ANCC IQ Domain 1-5

1. The PMHNP knows that the ego is a part of the personality and is the logical/rationale mind including defense mechanisms. What might this personality part say? - "I want" - "I should" - "I ought" "I evaluate

- "I evaluate" Rationale: The ego is the logical and rational mind. The ego monitors the id and would say "I think. I evaluate." Id: "I want" Ego: "I think, I evaluate" Superego: "I ought, I should"

1. When screening potential female clients for an incest survivor's group, which client would you exclude from selection to the group? - 36-year-old divorcee who brings a signed consent form to consult with her individual therapist - 26-year-old mother inquiring because her husband is concerned about her lack of interest in sex - 18-year-old college freshman who is talking openly about her incest experience for the first time. - 50-year-old third grade teacher who last attended a sexual abuse group when flashbacks occurred.

- 26-year-old mother inquiring because her husband is concerned about her lack of interest in sex Rationale: Initiation of any type of therapy at the insistence of another merits exploration of individual issues and couples relationship issues before entering any group therapy experience, and particularly an incest survivor's group. A variety of factors may be contributing to the diminished interest in sex of 26-year-old new mother and cannot be automatically attributed to issues of surviving incest. The other three clients are all self-identifying their interest in being in the incest survivor's group.

1. Understanding normal growth and development, at what age should a child use up to 1,000 words, use three- to four-word sentences, balance on one foot, and play "make believe"? - 3 years of age - 5 years of age - 2 years of age - 4 years of age

- 3 years of age Rationale: The language and nonverbal development of a child at age 3 consists of the following: speaks up to 1,000 words, uses three- to four-word sentences, follows 2-step commands, speech is understood by family, plays "make believe," balances on one foot, and briefly shares toys.

1. The following scenario is an example of the defense mechanism sublimation: - A mother of a child killed in a drive-by shooting becomes involved in legislative change for gun laws and violence. - A host despises one of the party guests yet greets him warmly and offers him food, beverages, and special attention. - An employee is embarrassed by a boss at work and angrily cuts a driver off on the way home. - A group therapy strongly dislike another member but claims that it is the member who dislikes her.

- A mother of a child killed in a drive-by shooting becomes involved in legislative change for gun laws and violence. Rationale: Sublimation is redirecting unacceptable feelings into an acceptable channel.

1. According to Erikson, the primary task of adolescent psychosocial development is "identity formation" and the associated virtue of "fidelity" to one's nascent self-definition and to one's ideology of "self-in-world." Which of the following behaviors would indicate successful navigation of this developmental milestone? - Easily identifies with a series of different groups from athletes, rave parties, computer geeks to heavy metal bands - Ability to tolerate differences in others while affirming one's own values and beliefs - Primary identification with "goth" friends despite ostracism by others - Ability to form a sexually intimate relationship sustained over several years

- Ability to tolerate differences in others while affirming one's own values and beliefs Rationale: Adolescents may defend against role diffusion by joining cliques or cults or by identifying with folk heroes. Intolerance of individual differences is a way in which the young person attempts to ward off a sense of identity loss. Fidelity is the ability to sustain loyalties freely pledged in spite of the inevitable contradictions of value systems. It is the cornerstone of identity and receives inspiration from confirming ideologies and affirming companionships.

1. Your patient is a 37-year-old male who you have diagnosed with major depression. He was referred to you by a Licensed Alcohol and Drug Abuse Counselor (LADAC) who has diagnosed him with Opioid Use Disorder-Severe. After your evaluation of the patient, you concur with the LADAC's diagnosis and treatment with an antidepressant and inpatient chemical dependency as his best chance of recovery. You discuss treatment with the patient ant tell him the rationale for your treatment choice. You discuss his failure to maintain abstinence, his health issues, the loss of friends and family, and other issues that surround using. He refuses the treatment, citing that he is able to care for himself and will continue to try on his own treatment but will try antidepressant medication and continue seeing his therapist on an outpatient basis. You: - Continue to discuss the benefits of inpatient treatment and the health needs of the patient until he accepts the recommendation. - Contact the LADAC counselor to manage the patient to place him in protective custody. - Accept his right to determine his own treatment plan. - Dismiss the patient from your service.

- Accept his right to determine his own treatment plan. Rationale: All patients have the right to self-determination unless they are mentally impaired, or so mentally ill that they may be of danger to themselves or someone else, and do not have a medical power of attorney, living will, or other predetermination legal document. Under some conditions and in some jurisdictions, there is a statute for a Board of Mental Health to convene to determine if a person is so mentally ill that they may be of danger to themselves or someone else, and need to be placed in protective custody. A peace officer may place a person under Emergency protective custody under such circumstances.

1. A mobile crisis team responded to an emergency call by a residential care home (RCH) manager. A 65-year-old resident had become increasingly agitated, insisted that the RCH cook was poisoning her food, and verbally threatened the cook. The RCH manager had found several days of the resident's medications hidden in her dresser drawer. Which is the most appropriate intervention by the mobile crisis team? - Admission to the gero-psychiatric unit at the community hospital. - Admission to the state psychiatric hospital. - Admission to a nursing home. - Admission to the crisis stabilization unit.

- Admission to the crisis stabilization unit. Rationale: The Universal Bill of Rights for Mental Health Patients (Title II, Public Law 99-319, Restatement of Bill of Rights for Mental Health Patients established by the Mental Health Systems Act of 1980) supports evaluation and treatment in the least restrictive environment. The crisis stabilization unit represents the least restrictive choice of the four listed and will likely have a much shorter period of stay before returning the patient to the RCH.

1. The NP has a Law Bill in the State legislature passed so that funds will be released to be used for housing the severe and persistently mentally ill. The NP contacts eight persons and asks them to telephone the State Senator who heads the health and Human Services committee. She asks them to tell the State Senator to vote to approve the bill. This NP is acting as an: - Stigma Reduction Agent - Care Provider - Policy maker - Advocate

- Advocate Rationale: Advocating for individuals, families, and communities is a part of the care that the Nurse and Psychiatric NP provide. He or she advocates for things that will reduce barriers to health such as safe, inexpensive housing.

1. The NP attends a local meeting where allocation of resources for healthcare will be discussed. One of the stakeholders has a pamphlet that describes the types of healthcare providers available to help persons in need of health care. The NP notices that NPs are labeled as "Paraprofessionals." In the meeting, the NP asks the organization responsible for the pamphlet why they have identified the NPs as paraprofessionals when an NP is by law working as 85-90% of the same capacity as a Medical Doctor. The NP goes on to explain what an NP does in various areas of practice. This is an example of: - Promoting nurse practitioners in the community - Public education on the NP scope and standards of practice - Correcting misinformation that deliberately misleads the public - Advocating for the role and value of the NP

- Advocating for the role and value of the NP Rationale: In 2009, an American Association of Retired Persons (AARP) pamphlet identified NPs as paraprofessionals, defined as personnel who are not members of a health profession but are trained to assist these professionals. NPs are expected to advocate for the role and value of the NP.

1. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) insures which of the following? - Small employers who insure 50 or fewer covered lives are exempt from the provisions of this MHPAEA law. - Annual or lifetime dollar limits on mental health and substance use disorder benefits are no lower than any such dollar limits for medical and surgical benefits offered by a group health plan. - Mental health and substance use disorder benefits must be available through both in-network providers and out-of-network providers by a group health plan. - Group health plans may obtain an exemption if they can demonstrate expected cost increase resulting from implementation of the parity provisions greater than a 5% increase in the cost under existing plan.

- Annual or lifetime dollar limits on mental health and substance use disorder benefits are no lower than any such dollar limits for medical and surgical benefits offered by a group health plan. Rationale: The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) provides federal legislation that requires any annual or lifetime limits on medical and surgical benefits be the same for mental health and substance use disorder benefits. Small employers who insure 2 to 50 employees can apply for an "opt-out" waiver, but they are not automatically exempt from the MHPAEA requirements. The group health plan will be required to provide in-network and out-of-network mental health and substance use disorder benefits only if it provides both in-network and out-of-network medical and surgical benefits. The group health plan my obtain an exemption or waiver if the first year of implementation results in 2% increase in group health plan costs over prior year that covers the following year, and if implementation results in 1% increase in group health plan costs in subsequent years. A section on actuarial determination of these increased costs is included in the law.

1. A PMHNP providing psychiatric consultation makes a home visit after the police found an 86-year-old widow wandering the streets at 4AM after emergency call from her daughter. The woman has been living with her daughter for the pat ten years after her husband dies. Her daughter is a 66-year-old, single, retired school teacher, appears thin, exhausted, and reports little sleep for past two years trying to care for her mother. The daughter reports that her mother becomes increasingly confused every evening and wanders the house unable to sleep at night. The daughter is unable to leave her mother alone for even a short period of time because unsupervised her mother will turn on the gas stove burner, leave it unattended, and she escapes the house at every chance to wander the neighborhood. Her mother is socially pleasant, disoriented to time and place, and does not recognize her daughter. Her mother thinks that the daughter is a housekeeper intent on stealing her money and possessions, which is upsetting to the daughter. What is the most important factor in determining the level of care needed for this elderly client? - Modification of environment such as bright lights in evening, identification bracelet, and safety lock on stove. - Linkage with home health aide 4 to 6 hours/three times per week, and community resources for respite care - Appraisal of daughter's health and her ability and willingness to continue caring for her mother at home. - Trial of low-dose atypical antipsychotic to reduce paranoid ideation, help sleep, and decrease wandering.

- Appraisal of daughter's health and her ability and willingness to continue caring for her mother at home. Rationale: The critical factor in determining whether care may be maintained in the home versus necessity for supervised care in a residential home or skilled nursing home is whether the daughter's health and her ability, willingness, and motivation to continue to care for her mother at home is viable. The other interventions are all contingent on the daughter's ability and desire to continue caring for her mother. As a person's care requirements may increase over time, the complexity of the care needed can take their toll on the caregiver. Problems arise when the caregiver's health starts to suffer or the aging person's needs exceed the caregiver's ability and resources.

1. To advocate for the skills and value of the NP, you: - Arrange for a local TV station to interview you about what PMHNPs can do for the community. - Arrange a meet and greet with other nurses at a drug luncheon promoting a psychiatric medication. - Arrange for you and other psychiatric nurses to participate in a blood drive for a local psychiatric hospital. - Arrange for your office to participate in a walk for Alzheimer's Disease.

- Arrange for a local TV station to interview you about what PMHNPs can do for the community. Rationale: Advocacy is more than doing something altruistic as a PMHNP. Advocacy is getting out, showing, and telling people the value of what you do as a PMHNP.

1. In co-leading a group of elementary children divorcing parents, a child shared that his parents were arguing over the weekend and calling each other names. What is the most appropriate intervention at this juncture? - Ask the child how he was affected by the incident and ask other children how they handle similar situations. - Ask the child how he was affected by the incident and facilitate sharing of similar incidents by other children - Ask the other children in the group if they experienced similar situations and how they handled their feelings - Allow the child to finish describing the situation and then ask how he felt about hearing this argument

- Ask the child how he was affected by the incident and ask other children how they handle similar situations Rationale: Self-disclosure: Use judgment as to the appropriateness of letting a child go into detail about personal matters in a group. In an elementary school group, you may not want to let a child go into detail about a parental fight. An important intervention is directing the child to express how he was affected by the incident. Children commonly think that they are the cause of parental fights; dispelling this usually erroneous belief is important for the group to address. It would not be helpful to invite other children to disclose details about parental fights, however facilitating sharing of similar feelings, thoughts, and coping strategies by the other children can be one means to help the entire group recognize that they are not responsible for their parents' arguments, behaviors, thoughts, or feelings.

1. During a medication follow-up appointment at a student mental health clinic, a 20-year-old college sophomore with depression and a history of binge drinking disclosed that she has been struggling with recurrent intrusive thoughts to overdose. She recently broke up with her boyfriend when she learned that he was sleeping with her closest girlfriend. She admits taking a handful of her sertraline prescribed by the PMHNP last weekend and was frustrated that it only made her sleep for a day. She's angry and ambivalent about the future, unwilling to make any promise not to harm herself, and has made veiled threats to "pay back both of them for cheating" (referring to her ex-boyfriend and girlfriend). What is the most appropriate intervention at this juncture? - Ask the student if she will agree to voluntary admission and arrange involuntary admission if necessary - Counsel the student that she would regret hurting herself and can move beyond this broken relationship - Ask the student to promise that she won't harm herself or anyone else and schedule next day counseling visit - Negotiate with the student to touch base daily by phone between counseling visits to avoid hospitalization

- Ask the student if she will agree to voluntary admission and arrange involuntary admission if necessary Rationale: When significant harm to the person or others are certain or highly likely, then a more stringent evaluation is warranted and a responsibility to intervene may exist. The purpose of intervening when self-harm or harm to others is likely is to restore the person to his or her previous ability to exercise autonomy. Chodoff (1976, 1999) argued defense of both of the need for involuntary hospitalization and the criteria that should be applied to such decisions. He argues that involuntary hospitalization may be warranted if "obvious disturbances that are both intrapsychic (for example, the suffering of severe depression) and interpersonal (for example, withdrawal from others because of depression)" exist. The student's unwillingness or inability to commit to no self-harm, her recent overdose attempt, her history of binge drinking, the inherent impaired judgment form binge drinking, and her veiled threats to harm others, are all risk factors which compound her level of imminent risk. Closer evaluation for safety on an inpatient unit is warranted.

1. Attachment relationships between infant and mother are considered critical by neurobehavioral researchers because: - Interaction influences development of the brain's limbic system - Attachment to significant relationships facilitates self-regulation of emotions. - Subtle emotional regulatory interactions can transiently or permanently alter brain activity levels - The mother functions as a regulator of the social and emotional environment

- Attachment to significant relationships facilitates self-regulation of emotions Rationale: While all of these statements are true, it is through attachment to significant relationships (e.g., mother, father, caregiver) that the young child begins to find ways for regulating and expressing emotions. Self-regulation of emotions is an emotional skill that continues to develop throughout childhood and into adolescence.

1. Which of the following best depicts the PMHNP in a grassroots mental health advocacy role? - Assisting with depression screening at a health fair in a local shopping mall. - Meeting state legislators during RN lobbying day organized by the state nurses' association. - Working on the campaign of an individual running for the state senate. - Attending a town hall meeting to seek timely police response to rising domestic violence crisis calls.

- Attending a town hall meeting to seek timely police response to rising domestic violence crisis calls. Rationale: While all descriptions can be categorized under professional activism, the response involving a specific mental health issue with a proposed action to improve care is timely police response to domestic violence crisis calls. Assisting with depression screening is a primary intervention and health promotion strategy.

1. A child who is seen by the PMHNP has difficulty feeling safe with his caregiver and is unable to feel comfort. Which theorist's theory would help explain the child's behavior and help guide treatment? - Bowen - Bowlby - Erickson - Freud

- Bowlby by not feeling safe with their caregiver Rationale: According to Bowlby and attachment theory, children who come from parents with high expressed emotion and unresolved losses tend to develop disorganized attachment characterized and an inability to feel soothing comfort.

1. You work as an Np makes you aware that there are many people who cannot afford to get services for their mental health needs. As part of your concern for social justice, you: - Act as a health screener at your child's kindergarten. - Act as a delegate at your local nursing convention. - Support a local candidate for office who is "progressive" about health care. - Care for a number of patients pro bono each year.

- Care for a number of patients pro bono each year. Rationale: Social justice is a part of giving to those who have no services, the services that they lack. Sometimes this is on a micro level by acting through your own efforts with your patients or on a macro level by working with a group to effect health law change to make health care a universal right.

1. In evaluating a 9-year-old girl referred by the school for evaluation of behavioral problems, which of the following reported behaviors raises the greatest concern? - Incomplete and late homework assignments - Chasing boys with provocatively posturing hips on playground - Seeming to daydream looking out classroom window - Difficulty staying on task during school day

- Chasing boys with provocatively posturing hips on playground Rationale: Sexually provocative behavior beyond normal growth and developmental ag e or stage can be a possible indicator of sexual abuse, which warrants further assessment and poses the greatest concern.

1. You are in a meeting of your state nurse practitioner legislative group. The group's director has asked you to present information on a law bill (LB) that is being presented for public hearing in the state legislature. The information covers how best to approach securing support from the state's Health and Human Services Committee (state senators and congressmen). As you begin to present the information, two of your colleagues on the committee begin to talk over you about their ideas and will now quiet down. The group director does not intervene to settle the meeting. You decide to: - Talk over colleagues. Ask them to allow you to finish before they make comments. Take questions at the end of the presentation. - Clear your voice and ask for attention. When that does not work, stop speaking until the situation resolves. If it does not resolve, sit down quietly until the behavior stops. - Confront the speakers for their ill behavior and ask them to be quiet until you have finished your presentation. - Ignore the speakers and ask the group director to settle the room so that you can finish your presentation.

- Clear your voice and ask for attention. When that does not work, stop speaking until the situation resolves. If it does not resolve, sit down quietly until the behavior stops. Rationale: She should wait quietly for them to stop their behavior. This is a situation of indirect bullying where the two colleagues were directly subverting the information that the presenter was attempting to present to the group. The definition of social bullying, which is defined as persistent, demeaning, downgrading activities incorporating vicious word and cruel acts that undermine self-esteem. Bullying is malicious and psychologically damaging. The speaker could choose to make a spectacle and shout over the persons interfering and cause chaos, throwing bad publicity on the nursing group as a whole. She could lose her own power by asking the group director to manage the rowdy persons.

1. Psychotherapy which stresses the importance of recognizing patterns of thoughts and how thought influence feelings and behaviors best describes: - Cognitive behavioral therapy - Family therapy - Supportive therapy - Group therapy

- Cognitive behavioral therapy Rationale: Cognitive behavioral therapy posits that by learning how thoughts and behaviors influence our feelings, we can learn to have more control over our feelings.

1. Which of the following is not associated with increased validity in a clinical research trial? - Sample size - Outcome measure - Randomization - Confounder

- Confounder Rationale: A confounder is a factor that distorts the true relationship of the study variable of interest by virtue of also being related to the outcome of interest. Confounders are often unequally distributed among the groups being compared

1. During an outpatient medication evaluation, a depressed client reports persistent anger toward his former boss after losing his job due to arguments and assaultive behavior toward co-workers. The client has been waiting outside the plant in the afternoon, watching for the boss to leave to confront him regarding his terminated employment. What responsibility does the PMHNP have in this situation? - Consult state board of nursing regarding state law requirements on reporting potential harm. - Advise the client to stop going to the plant and avoid any contact with his former boss. - Ask the client to sign a "no harm to others" agreement and document in chart. - Contact the client's boss to notify him of potential harm.

- Consult state board of nursing regarding state law requirements on reporting potential harm. Rationale: Tarasoff v Regents of the University of California (1974) established that a mental health professional has a "duty to warn" potential victims of impending danger from a patient. State laws vary by state. It is professional responsibility to know what is required in the state where one practices.

1. In a therapy session, a five-year-old patient shows the NP bruises on her back and legs. The child discloses that her mother's boyfriend hits her and tells her to "shut up." The NP is required to: - Contact Child Protective Services or similar services in the local community to investigate the child's safety. - Arrange to remove the child from the dangerous situation to protect her. - Take pictures of the bruises and save them in the child's file. - Contact the mother to investigate the situation further.

- Contact Child Protective Services or similar services in the local community to investigate the child's safety. Rationale: Individuals designated as mandatory reporters typically have frequent contact with children. Such individuals may include: social workers; teachers, principals, and other school personnel; physicians, nurses, and other healthcare workers; counselors, therapists, and other mental health professionals; child care providers; medical examiners or coroners; law enforcement officers.

1. A 43-year-old male patient presents to the PMHNP for a medication follow-up appointment. As part of his follow-up visit, his blood pressure reading is 156/102 millimeters of mercury. The patient states he has been having headaches for the last few weeks since he ran out of his blood pressure medication. The PMHNP's best action is which of the following? - Call the pharmacy to confirm which antihypertensive the patient is taking and write a 30-day supply of this medication - Refer the patient to the emergency department for an evaluation - Contact the patient's primary care provider, explain the patient's symptoms, and request his medication be refilled and he be given a follow-up appointment - Call a local FNP and request that she refill this patient's medication

- Contact the patient's primary care provider, explain the patient's symptoms, and request his medication be refilled and he be given a follow-up appointment Rationale: According to the scope and standards, standard 5A addresses the need for coordination of care for patients, using an interdisciplinary approach to care delivery.

1. A social worker concerned about a Nigerian refugee who seems to be suffering from severe post-traumatic stress disorder since arriving in U.S. three months ago referred this man to an African American female PMHNP in the community mental health center. The PMHNP builds rapport by exploring the values, beliefs, life experiences, and accepted behaviors of this young Nigerian man as she seeks to understand the context of his transition to the U.S. before making any diagnosis or proposed intervention. The PMHNP is striving to provide what type of mental health care? - Culturally competent care - Alternative care - Culture specific care - Individualized care

- Culturally competent care Rationale: Cultural competence is a process in which the healthcare professional continually strives to achieve the ability and availability to work effectively within the cultural context of the client. Culture is the totality of learned, socially transmitted beliefs, values, and behaviors that emerge from the members' interpersonal transactions.

1. You are a PMHNP and have many patients with comorbid and mental health issues. As a part of your continuous quality improvement (CQI) process you might best serve your practice by: - Develop a journal group with a general practice colleague to read the latest articles on self-care for advanced practice nurses. - Subscribe to Medscape and read it daily to see about new medications being developed for personality disorders. - Subscribe to Medscape Psychiatry and read it critically noting studies that apply to your patient's access to care issues. - Developing a peer review process of your charts with a general practice colleague.

- Developing a peer review process of your charts with a general practice colleague. Rationale: While all of these practices could serve continuous quality improvement, the only one that directly serves the needs of the comorbid medical /mental patient population is to begin a peer review process with an NP with a general practice/medical background.

1. A colleague emails on the company computer system regarding complaints about another coworker. In the message, the colleague makes several disparaging remarks about the other coworker and the difficulty of working with her. You reply: - She is just not doing things the way they were taught. She can't help it if she is not us, but she could try harder! - Really, I cannot believe that you get so upset over that little stuff. Help her understand where she is making a mistake and teach her how to do things correctly. - Did you talk with her about the issue you have with her? Saying bad things about your coworker will not solve the problem or make it better. - I understand your feelings, just put up with it. You are going to another shift in one month and will leave the problem behind.

- Did you talk with her about the issue you have with her? Saying bad things about your coworker will not solve the problem or make it better. Rationale: We are nurses and we must treat each other and all others ethically with respect. Verbal bashing and avoiding is a type of lateral violence. If you have a problem with someone, talk to him or her and find out what the issue is before you complain. We have to break the chain of abuse and treat each other with respect and kindness.

1. Your patient is receiving Medicare and Social Security Disability payments. This money helps her to pay for food, clothing, shelter, and medications. She recently began to work part-time. Her work has greatly improved her mood and self-perception. She has taken on more work. The additional income has caused her to lose her disability and Medicare funding. She is concerned that she will not be able to get her medication, pay for housing, and some of the other things she was able to afford before. How do you counsel her? - Advise her that her counselor can help her with financial issues - programs, services, and resources. - Discuss with her your assessment that her mood has improved since working and self-supporting. Assist her to find programs that will help her continue. - Advise her to maintain her Medicare and Social Security benefits because she will always have her food, clothing, shelter, and medication support. - Discuss with her the consequences of taking on "too much" work and losing her disability benefits.

- Discuss with her your assessment that her mood has improved since working and self-supporting. Assist her to find programs that will help her continue. Rationale: PMHNPs are care coordinators. We instill hope and follow-up with patient wishes. If working has helped the patient feel better and is not harming her, then help her to continue. Collaborate with community partners to stay knowledgeable of programs/services/resources.

1. The NP is on an airplane and the flight attendant asks if there is a medical professional on the flight. The NP agrees to help. The NP is presented with a young woman who is suffering from a severe panic attack. The woman is nauseated and lying on the floor of the plane. The woman has trouble communicating much more that she is upset, afraid, and her husband is a few airplane stops away at an air force base where she is headed. The woman's pulse is 89 and regular and her respirations are 18 and regular. The woman occasionally pants and vomits some pale brown liquid. You provide information to the flight medical doctor on call. At the destination, the flight attendant offers to give you some Alprazolam 0.5 mg to give to the patient. You: - Give her the Alprazolam to help her calm down until you get to the destination. Then, she can go to the hospital. - Do not give the medication. Ask her if she would like to take the medication. If she agrees, allow the flight attendant to give it to her. - Give her the Alprazolam so that she can calm down and go on to her next flight - Do not give the medication. Instead, wait until the plane lands and a full evaluation can be completed at the local hospital.

- Do not give the medication. Instead, wait until the plane lands and a full evaluation can be completed at the local hospital. Rationale: The NP cannot assess if this person is under the influence of any medications or chemicals of abuse Giving her medication could potentially worsen the condition. It is better for the NP to be with the person, help her emotionally, observe, and manage her until the plane lands. Then, she can turn the patient over to the Emergency Medical Technician (EMT) team waiting at the terminal.

1. A 45-year-old woman with Type I Bipolar Disorder experiencing an acute episode of depression with psychotic features requires a temporary leave of absence from her job as an administrative assistant to a school principal. The patient has signed a release of information for the PMHNP to disclose full mental health records to the principal and the human resources department to facilitate her gradual return to work. The patient fears that she will lose her job due to her psychiatric disorder. What is the most appropriate information the PMHNP can provide in this situation? - Employers cannot discriminate against individuals with a mental health disorder, which is considered a disability covered by the Americans with Disabilities Act of 1990. - Employers cannot discriminate against individuals with a mental health disorder, which is protected as confidential health care information by the Health Insurance Portability and Accountability Act of 1996. - Employers cannot discriminate against individuals with a mental health disorder, which is considered equivalent to a medical disorder by the mental Health Parity Act of 1996. - Employers cannot discriminate against individuals with a mental health disorder, which is a right insured by the Universal Bill of Rights for Mental Health patients of 1980.

- Employers cannot discriminate against individuals with a mental health disorder, which is considered a disability covered by the Americans with Disabilities Act of 1990. Rationale: The Americans with Disabilities Act of 1990 prevents employers from discriminating against individuals with mental health disorders in employment decisions. The law mandates that reasonable accommodations need to be made for that individual. Accommodations include any adjustments to a job or work environment, such as modifying work schedules, acquiring or modifying equipment, or restructuring a job.

1. As a PMHNP who is working in a large health system and understands models of change, which of the following processes are typically included in these models? - Engaging stakeholders, addressing organizational barriers, and evaluating the impact of the practice change - Engage the unit-level manager, assess unit barriers, and obtain funding to implement the change - Conduct a literature search, write the proposal, and obtain funding for the change - Form a committee, identify the need, and evaluate staff satisfaction

- Engaging stakeholders, addressing organizational barriers, and evaluating the impact of the practice change Rationale: Most organizational change models (Hopkins, Iowa, and Stetler) include similar processes necessary for organizational change, and these models do not include obtaining funding, but rather focus on stakeholders, organizational barriers, and evaluation methods.

1. Which of the following is not the responsibility of Institutional Review Boards (IRB) in the research process? - Ensure that animal studies are conducted using humane methods - Ensure that informed consent is obtained and documented - Ensure that risks to participants are minimized - Ensure that adverse events are reported and risks/benefits are re-evaluated

- Ensure that animal studies are conducted using humane methods Rationale: IRBs were established to protect the rights and welfare of human research participants. Animal studies are not within the purview of IRBs.

1. The group leader wants to help the group members work through the feelings of emptiness that all the group members described as one of their reasons for wanting to be part of the group. In an effort to do this, the leader uses interventions that will increase their awareness of choices and responsibility for the consequences of their choices. This approach is congruent with the following theoretical framework: - Existentialism - Psychodynamic - Bowen Gestalt

- Existentialism Rationale: The existential theoretical framework places primary emphasis on the role of choice and responsibility in the therapeutic progress, challenging people to look at the choices they do have, however limited they may be, and accepting responsibility for choosing for themselves. This is based on the underlying assumption that people can exercise their freedom to change situations. Consequently, the group leader focuses members to examine what they are thinking, feeling, and doing rather than attempting to change others. The group context offers people opportunities to identify and clarify their thoughts, beliefs, feelings, and the way they are acting. Existential factors frequently addressed within both individual and group therapy identified by Yalom (2205) include: 1) recognizing that life is at times unfair and unjust; 2) recognizing that ultimately there is no escape from some of life's pain or from death; 3) recognizing that no matter how close one gets to other people, one must still face life alone; 4) facing basic issues of one's life and death, thus living one's life more honestly and less caught up in trivialities; and 5) learning that one must take ultimate responsibility for the way one lives one's life regardless of guidance and support from others.

1. A 37-year-old male with schizophrenia, paranoid type, lives in supervised housing and is followed by the Assertive Community Treatment Team through a Community Mental health Center (CMHC) where the PMHNP notes that he has refused to see any PCP during the past several years despite efforts by case managers to accompany him to medical visits. He ahs gained 30 pounds in past three years on clozapine since his last inpatient hospitalization. His WBC and ANC counts remain within normal limits, but he ahs elevated cholesterol, lipids, and A1C levels. What is the most appropriate intervention to facilitate care for this patient? - Advise the patient that needs to see a PCP to treat his elevated cholesterol and blood sugar levels and ask what has prevented him from seeing a PCP when referred in past. - Advise the patient that he needs to see a PCP to treat his elevated cholesterol and blood sugar levels and ask his preference for referral to one of the CMHC's affiliated PCPs. - Explain the health risks of his elevated cholesterol and blood sugar levels and that he may eventually have to be hospitalized for medical treatment because this is a serious problem. - Explain the health risks of his elevated cholesterol and blood sugar levels and separately ask the patient and case manager what has prevented him form seeing PCP when referred in past.

- Explain the health risks of his elevated cholesterol and blood sugar levels and separately ask the patient and case manager what has prevented him form seeing PCP when referred in past. Rationale: Basic explanation of the health risks of the elevated cholesterol and blood sugar levels, individual exploration of his fears and reasons for not seeing a PCP, and separate exploration of the case manager's observations and understanding of the patient's avoidance behavior is the most likely approach to facilitate the patient's understanding and consent to this coordination of care. Coercive approaches such as invoking fear of medical hospitalization are not warranted or ethically appropriate. Veracity is an ethical principle underlying the idea of trust and fiduciary relationships. Veracity or truthfulness in giving patients information about health care needs facilitates autonomous choice and enhances patient decision-making.

1. As a PMHNP, you accept an RN student who is studying to become a PMHNP. You ask the student to perform an initial psychiatric evaluation on a new patient while you observe. As the preceptor, you are responsible for: - Gaining permission from the patient for the student to perform the evaluation and to ensure the quality of the evaluation. - The patient feeling that he or she is being judged for "incarceration" in a chemical dependency treatment program. - Gaining permission from the patient for the student to perform the evaluation. The ability of the student to perform the evaluation is their professional responsibility. - Satisfaction of the patient with the outcome of the evaluation.

- Gaining permission from the patient for the student to perform the evaluation and to ensure the quality of the evaluation. Rationale: As a preceptor or educator, when you give an assignment to a student you are responsible and accountable for assessing if the student is able to carry out the assignment, if the patient is willing to have a student perform care for them, and if the care performed is up to standard. The patient should be treated with respect and dignity. It does not matter if the patient is happy with the outcome of the evaluation. The patient who received a diagnosis that they do not want to get is equally upset and unhappy with their outcome. A good evaluation tells the truth of the situation despite the happiness or unhappiness of the patient with the outcome.

1. The NP requires all patients to have a se of laboratory tests done each year to check changes in values as a safety measure. The patient states that these labs were done at his Internal Medicine Physician's office within the last month. The NP states that she will accept those labs as long as they cover all of the labs that she requires for the yearly check. The patient then verbally gives the NP his Internal Medicine Physician's office number to call and requests that she get the lab results. The NP then: - Faxes a formal request to the Internal Medicine Office and physician requesting the laboratory results. - Gets a signed release of information from the patient for the Internal Medicine Physician for the laboratory results. - Mails a formal request to the Internal Medicine office and physician requesting the laboratory results. - Calls the Internal Medicine office and verbally requests that they fax over the laboratory results.

- Gets a signed release of information from the patient for the Internal Medicine Physician for the laboratory results. Rationale: Private healthcare information is private and cannot be released without a signed release of information pe the Health Insurance Portability and Accountability Act (HIPAA). As long as patients do not object, the health care provider is allowed to share or discuss health information with the family, friends, or others involved in their care of payment for their care. The provider may ask your permission, may tell you he or she plans to discuss the information and provide an opportunity to object, or may decide, using his or her professional judgment, that you do not object. In any of these cases, the health care provider may discuss only the information that the person involved needs to know about the care or payment for the care. Healthcare providers must have a signed consent.

1. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law intended to protect employed Americans' privacy, confidentiality, and access to health care through health insurance coverage. Knowledge of major HIPAA provisions enables the PMHNP to advise patients regarding health care coverage. Which of the following statements regarding HIPAA is true? - HIPAA replaces the State as the primary regulator of health insurance. - HIPAA increases ability for workers changing jobs to get health coverage. - HIPAA eliminates all use of pre-existing condition exclusions. - HIPAA guarantees health coverage for all workers.

- HIPAA increases ability for workers changing jobs to get health coverage. Rationale: HIPAA provides federal legislation to protect employed Americans yet does not supersede the role of States as primary regulators of health insurance and does not make universal guarantees of health coverage. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law intended to protect employed Americans by decreasing the chance of losing health insurance coverage, facilitating change from one health plan to another, and facilitating purchase of individual or family health insurance coverage if coverage lost from an employer's plan or no other health insurance coverage is available.

1. When working with adolescents who have poor affect regulation and limited response flexibility, therapists strive to provide a therapeutic frame open enough for changes and consistent enough for stability and safety. Which of the following responses characterizes such a therapeutic frame? - Charismatic, engaging, expressive - Detached, neutral, objective - Mindful, reflective, intentional - Empathic, consistent, strict

- Mindful, reflective, intentional Rationale: The therapist who is able to be mindful, reflective, intentional, and genuine in their responses to all clients, not just adolescents, offers a model for thoughtfully appraising the thoughts, feelings, and emotions of others rather than relying on a strict set of rules or being caught up in emotional or reactive responses. Maintaining this therapeutic frame can be challenging when working with adolescents who act-out, have poor affect regulation, and limited response flexibility, yet this therapeutic frame is at the core of individual, group, and family therapy interventions.

1. You notice that you have begun to care less about your patient's needs. You are tired, unhappy, and unsatisfied in your job. You talk to your office confidant, another PMHNP about feeling possible "compassion fatigue." He indicates that while he can understand your concerns based on your self-assessment, but he does not believe you have compassion fatigue because he has not observed you: - Heavily criticizing others during meetings, sitting in your office alone all the time, dressed in the same outfit all the time, and in denial about your problems. - Constantly tired, wanting to do more of the paper work and less of the patient work, wanting to stay longer and chat in the break room rather than be in your office alone. - Hyperactive but having little productive work to show for it, poor concentration, not listening to others despite being present, and constantly forgetting things needed for daily work. - Staring off into the distance, suddenly crying for no reason, rapid changes in mood, impulsive spending, valuing and devaluing people.

- Heavily criticizing others during meetings, sitting in your office alone all the time, dressed in the same outfit all the time, and in denial about your problems. Rationale: It is a professional responsibility, as an NP, to monitor ourselves for compassion fatigue. Compassion fatigue is a state experienced by those helping people or animals in distress. It is an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it can create a secondary traumatic stress for the helper. Some of the symptoms include denial about problems, excessive blaming, holding in emotions, isolating form others, an unusual amount of complaints, complaining about administrative functions, substance abuse used to mask feelings, compulsive spending, over eating, gambling, or sexual addiction, and poor self-care and self-hygiene.

1. As a PMHNP using Family Systems theory, you know that families seek equilibrium in the face of change. This is an example of which concept? - Homeogenesis - Morphogenesis - Morphostasis - Homeostasis

- Homeostasis Rationale: The essence of family homeostasis is that families seek equilibrium. When screening potential female clients for an incest survivor's group, which client

1. During a session, your patient asks to be able to contact you via your Facebook page on the internet. You reply: - I cannot do that because I have a concealed Facebook identity; and I cannot reveal that to my patients - I would be happy to communicate with you. It makes it easier for me to reach you this way. - I would be happy to use Facebook but you will have to use a private message so that you can be anonymous - I cannot do that because Facebook does not protect your Private Health Information

- I cannot do that because Facebook does not protect your Private Health Information Rationale: Using Facebook breaks patient-provider confidentiality, in addition to blurring ethical boundaries of the therapeutic relationship. Facebook does not protect private health information. Information on the site is available for anyone to see or hack into even if private messaged.

1. Your patient wants to communicate with you through email. You have a secure email account that is encrypted and will protect health information as required by the Health Insurance Portability and Accountability Act (HIPAA). Your patient does not have an encrypted email account. Your reply is: - I do not like to communicate through email. I would prefer to talk to you in person or over the telephone only. - In order to communicate back and forth, you will have to find a way to encrypt your protected health information (PHI). - I have no problems with you communicating with me through my personal email. - I can encrypt our email communications to be sure that your protected health information (PI) is unavailable to others and protect you.

- In order to communicate back and forth, you will have to find a way to encrypt your protected health information (PHI). Rationale: Unencrypted email is "like sending a postcard through the mail," everyone can read it. Without encryption on both sides of the communication, there is no way to provide protection for PHI.

1. Which of the following would not be included in a progress note? - Risk/benefit analysis for change of medication - Patient's self-rating on target symptoms - Incident report on medication error - Standardized outcome measures

- Incident report on medication error Rationale: Incident reports are part of an organizational reporting mechanism for risk management, but are not included in the medical record. The progress note is part of the medical record that included documentation of patient encounters with the following format: 1) reason for the encounter and relevant history; 2) physical exam findings, prior diagnostic test results; 3) assessment, clinical impression, or diagnosis; 4) plan for care; and 5) legible identity of the provider. Additionally, if not documented the rationale for ordering diagnostic and other ancillary services should be easily inferred; past and present diagnoses should be accessible to the treating and/or consulting provider; appropriate health risk factors identified; patient's progress, response to and changes in treatment, and revision of diagnosis should be documented. The progress note should reflect the type of services and diagnostic codes reflected on the billing statement: CPT codes for service provided, and ICD-9_CM and/or DSM-IV diagnostic codes.

1. Sam, a 6-year-old female, presents with her mother for a new psychiatric evaluation. Her mother reports that Sam is not making friends at school, stats be herself, will not read aloud in class, and requests adult reassurance before making a decision. Which stage of Erik Erikson's Stages of Development is Sam having difficult mastering? - Identity versus role confusion - Industry versus inferiority - Intimacy versus role isolation - Trust versus mistrust

- Industry versus inferiority Rationale: A child between 5 and 13 years old is working toward learning new skills and taking pride in those new skills. Pleasure and boundaries, which is Erikson's Industry versus Inferiority stage.

1. You have students from local psychiatric nurse practitioner programs follow you in your clinical practice to show them what you do as a PMHNP. This is called being a: - Preceptor - Mentor - Teacher - Professor

- Preceptor Rationale: The preceptor is a 1;1 relationship sustained over a short time where each person brings something to the relationship. It is a contracted, defined role with goals. The preceptor is in a teaching role. Teaching is completed through the observed performance, examples, and role modeling.

1. A patient is followed by the PMHNP psychotherapist and states, "I went to see my primary care provider, and she told me my liver is working harder than it should and she thinks it might be duet o my drinking. I don't think I have a drinking problem, but I don't want to have any health problems either. Can you give me the names of where Alcoholics Anonymous Groups are located? I told my PCP I would try and cut back a bit." What state of readiness to change is this patient in? - Preparation - Action - Contemplation - Precontemplation

- Preparation Rationale: This patient has identified a problem and is getting ready to change, which is the preparation stage of change.

1. Which of the following brief intervention statements incorporates the key elements of motivational interviewing to reduce risk related to binge drinking at a college campus? - Mary, you know the risk of STDS from unprotected sex and you know what happens when you drink at frat parties. I can provide free condoms, but the real situation is getting you to cut back on your drinking. Let's discuss some ways to cut back that will work for you. - John, you were fortunate to avoid a car crash after leaving the frat party intoxicated. No one can force you to change your drinking patterns, but I think you can drink in a responsible way and need to limit yourself not to exceed three drinks at a party. Let's discuss some ways to cut back that will work for you. - Bill, you could have died from alcohol poisoning with a blood alcohol level that high (2.4 mEq/L). Lucky that your roommate called the paramedics and got you to the Emergency Department. How can I get you to stop the binge drinking? I know you don't want your parents to know about your drinking problem. Let's discuss some ways to cut back that will work for you. - Natalie, your drinking and driving scares me. You're lucky that you or your friends in the car weren't injured. I know you've tried to cut back on drinking at the frat parties, but something's not working. You need to stop after two drinks. Let's discuss some different ways to help you do that.

- John, you were fortunate to avoid a car crash after leaving the frat party intoxicated. No one can force you to change your drinking patterns, but I think you can drink in a responsible way and need to limit yourself not to exceed three drinks at a party. Let's discuss some ways to cut back that will work for you. Rationale: Motivational approaches to help patients recognize a health-related problem and develop change strategies are priority interventions for patients with substance use disorders. Brief intervention includes feedback, responsibility, advice, menu of treatment options, empathetic counseling, and optimism about self-efficacy. Miller and Sanchez (1994) coined the acronym FRAMES to summarize the effective elements of brief intervention. Feedback Responsibility Advice Menu of options Empathy Self-efficacy

1. The literature on group outcomes has revealed that negative group outcomes have been associated with which of the following qualities in group leaders? - Leaders who initiate discussions of feelings - Leaders who reveal too much of their personal experiences - Leaders who are overly confrontational - Leaders with a timid interpersonal style

- Leaders who are overly confrontational Rationale: Corey & Corey (2002) acknowledge that forging an effective group requires an appropriate balance between support and challenge. Groups that have either explicit or implicit norms limiting group interactions to supportive ones do not have the power to help people challenge themselves to take significant risks. In contrast, groups that stress confrontation as a requisite for "peeling away the defensive maneuvers of members" are characterized by hostile and increasingly defensive interactions. The reviews of research that describe negative outcomes in group work consistently cite that aggressive confrontation as the leadership style with highest risks. While self-disclosure by a group leader needs to be thoughtful in purpose and timing, in and of itself, it is not associated with negative group outcomes.

1. The PMHNP joined the local National Alliance on Mental Illness Board. Serving as a board member to advocate for access to care and parity of services is an example of which standard of professional performance? - Practice - Collegiality - Leadership - Consultation

- Leadership Rationale: The PMHNP has measurement criteria under standard 15 from the Psychiatric-Mental Health Nursing: Scope and Standards of Practice - 2nd Edition. Leadership to "utilize ethical principles to advocate for access and parity of mental health services." - American Nurses Association, American Psychiatric Nurses Association and International Society of Psychiatric Mental Health Nurses, (2014) page 169.

1. PMHNPs seeking admitting privileges at a community hospital with inpatient psychiatric services need to influence policymakers at which of the following levels? - State board of nursing - State legislature - County board of health - Local hospital

- Local hospital Rationale: Local PMHNPs who want admitting privileges will want to persuade the appropriate hospital decision maker, through facts, figures, and a presentation of projected benefits to the hospital, of the need to change policy and allow PMHNPs to admit patients.

1. You are a PMHNP working in a hospital health system. The hospital administration has implemented a productivity system where all the Psychiatrists and NPs in the department of psychiatry will now have to see four patients per hour. You have informed the administration that this is not a good system because many patients are in fragile mental and physical health, require case management, and need extensive care during their medication management sessions to achieve good management of their symptoms and recovery. The hospital administration has reinforced that the productivity system will stay in place and is mandatory. You inform the administration that you cannot work under these conditions. Administration informs you that you are abandoning your patients. You: - Make the decision to stay, as you cannot abandon your patients. - Make the decision to leave your position. Tell your patients the hospital is treating them poorly. - Make the decision to leave your position, as you cannot support a system that disregards the needs of the patient. - Make the decision to stay, telling your patients the hospital is treating them poorly.

- Make the decision to leave your position, as you cannot support a system that disregards the needs of the patient. Rationale: As an NP, you cannot support a health care system that devalues the needs of the patient, provides a poor healthcare environment, or is morally doing the wrong thing. If you remain in the workplace, you are tacitly supporting the ethically improper decision of the administration

1. A number of theories with biologic, psychological, and social underpinnings have been postulated to explain violence between intimate partners and in the family. Which statement best illustrates the psychosocial theory of intergenerational transmission of violence in explaining why men become batterers? - Men with personality disorders including antisocial, borderline, narcissistic, and dependent are prone to violence toward intimate partners. - Men with alcohol and substance use disorders have disinhibition of social restraints and higher prevalence of violent behavior. - Men with traumatic brain injury are prone to seizure disorders, attentional dysfunction, and aggressive behavior. - Men who witness violence in their family of origin often perpetuate violent behavior in their families as adults.

- Men who witness violence in their family of origin often perpetuate violent behavior in their families as adults. Rationale: Findings of extreme violence in the parental homes of batterers and battered individuals who grew up witnessing violence are common, and support the intergenerational transmission of violence theory.

1. The PMHNP implements a psychoeducation group for parents on the importance of developing secure attachments between the child and parent, and includes information about normal growth and development at specific ages. This is an example of what level of prevention? - Tertiary - Secondary - Indicated - Primary

- Primary Rationale: Providing parents with information about protective factors and information about normal growth, development, and attachment is an example of a primary prevention strategy.

1. The initial advanced practice role for PMHNP nurses was the Clinical Nurse Specialist (CNS) that worked as a therapist and educator. Later, the PMHNP role was developed to serve the need of a primary care psychiatric provider that could perform evaluations and medication management services in hospitals and other venues. As of 2015, the Consensus Model for Advanced practice Registered Nurse (APRN) practice regulation (i.e., licensure, accreditation, certification, and education-LACE) for the Psychiatric APRN role is approved for a: - NP that treats the psychiatric mental health population in the primary care setting only. - NP that treats the Psychiatric mental health population from birth through geriatrics. - NP that treats the adult psychiatric mental health population only, under the supervision of a physician. - NP that treats the psychiatric mental health population in the hospital setting only.

- NP that treats the Psychiatric mental health population from birth through geriatrics. Rationale: Certified nurse practitioners (CNP) are prepared to practice as primary care CNPs and acute care CNPs. CNPs provide care along the wellness-illness continuum, across many settings and the entire lifespan. CNPs are members of the health delivery system, practicing autonomously in areas as diverse as family practice, pediatrics, internal medicine, geriatrics, and women's health care. CNPs are prepared to diagnose and treat patients with undifferentiated symptoms, providing initial, ongoing, and comprehensive care for health promotion, disease prevention, health education, and counseling.

1. As a PMHNP, you evaluate your patients for health concerns and beyond, in a holistic manner. Your current patient has a blood sugar of 186 and a hemoglobin A1C of 6.7. You refer this patient to an internal medicine practitioner with whom you frequently share patients. You have just violated: - The Stark law. - The DATA Act. - No statute. - The Adams Act.

- No statute. Rationale: You are permitted to refer your patient to an appropriate provider of care as long as you have no financial gain for the referral and are doing this in the best interest of the patient.

1. You are an NP who performs psychotherapy. Your patient is distraught, an you call in the NP who is performing the medication management to sit in and discuss and determine if an emergency situation evaluation is needed. After the discussion of medication changes that will take place, the medication manger NP asks the crying patient if she needs a hug. The patient stands and extends her arms outward. The medication NP gives her a chaste hug and leaves the room. Is this a case of inappropriate touch or battery? - Yes. This is a case of battery. The patient did not verbally say that it was okay to touch. - Yes. This is inappropriate, as you never touch a patient under any circumstances. - No. This is a case where there was a question asked, nonverbal assent was given, and the NP gave the patient a hug to help the patient cope. - No, but nonverbal communication methods are not sufficient for ensuring agreement to hug a patient.

- No. This is a case where there was a question asked, nonverbal assent was given, and the NP gave the patient a hug to help the patient cope. Rationale: Giving a patient a hug is okay, but it must be preceded by a check to be sure that the patient agrees. The patient had the right to refuse and keep his or her won barriers to their body. Many times a chaste hug is appropriate in the therapeutic relationship. As long as the patient and NP know each other well and there is no psychiatric reason for it to be inappropriate.

1. A frail 76-year-old woman with Alzheimer's type dementia in a skilled nursing facility has been increasingly agitated, combative, and has struck out at other patients in the dining room and at staff attempting to care for her. What would be the most appropriate initial intervention by the consulting PMHNP who receives a call from the nursing staff requesting medication and restraint orders? - Order short-acting benzodiazepine and close observation until you can evaluate in person - Order soft wrist and vest restraints until you can evaluate in person - Oreder low-dose atypical antipsychotic and soft vest restraint until you can evaluate in person - Order close observation by staff in quiet area secluded from other patients until you can evaluate in person

- Order close observation by staff in quiet area secluded from other patients until you can evaluate in person Rationale: Due to patient's frailty, limited risk to inflict real physical harm, increased fall risk if sedating medication used, and potential increased agitation if physically restrained, the least restrictive approach is to provide close observation in a quiet, secluded area until further evaluation by PMHNP in person can be completed. In a skilled nursing facility, caution must be exercised not to overly rely on physical and chemical restraints. Sudden onset of behavioral, mood, and sensorium changes are more likely attributed to delirium whose etiology is more likely due to reversible underlying medical problem such as urinary or respiratory infections. Grace (2009) notes that "although much has been written about the problems associated with restraint use for elderly people and strides have been made in raising awareness and even in changing standards of care in this regard, the practice of using chemical and physical restraints to manage perceived problematic behavior of elderly people has not been eradicated. The underlying assumption in using restraints is that the person's safety is at issue and that restraining the person will protect him or her...Sometimes a person is also restrained if that person's actions are imminently likely to cause harm to another...Chemical restraints involve the use of drugs to calm behavior and/or to sedate the patient. Although restraints are ostensibly used to protect patients, often they are used for the expedience or relief of caregivers, nurses, aids, or family members. Thus, their use is often harmful and unethical." (p. 395).

1. Cognitive behavioral therapy (CBT) is often one of the first-line treatments for anorexia nervosa. One of the primary goals of CBT is to assist the patient in which of the following ways? - Overcome distorted thinking - Resolve symptoms of depression - Restore weight above 85% of normal - Improve interpersonal relationships

- Overcome distorted thinking Rationale: CBT teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs.

1. A PMHNP practices in a state requiring a collaborating psychiatrist. The PMHNP reviews all new and complex cases with the psychiatrist on a monthly basis. A young adult patient with recurrent depression ahs been under the care of the PMHNP for 3 months when she commits suicide. The family sues for wrongful death. Who is legally responsible for this patient's care in a court of law? - Primary responsibility of PMHNP and secondary responsibility of psychiatrist - Psychiatrist - Equal responsibility of PMHNP and psychiatrist - PMHNP

- PMHNP Rationale: Regardless of collaborating psychiatrist, it is the PMHNP who is responsible for the patients under his or her care in a court of law. The PHMNP is considered an autonomous Advanced Practice Nurse role.

1. The guidelines that a group, community, or organization develop regarding its goals, direction, and priorities, and the way it implements its resources to attempt to reach those goals is the definition of: - Policy - Law - Politics - Precedent

- Policy Rationale: Policy specifically reflects what a group, community, or organization holds dear and is willing to utilize to make its goals achievable. An example is a Health and Human Services (HHS) policy that delineates what HHS is willing to expend to achieve the goal of one of its mandated projects. Law is a legislative bill that tells you what has to be done, policy tells you how it will be done. Precedent is how things were done by a specific group in the past.

1. When a clinical trial fails to reject the null hypothesis (i.e., when p-value > 0.05), the investigator may have missed a true intervention effect. One should consider the following to avoid a Type II error: - Alpha level - Power - Effect size - Sample bias

- Power Rationale: Type II error occurs when investigators falsely reject the null hypothesis and conclude that no relationship exists between variables when, in fact, a relationship does exist. This occurs when there is insufficient power to detect the difference between variables, and is linked to the adequacy of the sample size. If a sample size is too small, the study will have insufficient power to detect differences between groups, if differences exist.

1. As an individual advanced practitioner, you cannot afford to have a standalone Electronic Health Record (EHR) system to keep all of your patients' health information on a computer-based system. How could you problem-solve this dilemma? - Process your patient records manually, in your current fashion. You are keeping a full record according to HIPAA. - Process your notes manually and keep them in a locked file. The records are available for copy and distribution at any time. - Process your notes and patient records on a laptop that you are able to transport between your office and home office. You always have the records available if needed. - Process your notes and patient records in a secure electronic system with a template for patient information and interactions, supporting quick access within your network.

- Process your notes and patient records in a secure electronic system with a template for patient information and interactions, supporting quick access within your network. Rationale: Having an EHR system is the ideal situation according to the US Health and Human Services and The Office of Clinical Quality and Safety. Not all offices have the ability to afford installation and maintenance of such systems. The US government has established financial help for EHRs in rural hospitals. For single practitioner offices, doing the best possible to keep information ready for quick access is the best possible solution. Without an EHR, incentives for having an EHR will not be available to you.

1. An NP decides to back to school to gain further knowledge about the neurological basis of psychiatric illnesses. She is not doing this to maintain her licensure but to enhance her knowledge. This is an example of: - Nursing informatics - Nursing research - Professional development - Continuing education credits

- Professional development Rationale: Professional development is a lifelong phase of learning that the nurse uses to develop, maintain, enhance professional nursing practice, and support individual nursing goals.

1. Which study design is appropriate in determining the difference in effectiveness of one medication compared to another medication in the treatment of bipolar disorder? - Cross-sectional design - Case-controlled trial - Randomized controlled trial - Cohort design

- Randomized controlled trial Rationale: When the research question is treatment-based, you would likely choose a randomized controlled trial where patients are randomly allocated to control or treatment groups.

1. The risk of being overly empathetic as a therapist is commonly characterized by which of the following responses by the client? - Re-enacted attachment with merger and fusion - Re-enacted attachment with dependency and acting-out - Re-enacted attachment with alienation and isolation - Re-enacted attachment with understanding and change

- Re-enacted attachment with dependency and acting-out Rationale: Dependency often forms as a result of parent's genuine affection, extreme attachment, and overprotection. Being overly empathetic as a therapist can foster transference and dependency. This can be followed by acting-out to push away from the dependent attachment on the therapist.

1. A PCP consults the PMHNP for guidance on medication management for a family member she is prescribing medication for bipolar I disorder, because the family member does not have health insurance and cannot afford to see a mental health provider. What would be the most appropriate response by the PMHNP? - Determine acuity and phase of bipolar I disorder to advise on appropriate generic medications - Recommend free clinic and report nurse practitioner to state board of nursing practice violation - Offer to see the patient pro bono and manage medications - Recommend that she not manage a family member's medication and recommend free clinic

- Recommend that she not manage a family member's medication and recommend free clinic Rationale: While there may be no law specifically prohibiting a practitioner with prescriptive authority from prescribing legend drugs, such as antibiotics, to family members or oneself, unless a PMHNP or family member is enrolled as a patient at the PMHNP's practice setting, the PMHNP is unlikely to be covered under a collaborative agreement with a physician for a diagnosis, medical management, and prescribing. Collaborative agreements are specific to a practice setting. In states where no collaborative agreement is required, a PMHNP who prescribes for a family member is on somewhat firmer ground. The situation is more serious when the drug is controlled. Pharmacy laws make it illegal in many states to prescribe controlled substances for family members and oneself.

1. In working with elderly residents at a nursing home, the goals of reminiscence groups include all of the following except: - Improve cognitive function - Maintain self-esteem - Reduce wandering - Facilitate life review

- Reduce wandering Rationale: Wandering behavior is not likely to be affected by reminiscence groups. Reminiscence is the thinking about or relating of past experiences. Reminiscing encourages elderly residents, either individually or in group settings, to discuss their past and review their lives. Reminiscence helps maintain self-esteem, stimulate thinking, and support the natural healing process of life review. Activities that facilitate reminiscence include writing an account of past events, explaining pictures in old family albums, sharing stories about a particular theme or life event, such as their first car.

1. You notice that you have begun to care less about your patient's needs. You are tired, unhappy, and unsatisfied in your job. You talk to your office confidant, another PMHNP about your feelings and concerns about how this might impact your practice. Together, you discuss your need to: - Leave your present employment in nursing and find a different career path in something that fulfills you better. - Leave your present employment and find a different career in nursing that fulfills you better. - Reduce your present workload to get more rest and practice better living, eating, exercise, and living skills. - Avoid those things about your present employment that upset you and get involved in a yoga class.

- Reduce your present workload to get more rest and practice better living, eating, exercise, and living skills. Rationale: Psychiatric Nursing teaches holistic wellness through a balance lifestyle and correct use of medications and therapy. The NP needs to heed her own advice/practice. In order to be good role models to our patients, we have to lead the balanced holistic lives we preach. We have to be healthy enough in our own bio/psycho/socio/spiritual realms to help our patients heal. Leaving your present job for another without looking at what is problematic will only take the problems you now have with you. Avoiding problems does not resolve them. The Yoga class might help begin a path of healing but not without a healthy lifestyle.

1. As an NP, you teach your patients that mental illness is no different from any other physical illness that a person suffers. In classes for the community, you emphasize that everybody ahs a brain and it is another organ in the body. You remind your audience that illness in the brain is no different from illness in the heart, lungs, or liver. This is an example of: - Integrated health - Cross education - Holistic dynamism - Reducing stigma

- Reducing stigma Rationale: Stigma is one of the worst offenders separating persons suffering with mental illness from the mainstream. There is a spoken and unspoken prejudice against anyone who suffers with a mental illness. Persons suffering with schizophrenia are not treated the same way that other persons are treated in medical practitioner's offices, stores, postal offices, or other public and some private venues. It is the duty of every PMHNP to change this and reduce and/or eliminate this stigma.

1. You are treating a new patient. He indicates that he is a Muslim and follows all of the principles of that religion. He is suffering from depression. What special considerations should you take to help him in his treatment? - Refer him to a male practitioner for medications and explain the patients' need to use medications that contain no gelatin products. - Refer him to a male therapist and continue to research medications that do not contain vanilla products. - Refer him to a male practitioner for medications and continue to research medications that do not contain any fish or animal fats. - Refer him to a male therapist and continue to research medications that do not contain blood or horse byproducts.

- Refer him to a male practitioner for medications and explain the patients' need to use medications that contain no gelatin products. Rationale: Many Muslims prefer to be treated by a member of the same sex and are very modest. Males in the culture prefer to be present when their wife is examined or treated, and prefer to have her treated by a female. In the Muslim culture, it is religious law to avoid shellfish, all cloven-hoofed animals except camels, all fanged predatory animals, (i.e., bats), and all blood products. Gelatin is a derivative of hooves. In addition, the Qur'an bans alcohol, relating to the recommended restriction of vanilla. The food industry uses alcohol-based vanilla flavoring most frequently.

1. What is the main differentiating factor between repression and suppression? - Repression is involuntary and suppression is voluntary. - Repression is voluntary and suppression is involuntary. - Repression is unconscious and suppression is involuntary. - Repression is conscious and suppression is unconscious.

- Repression is involuntary and suppression is voluntary. Rationale: Repression is the involuntary or unconscious exclusion of painful/disturbing thoughts or feelings from awareness. Suppression is the intentional or conscious exclusion of painful or disturbing thoughts or emotion from awareness.

1. A 68-year-old, retired African-American widower who served for 30 years as an Army officer was recently diagnosed with terminal lung cancer. He made plans to die at home with hospice care. He was hospitalized for a broken hip and succumbed to complications in the hospital. Despite his request to be addressed as "Mr. Baxter" the hospital staff persisted in calling him by his first name, "John." Which principle of culturally competent care does this violate? - Autonomy - Advocacy - Collaboration - Respect

- Respect Rationale: Respect of cultural values and beliefs is violated in this scenario.

1. The core values that underlie advanced practice nursing and culturally competent care include: - Care, respect, collaboration - Autonomy, respect, collaboration - Respect, advocacy, partnership - Care, advocacy, respect

- Respect, advocacy, partnership Rationale: The culturally competent PMHNP is knowledgeable and respectful of diverse cultural beliefs and practices, partners with the patient to develop a care regimen that produces the desired health outcomes within the context of the patient's cultural values, and advocates for the development of culturally appropriate patient care services.

1. In counseling a 23-year-old, 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 PMHNP: - Educates about importance of maintaining fluid and electrolyte imbalance - Explains that the symptoms are most likely caused by viral infection - Identifies what steps the mother has already tried in caring for the child's symptoms - Respects the mother's understanding of the child's illness

- Respects the mother's understanding of the child's illness Rationale: The culturally competent PMHNP respects culture-bound beliefs before proceeding with further steps in the assessment and appropriate interventions. The culturally competent PMHNP would then proceed to negotiate with the mother to reach beneficial health outcome for the child.

1. The NP is working with a patient secondary to an injury that he sustained while working on the job. The NP is managing both the medications and psychotherapy portions of this patient's care. The patient is involved in workman's compensation regarding his injury. The patient's employer sends the NP a release of information form requesting the patient's complete medical record. The NP: - Sends the complete record including psychotherapy notes. - Declines to send the records due to the workman's compensation case. - Talks to the patient before sending records to the employer. - Sends the complete record but withholds the psychotherapy notes.

- Sends the complete record but withholds the psychotherapy notes. Rationale: In some cases, the privacy of a patient's psychotherapy notes is protected from release of information and can be withheld. Psychotherapy notes are notes that a mental health professional takes during a conversation with a patient. They are kept separate from the patient's medical and billing records. Health Insurance Portability and Accountability Act (HIPAA) also does not allow the provider to make most disclosures about psychotherapy notes about you without your authorization.

1. The NP is seeing a patient for both psychiatric and chemical dependency illnesses. The patient wants the NP to send medical records to his General Practitioner. The NP tells the patient that because of Federal Law 42 CFR, he must: - Sign once combined release that does not mention his chemical dependency illness due to its special protected nature - Sign two separate releases due to the special protected nature of psychiatric information. - Sign two separate releases of information due to the special protected nature of chemical dependency information. - Sign one combined release that designated that he is being treated for both chemical dependency and psychiatric illnesses.

- Sign two separate releases of information due to the special protected nature of chemical dependency information. Rationale: Federal Law 42 CFR requires a separate release of information for the release of any information on chemical dependency.

1. Tommy, a 10-year-old boy, is brought to the clinic for a follow-up appointment. During the visit, his mother askes the psychiatric mental health nurse practitioner if it is normal for Tommy to be fixated on rules and is now distressed when things are out of place in his room. Understanding Jean Piaget's stages of development, the PMHNP is aware that Tommy is having difficulty mastering what cognitive developmental stage? - Stage of concrete operations - Stage of formal operations - Stage of preoperational thought - Sensorimotor

- Stage of concrete operations Rationale: Children who have a hard time with syllogistic reasoning, in the stage of concrete operations in ages 7 to 11 years, can be overinvested in rules and develop obsessive compulsive behaviors.

1. Your patient is a 32-year-old who is diagnosed with major depression-recurrent, insomnia, and chronic lower back pain. The patient has seen you for three medication management sessions over the last two months. During the fourth medication management session, the patient states that money is tight and an appointment is required with the general practice (GP) physician every time a refill of the Hydrocodone (pain medication) is needed. The patient asks you to refill the Hydrocodone to save the cost of another medical visit. You: - State that you can refill this prescription just once. - State that you would be willing to call his GP to discuss the issue and help him out. - State that your certification is for psychiatric care only and refer him back to his GP. - State that you are willing to discuss alternative medications to manage his pain.

- State that your certification is for psychiatric care only and refer him back to his GP. Rationale: The NP practices within the scope of his/her licensure, education, and certification.

1. When working with a family in therapy, you plan to address differentiation of self, triangles, and genograms. What family therapy approach will you be utilizing? - Systemic family therapy - Structural family therapy - Emotionally focused family therapy - Strategic family therapy

- Systemic family therapy Rationale: Systemic family therapy developed by Murray Bowen utilizes differentiation of self, triangles, and genograms.

1. When working with an avoidant patient with a history of trauma, what type of communication techniques are helpful? - Techniques to increase arousal - Techniques to decrease arousal - Clarification and close-ended questions - Reflection and open-ended questions

- Techniques to increase arousal Rationale: Activation is needed to allow memories stored in the amygdala to be processed. Techniques to decrease arousal

1. The NP sees and opportunity to help her patient who suffers from anxiety and hypertension by utilizing a medication that can treat both issues. She talks to her patient about using Atenolol 25 mg ½ tab PO QHS to manage his hypertension and his chronic anxiety. To promote both the patient's continued health and collaboration, the NP: - Telephones the PCP's office and leaves a message about the change in medication - Tells the patient to let his PCP know about the change in medication - Faxes a copy of her care notes to the PCP to inform the PCP of her plan of care - Telephones the patient's PCP to discuss the use of the Atenolol before starting the medication

- Telephones the patient's PCP to discuss the use of the Atenolol before starting the medication Rationale: Too often, there is little communication between providers, and the patient suffers from this lack of communication. The collegial, and best practice, is for providers to communicate with each other about care for their shared patient and make decisions together whenever possible. Using one medication rather than multiple medications is in the patient's best interest and saves the patient from polypharmacy.

1. Your mother calls you at the office and asks you to call in a prescription for her. The medication is for her sleeping pills, Eszopiclone (Lunesta) 3 mg 1 PO QHS #30. You: - Tell her to call the provider who normally prescribes that medication for her. - Call your mother's provider and ask the provider to call your mother's script in for her. - Tell her that you will only do it "just this once" for her and then call the script into her pharmacy. - Call the script into her pharmacy with three additional refills, just like any other patient.

- Tell her to call the provider who normally prescribes that medication for her. Rationale: It is not illegal to call a family member's prescription in but it is not recommended to prescribe for someone with whom you have a close relationship. You do not have the proper distance and perspective to make the medical decisions that a disinterested third party can make. Prescribing scheduled medication for yourself or your family members can get you and your license in trouble. Do not call your mother's prescriber unless your mother is too ill to do it herself.

1. You are considering using text message technology with your patients as a way to communicate quickly in our fast-paced world. What considerations are necessary when texting? - Text messaging using a secure text messaging platform within specific Joint Commission guidelines could be used for orders only. - The use of text message technology is not recommended by regulatory agencies. - Text messaging is safe because of advanced security platforms for protecting protected health information (PHI) in smart devices. - Text messaging is becoming the accepted standard of communication since the availability of means for retrieving protected health information (PHI) from any device.

- Text messaging using a secure text messaging platform within specific Joint Commission guidelines could be used for orders only. Rationale: Unsecured texting and emailing from mobile devices is risky because these mobile devices are at risk for being lost, stolen, or damaged. Theft and loss of a mobile device containing PHI presents obvious security reasons. In a departure from prior policy, the Joint Commission now permits licensed independent practitioners, in accordance with the law and other relevant regulations and policies, to send orders via text messaging "as long as a secure text messaging platform is used and the required components of an order are included." Criteria for a secure platform include a secure sign-on process, encrypted messaging, delivery, and read receipts, date and time stamp, customized message retention time frames, and a specified contact list of those authorized to receive and record orders.

1. To demonstrate her support for social justice, within her role as a PMHNP caring for the person who is homeless with mental illness, the PMHNP: - Volunteers to serve food at the local Home for Girls. - Teaches Sunday School. - Volunteers to walk at the March of Dimes walk each year. - Volunteers her clinical services at the psychiatric clinic, run by a local mission project.

- Volunteers her clinical services at the psychiatric clinic, run by a local mission project. Rationale: Social justice is bringing things to those who have the least means of getting them but need them the most. In this case, the homeless mentally ill need the PMHNP's skills more.

1. The NP is seeing a 72-year-old male for depression management. Upon assessment, the patient is alert, oriented, and non-suicidal or homicidal. The patient is able to manage his activities of daily living. The NP witnesses the man's wife verbally abusing him on several occasions. The NP has verbal reports from staff nurses and their nursing notes that the man has come into the unit with bruising and contusions inconsistent with his affluent lifestyle and physical health condition. When the NP speaks to the man about the physical and verbal abuse, he tells her that it is occurring. He also tells her that he does not want to do anything about the situation. He tells her specifically that he does not want her to contact any authorities about the situation. - She is required to contact Adult Protective Services or similar services in the local community to investigate the senior citizen's safety. - The NP must do as the patient requests as long as he is competent. - Take pictures of the bruises and contusions and save them to the patient's record. - Arrange to remove the patient to a safer environment.

- The NP must do as the patient requests as long as he is competent. Rationale: The patient is an adult, competent to arrange his own life. He has the right to make decisions for himself. Not all states have mandatory elder abuse statutes or mandatory domestic abuse statutes.

1. Per the Health Insurance Portability and Accountability Act (HIPAA), an NP who is an independent, single practitioner practice is considered a "Covered Entity" because: - Writes information and generated protected health information - May accidentally release protected health information - Maintains charts with patient information that contains protected health information - The NP transmits protected health information in electronic forms

- The NP transmits protected health information in electronic forms Rationale: Having the ability to transmit protected health information qualifies the independent NP as a covered entity and requires the complete package of HIPAA required protection in place to protect patient information.

1. As a PMHNP you frequently are asked to "case manage" your patients for more than psychiatric issues. Your 68-year-old patient, with Medicare as the primary insurance, states that varicose veins are an issue and that treatment is needed. You know that your sister is the best vein surgeon in your city and refer the patient to her. You have just violated: - The Stark Law - The DATA Act - The Harter Act - The Adams Act

- The Stark Law Rationale: Per the Stark Law, you are not permitted to refer family members for treatment of your patients as this could be seen as fraudulent by the Federal government/Medicare. Stark law Guidelines-Chapter IV-Centers for Medicare & Medicaid Services, Department of Health and Human Services-Part 411-limits Medicare payment to siblings.

1. A newly graduated NP wants to open a private psychiatric practice in her hometown. She wants to find out about the laws that cover her responsibility and the legal liability that this practice will encounter for her as an independent PMHNP. Her best source of information is: - Local Psychiatric Nurse Practitioners in practice. - Her City Statutes. - The American Academy of Nurse Practitioners. - The State Statues on Nursing or Advanced Nursing Practice.

- The State Statues on Nursing or Advanced Nursing Practice. Rationale: In general, the states govern all nursing and Advanced Nursing Practice legislation. This is the law that governs what a Nurse and Advanced Practice Nurse may do in that state. Further, the State's Health and Human Services Department will have documentation on the laws, defining what the laws mean and how the laws are interpreted.

1. When interpreting confidence intervals around relative risk reduction, a wider confidence interval reflects that: - There is no statistically significant difference in effect. - The estimate of effect is more precise. - There is a statistically significant difference in effect - The estimate of effect is less precise

- The estimate of effect is less precise Rationale: Confidence intervals reflect a range of values within which one can be confident that the true value is situated. Wider confidence intervals are usually based on smaller sample sizes and fewer number of outcome events and indicate less precision in estimate of effect.

1. Your new 30-year-old patient with Generalized Anxiety Disorder has been on Alprazolam (Xanax) 0.5 mg 1 tab PO BID PRN anxiety for the past 7 years after trials of multiple SSRIs. She uses this medication about two times per week for "extreme" anxiety. Your personal bias as a careful psychiatric nurse practitioner is that benzodiazepines should only be used with other non-addictive antianxiety medications and internally generated coping skills to manage anxiety. In discussing the case with the patient, you recognize that she has been carefully using the Alprazolam, has tried other methods to reduce anxiety, and is working with a therapist. What will your plan of care be? - The patient may do better with increased therapy. Consult the therapist and wean her off the Alprazolam. - The patient is coping well with a limited amount of Alprazolam. Reinforce safe use of benzodiazepines. Continue the medication and encourage use of more internal coping mechanisms. - The patient is using Alprazolam too often. Reinforce safe use of benzodiazepines. Help her to wean off the medication and use more internal coping mechanisms. - The patient is coping well with the limited amount of Alprazolam, but may do better with Atenolol (Tenormin) 25 mg PO QHS. Change the medication prescribed.

- The patient is coping well with a limited amount of Alprazolam. Reinforce safe use of benzodiazepines. Continue the medication and encourage use of more internal coping mechanisms. Rationale: The patient has the right to stay on the medication that has worked for her if she is not abusing it. This bias has connection to safe patient practice but the patient is doing the work to manage her issues. In accord with the Code of Ethics for Nurses and patient-centered care, the patient has a right to make decisions in her own care as long as she is not endangering herself.

1. Your patient is a 40-year-old male who has suffered from depression since he was age 21. He has tried numerous antidepressant medications and combinations of medications to no avail. There is a response but no recovery for this patient. He is currently taking Duloxetine 120 mg 1 PO QAM with a response. You prescribe a new medication to help with resistant depression, Brexpiprasole (Rexulti) 0.5 mg 1 PO QAM. He tries samples of the medication for 1 month and he experiences recovery from depression. When he takes the prescription to the pharmacy, he finds that his insurance will not cover the cost of the medication sufficiently. The patient tells you that he just cannot afford the medication and wants to stop it. What do you do? - The patient is not in danger of self-harm and has the right to define his own health. Continue to research other medications that will help him. - Refer the patient to a psychiatrist because you cannot help him. - Stress the need for recovery and push for him to make the financial sacrifices to afford the Brexpiprasole. - Work with the pharmacy representative to get as many samples as possible. Give them all to the patient so that he ahs a supply of the Brexpiprasole.

- The patient is not in danger of self-harm and has the right to define his own health. Continue to research other medications that will help him. Rationale: Recovery is the goal of treatment, but sometimes the patient cannot afford the means of reaching recovery. This is when the NP must do all that he or she can to help the patient. However, all that he or she can do must be ethical and follow what the patient wants and needs in their definition of health. It does not help the patient to be bankrupt and free of depression. It is unethical to divert most of the supply of a new medication to one patient when the medication is intended to try on many patients. Referring a patient because you do not have a ready answer and feel their plan of care is difficult is not ethical. There are legitimate reasons to refer a patient when you cannot help them. This is not one of those.

1. Which of the following is not insured by the Universal Bill of Rights for Mental Health Patients? - The right to freedom from restraint or seclusion, other than as a mode of treatment during an emergency situation. - The right to be given a reasonable explanation of one's general mental and physical condition, the objectives of treatment, and the possible adverse effects of recommended treatment. - The right to refuse a particular mode of treatment regardless of informed, voluntary, written consent, or situation. - The right to ongoing participation in the planning of mental health services provided in a manner appropriate to a person's capabilities.

- The right to refuse a particular mode of treatment regardless of informed, voluntary, written consent, or situation. Rationale: The right to refuse a particular mode fo treatment is insured except during an emergency situation wherein the patient is deemed imminent danger to self or to others, which includes the treatment team staff. All other responses are included in the Universal Bill of Rights for Mental Health Patients (Title II, Public Law 99-319, Restatement of Bill of Rights for Mental health Patients established by Mental Health Systems Act of 1980).

1. Which of the following would not be recommended practice in psychotherapy with patients diagnosed with borderline personality disorder? - Utilization of concomitant individual and group approaches - Mutually agreed limited setting - Establishment of clear roles of patient and therapist - Therapist as a passive listener

- Therapist as a passive listener Rationale: In psychotherapy for patients with borderline personality disorder, it is important that the therapist be an active and directive, not passive, listener.

1. Outcomes measurement is the collecting and reporting of data about the effect of an intervention. Purposes of outcome measurement include all of the following except: - To suggest changes in treatment - To analyze the effectiveness of an intervention - To practice profile patterns of providers - To observe errors in data reporting of an intervention

- To observe errors in data reporting of an intervention Rationale: Outcomes measurement entails evaluating the outcome of care. Outcomes are measured to suggest changes in treatment, to analyze the effectiveness of an intervention, or to profile practice patterns of providers.

1. Johnny, an 8-year-old male, presents with his foster mother for an initial evaluation. When interviewing the foster mother alone, it is confirmed that Johnny was taken out of his home due to sexual abuse by his stepfather. As the treating PMHNP, you know which of the following are evidence-based treatments for Johnny: - Interpersonal therapy - Trauma focused cognitive behavioral therapy - Family therapy - Behavioral therapy

- Trauma focused cognitive behavioral therapy Rationale: Trauma focused cognitive behavioral therapy is the minimum standard of therapy for a child with a history of trauma.

1. You see a patient for a routine medication visit. At the end of the session, the patient asks questions and the session ends up 50 minutes in length. You normally charge for the 30-minute appointment, but instead you charge for the 1-hour appointment. The 1-hour appointment includes a full body assessment that you did not perform. This violation is known as: - Over-coding - Super-coding - Down-coding - Up-coding

- Up-coding Rationale: Up-coding is a fraudulent practice in which the provider services are billed at higher procedure codes than were actually performed, resulting in a higher payment by Medicare or other third-party payers.

1. During a trauma recovery group a new member has a flashback of her sexual assault. She struggles to regain emotional control. What is the most appropriate intervention strategy at this juncture? - Encourage the woman to describe the event and associated thoughts and feelings at that time to facilitate desensitization. - Use eye contact, ask her to push her feet firmly on the floor, and speak with her in the present so that traumatic feelings can be talked about as memories. - Assist her in regaining emotional control by orienting her to the present time and place. - Monitor the responses of other group members that may have similar flashbacks triggered by the description of this new member's traumatic event.

- Use eye contact, ask her to push her feet firmly on the floor, and speak with her in the present so that traumatic feelings can be talked about as memories. Rationale: Strategies to manage flashbacks include identifying the phenomenon as a flashback or dissociative period and grounding techniques. Grounding means bringing the person's level of awareness to the immediate therapeutic environment by noticing things in the present: rubbing the upholstery on a chair, making sure the room is properly lit, good eye contact, stomping one's feet, deep breathing, walking outside, and supportive self-talk. Helping the individual develop a dual awareness of the flashback being linked to traumatic events of the past associated with traumatic feelings, enables the individual to talk about the traumatic feelings in the present as memories. While monitoring responses of other group members who may have similar flashbacks triggered is important, the initial focus is on the member experiencing the flashback.

1. When counseling a woman with children who is living in a violent domestic relationship, the PMHNP needs to advise that: - Anxiety, depression, dissociation, and PTSD symptoms are common in survivors - Written material about shelters found by the perpetrator may trigger further violence - Restraining orders can be helpful in preventing further violence - Shelters routinely provide care for both mothers and their children

- Written material about shelters found by the perpetrator may trigger further violence Rationale: Although anxiety, depression, dissociation, and PTSD are common symptoms in survivors of domestic violence, the greatest priority is to develop a safety plan. Restraining orders cannot always protect someone in domestic violence situations and in some cases may exacerbate the situation. Shelters do not always provide care for children, particularly if they are boys over 14 years of age. Do not provide information that may not be true. It is true that written material about shelters and domestic violence, if found by the perpetrator, can provide an excuse for further battering or violence. The woman needs to be advised either not to take printed material or ensure that it cannot be found by the perpetrator. It is safer to provide shelter numbers that can accommodate her specific needs (housing for children) without additional information.

1. You frequently use your iPhone/smart phone to connect with your office, the pharmacy, and patients. These multifunction devices assist you in your practice. What needs to happen to the protected/private health information on your phone after you conclude a healthcare interaction? - You document it fully in the patient record as a patient interaction. - You document an abbreviated note of the phone conversation. - You document that you had a telephone interaction only. - You document it briefly, only if it is important.

- You document it fully in the patient record as a patient interaction. Rationale: All patient interactions must be documented fully. Information from electronic devices can be lost when devices fail, working memory fails, or are lost or stolen. This information could be required in court or any other legal proceeding at a later time.