Psychosocial/Psych questions with well detailed answers /rationales /verified /latest vers, Exams of Nursing

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Psychosocial/Psych questions with well detailed answers

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1. A 76 year-old depressed patient is started on an SSRI. When should another antidepressant be tried if there is no response?: 8-12 weeks Most learned authorities agree that if there is no response by 8- weeks at a maximal therapeutic dose, a different antidepressant should be tried. The 8-12 week period is the correct time frame because it will take this long to increase the dose and attempt to reach maximal dose for therapeutic response. 4-6 weeks is nearing the appropriate time frame, but this may be too short a period of time to reach and evaluate therapeutic dose.
2. Which patient is most likely to exhibit depression related to his illness? A patient with:: Parkinson's disease Diseases associated with the central nervous system are associated with high rates of depression. These include stroke, Parkinson's disease, multiple sclerosis, and dementia. Other illnesses associated with high

rates of depression are cancer and cardiovascular illnesses like myocardial infarction. Depression worsens the outcome of any physical illness.

3. A patient with an eating disorder may concomitantly exhibit:: Anxiety disor- ders Affective disorders, anxiety disorders, and substance abuse issues are common in patients who have eating disorders. Obsessive-compulsive disorder is also common- ly observed. Patients with eating disorders are more likely to have a first or second degree relative with an eating disorder, affective disorder, or alcohol abuse. There is no evidence that patients with eating disorders exhibit a higher incidence of sleep disorders or liver disease. Thyroid disease should always be assessed in patients with eating disorders, but this does not represent the reason for weight loss when eating disorder is present.
4. Which criterion below is a criterion for Alzheimer's Disease?: Impairment of executive function The diagnostic criteria for Alzheimer's disease (AD) was established by

DSM V and other organizations. The criteria are similar. Criteria include a gradual onset of cognitive decline. A rapid onset usually indicates another etiology, perhaps, delirium. Other criteria include impairment of recent memory, difficulty with language or finding words, the inability to execute skilled motor activities, disturbances of visual processing or disturbances in executive function that includes abstract reasoning and concentration. Focal neurologic signs are consistent with a vascular dementia. Radiologic evidence is not a criterion for diagnosis, though it may support the diagnosis of AD. There is no laboratory evidence of AD.

5. An 80 year old adult has begun to use over the counter diphenhydramine to help him fall asleep. What common side effect can occur in older adults with use of this medication?: Next day sleepiness Diphenhydramine should be avoided in older adults. Diphenhydramine exhibits potent anti-cholinergic effects in patients who take this, but especially in older adults. Urinary retention is common (not incontinence) in older men with benign prostatic hyperplasia, but retention occurs in women too. Diphenhydramine is contraindicated in

patients with glaucoma. The most serious side effect is cognitive impairment, like daytime sleepiness. Visual disturbances can occur as well as annoying side effects like dry mouth and constipation.

6. A 69 year-old female patient reports feelings of anhedonia for the last month. What should be part of the nurse practitioner's assessment?: Depression Anhedonia is the loss of pleasure or interest in things that have always brought pleasure or interest. If this is the case, this patient should be screened for depression. Anhedonia is a red flag for depression.
7. A 70 year-old male patient has an elevated MCV with an anemia. His triglyc- erides are 420. What should be suspected?: Alcohol abuse This patient has an elevated mean corpuscular volume. This indicates a macrocytic anemia. Common macrocytic anemias are B12 deficiency and folate deficiency. These are common in older patients, especially if they consume large quantities of alcohol. This patient also has elevated triglycerides. Triglycerides are commonly elevated when patients are exposed to

alcohol and carbohydrates. This patient's history indicates two elements that indicate alcohol abuse. He should be questioned regarding alcohol abuse.

8. Which symptom listed below is typical of depression?: Early morning wak- ening Sleep difficulty is a common complaint among patients with depression. Patients with difficulty falling asleep are often anxious. Frequent waking and early morning wakening are often complaints by patients with depression. There is no agreed on physiologic explanation, but, this is a common symptom.
9. Delirium differs from dementia because delirium:: often develops acutely Delirium is a change in consciousness or cognition. It may be accompanied by a physical diagnosis like urinary tract infection; or it may be due to consumption of a medication. Regardless, a change in cognition or consciousness needs immediate evaluation. The evaluation should include a medication review, physical exam and laboratory evaluation,

and mental status exam.

10. Which screen for alcohol abuse has been validated in the elderly?: CAGE CAGE is a screen for alcohol abuse that is validated in adults and older adults. The C stands for "have you ever felt you should CUT down" your alcohol consumption. The A stands for " does other's criticism of your drinking ANNOY you". G stands for "have you ever felt GUILTY about drinking". The E stands for "have you ever had an EYE opener to steady your nerves or get rid of a hangover". A positive response on any question constitutes a positive screen.
11. MMSE helps to identify patients with symptoms of:: dementia The mini mental status exam (MMSE) is a very common and easily administered cognitive evaluation for dementia. It tests orientation, recall, attention, calculation, language manipulation, and constructional praxis. It is not sensitive for mild dementia and may be influenced by educational level and age. Even with these limitations, the MMSE is the most widely used cognitive test for dementia in the US.
12. An adolescent female patient with anorexia nervosa must exhibit 4

criteria for diagnosis. Which criterion listed below is NOT part of the diagnostic criteria?: Weight below 90% of ideal body weight Weight below 85% of ideal body weight is the correct criterion. This involves refusal to gain or maintain weight within normal range. Occasionally weight below ideal body range does not involve losing weight, but instead involves refusal to gain weight during a growth spurt. This is commonly observed during pubertal growth spurts and is more common in adolescent females than males. The other three criteria are correct as listed.

13. Which statement about bulimia nervosa is accurate?: High dose SSRIs are used to treat this The medications of choice to treat bulimia nervosa are the SSRIs. Generally, high doses are required. Wellbutrin is not an SSRI and should not be given to patients with eating disorders because of great fluctuations in drug levels related to purging. Generally, this is more common in women than men. Loss of control IS a character- istic of this illness.

14. The most common mental disorder in older adults is:: anxiety Anxiety is very common in older adults. Depression is very common too, and may accompany anxiety in older adults. The prevalence of anxiety may be due in part to other physical illnesses or serious diseases or disorders, like cancer, Parkinson's disease. New onset anxiety should prompt the examiner to consider withdrawal of medication or side effects of medication being taken at therapeutic levels.
15. A 19 year-old college student is at least 15% below her ideal body weight. She reports doing well in classes but drinks alcohol nightly, and several cups of coffee throughout the day. She is bradycardic and gets dizzy when she stands. What may also be observed in this patient?: Amenorrhea This patient has anorexia nervosa. She is far below ideal body weight and exhibits evidence of poor nutrition and health. More than 90% of patients with anorexia are amenorrheic. These patients have low levels of leuteinizing hormone and follicle stimulating hormone. Because of prolonged hypoestrogenic states, they are highly susceptible to osteopenia and osteoporosis. It is not known why, but, many patients with anorexia also exhibit mitral valve prolapse, not mitral regurgitation.

Because she is bradycardic, an EKG should be performed. QT prolongation is common in these patients, especially when bradycardia is present. Hypotension is more common than hypertension in anorexic patients.

16. Serotonin syndrome may result from taking an SSRI and:: Dextromethor- phan Serotonin syndrome is a potentially life-threatening condition. The syndrome occurs when there is too much serotonergic activity in the central nervous system. It can occur with an interaction between two medications, like an SSRI and dextromethor- phan, an SSRI and a triptan, an intentional overdose, or with high doses of an SSRI in a particularly sensitive patient. Symptoms of serotonin syndrome include hyperreflexia, clonus, rigidity in the lower extremities, tachycardia, hyperthermia, hypertension, vomiting, disorientation, agitated delirium, or tremor. None of the other medications listed can precipitate serotonin syndrome.
17. A patient who abuses alcohol will probably exhibit:: elevated ALT, AST, and GGT

Liver enzymes rise in response to acute injury to the liver. ALT and AST are frequently elevated when alcohol abuse occurs. Specifically, the AST is usually the higher of the two enzymes and can signify alcohol abuse when it is more than 2 times greater than the ALT. In patients who abuse alcohol daily, the ALT and AST may be normal. GGT, gamma- glutamyl transferase, is often elevated even when ALT and AST are normal. It can help identify damage to the liver as a result of alcohol abuse.

18. Which of the following characterizes bulimia nervosa?: Binge eating Recurrent episodes of binge eating characterize bulimia. Loss of control is always present, especially when eating. This results in eating quantities of food far beyond what would normally be consumed. Binge eating is always followed by a compen- satory activity. This may take the feature of purging or nonpurging. Nonpurging involves excessive exercise or post-binge fasting. Binges and the compensatory activity occur a minimum of twice weekly for at least 3 months for diagnosis of bulimia nervosa.

19. Tricyclic antidepressants may be safely used in older patients who have:- : hypothyroidism Tricyclic antidepressants (TCA) are particularly UNSAFE in patients with conduction defects. Use of TCAs can induce bradyarrhythmias and thus can be deleterious for any patient, but especially in older adults who may be prone to this because of conduction defects and underlying myocardial ischemia. Patients with glaucoma and benign prostatic hyperplasia should avoid TCAs as well because of the anticholiner- gic effects. Selective serotonin reuptake inhibitors (SSRI) should be considered first line for most older patients with depression.

20. A patient with acute anxiety will experience the fastest relief of symptoms when he is treated with:: Benzodiazepine The most rapid relief of anxiety symptoms will occur with a benzodiazepine. The relief occurs with each dose and tapers as the dose is metabolized. The other agents listed will take multiple doses, or days to weeks before relief is experienced. With daily and continued use of

benzodiazepines, the anti-anxiety effect may become diminished.

21. A depressed patient is started on an SSRI. When should another antide- pressant be tried if there is no response?: 8-12 weeks Most learned authorities agree that if there is no response by 8- weeks at a maximal therapeutic dose, a different antidepressant should be tried. The 8-12 week period is an appropriate time frame because it will take this long to increase the dose and attempt to reach maximal dose for therapeutic response. 4-6 weeks is nearing the appropriate time frame, but this may be too short a period of time to reach and evaluate therapeutic effect.
22. A patient has been diagnosed with anxiety. What sleep disturbance might she have?: Difficulty falling asleep Patients with anxiety complain of difficulty falling asleep. Patients with depression complain of early morning awakening and difficulty remaining asleep. A manic patient may state that he never feels tired enough to sleep.
23. The preferred medication class to treat patients with an initial episode

of depression is:: SSRIs The major classes of antidepressants used to treat depression are listed in this question. Multiple studies have concluded that there is no clear choice on selection of one class over another for efficacy. However, SSRIs are usually the first choice because they are associated with fewer side effects and there is less danger of suicide with an overdose. Monoamine oxidase inhibitors are involved with a number of drug-drug and drug-food interactions and so these are seldom chosen initially.

24. Which statement about attention deficit disorder (ADD) is correct?: DSM V is used to diagnose a child with ADD ADD and ADD with hyperactivity are two separate diagnoses. This disorder is more common in boys (5:1) and symptoms must be present by age 7 for at least 6 months before diagnosis can be made. DSM V should be used to diagnose children. Parents and/or teachers should establish specific elements. Examples include fidgeting, difficulty remaining in seat, excessive talking, impatient when asked to wait their turn, blurting out answers before time, and interrupting conversation.

These must be established in more than one environment.

25. Which findings suggest that a patient may be abusing alcohol?: Macrocy- tosis, tremulousness, hypertension Findings that should trigger an examiner to suspect alcohol abuse in a patient are tremors, hypertension, rhinophyma, peripheral neuropathy, telangiectasias, and hepatosplenomegaly. A patient does not usually exhibit all of these characteristics. In fact, he may not exhibit any of these symptoms and still abuse alcohol. The symptoms listed in the other choices are not specifically associated with alcoholism. Macrocytosis is common in alcoholics because there is a high rate of B12 deficiency and folate deficiency; both produce macrocytic anemias.
26. Which patient is at highest risk of suicide?: 86 yr-old male with chronic pain Elderly patients and males are more successful when they attempt suicide. Those at highest risk are white males 85 years or older. Symptoms in the elderly that should

be of particular concern to healthcare providers, because they are associated with increased risk of suicide, are hopelessness, insomnia, unremitting pain, alcohol abuse, restlessness, and impaired concentration.

27. A good first choice of antidepressants in an older adult is:: an SSRI An SSRI is a good choice of an antidepressant in an older adult because of the decreased side effects seen when compared with the other agents listed, but especially a TCA. These can produce conduction defects in older adults, sedation, and potent anticholinergic side effects.
28. Elderly patients who are treated for depression with tricyclic antidepres- sants (TCAs) often exhibit:: Arrhythmias The TCAs have pronounced anticholinergic activity and thus, produce bothersome side effects like dry mouth, constipation, urinary retention, confusion, and even delirium. The TCAs block H1 receptors that may be responsible for sleepiness and weight gain. Hypotension may also result, especially in the elderly. This may be due to an alpha-1 receptor blockade. These medications must be used very cautiously in the

elderly because they can produce bradycardia and prolongation of the QT interval. Therefore, a resting EKG is necessary prior to starting any TCA.

29. A patient with bipolar disease has purchased a $10,000 baby grand piano. He does not play the piano. Consistent with a manic episode in bipolar disease, this is an example of:: Grandiosity During a period of mania, common symptoms are inflated self-esteem and grandios- ity (like a buying a baby grand piano), decreased need for sleep, hyper verbosity (excessive talking), racing thoughts and flight of ideas, distractibility, and excessive involvement in pleasurable activities that can be associated with very painful conse- quences later.
30. What is the usual age of onset of symptoms for patients with bipolar disorder?: Between 15 and 30 years The usual age of onset of symptoms is between 15 and 30 years. Onset of symptoms almost never occurs in patients older than age 65 years or younger than 15 years.
31. A patient presents to the nurse practitioner's clinic and states that she

feels sad and thinks she's depressed. What information is important to elicit in order to diagnose her with depression?: How long have you felt like this? In order to diagnose a patient with depression, certain criteria must be met. DSM V has established specific criteria that must be present for a diagnosis of depression to be made. One essential criterion is the presence of depressed mood for at least 2 weeks. If the depressed mood has lasted less than this, a diagnosis is premature. Information about family history supports a diagnosis but is not a criterion. The last two questions assess for risk of suicide.

32. The nurse practitioner (NP) is treating a 22 year-old for depression with high dose fluoxetine. After several months of dosage changes, she is finally doing well and comes today for a follow up visit. She is happy and states that she might be pregnant. A urine test indicates pregnancy. The NP has referred the patient to an obstetrician who will see the patient in 4 weeks. How should the fluoxetine be handled today?: Let the obstetrician and patient make a decision about continuing fluoxetine

Fluoxetine is one of the best studied selective serotonin reuptake inhibitors in pregnancy and lactation. There has been no reported evidence of teratogenicity. While the healthcare provider would rather this patient not take a medication while she is pregnant, consideration must be given to the severity of her depression and her response to treatment. The discussion the NP and obstetrician will have with the patient should include risks and benefits of treatment, and potential risks of stopping fluoxetine. The risk of exposure to medication must always be weighed against the risk of not treating this patient. All psychotropic medications cross the placenta and so developing fetuses are exposed to these medications. Fluoxetine is a category C medication.

33. The major advantage of the CAGE questionnaire is:: brevity of questions The CAGE questionnaire is a screen for alcohol abuse. It consists of 4 questions that can be quickly and easily incorporated when eliciting a patient's history. The "C" is to remind the questioner to ask the patient whether he's ever felt the need to "C"ut down on drinking; "A"nnoyed by criticism about his drinking; "G"uilty about his drinking; in need of an

"E"ye opener. These 4 questions are very easy to ask and can be answered with a simple yes/no response. The majority of patients with alcoholism respond yes to at least 2 of these questions. Patients without alcohol problems virtually never respond "yes" to 2 or more. The questionnaire is known to have high sensitivity and specificity, but is less sensitive for early or heavy drinking.

34. A nurse practitioner suspects that a patient is abusing ethanol. What laboratory values would support this suspicion?: Elevated ALT, AST, and GGT Liver enzymes rise in response to acute injury to the liver. ALT and AST are frequently elevated when alcohol abuse occurs. Specifically, the AST is usually the higher of the two enzymes and can signify alcohol abuse when it is more than 2 times greater than the ALT. In patients who abuse alcohol daily, the ALT and AST may be normal. GGT, gamma-glutamyl transferase, is often elevated even when ALT and AST are normal. It can help identify damage to the liver as a result of alcohol abuse.

35. A patient with bipolar disease has purchased a $10,000 baby grand piano. He does not play the piano. This behavior is typical during:: Mania During a period of mania, common symptoms are inflated self-esteem and grandios- ity (like a buying a baby grand piano), decreased need for sleep, hyper verbosity (excessive talking), racing thoughts and flight of ideas, distractibility, and excessive involvement in pleasurable activities that can be associated with very painful conse- quences later.
36. Which depressed patient below has characteristics that are risk factors for suicide?: 78 year old male recently widowed Demographic risk factors for suicide are male gender, older age, having been recently widowed, and living alone. Dentists and other health care workers are at risk for successful suicide because of their knowledge of and access to medications that could be used to commit suicide.
37. What statement describes depression in older adults?: They can be man- aged with some of the same medications as younger adults. Depression in older adults is difficult to diagnose because they may

present with symptoms such as decreased energy, may associate depressive symptoms with "just getting older" and not mention them to healthcare providers, or they may present with somatic complaints. This last symptom is common in younger adults. Laboratory evaluation should include a CBC, TSH, B-12 level, electrolytes, urinaly- sis, and others as indicated by history. Many medications used to treat depression in younger patients are used in older patients. The dosages are usually decreased.

38. A newly diagnosed pregnant teenager has suspected depression. Before a diagnosis is made, she should have a CBC, TSH, renal and liver function tests and:: urine toxicology screen There is a high correlation between psychiatric disorders and drug/alcohol use. This should be ascertained as soon as possible since these can have serious implications on the fetus/mother's health. None of the other tests listed have an impact on diagnosis of depression in a pregnant patient. CBC, TSH, and renal/hepatic function tests are used to screen depression "look a likes" (anemia, hypothyroidism, renal or hepatic dysfunction). Hemoglobin A1C is a good idea but is not as

urgent as the urine toxicology screen unless there are diabetes risk factors present.

39. The most common co-morbidity associated with depression is:: Anxiety Anxiety is the most common co-morbidity associated with depression; especially panic disorder, obsessive-compulsive disorder, and post- traumatic stress disorder. All of the other choices listed are co- morbidities associated with depression, but do not occur with the same frequency. When these co-morbidities occur in conjunction with depression and are not treated, they worsen the prognosis.
40. A patient with an eating disorder might exhibit evidence of:: Anxiety disor- ders In patients with eating disorders, it is common to identify affective disorders, anxi- ety disorders, or substance abuse issues. Obsessive- compulsive disorder is also commonly observed. Patients with eating disorders are more likely to have a first or second degree relative with an eating disorder, affective disorder, or alcohol abuse. There is no evidence that patients with eating disorders exhibit a higher incidence

of sleep disorders, or have been sexually abused. Thyroid disease should always be assessed in patients with eating disorders, but this does not represent the reason for weight loss when eating disorder is present.

41. A patient with anorexia nervosa (AN) had symptoms that began about 6 months ago. She presents today and is diagnosed with AN. She has a laboratory evaluation. What might be expected?: Normal lab values Most lab values remain normal until late stages of the illness in patients who are anorectic. The initial lab assessment should include a CBC, glucose, electrolytes, BUN, Cr, and a pregnancy test in females who are amenorrheic.
42. A 34 year-old bipolar patient has been placed on a fluoxetine and valproate for manic depressive symptoms. He has had great improvement in his symp- toms and has returned to work. The psychiatrist has released him to your care. What must be monitored in this patient?: Valproate levels, platelet count, liver function studies

Valproate has been associated with liver toxicity and failure, and thrombocytopenia. Liver function studies and platelet counts should be monitored prior to therapy and then regularly as indicated by the drug manufacturer. Valproate levels should be measured to insure target blood level between 50-125 micrograms/mL. Common side effects of valproate are nausea, vomiting, easy bruising, and tremors.

43. A 29 year-old postpartum female reports that she is having difficulty with concentration, sleep, and has feelings of guilt. She states that she feels sad most of the time. These symptoms have been present since the birth of her baby about one month ago. She can be diagnosed with:: PPD This patient is correctly diagnosed with postpartum depression. Postpartum de- pression is diagnosed when depression begins within the first month after delivery. There are 9 symptoms that characterize depression (in non-pregnant patients) and these are used in postpartum patients as well. When a patient exhibits fewer than 5 symptoms, but at least 2 of these symptoms every day for most of the day for at least 2 weeks, s/he may be diagnosed with minor depressive disorder. Depressed mood must be one of these symptoms. If s/he exhibits 5 or

more, s/he may be diagnosed with major depressive disorder. In dysthymia, similar symptoms are evaluated, and they must be present at least 2 years. Hypothyroidism can account for feelings of low energy, but hypothyroidism does not produce feelings of guilt or other symptoms associated with depression.

44. A 4 year-old is being examined today in the NP clinic. He appears shy and does not make eye contact with the examiner. The mother does not make eye contact with the examiner either. The patient lacks animation and does not smile. What likely possibility must be considered?: Neglect is possible The possibility of neglect should always be given when a young patient and caregiver make poor eye contact with the examiner. Other clues to neglect are a lack of ani- mation and no social smile. Additionally, the child should be observed for nutritional status, behavior, attitude, and physical appearance. Sexual abuse should also be considered, but there is nothing in the stem of the question to suggest this or a lack of medical insurance.

45. Carbamazepine is used in patients with bipolar disorder for mood stabi-