullary reticular formation Where is serotonin produced? - raphe nuclei Where is dopamine produced? - substantia nigra, ventral tegmental area, nucleaus accumbens Where is acetylcholine synthesized? - Basal nucleus of Meynert Hippocampus - a neural center located in the limbic system; helps process memory and manage stress

Limbic System - The limbic system is the part of the brain involved in our behavioral and emotional responses, especially when it comes to behaviors we need for survival: feeding, reproduction and caring for our young, and fight or flight responses.

• Hippocampus
• Amygdala
• Hypothalamus
• Thalamus Amygdala function - Responsible for the response and memory of emotions, especially fear Thalamus function - relay station for sensory impulses, pain hypothalamus function - homeostasis, temperature, thirst, appetite, sex drive, sleep cycle, emotions

• believed to serve a regulatory role in aggression anterior cingulate cortex - brain region that regulates cognitive function, decision making, empathy, impulse control, and emotions Cerebellum - Balance and coordination signs of lead toxicity - developmental delay, learning diff., irritability, loss of appetite, weight loss, sluggishness, fatigue, abdominal pain, vomiting, constipation, hearing loss, seizures, eating non-food items PICA Hint home built before 1970's TEST FOR LEAD When caring for an infant that is about to die? - GIVE THE BABY TO THE PARENTS and allow them to grieve Risk factors for osteoporosis - Age smoking caffeine lack of exercise diet lacking calcium and vit D Provide Education If discharging a patient that is not following up with outpatient care, organize ways to help the patient get to the appointment REMEMBER STAY INVOLVED IN THE CARE - Assume you are doing group therapy and there is a patient that is not comfortable sharing but you are trying to promote interpersonal learning. What should you do? - Provide adjunctive individual session that will help facilitate group participation Cognitive Therapy - - Aaron Beck

Replacing irrational or distortive thoughts with positive thoughts Behavioral Therapy - - Arnold Lazarus focuses on changing behavior by identifying problem behaviors, replacing them with appropriate behaviors

• Exposure
• Relaxation
• Skills training
• Role Playing Humanistic Therapy - - Carl Rogers person-centered therapy
• Self-actualization
• Self-Directive Growth
• Everyone has the potential to actualize and find meaning in life Existential Therapy - Victor Frankl - an insight therapy that focuses on the elemental problems of existence, such as death, meaning, choice, and responsibility, emphasized making courageous life choices.
• Emphasizes accepting freedom and making responsible choices
• Focus on the present Why am I here, What is my purpose Interpersonal Therapy - Gerald Kierman & Myrna Weissman --Used for people who have trouble interacting with others, relationship distress
• Marital conflict
• 12 - 16 weeks (3- 4 months) EMDR Phases - Desensitization Phase: visualize the trauma, verbalize negative thoughts but remain attentive to physical sensations Installation Phase: Installs and increases strength of the positive thoughts that the patient has declared as a replacement Body Scan: Visualize the trauma along with the positive thought and then scan ones body mentally to identify any tension within Group therapy: Installation of hope - participants develop hope for creating a different life; they gain hope from others Group therapy: Universality - people have similar problems, thoughts, and feelings and they are NOT ALONE Group Therapy: Altruism - sharing of oneself with another and helping another

Group Therapy: Imitative Behavior - Patients can increase their skills by imitating the bx of others Group Therapy: Interpersonal learning - interacting with others increases adaptive interpersonal relationships Group Therapy: Group Cohesiveness - Patients develop an attraction to the group and other members as well as a sense of belonging Group Therapy: Catharsis - Patients openly express their feelings which were previously suppressed Group Therapy: Existential Factors - Groups enable participants to deal with the mean of their own existance Group Therapy: Corrective Refocusing - Participants reexperience family conflicts in the group, which allows them to recognize and change behaviors that may be problematic Group Phases - forming, storming, norming, performing, adjourning Family Systems Therapy - Murray Bowen

• a person's problematic bx may serve a function for the family or be a symptoms of dysfunctional patterns KEY WORDS* Self-Differentiation, Triangulation, Triangles Structural Family Therapy - Salvador Minuchin
• How, when, and who whom family members relate KEY WORDS* Mapping Hierarchies Boundaries Strategic Therapy - Jay Haley
• Symptoms are a way to communicate metaphorically in a family
• Symptom focused KEY WORDS* Straightforward directive Paradoxical directive (reverse psychology) Reframing (you are not jealous of your sister you just care for her so much) Solution Focused Therapy - - MIRACLE QUESTIONS
• EXCEPTION-BASED FINDING - SCALING QUESTIONS Meditation - if teaching about meditation must tell them about MUSCLE RELAXATION

If patient tells you something BEFORE you ASSESS- EXPRESS EMPATHY "I'm sorry this happened to you." - USE OPEN ENDED QUESTIONS unless talking to a child or someone that is unable to construct a narrative then use CLOSED ENDED or YES/NO - PICOT - P: Population I: Intervention C: Comparison O: Outcome T: Time If a patient has rheumatoid arthritis check - ESR Therapy session with husband and wife & only one shows up - Reschedule A patient's mother calls and tells you that her son has been sodomized by their 15 year old brother - tell mother DO NOT LEAVE THE CHILD ALONE WITH THE BROTHER

• Provider calls CPS
• Arrange crisis therapy for family Patient is moving out of state - if there is no imminent danger then provide enough medication for them to establish a new provider Level 1 evidence - systematic reviews of random control trials (RCTs) or Meta-analysis or RCT-highest internal validity due to randomizations At least (2) Level 2 Evidence - systematic reviews of cohort studies
• little bias because the subjects are identified prior to outcome - randomization is lost Shrill Cry - Intracranial pressure Child between the ages of 3 - 6 masterbating - Normal to play with genitals (PHALLIC STAGE) NORMAL do not assume they have been abused* Mom is concerned that her son age 10 has swelling in his chest and she is concerned he is developing breasts - Young boys ages 9-16 years old often have NORMAL BREAST ENLARGEMENT which disappears within 6 months *reassure them that this is normal Elderly female presents with decreased sex drive - Check Testosterone level Sex Hormone-Testosterone is involved in sex drive
• MUST KNOW THAT WOMAN have TESTOSTERONE TOO

alcohol dehydrogenase - an enzyme active in the stomach and the liver that metabolizes alcohol

• WOMAN HAVE LOWER ALCOHOL DEHYDROGENASE (metabolizes alcohol)
• This is why woman get drunk faster
• Lower levels of this enzyme may also cause a higher propensity to develop LIVER DISEASE When OB wants to hire psych providers - they want to increase mental health access to those that need it the most Normalizing grief and loss in children - Don't tell them what to do because grief responses vary
• i.e Don't tell them to stop working that is prescriptive advise
• With children the most important thing is to reinforce FAMILY support an supportive therapy such as group therapy so they can learn from other children who have experienced similar events palmar grasp reflex - normal up to 5 - 6 months If older baby still has this reflex->refer to specialist Moro (startle) reflex - Normal till 5 - 6 months If present past normal range->refer to specialist If not present within the normal age->Xray may be a sign of a broken bone, nerve injury, or spinal injury Babinski reflex - Normal up to 2 years If present past normal range->refer to specialist PDE- 5 inhibitors - Sildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) RAPIDLY ABSORBED Used for erectile disfunction Difference between BMI in anorexia vs Bulemia - Anorexia-Low BMI Bulemia-Normal BMI Parent brings in 16 - year-old with BMI 12, Pulse LOW, BP LOW and you determine the patient needs to be sent for medical evaluation but the parents refuse - Contact CPS You read and article that says that most children with ADHD abuse substances...
• To translate this information into practice what should you do? - - Screen ALL children for ADHD for SUBSTANCE USE
• OR Screen ALL children with SUBSTANCE USE for ADHD accupuncture - used for pain and depression

Habeas Corpus - legal concept that protects patients from unlawful hospitalization

• May be a reason to leave AMA Disseminated Encephalomyelitis - inflammation of nervous system
• MUST DO NEURO EXAM
• EXAM: May present with ASSYMETRICAL BODY MOVEMENTS Assume you are interviewing a patient and you want them to provide information in a specific timeline, but they are unable - TO help ask them specific questions which helps to ANCHOR their memory Before you administer a medication, you must educate them about the medication but first you should assess - BUT FIRST ASSESS WHAT THEY KNOW ALREADY or WHAT THERE BELIEVES ARE ABOUT THE MEDICATION Patient presents with iatrogenic effect - assess ALL the medications that the patient is taking
• Don't assume that it is from the medication you prescribed When trying to pass a policy and your co-workers are against it what should you do - educate them on how the policy will benefit patient care To promote a policy how do you get the word out there - Think most FEASIBLE option with WIDE net or audiance Working in outpatient setting and you want to ensure continuous improvement in quality of care. - - Create an instrument to monitor clinical outcomes (this helps to identify what you are doing right or wrong) Autoimmune disease can lead to increased - Cytokine level If a child is urinating the bed - - Teach parents to use alarm clock to wake up to urinate (NON PHARM FIRST)
• If that doesn't work try DESMOSPRESSIN (decreased enuresis) Are you allowed to look up a patient on social media? - No it violates their trust Assume you started a patient on a medication and they go home and find out that there is a black box warning on the medication that you were unaware of. They call with concerns... -
• First, go online and do your own research
• Research the RISK vs BENEFIT before you tell the patient to stop the medication Risk factors for sleep apnea - excessive weight, obesity, diabetes, smoking

Tolerance - you need higher doses of the medication in order for the medication to be effective PHQ- 9 - > 5 mild depression

10 moderate 15 moderately severe 20 severe Max score 27 HAM-D - >10 Mild 14 Moderate 17 Severe HAM-A - >8 Mild 15 Moderate 24 Severe Beck Depression Inventory (BDI) - 0 - 13 Subclinical 14 Mild 20 Moderate 29 Severe 40 EXTREME Max score 63 GAD- 7 Scoring - 0 - 4: Minimal Anxiety 5 Mild Anxiety 10 Moderate Anxiety 15 Severe Anxiety Max score 21 COWS - Medicate with PRNS at score of 7 or above Consider Subutex or Suboxone at 13 or above Remember Methadone is the LEAST safe option due to cardiac issues CIWA - Begin PRN medication at 8 or above Scores of 15 or above consider scheduled medications Patient in alcohol withdrawal and you are choosing medication for CIWA, check what? - LFT if liver disease use ATIVAN because of short half life over VALIUM

REMEMBER DETOX SHOULD NOT OCCUR OUTPATIENT-->residential or inpatient is needed especially if pregnant. REMEMBER SAFETY FIRST - Idealization - Seeing someone else as perfect, ideal, or more worthy than everyone else This is often seen in grieving before acceptance of the loss Appreciative Inquiry - is an approach to organizational change which focuses on strengths rather than on weakness Example do not focus on what the employee does wrong focus on what they do well Reflective Practice - Links theory to practice with a goal of correcting practices that are incorrect. Example Debriefing after a restraint to find out what went wrong or what went right DEBFRIEFING MAY BE A KEY WORD

• After an incident--> Debrief Assume you started the patient on an antidepressant and now they complain of insomnia -

1. Before changing medication, CHANGE THE TIME OF DAY THEY ARE TAKING THE MED Conflict of interest between pharmaceutical companies and Nurse Practitioners i.e promises to sponsor NP loan forgiveness. You want to create a policy to address this. First you must examine... - study the relationship between the industry provided samples and industry sponsored education If a patient is involuntarily admitted can they still refuse medications? - they can still refuse medications, UNLESS it is an emergency or if the court determines they must take medications Scope of practice is determined by - State board of Nursing Scope of practice defines - NP roles and actions

• Varies broadly state to state If you would like to perform ECT as an NP what should you review - The state scope of practice standards to see if it is allowed and what certification is needed Standard of practice is determined by - ANA
• Provides a way to judge nature of the care provided The PMHNP is required by law to carry out care in accordance with what other reasonably prudent nurses would do in the same or similar circumstances. Thus, provision of high- quality care consistent with established standards is critical Exceptions to Confidentiality - - Answering court orders, subpoenas, or summonses *high yield (if you don't release or lie about knowing this is PERJURY)
• Insurance companies

• Giving information to attorneys involved in litigation
• Intent to harm self or others
• Meeting state of federal requirements for reporting disease states
• When the need for information outweighs the principle of confidentiality i.e unconscious patient and their life is at stake Tarasoff principle - 1976 - duty to warn victims of potential harm from client may vary by state so you must check with your state board of nursing first...it may not be your responsibility to notify If you are taking care of a patient and during the process of interview she tells you that her husband just texted her that her husband is going to kill self - - Call the police, provide the address informed consent - - Communication process between the provider and client that results in client's acceptance or rejection of proposed treatment
• Ensure they understand the risks vs benefits If patient is able to reiterate the risks vs benefits of procedure or treatment, they are able to give consent* Example patient comes to the hospital, and they are unable to give consent i.e to sick to agree to treatment you must - assess need for involuntary treatment Justice - doing what is fair, fairness in all aspects of care Nonmaleficence - do no harm Beneficence - doing good/promoting well-being Fidelity - being true and loyal Veracity - telling the truth, patients have the right to know the truth about their treatment Autonomy - doing for self (right to self-determination) New male patient has a 10 year history of substance abuse, depression, and anxiety. He is requesting Xanax. Which principle should the PMHNP employ moving forward? A. Beneficence B. Fidelity C. Non-Maleficence D. Veracity - C. Non-Maleficence Do no harm, giving Xanax would endanger him secondary to the high abuse potential and imminent danger if he were to overdose on Xanax

If no history of substance use, then beneficence would be appropriate because the Xanax would help the anxiety Acute agitation and anxiety vs acute agitation and psychosis IM ordered - IM ativan for agit/anx IM antipsychotic for agit/psychosis Patients have the right to be treated in the Least - Restrictive Setting The PMHNP is asked to consult with a local inpatient psychiatric facility to provide nursing staff development. After meeting with the administrator to identify the nature of the problem requiring the consultation, the PMHNP's next step is to: A. Create interdisciplinary teaching team B. Develop Outcome measures C. Market the educational plan D. Utilize a survey to assess the educational needs of the staff - D. Utilize a survey to assess the educational needs of the staff 3 Interventions vs 1 Assessment FIRST YOU NEED TO ASSESS FIRST What is the best way to reduce stigma - THROUGH EDUCATION *THINK WIDEST AUDIENCE Just Culture - individuals are continually learning, designing safety systems, and managing behavioral choices The PMHNP is concerned about access-to-care issues in the local community and wants to help develop health care policy to help patients access care more effectively. A. Asking the clinical manager to explore options for access B. Organizing a political protest C. Working with the local chapter of the nurses professional association D. Writing letters to the editor of the local newspaper - C. Working with the local chapter of the nurses professional association Remember strength in numbers but STAY INVOLVED i.e asking the manager just passes off If a patient from a specific culture is refusing to accept any diagnosis of mental health disorders because of shame what could be done to address this barrier? A. Educate the family B. Political advocacy C. Public Health Concern D. Community education programs - D. Community education programs

*Narrow down to education A/D...then think WIDE NET =Community EDUCATION A client with Biolar I disorder presents to your PMHNP office for a follow-up visit. During the visit the client informs you he no longer wants to be treated with medication. , and he does not have bipolar disorder, that was a misdiagnosis, He further informs you he stopped all his medications 2 months ago and is here to thank you for your care and tell you he no longer needs appointments. Understanding ethical conflict, you use which of the following ethical principles? A. Autonomy B. Nonmaleficence C. Justice D. Beneficence - A. Autonomy Patient's have the right to self-determination Recovery Model * RELAPSE IS A LEARNING OPPORTUNITY - - Treatment approach that does not focus on full symptom resolution but emphasizes on resilience and control over problems in life

• Self-Direction (do not tell them what to do)
• Individualized and Person-Centered
• Non-Linear, Recovery is not a step-by-step process, but one based on continual growth, occasional setbacks, and learning from experience In counseling a 23 y/o married Hispanic mother who brought her 4 year old son to the clinic for "mal de ojo" with symptoms of fitful sleep, diarrhea, vomiting, and fever the PMHNO; A. Identifies what steps the mother has already tried in caring for the child B. Explain that the symptoms are viral infection C. Educates about importance of fluid electrolyte imbalance D. Respects the mother's understanding of the child's illness - A. Respects the mother's understanding of the child's illness *In cultural questions remember RESPECT FIRST! Even before assessment Quality Improvement - Projects designed to improve systems, decrease cost, and improve productivity What is an example of a quality improvement process? - Plan, Do, Study, Act Retrospective Chart Review is an example of a Quality Improvement Process If they ask HOW the NP would do a quality Improvement Process the answer may be Plan, Do, Study, Act -