FNP Review Dunphy-Chapter 18 Psychosocial Problems

Andrew, age 36, has come to you with complaints of insomnia, weight loss, and recent recurring thoughts about death. These symptoms were precipitated by the unexpected, sudden death of a colleague. You know the following things about making a diagnosis of unipolar major depression: A. A primary criterion of a major depressive episode is a depressed mood or anhedonia. B. A depressed mood must be present for more than 3 months to make a formal diagnosis of major depressive disorder. C. Changes in relationships must occur to make this diagnosis. D. This depressed mood must occur following a precipitous event such as occurred in the case of Andrew.

A A major depressive episode is a period lasting at least 2 weeks, with five or more of the following symptoms: depressed mood, anhedonia, insomnia or hypersomnia, change in appetite or weight, psy- chomotor retardation or agitation, low energy, poor concentration, thoughts of worthlessness or guilt, and recurrent thoughts about death or suicide. At least one of the symptoms must be depressed mood or anhedonia. There is no consistent evidence that changes in relationships are necessarily involved and/or that a precipitous event is necessary to pre- cipitate a major depressive episode.

When the PMHNP experiences feelings or thoughts toward a patient, this is termed A. countertransference. B. transference. C. empathy. D. reflection.

A A therapeutic relationship, sometimes referred to as a therapeutic alliance, refers to the close and con- sistent association between a therapist and patient/client for the purpose of beneficial changes in prob- lematic feelings and behaviors in the client. The close nature of this relationship often causes the per- son in therapy to project feelings onto the therapist and become attached to the therapist, mimicking their relationship with their family of origin. This is often referred to as transference. Counter- transference refers to the therapist, in this case the PMHNP, becoming overly attached to the client/ patient. Reflection and empathy are therapeutic techniques to encourage the sharing of feelings by the patient/client.

Marion has been going to AA but is still struggling with the desire to drink. She comes to see you. You decide to prescribe acamprosate (Campral). You expect that this drug will A. help to reduce the urge to drink. B. erase any desire to drink. C. cause unpleasant effects if alcohol is ingested. D. block the euphoric effects and feelings of intoxication when alcohol is ingested.

A Acamprosate (Campral) is a substance that is thought to reduce the urge to drink in someone maintaining sobriety, such as Marion. It does not erase the desire to drink. It does not cause unpleas- ant effects if alcohol is ingested; drugs such as disulfiram (Antabuse) do cause unpleasant effects if alcohol is ingested. Naltrexone blocks the euphoric effects and feelings of intoxication. This allows peo- ple with alcohol addiction to reduce their drinking behaviors enough to remain motivated to stay in treatment, avoid relapses, and take medications.

Which cranial nerve(s) are you assessing when you examine the client's mouth and tongue motor movement for tardive dyskinesia? A. Cranial nerves 9, 10, and 12 B. Cranial nerve 8 C. Cranial nerves 7 and 11 D. Cranial nerves 1, 2, and 3

A Cranial nerves: 9, the trigeminal nerve; 10, the trochlear nerve; and 12, vestibulocochlear nerve are the cranial nerves that will demonstrate abnormal- ities in function, such as uncontrolled movements in your face - namely your lips, jaw, or tongue. This is called tardive dyskinesia, a side effect of antipsy- chotic medications. Cranial nerve 8 is the optic nerve; cranial nerves 7 and 11 are the olfactory nerve and vagus nerve, respectively; and cranial nerves 1,2, and 3 are the abducent, accessory, and facial nerves, respectively.

Sally, age 17, is a new patient. She has just relocated from a different state. She comes to you with an existing diagnosis of anorexia nervosa (AN) but is not on any treatment. This diagnosis occurred shortly before her move. You recommend which of the following initial treatments: A. pharmacotherapy with an antidepressant. B. psychoanalysis. C. hospitalization for hydration and correction of electrolyte imbalance. D. an appetite stimulant.

A Depression is a common comorbidity associated with this disorder. Thus, putting Sally on a courseof antidepressant therapy is an appropriate way to begin treatment. Psychoanalysis as a modality has not proven particularly effective; cognitive behav- ioral therapy has shown more progress. There are appetite stimulants—specifically cyproheptadine (Periactin)—that can be used before meals to reduce anxiety and enhance appetite, but you should decide to determine if there is any change in appetite with antidepressant therapy. Likewise, in some cases a patient with AN may need hospitalization for hydration and correction of electrolyte imbalance, but Sally is not in need of that intervention at the present time.

Jenny, a sophomore in college, presents to you complaining about anxiety and feelings of insecurity. She reports frequent headaches and difficulty sleeping. As you take Jenny's history you remain alert for risk factors for the development of generalized anxiety disorder (GAD). These risk factors include A. substance abuse. B. schizophrenia. C. anorexia nervosa. D. personality disorder.

A It is known that substance abuse is a risk factorfor GAD, as is post-traumatic stress disorder, and obsessive-compulsive disorder (OCD). It is espe- cially important to rule out other types of anxiety disorders before settling on GAD as a diagnosis.

You have decided to put your 88-year-old client Ann, diagnosed with Alzheimer's disease, on memantine (Namenda). What do you need to evalu- ate before starting this treatment? A. A metabolic panel and liver function tests B. A CBC C. A sedimentation rate D. A C-reactive-protein

A Memantine (Namenda) is the first of a newclass of drugs designed to treat the symptoms of Alzheimer's disease and vascular dementia. Other Alzheimer's drugs, such as donepezil (Aricept), work by improving communication between brain cells. Memantine works differently, preventing the damage and destruction of brain cells that occurs due to increased levels of a chemical in the brain called glutamate. Memantine is more commonly prescribed to individuals in middle to late stagesof dementia since it can often help individualsfor whom cholinesterase inhibitors have stopped working. Furthermore, as the drugs affect the brain in different ways, individuals may use both cho- linesterase inhibitors and memantine at the same time. It is important to remember that memantine and other Alzheimer's drugs do not stop or reverse dementia's progression, but they can help slow the disease. In general, individuals who use memantine experience few side effects. The most commonly experienced side effects include dizziness, head- aches, and constipation. Memantine may not be suitable for individuals with kidney or liver disease or a seizure disorder.

There are well-validated screening instru- ments to assist in diagnosing psychosocial problems, as well as tracking progress with treatment. Your patient Gloria, age 29, presents with symptoms of restlessness and anxiety. You decide to have Gloria fill in the following screening instrument. A. GAD-7 B. PHQ-9 C. CAGE screening exam D. Life event checklist (LEC)

A The generalized anxiety disorder seven-item (GAD-7) scale should be used to screen for GAD in primary care. It has been found to have acceptable reliability and criterion, construct, factorial, and procedural validity. The GAD-7 is sensitive to change and can be used to monitor symptom severity over time.

You are treating Amy, age 24, for general- ized anxiety disorder (GAD). You have started her on an SSRI. Amy asks how long she must take this medication. She is not sure she likes the medication. You explain that A. standard practice is to continue the medication at least 6 months after remission is achieved, and that it takes about 3 months to achieve remission. B. she must remain on this medication for the rest of her life. C. she can discontinue it any time that she wants. D. you must evaluate her response to this specific medication and dosage and there might need to be changes to achieve remission.

A This is standard practice for the treatment of GAD. The patient should be ill-advised to stop the drug whenever she feels like it as most likely her symptoms will recur. The patient will not necessarily have to take this drug for the remainder of her life. You do advise her of the standard recommended times for taking medication, as you do know this.

You are assessing Johnny, who is 22 years old. You determine that Johnny's ideas are not logical and do not make sense. What finding is this? A. Thought process B. Thought content C. Memory D. Ability to concentrate

A Thought process refers to how the client thinks,and this is inferred from speech and speech patterns. Thought content is what the client actually says, the "content" of their thought. Memory is assessed by asking questions such as "Who is the current presi- dent?" "In what country are we?" "What is the state capital of the state that you live in?" Ability to con- centrate is assessed by asking the client to perform certain tasks such as "Spell the word world back- ward" or "Repeat the days of the week backward."

Which of the following statements is true regarding depression? A. Depression is more prevalent among males. B. Up to 20% of the population in the United States will experience a significant episode of depression at some point in their lives. C. After one episode of depression, there is an 80% chance of a recurrence. D. Primary care providers fail to detect about 75% of patients with depression.

B

Jill, age 26, is diagnosed with schizophrenia. She exhibits a form of abnormal speech involving creating new, idiosyncratic words. What is this form of speech referred to? A. Derailment B. Neologism C. Word salad D. Tangentiality

B A neologism is the creation of new, idiosyncratic words. Derailment is switching topics without a log- ical sequence. A word salad is words placed together without any sensible meaning. Tangentiality is getting off the topic without answering questions appropriately.

You are working with 35-year-old Janet, who was diagnosed with a narcissistic personality disorder. You are her primary care provider. What is the best interpersonal approach for dealing with this client? A. Supportive B. Matter-of-fact C. Friendly D. Cheerful

B A person with a narcissistic personality disorder can be extremely manipulative. It is important to set lim- its right from the beginning of the encounter. Thus, adopting a neutral, matter-of-fact tone offsets the ability of the client to take control of the encounter.

You are seeing a client in a long-term care facility who has been prescribed Risperdal 2 mg bid for several years. Which of the following screening tools would you utilize to assess for EPS symptoms? A. SCARED tool B. AIMS tool C. COW tool D. Mini-Cog tool

B Abnormal Involuntary Movement Scale (AIMS)is a physical exam that the practitioner should administer yearly to a patient on antipsychotic med- ications to assess for signs of tardive dyskinesias. The SCARED tool does not exist; nor does the COW tool. The Mini-Cog tool is a 3-minute instrument to screen for cognitive impairment in older adults in the primary care setting.

A distinguishing feature of neurocognitive disorder Lewy body dementia is A. forgetfulness. B. visual hallucinations. C. amnesia. D. confusion.

B Although confusion and forgetfulness may be a com- ponent of Lewy body dementia (sometimes referred to as dementia with Lewy bodies), visual hallucina- tions are a hallmark diagnostic criterion. Amnesia is defined as a complete absence of memory, which is seldom the case.

You suspect that Mr. Blum, age 69, has major depression. In deciding on what antidepressant to start Mr. Blum on after validating that his symptoms meet the diagnostic criteria for major depression, you know you must consider the following. A. SSRIs are always the best place to start. B. You must consider a variety of factors, such as side effect profile, safety profile, as well as patient preferences, to name just a few. C. It will take at least 4 weeks to see improvement after beginning an SSRI. D. Antidepressants will not be effective unless combined with some form of psychotherapy.

B Although there is good evidence that an SSRI may be an effective way to treat an episode of major depression, there are always a variety of factors to consider in any treatment decision.

What is a common behavioral sign of autism? A. Early language development B. Indifference to being held and hugged C. Creative imaginary play with other children D. Clinging to parents

B Autism spectrum disorder (ASD) is a biologically based neurodevelopmental disorder characterizedby impairments in two major domains: (1) deficits in social communication and social interactionand (2) restricted repetitive patterns of behavior, interests, and activities. ASD encompasses disor- ders previously known as autistic disorder (classic autism, sometimes called early infantile autism, childhood autism, or Kanner's autism), childhood disintegrative disorder, pervasive developmental dis- order-not otherwise specified, and Asperger disorder (also known as Asperger syndrome). Early language development, clinging to parents, and creative play with other children do not fall under this definition. Indifference to being held and hugged is more con- sistent with deficits in social communication and social interventions.

Marty, age 23, has been diagnosed with an opioid-use disorder after having a car accident 3 years ago and being on oxycodone since then. It is affecting his work, and he wants to stop but can't. What do you recommend? A. That he quit "cold turkey," as that is the safest method of getting off opioids. B. You recommend Suboxone along with counseling. C. You suggest that he enter a detox program. D. You share that success has been reached with weaning off of opioids slowly.

B Buprenorphine (Suboxone), via a buccal film, immediate-release injection, or transdermal patch, has been found effective along with counselingin treating an opioid-use disorder. Misuse of the medication or overdosing may pose a serious fatal respiratory depression. While dependence on Suboxone may occur, it is safer than opioids. While going cold turkey seems like an option, Marty might not tolerate the withdrawal symptoms without med- ical support. Entering a detox program will clear out the opioids in his system, but the desire for opioids would remain. Similarly, many have been successful with weaning off of opioids slowly, but since Marty has been on this for 3 years, this will probably not be the best option. When discontinuing therapy, there should be a gradual downward titration of the dose of Suboxone to prevent withdrawal, and depending on the situation, medical support may be needed.

You have put Joe, age 33, on clozapine (Clozaril). Before starting this drug, Joe needs to understand A. the dietary restrictions. B. that he must have his blood drawn to monitor his white blood count. C. that he must avoid the sun. D. he needs to start an exercise routine.

B Clozapine (Clozaril) is used to treat certain mental/ mood disorders (schizophrenia, schizoaffective disorders). Clozapine is a psychiatric medication (antipsychotic type) that works by helping to restore the balance of certain natural substances (neuro- transmitters) in the brain. Clozapine decreases hal- lucinations and helps prevent suicide in people who are likely to try to harm themselves. It enables posi- tive thinking and decreases nervousness. Clozapine treatment has caused severe neutropenia, defined as an absolute neutrophil count (ANC) less than 500/μL. Severe neutropenia can lead to serious infection and death. Orthostatic hypotension, bra- dycardia, syncope, and cardiac arrest have occurred with Clozapine treatment. The risk is highest during the initial titration period, particularly with rapid dose escalation. These reactions can occur with the first dose, with doses as low as 12.5 mg per day. Initiate treatment at 12.5 mg once or twice daily, titrate slowly, and use divided dosages. Use cloza- pine cautiously in patients with cardiovascular or cerebrovascular disease or conditions predisposing to hypotension (e.g., dehydration, use of antihyper- tensive medications).

You are seeing Joyce, age 36, who suffers from panic disorder. You have started her on fluoxetine (Prozac) about a week ago. She comes to see you today complaining of diarrhea and nausea. You advise A. that she should stop taking this medication. B. that she needs to try taking the medication with food and schedule her to see you in a week. C. this is a common, long-lasting side effect of this medication but counsel that she should hang in there as the therapeutic effect on panic disorder will be worth it. D. that she should switch her to a different medication.

B Fluoxetine (also known by trade names Prozac and Sarafem) is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. It is used for the treatment of major depressive disorder, obsessive-compulsive disorder (OCD), bulimia nervosa, panic disorder, and premenstrual dysphoric disorder.

Helen is accompanying her 65-year-old mother, Dalia, for her visit with you, her primary care provider. Helen states, "My mother is a hoarder." You know that hoarding disorder is A. a variant of schizophrenia. B. increases with age. C. common and non-life threatening. D. only effectively treated with psychodynamic therapy.

B Hoarding had previously been defined as a symptom of obsessive-compulsive disorder (OCD), not schizo- phrenia. It is now defined in its own category, as a progressive, debilitating, and compulsive disorder. It occurs in 2% to 5% of the population, increases with age, and is more common in females.

The PMHNP is counseling a family in which the mother is constantly worrying about the well-being of her children, to the point she does not allow the children to be out of her sight. You decide to try the technique paradoxical directive and direct the mother to worry about everything she can for 1 hour each day. Which of the following therapeutic models utilizes the use of paradoxical directive? A. Minuchin's Structural Therapy B. Haley's Strategic Therapy C. Beck's Cognitive Therapy D. Bowen's Family System's Theory

B Jay Haley developed this strategic approach to family therapy. Typically, the therapist's rationale is aimed at diminishing the problem behavior, where the paradoxical directive explicitly encourages the individual to perform the same behavior, catching the client in a situation that demands doing more of something in order to diminish the problem behav- ior. Salvador Minuchin was also a family therapist who emphasized understanding the interrelated nature of family dynamics as "systems." Murray Bowen, a psychologist, conducted pioneering work on the process of differentiation in a family unit necessary for autonomous personality development. Aaron Beck, another therapeutic pioneer, is consid- ered the founder of cognitive behavioral therapy.

You have started Donald, age 44, on parox- etine hydrochloride (Paxil). You advise Donald to be aware of which of the following side effects? A. Flatulence B. Nausea C. Increased appetite D. Changes in hearing

B Paxil (paroxetine hydrochloride) is a selective serotonin reuptake inhibitor (SSRI) antidepressant used to treat depression, panic attacks, obsessive- compulsive disorder (OCD), anxiety disorders, post-traumatic stress disorder, and a severe form of premenstrual syndrome (premenstrual dysphoric dis- order). Side effects include headache, nervousness, restlessness, drowsiness, dizziness, nasal irritation, sleep problems (insomnia), nausea, decreased sex drive, and potential impotence.

Robert, age 24, hesitates 30 seconds or more before responding to any question. He has a diagnosis of schizophrenia. How would you describe this hesitancy? A. Latency of response B. Poverty of speech C. Blunted affect D. Thought blocking

B Poverty of speech is the correct term for this speech pattern. Latency of response is not a validated descriptive term related to thought processes. Thought blocking refers to stopping abruptly in the middle of a sentence. Blunted affect involves showing little or a slow-to-respond facial expression, related to mood.

You know that when a patient with bipolar disorder is experiencing an acute manic phase, the patient's speech often becomes unrelentingly rapid, often without pause, and loud. It may be intelligible or unintelligible. The patient may interrupt frequently and be unable to listen to others. This is referred to as A. flight of ideas. B. pressured speech. C. agitated speech. D. grandiosity.

B Pressured speech is the correct term for the speech described in the question, a hallmark of an acute manic episode. It is true that the speech can be described as agitated, but the standard term for this speech is "pressured speech." It describes more specifically other aspects of this speech besides agitation, such as the constant interrupting and inability to stop talking. Flight of ideas refers to thought process and content, not a pattern of speech. Grandiosity is related to mood and affect, not speech.

You are working with Janey, age 18, who suffers from bulimia. You encourage her to use the technique of self-monitoring. This involves which of the following? A. Ask the client to make out daily meal plans for 1 week. B. Ask the client to write about all feelings and experiences related to food. C. Teach the client about nutritional content and calories of various foods. D. Encourage the client to ignore feelings and impulses related to food.

B The binging and purging of bulimia often occur when the person is in a "mindless" state. It is important that the person begin to get in touch with his or her feelings and experiences related to food.

Your patient, Mr. Ross, age 81, complains of a decreased appetite, listlessness, and depression. You rule out any physiological causes, and you decide to start Mr. Ross on an SSRI. Important factors involving use of psychoactive drugs in elderly clients differ from treatment decisions in younger patients because A. psychoactive agents are not as effective in this population. B. the elderly are more sensitive to the side effects of psychoactive substances; treatment decisions must include side-effect profiles. C. psychoactive substances should be avoided in this population. D. elderly clients are not as likely to remember to take their medications.

B The elderly are more sensitive to side effects, andit is important to consider side effect profiles as well as sensitivity to both therapeutic and toxic drug effects. The adage "start low and go slow" is important to consider in this population, so you might start Mr. Ross on one-third to one-half of the usual therapeutic dose and monitor his response. It is important to not avoid psychoactive substances in this population if they are warranted or to fall into stereotypical thinking such as someone of this age being not as likely to remember to take his or her medication. And there is no evidence that psychoactive agents are not as effective in this pop- ulation. As in any treatment decision, benefit versus risk must be weighed. Issues of polypharmacy and presence of concurrent diseases should all be taken into consideration. Avoid not treating when suffer- ing could reasonably be alleviated.

Aaron, age 10, is brought in to see you, his primary care provider, because he is suffering from enuresis. Your treatment plan includes behavioral modification, positive reinforcement, and the follow- ing medication: A. risperidone (Risperdal). B. imipramine (Tofranil). C. olanzapine (Zyprexa). D. methylphenidate (Ritalin).

B There is no cure for bedwetting, but imipramine (Tofranil) may be used to treat enuresis in children ages 6 to 12. Desmopressin acetate (DDAVP), a synthetic form of the hormone vasopressin that decreases the amount of urine produced by the kidney, is also used for treatment of enuresis.

A normal serum lithium level for maintenance and safety is A. 50 to 100 mEq/L. B. 0.5 to 1.2 mEq/L. C. 10 to 50 mEq/L. D. 0.1 to 1 mEq/L.

B This is the recommended safety levels for mainte- nance doses of lithium. Answers A, C, and D are all out of the range of normal dosing.

The PMHNP is working with a family con- sisting of a mother, father, and four children. The mother and father argue frequently and often drag their youngest daughter into their disagreements. What term best describes this style of communi- cation in the family? A. Disengagement B. Triangulation C. Enmeshment D. Emotional cutoff

B Triangulation is a form of manipulation and is a dysfunctional behavior. Instead of communicating directly with each other, the dyad—the parents— use a third person, in this case the youngest daughter, to communicate with each other, thus forming a communication triangle.

You are seeing Grace, age 45, who is severely depressed. She is seeing a psychiatrist but is here to see you today for a cough. However, she answers all your questions slowly, and demonstrates psychomotor retardation. She also is requesting medication to help her sleep. You fear she is sui- cidal. What is the first thing you must do? A. Call Grace's psychiatrist. B. Ask Grace directly if she is thinking of killing herself, if she has a plan for when, where, and how she plans to do this. C. Call her family. D. Spend time counseling her.

B Your immediate duty is to assess her suicidal ideation and/or lethal plan. You must carefully document this assessment. You may need to call her psychiatrist and/or family, but it is not the first thing you must do. You may also spend time counseling her, but this would only be after assessing the level of suicidality. It must be directly but compassionately confronted.

Which of the following is a validated screening instrument for depression? A. AUDIT B. Mood Disorder Questionnaire (MDQ) C. PQH-9 D. Life event checklist (LEC)

C

A significant trend in mental health care is the integration of behavioral health in primary care. These efforts aim to deliver comprehensive care of the whole person, leading to less fragmentation in care and achievement of the triple aim to reform and improve health care. The triple aim is A. a combination of care providers at the point of care. B. the need for primary care providers to provide more mental health care. C. better population health, enhanced patient experience, and reduced cost of care. D. shared record-keeping between psychiatrists and primary care providers.

C By definition, the triple aim is better popula-tion health, enhanced patient experience, and reduced cost of care. To achieve these goals, many approaches need to happen that include teams of care providers at the point of care, such as behav- ioral health providers being integrated into the primary care team, as well as shared record-keeping. The patient should always be at the center of care.

James, aged 62, is on a selective serotonin reuptake inhibitor (SSRI) for his depression. While the medication has helped his depression, he states that he has noticed a decline in sexual function and asks about this. What do you tell him? A. "Keep taking it. You must acclimate your system to the medication. The sexual dysfunction will get better. We will employ watchful waiting." B. "You should stay on the medication and we can order a drug like sildenafil (Viagra) or tadalafil (Cialis) to offset the adverse effects of the SSRI." C. "While this medication has effectively helped with your depression, we'll go ahead and change the classification of medication." D. "Because this SSRI has helped your depression, that is the most important thing."

C Depressed patients who are troubled by SSRI sexual dysfunction may be switched to a non-SSRI anti- depressant like bupropion (Wellbutrin). Watchful waiting alone is typically not effective. While taking Viagra or Cialis may work, it is better to try another antidepressant than add an additional med- ication. Telling James that he should be happy his depression is better is negating the fact that he is concerned with sexual function and is not a thera- peutic response.

What are the most common side effects of the SSRIs? A. Jaundice and agranulocytosis B. Cough and rash C. Dizziness, drowsiness, and dry mouth D. Convulsions and respiratory difficulties

C Drowsiness, dizziness, and dry mouth are the most common side effects of SSRI. Convulsions are not common documented side effects, nor are respira- tory difficulties. Likewise, cough, rash, jaundice, and agranulocytosis are not common documented side effects in the literature.

What is the prevalence of GAD in the United States? A. 10.2% to 15.4% B. 1.3% to 4.4% C. 5.1% to 11.9% D. 13.2% to 18.7%

C Generalized anxiety disorder (GAD) is commonin both community and clinical settings. Epidemio- logical studies of nationally representative samples in the United States have found a lifetime prev- alence of GAD of 5.1% to 11.9%. A review of epidemiological studies in Europe found a 12-month prevalence of 1.7% to 3.4% and a lifetime preva- lence of 4.3% to 5.9%.

The nurse theorist best known for her writ- ing about the therapeutic nurse-client relationship is A. Lillian Wald. B. Martha Rogers. C. Hildegard Peplau. D. Dorothea Dix.

C Hildegard Peplau significantly shaped psychiatric nursing practice. She wrote two significant books, Interpersonal Relations in Nursing in 1952 and Interpersonal Techniques: The Crux of Psychiatric Nursing in 1962. She described the therapeutic nurse-client relationship with its phases and tasks and wrote extensively about anxiety, including defining stages of anxiety. Martha Rogers, a truly innovative and original nursing thinker/theorist, developed a "grand" nursing theory. Lillian Wald was a public health nurse pioneer at the turn of the 20th century. Dorothea Dix (April 4, 1802 to July 17, 1887) was an American activist on behalf of the indigent mentally ill. Through a vigorous pro- gram of lobbying state legislatures and the United States Congress, Dix created the first generation of American mental asylums. During the Civil War, she served as a Superintendent of Army Nurses.

The United States is in the midst of a severe opioid-use epidemic. How many people in the United States died from drug overdose in 2016? A. 25,800 B. 45,500 C. 72,287 D. 84,300

C In 2017, there were 72,287 deaths from drug overdoses; approximately 49,000 (66%) involved opioids. This number increased 10% from the year before and has doubled in 1 decade. In 2017, 29,000 of those deaths were related to fentanyl and fentanyl analogs (synthetic opioids). The Center for Disease Control and Prevention identified three waves of the overdose epidemic: prescription opioids, heroin, and most recently, ultra-potent illegally manufac- tured fentanyl.

The receptionist in your office calls you into the waiting area. In the area is a new client, pacing, with clenched fists, and a flushed face. He is swearing and yelling. What phase of the aggression cycle is he in? A. Anger B. Triggering C. Escalation D. Crisis

C In the escalation phase of this cycle, interventions include taking control of the situation but speaking calmly and nonthreateningly. Convey empathy. Direct the client to take a time out. Listen. Invite him to a quiet room. Offer medication.

Angela, age 50, has been taking an SSRI for more than a year for new onset unipolar depressive episode. Initially beginning at a low dose of an SSRI, her dosage was increased during the first 6 months of therapy. She has been stabilized at a dose for more than 6 months since then, totaling more than 12 months of pharmacotherapy. She would like to get off this drug. She feels her depression has stabilized. She has been actively involved with a CBT therapist. She feels she can cope without medication. Your best course of action is to A. stop the medication completely and monitor Angela closely. B. convince Angela that she is doing so well that you do not think it is a good idea to do anything different with her medication at the present time. C. agree to try to gradually decrease the dosage of the drug. D. suggest switching to a different medication at a lower dose.

C It is not a good idea to decrease any psychotropic medications suddenly. Although not addicting in the traditional sense, there can be potential prob- lems with rebound, meaning a temporary returnof symptoms; recurrence of the original symptoms; or withdrawal, meaning new symptoms resulting from discontinuing the drug. There is no rationale for switching to a new medication, since the one she is on has had a good effect. A patient-centered approach to care means that Angela's desire to stop, or decrease the medication as your clinical judgment suggests, needs to be heard. Relapse is highest in the first 2 months after discontinuation of therapy. This needs to be discussed with Angela. Additionally, it is known that those persons with more than 2 epi- sodes of MDD relapse within 1 year at an 80% rate.

Juliana, age 17, has lost a lot of weight recently, constantly talks about her weight, goes to the bathroom after meals, and is depressed. Why do you diagnose this as bulimia nervosa rather than anorexia nervosa? A. Juliana has had a significant weight loss recently. B. She is depressed. C. She goes to the bathroom after meals. D. Juliana has amenorrhea.

C Juliana goes to the bathroom after meals to vomit up (purge) the meal she just ate. Both anorexia ner- vosa and bulimia nervosa may result in a significant weight loss. In addition, both conditions involve depression. Bulimia nervosa typically involves irregular menses while anorexia nervosa results in amenorrhea.

Your client Johnny tells you he has had a car accident. You say, "Tell me about the accident." What type of therapeutic communication is this response? A. Offering self B. Reflection C. General lead D. Making observations

C This statement is not making an observation, nor is it reflecting back to the client. An example of offer- ing self is making oneself available to help. You are inviting further communication about the accident. See Chapter 2 for additional therapeutic communi- cation techniques.

You see Gerald, age 78, for his annual phys- ical. He complains of feeling "very down" and not having much desire to do anything. Gerald reports that he cannot recall feeling this way before. He has lost 8 pounds and reports that his appetite is not what it used to be. He blames these feelings on "old age." You suspect that Gerald may be suffering from depres- sion. You know that depression in older adults is A. to be expected given the amount of loss they face. B. not very common—older adults know how to face loss and have a sense of perspective. C. not a normal consequence of aging. D. higher in men than women; women are more used to caring for themselves.

C Late-life depression is a serious health concern, but it is not a normal consequence of aging, nor is it to be expected. Late-life depression remains underdiag- nosed and inadequately treated. Late-life depression often goes undetected and has a significant adverse impact on quality of life, outcomes of medical dis- ease, health care utilization, and morbidity and mortality. The overwhelming majority of older adults with depression initially present to primary care, often with somatic complaints. Sadness and grief are normal responses to life events that occur with aging, such as bereavement; adjustment to changes in social status with retirement and loss of income; transition from independent living to assisted or residential care; and loss of physical, social, or cognitive function from illness. Despite these losses, healthy independent community- dwelling elderly in the United States have a lower prevalence rate of clinical depression than the gen- eral adult population. Older women have higher rates of depression than older men.

Medications may be needed in additions to screening, early intervention, counseling, and education to treat alcohol use disorder (AUD), moderate to severe subtype. You are treating Jerry, age 60, who has this diagnosis. He has been in detox numerous times. Jerry is desperate to stop drinking. He continues his usual heavy usage of alcohol and is fearful of the consequences. You decide you must consider pharmacological therapy for this client. What drug is your best choice? A. Citalopram (Celexa) B. Chlorpromazine (Thorazine) C. Naltrexone (Revia) D. Disulfiram (Antabuse)

C Naltrexone (Revia), an opioid antagonist thatis a synthetic congener of oxymorphone with no opioid agonist properties, has been used effectively for treatment of AUD in combination with non- pharmacological treatment. It can be started when a patient is still drinking alcohol. Naltrexone usein randomized trials demonstrated lower relapse rates, fewer days drinking, and a decrease in crav- ing for alcohol.

The mainstay of treatment for schizophre- nia is A. hospitalization. B. intensive counseling. C. antipsychotic medications. D. entering a self-help program like Alcoholics Anonymous (AA).

C Pharmacotherapy with antipsychotic medicationsis the mainstay of treatment for schizophrenia. While hospitalization in a psychiatric setting may be helpful, it is useless without concurrent pharmaco- logical therapy. Intensive counseling is also helpful but not by itself. Many groups are available to assist with support but should be used with the adjunct of medications.

You are seeing Marion, age 66, for a check of her hypertension. She says, "Since my husband died, I started having a glass of wine before dinner. Now, it has become a glass of wine before dinner, wine with dinner, and wine after dinner! Do you think I need to go to AA?" This statement indicates that Marion is in what stage of change according to Prochaska's theory of change? A. Precontemplation B. Contemplation C. Preparation D. Action

C Prochaska, a well-known psychologist who studies behavioral change, postulates a five-step model of change. Precontemplation is when a person is unaware that a problem exists and/or is not interested in change. Contemplation is when a person starts considering change. Preparation is when someone begins to think of things to do about the problem. Marion's thoughts about planning to go to AA demonstrates she has contemplated the problem, noting the amount she is drinking, and is actually preparing to take action about the issue, going to AA. Actual action is when the person actually initiates the action. Marion would attend an AA meeting in this stage of change.

The American Academy of Pediatrics (AACP) recommends screening for autism spectrum disorder at what age(s)? A. Birth and 12 months B. 6 and 12 months C. 18 and 24 months D. 2 and 3 years

C The American Academy of Pediatrics (AACP) recommends screening for autism spectrum disorder at 18 and 24 months. Research has found that ASD can sometimes be detected at 18 months or younger. By age 2, a diagnosis by an experienced professional can be considered very reliable.

Personality structures of id, ego, and super- ego were originally described by A. Hildegard Peplau. B. Harry Stack Sullivan. C. Sigmund Freud. D. R. D. Laing.

C These concepts of personality structures were foun- dational to Freud's thinking. He saw the ego as the mediator between the superego (the "conscience") and the id (basic, innate desires such as pleasure seeking, aggression, and sexual impulses). The ego represents the mature and adaptive behavior that allows a person to function successfully in the world. Anxiety, in Freud's view, arose out of the attempt by the ego to balance impulsive instincts of the id with the stringent rules of the superego. Freud also used dream analysis as a primary technique of psy- choanalysis to tap into the patient's unconscious, or preconscious, mind. These thoughts and emotions are not conscious, yet they are motivating behavior and thoughts, even though a person may be unaware of them. Dream analysis helps to bring them to the conscious mind, where these feelings and thoughts can be examined.

You are seeing Edward, age 26, for a primary care appointment. Once in your exam room, Edward becomes increasingly upset. He is rapidly pacing, clenching his jaw, hyperventilating, trembling, and wringing his hands. He is pounding his fist into his other hand. His speech is high pitched and random. He seems preoccupied. You identify his anxiety level as A. mild. B. moderate. C. severe. D. panic.

C This is definitional. In a person with a panic attack, you would see an inability to verbalize at all and difficulty in breathing. Most likely the person will be sweating and hyperventilating. The heart may be racing, there may be chest pain, and there may be tingling and numbness in fingers secondary to hyperventilation. Mild anxiety is common in every- day life. At this level, you're likely open-minded, although stressed. You might experience this level of anxiety as you await a job performance review or if you're lost in a new city. Symptoms might include fidgeting, irritability, sweaty palms, and heightened senses. Mild anxiety is typically motivational, mean- ing it helps someone focus on seeking a solution to the challenges faced. For example, if someoneis lost in a new place, that person might look for a safe place to ask for directions. Once that person got his or her bearings, the anxiety will likely dissipate quickly. This is typical of mild, situational anxiety. At a moderate level of anxiety, someone is likely to focus exclusively on the stressful situation directly in front of him or her and ignore other tasks. Say someone has taken a child to the playground and lost sight of him. That person might experience a faster heartbeat, dry mouth, sweating, and stomach pain or nausea. His or her speech may be rapid and high-pitched and hand and arm movements are likely more exaggerated. Nervous habits, like biting fingernails or wringing the hands, are common. That person's singular focus is likely where the child might be. Once the child is found playing with other children, the symptoms subside.

Amanda, age 24, is undergoing treatment for anxiety and depression with cognitive behavioral therapy (CBT). What does this approach to therapy involve? A. CBT is always given in conjunction with psychiatric medications. B. CBT is built on "talk therapy," and the therapist meets weekly with the client for an indefinite period. C. CBT emphasizes collaboration and active participation. D. CBT involves the whole family unit.

C When a patient is treated with CBT for anxiety and depression, they may also receive psychiatric med- ication, but often they do not. CBT is a treatment modality that has been proven to be as effective as medication for anxiety and depression. CBT is a time-limited approach to therapy and involves spe- cific techniques, not "talk therapy" in and of itself. It does not involve the family unit but rather is an individual approach. CBT does involve patient col- laboration and active participation.

Rose, age 70, lost her husband 8 months ago. She visits you, her primary care provider, com- plaining of nighttime panic and depression. She states, "I don't have anything to live for anymore." You suspect complicated grieving. You know that physiological responses of complicated grieving include A. impaired appetite, weight loss, lack of energy. B. tearfulness when recalling significant memories of the deceased. C. impaired immune response, increased mortality rate from heart disease, increased prolactin levels. D. persistent depression, signs of panic disorders, and ongoing grief.

D

Your patient, Mrs. Smith, age 49, reports restlessness, anxiety, palpitations, and insomnia. You suspect generalized anxiety disorder (GAD). You know you need to rule out underlying medical disorders before making a diagnosis of GAD and beginning treatment. You need to screen Mrs. Smith for A. vitamin D deficiency. B. nuclear antibody tests. C. sleep apnea. D. arrhythmias and thyroid screen.

D A simple EKG done in the office can screen out arrhythmias, and a thyroid screen can rule out hyperthyroidism, which could cause some symptoms typical of anxiety. You would need further data before deciding if her insomnia warrants a potential diagnosis of sleep apnea. Nuclear antibody tests are used to diagnose autoimmune disorders andMrs. Smith's symptoms do not support ordering this. Fatigue can be associated with vitamin B12 deficiency, but overall vitamin D deficiencies do not figure into any of Mrs. Smith's other symptoms. The more likely physiological culprits would be an arrhythmia or hyperthyroidism.

Joshua, age 58, has insomnia and states it is affecting his work, and that he is falling asleep at the wheel of his car. You discuss sleep hygiene with him and recommend the following strategy. A. Try to catch up on your sleep on the weekends. B. Take a nap every afternoon. C. Turn on the sleep timer when watching TV in bed at night so you don't have to wake up and turn the TV off. D. If not asleep after 20 minutes, read a chapter in a book in room other than the bedroom.

D If Joshua is not asleep after 20 minutes in bed, he should get up and engage in a quiet activity, like reading, outside of the bedroom before returning to sleep. He should avoid daytime naps, maintain a regular sleep and wake schedule 7 days a week, and not watch TV in bed. The bed should only be used for sleeping and sex.

You are seeing Timothy, age 53, for OCD. Timothy has a ritual of constant, excessive clean- ing. An appropriate intervention would be A. intense psychodynamic therapy sessions. B. creating negative reinforcement for ritual performance. C. interruption of rituals with distracting activities. D. a structured schedule of activities throughout the day.

D Negative reinforcement has not been proven to be effective for OCD, and distraction rarely works. A structured schedule of activities builds a program for Timothy to become involved with and has more of a chance of success of his becoming more engaged with new activities and less engaged with his rituals.

You are seeing Sonny, age 70, who has a history of anger issues. What medication requires cautious use in a potentially aggressive client? A. Mood stabilizers B. Lithium C. Antipsychotic medications D. Benzodiazepines

D Paradoxical rage reactions due to benzodiazepines occur as a result of an altered level of consciousness, which generates automatic behaviors, anterograde amnesia, and uninhibited aggression. It is estimated that anywhere between 1% to 20% of benzodiaze- pine users experience some form of increased anger or express aggression. These aggressive incidents occurred at both low and high doses and by indi- viduals with and without histories of this kind of behavior.

You are caring for a client with borderline personality disorder. The client states, "You are the best nurse in the world, the other nurse practitioner is terrible." You should recognize the client's statement as which of the following defense mechanisms? A. Rationalization B. Repression C. Conversion reaction D. Splitting

D Splitting is a quite common ego defense mechanism, defined as the division or polarization of beliefs, actions, objects, or persons into good and bad by focusing selectively on their positive or negative attributes. Repression, in psychoanalytic theory, is defined as a defense mechanism whereby the person excludes distressing memories, thoughts, or feelings from the conscious mind. Rationalizationis a defense mechanism often used to avoid feelings of anxiety, guilt, or other negative emotions and involves the justification of an unacceptable behav- ior, thought, or feeling in a logical manner, avoiding the true reason for the action. Conversion reaction, formerly called hysteria, is a type of mental disorder characterized by physical symptoms, such as sudden blindness, or inability to walk, for which no organic cause can be found.

Primary care providers (PCPs) have a significant role in reducing excessive alcohol use. PCPs do this by A. prescribing medications such as antidepressants. B. screening and referral. C. staging interventions. D. screening, early intervention, counseling, and education.

D The PCP plays a critical role in reducing excessive alcohol use. This role involves screening at regu- lar intervals, including the use of such validated instruments as the CAGE Questionnaire, as well as various physiological parameters. Early inter- vention should occur when progressive, increasing, and excessive use of alcohol is identified. Early intervention should begin with counseling, which means an open discussion with the client about increasing and excessive usage. Counseling should include providing education as to what constitutes excessive usage, as well as identifying strategies for change.

You are treating Andra, age 39, for a somatoform disorder. Andra was scheduled to perform in a piano recital, but she was forced to cancel because she developed numbness in her right hand. The consequences of this symptom—not having to perform—is best described as A. avoidance. B. behavioral coping. C. phobia. D. secondary gain.

D The concept of secondary gain is best described as the advantage that occurs secondary to stated orreal illness. Transition into the "sick role" may have some incidental secondary gains for clients; in this case, Andra did not have to perform at the recital, something she really did not want to do. She did not state or even admit that to herself, but rather unconsciously developed a physiological symptom, thus saving face. Numbness in the hand is not a phobia. It is not as simple as avoidance since a phys- ical symptom developed, masking the fact that she wanted to avoid performing. It is not true behavioral coping; that would involve "owning" her feelings about not wanting to perform in the recital and asserting herself to have not agreed to do it.

You are seeing Anthony, age 48, for a new patient visit. He tells you "My biggest problemis trying to deal with a divorce. I didn't want a divorce. I still do not want a divorce. But my wife is leaving!" Your best response is A. "I'm so sorry. No wonder you are upset." B. "Can you tell me about it?" C. "You must be devastated." D. "Sounds like it has been a difficult time."

D The statement "Sounds like it has been a difficult time" is the most open-ended response, and most likely to encourage more sharing by the client. It is also the most empathic response.

Life expectancy rates in the United States have declined for the first time for several years in a row. The reasons for this are A. little understood B. increased suicide rates C. more drug-resistant and/or nosocomial infections D. the opioid crisis

D There has been an overall rise in suicide rates for several years, but these numbers are not significant enough to account for the decrease in life expectancy. Deaths from opioid overdoses have continued to rise in dramatic numbers, and it is more accepted that it is this rise that has accounted for an overall decrease in life expectancy. Some theorize that opioid deaths may actually be suicides, but this can be difficult to tease out.

Ms. Dortney, age 55, is very fearful because of a breast lump the NP has just identified. The patient begins to cry and states, "I'm afraid of having a mammogram." Your initial response is A. "You must have the mammogram." B. "Don't worry; I'm sure it is nothing." C. "Wonderful advances have been made in breast cancer research." D. "You're feeling scared?"

D This example of therapeutic communication acknowledges the client's fear and encourages her to verbalize her feelings. Table 2-1 in Chapter 2 reviews communication techniques that facilitate therapeutic communication and those that do not.

Unipolar major depression (major depres- sive disorder) is diagnosed in patients who have suffered at least one major depressive episode and have no history of mania or hypomania. As a primary care provider, you know the following about unipolar depression. A. Unipolar depression is easily treated with antidepressant therapy, typically an SSRI. B. Cognitive behavioral therapy (CBT) is not effective in major depression. C. You should refer those you diagnose with unipolar major depression for long-term psychoanalyticor psychodynamic therapy before starting pharmacotherapy. D. Nonspecific factors (e.g., conveying empathy, establishing rapport, developing a therapeutic alliance and sense of collaboration, and instilling hope) may affect patient outcomes as much as the choice of antidepressant.

D Unipolar depression is not easily treated. In real- ity, major depression is highly recurrent. Following recovery from one episode, the estimated rate of recurrence over 2 years is greater than 40%; after two episodes, the risk of recurrence within 5 years is approximately 75%. SSRIs are effective in many cases for some periods of time, but drug selection, dosage, monitoring, and side effects are many ofthe factors involved in efficacious treatment. In randomized trials, long-term psychoanalysis and/or psychodynamic therapies alone have not proven effective; in contrast CBT has proven efficacious as a therapeutic approach. A therapeutic alliance with a care provider, as described in answer D, is critical to patient-centered care.

You are seeing Sally, age 60, who is severely depressed. She is also complaining of inability to sleep and anxiety. You must decide on what prescription to order for her. Which is most dangerous if taken as an intentional overdose? A. A 3-week supply of nefazodone (Serzone) B. A 3-day supply of diazepam (Valium) C. A 4-week supply of fluoxetine (Prozac) D. A 2-week supply of nortriptyline (Aventyl, Pamelor)

D When choosing an antidepressant for a severely depressed client, the safety profile of the drug must be considered. How toxic is the prescribed medication if the client takes an overdose? Of the choices above, a 2-week supply of a tricyclic antidepressant, in this case nortriptyline, would be the most lethal. The SSRIs, such as fluoxetine, and the atypical antidepressant nefazodone have much better safety profiles when taken in over- dose. The dosage of diazepam is for an extremely limited period.