PMHNP purple book questions
Which of the following is the best rationale for using cognitive behavioral therapy?
Recognize and change his or her automatic thoughts.
An example of a mature, healthy defense mechanism is:
Suppression.
The purpose of the American Nurses Association's Psychiatric-Mental Health Nursing: Scope and Standards of Practice is to:
Define the role and actions for the NP.
Alice is a 68-year-old woman who presents to you with concerns about her memory. She explains that her mother and grandmother both experienced dementia and she wants to do what she can to prevent this terrible disease. Alice is treated for hypertension, which is well controlled; other than that she is in good health. She is socially and physically active and participates in a monthly cooking class, volunteers at her church, and plays bridge twice a week at the senior center. She says, "I understand that I am losing brain cells at my age, but I would still like to keep my mind and body active." Which is the best response to Alice?
"Although most brain development occurs early in life, we still form some new brain cells in a couple of areas of the brain during adulthood. You should continue with your activities because they offer excellent physical and mental health benefits and are neuroprotective?"
A client who has been addicted to opioids has not used in 15 days. During your medication management visit, the client states, "I'm going to die from not having my Opanas. You need to give me something now." The PMHNP's best response is:
"I know you are feeling very uncomfortable, let's take your vital signs and talk about a trial on Catapres to treat your withdrawal symptoms."
Jason misses several appointments. The PMHNP notes she feels resentful toward Jason and is struggling with how to respond to Jason when he finally comes in for his appointment. Which of the following demonstrates a therapeutic response?
"Jason, help me understand what's going on so we can figure out how to proceed."
John, a client with paranoid personality disorder, states the following: "I noticed there is a red light in the upper corner of your door and it has been going on and off during our sessions. Are you recording me?" What is the PMHNP's best response?
"John, thank you for asking the question. The light you see in the upper corner of my door tells me when a client has arrived and is in the waiting room. The client turns on the light, as you do, when they arrive in the waiting room, alerting me their arrival, and I turn off the light when we get into the office using the switch by my desk."
The PMHNP is planning to work with a client using an individual therapy model of care. During the first session, the client makes the following statement: "This is my third time my son has run away. I've grounded him, taken away his bike, even tried cutting off his allowance and confining him to his room. What should I do now?" The most therapeutic response for the PMHNP to make is:
"Maybe that depends on what you are trying to accomplish."
You have been working with Cody, a 30-year-old single man, in weekly individual psychotherapy for 3 weeks. At the start of session 4 he says, "I noticed when I came in that your usual parking spot has a new car in it with temporary tags, and it's a BMW. Nice car." What is the best response form the PMHNP psychotherapist to Cody?
"Sounds like having expensive things is important to you."
A client says to the PMHN, "Some days life is just not work it. All my wife and I ever do is fight and scream. Things at home would be calmer and simpler if I just wasn't there anymore." The most therapeutic response for the PMHNP to make is:
"Tell me what you mean by 'it would be simpler if you just weren't there anymore'."
You are the PMHNP treating Tim, a 10-year-old child, for ADHD and social anxiety disorder. His mother presents with Tim for his scheduled individual therapy session. At the end of the session his mother says, "I need to take Tim to see his pediatrician and at the last visit I was told he needed some HPV shot. I don't know, he's a boy, why would he need that? What do you think?" What is the PMHNP's best response to her question?
"The Centers for Disease Control and Prevention (CDC) recommends the human papillomavirus (HPV) vaccine for all boys and girls at age 10. HPV can cause cancer for both men and women, and the vaccine is effective in protecting against the virus. Can you tell me your concerns about Tim getting this vaccine?"
What differentiates atypical antipsychotic medications from first-generation or typical antipsychotic medications?
5HT2a receptor antagonist properties.
The role of neurotransmitters in the central nervous system is to function as:
A communication medium.
According to the DSM-V, which of the following is true?
A culturally expected response to a stressor in not a mental disorder.
Mrs. French has been in individual therapy for 3 months. She has shown much growth and improvement in her functioning and insight and is to discontinue services within the next few weeks. In the next session, after you discuss service termination, she suddenly begins to demonstrate the original symptoms that had brought her to treatment initially. She is now hesitant to discharge, wants to continue services, and is displaying an increase in regressive defense mechanisms. What is the best explanation for Mrs. French's behavior?
A sign of normal resistance to termination seen in the termination phase of therapy.
You are treating a client with schizophrenia who takes clozapine. What laboratory values will indicate the client needs to discontinue treatment?
Absolute neutrophil count of less than 1000/uL.
One of the health care changes that has occurred as a result of the affordable care act (ACA) is that doctors/hospitals/clinic groups or health systems are coming together and assuming the responsibility for quality care to large groups of individuals insured by Medicare. The health care clinics/systems doctors or hospitals that join together are called which of the following?
Accountable Care Organization (ACO).
When working with a 26-year-old, Mike, who presents for treatment of cannabis use and gambling, you use motivational interviewing techniques. As a PMHNP, you are familiar with the core counseling skills used in motivational interviewing. Mike made the following statement: "I don't know why I came here in the first place but I thought maybe some medication would help me." You respond by saying, "You're feeling confused about the process" and Mike replies, "I never thought I'd need to come to a place like this." You respond, "You kept your appointment today and I appreciate the courage it took for you to come here." What two motivational interviewing techniques are used in this interaction?
Affirming and reflecting.
As a PMHNP, you understand the genetic factors that contribute to psychiatric and personality disorders. Persons who develop antisocial personality disorder often are raised in families with high rates of which of the following?
Alcohol use disorder.
In forming a therapeutic relationship with clients, the PMHNP must consider developing many characteristics that are known to be helpful in relationship-building. Which of the following is an essential part of building a therapeutic relationship?
Authenticity.
When treating older adults, you should keep in mind that they are more sensitive to issues of drug toxicity because of which of the following reasons?
Decreased protein binding.
A 23-year-old woman is brought into the ER after attempting suicide by cutting her wrists. Which nursing action by the PMHNP would be of highest priority initially?
Take her vital signs.
What is the best treatment for AIDS dementia complex?
Antiretroviral therapy.
Mrs. Shea has come to the mental health center seeking treatment for depression. She has a history of a suicide attempt by overdose 1 month ago. She was started on imipramine (tricyclic antidepressant [TCA]) after that event but stopped taking the medication 1 week later because it "did not good." The PMHNP meets with Mrs. Shea to plan care with her. Which of the following is the most appropriate initial action?
Asking Mrs. Shea how to help her.
Tommy is an 8-year-old who presents to the PMHNP for evaluation of attention-deficit hyperactivity disorder. His mother completed the Vanderbilt ADHD rating scale and brought in the Vanderbilt teacher rating scale. Both your clinical interview and the rating scales indicate Tommy has ADHD. What assessment indicator(s) need to be completed prior to starting a stimulant medication?
Assess for family history of cardiovascular disease and, if positive for conduction problems, order an electrocardiogram before prescribing medication.
When working in individual psychotherapy with a client who has a personality disorder, what are the primary treatment goals?
Assist the client in changing dysfunctional interpersonal relationships and use of immature defense mechanisms.
A client with bipolar I disorder presents to your PMHNP office for a follow-up visit. During the visit the client informs you that he no longer wants to be treated with medication, and he does not have bipolar disorder, that was a misdiagnosis. He further informs you he stopped all his medication 2 months ago and is here to thank you for your care and tell you that he no longer needs follow-up appointments. Understanding the ethical conflict, you use which of the following ethical principles in working with this client?
Autonomy.
Which of the following best describes homeostasis in a family system?
Balance or stability that the family returns to despite its dysfunction.
Sean is a 47-year-old Gulf War veteran who was in combat during Operation Desert Storm. Sean has been treated by the PMHNP for major depressive disorder and associated anxiety symptoms. During the most recent visit, the PMHNP learns that Sean sustained a traumatic brain injury during this service, which was recently diagnosed at the TBI clinic in the Veterans Affairs clinic. What is the rationale for the PMHNP to taper Sean off clonazepam?
Benzodiazepines cause memory problems and confusion in clients with a history of a TBI.
When prescribing a selective serotonin reuptake inhibitors (SSRI) for a child or young adult up to age 24, what education must be included?
Black box warning about increased suicidality in this population.
You are treating Timothy, a 16-year-old boy, for an eating disorder. Timothy is of normal weight and socially extroverted, at times appearing to seek attention when in a peer group or class. Timothy's symptoms are most consistent with which eating disorder?
Bulimia nervosa.
Tim is a board-certified Psychiatric-Mental Health Nurse Practitioner (PMHNP) working in a busy community mental health center (CMHC). He is currently seeing a client diagnosed with bipolar I disorder who has comorbid hypertension and diabetes. During the visit, Tim takes the client's blood pressure and her reading is 160/94 mmHg. The client denies any headaches, nausea, chest pain, or shortness or breath. The client states "I can't afford all these medications so I haven't seen my doctor in 7 months and I am out of all my blood pressure and sugar medications, can you give me some?" What is Tim's most appropriate action?
Call the client's primary care provider, explain the situation, and coordinate the client getting an appointment and medication refills.
A PMHNP who is working on the consult liaison service is referred to a patient in the medical intensive care unit by the attending hospitalist. The consult note read "Evaluate the patient for competency to make independent medical decisions and consent for a surgical procedure." Based on the scope of practice of a PMHNP, which response would be most appropriate?
Call the hospitalist and provide education that competency is a legal concept and explain that you can assess the patient for the capacity to make medical decisions.
In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), how should a personality disorder be coded?
Coded with the major psychiatric disorder.
Persons with obsessive-compulsive personality disorder often use isolation as a defense mechanism. Which of the following examples best describes isolation as a defense mechanism?
Describing information with very little affect variation.
Which known teratogenic effects can be caused by the common psychotropic medications divalproex and lithium?
Divalproex - spina bifida. Lithium - Epstein anomaly.
For the client who has paranoid personality disorder, what are the best treatment strategies?
Do not challenge negative views or recollection of events.
Which is true about pharmacologic treatment of anxiety in older adults?
Drugs that are highly oxidized are more unpredictable than drugs that are mostly conjugated.
What four elements need to be present for a malpractice lawsuit to be filed?
Duty of care, Breach of standard of care, Injury, and Injury must be related to breach of the standard of care.
A client is displaying low self-esteem, poor self-control, self-doubt, and a high level of dependency. These behaviors indicate developmental failure of which of the following stages of development:
Early childhood.
Health care economics is concerned with making decisions so the benefits outweigh the cost of resource utilization. What are two concepts that healthcare economics is concerned with in regard to fair distribution of resources and allocation?
Equity and efficiency.
You are treating a 14-year-old female for attention-deficit hyperactivity disorder (ADHD) who has a family history of bipolar disorder. As a PMHNP familiar with symptoms of both ADHD and pediatric bipolar disorder, you know the following are overlapping symtpoms of both disorders:
Excessive talking, increased activity, and distractibility.
Mrs. Kemp is voluntarily admitted to the hospital. After 24 hours, she states she wishes to leave because "this place can't help me." The best nursing action that reflects the legal right of this client is:
Explain that the client cannot leave until you can complete further assessment.
A client who is experiencing difficulties with working memory, planning and prioritizing, insight into his problems, and impulse control presents for assessment. In planning his care, the PMHNP should apply his or her knowledge that these symptoms represent problems with the:
Frontal lobe.
The primary excitatory neurotransmitter is:
Glutamate.
Which of the following client statements best describes imitative behavior as a therapeutic factor in group therapy?
Group members begin to model aspects of other members of the group and group leaders.
Which type of hallucination is rare in persons with psychotic illnesses and is often associated with an organic etiology?
Gustatory hallucinations.
As a PMHNP working in an outpatient addiction clinic, you often refer your clients to community AA and NA meetings. Using Yalom's therapeutic factors, you are aware that peer-led groups can inspire and encourage other group participants. Which therapeutic factor is instilled in AA and NA group members?
Hope.
When conducting a neurological examination on a client, the PMHNP asks the client to hold out her arms and stick out her tongue while assessing for tremors. Which cranial nerve is being assessed?
Hypoglossal.
A client presents with complaints of changes in appetite, feeling fatigued, problems with sleep-rest cycle, and changes in libido. What is the neuroanatomical area of the brain that is responsible for the normal regulation of these functions?
Hypothalamus.
A 20-year-old Asian man who was recently diagnosed with schizophrenia comes to your office for a follow-up appointment. During the assessment, he talks about his experience in the group home, thinking that the television is sending him messages through news anchors during the 10pm evening news. What symptom is the client describing?
Ideas of reference.
The concept of target symptom identification is best explained as:
Identification of specific, precise, and individualized symptoms reasonably expected to improve with medication.
The goal of the psychiatric assessment process performed by the PMHNP is to:
Identify the mental health needs of the client.
Which of the following is a function of the psychiatric interview?
Identify the mental health needs of the client.
Mr. Johnson is a 54-year-old client you have been seeing for several weeks in therapy. While discussing his current concerns of marital stress, he lies on the floor and assumes the fetal position. This is most likely an example of:
Immature regressive defense mechanism.
Mr. Johnson is a client newly admitted to an inpatient psychiatric hospital. The PMHNP on call at the facility plans to perform the initial intake assessment and diagnostic process. Mr. Johnson asks to please talk in his room because, he says, "People make me nervous." His room is at the end of the hallway and is the farthest away from the nursing station. The PMHNP's action should be based on awareness that the best location to do the assessment is:
In a quiet place, be public enough to get assistance with client care should it be required during the assessment.
Which of the following statements best reflects the difference between the nurse-client (N-C) relationship and a social relationship?
In the N-C relationship, the primary focus is on the client and the client's needs.
Signs and symptoms of cannabis intoxication include:
Increase sensitivity to external stimuli.
Why is group therapy beneficial?
It is always time limited.
Mary is a Psychiatric-Mental Health Nurse Practitioner (PMHNP) who is working in a hospitalist role. Mary has encountered over five incidences in which attending psychiatrists and medical residents have been demeaning to nursing staff and not answering calls in the middle of the night or telling the nursing staff to write orders and the MD would sign off in the a.m. Mary is concerned about errors and wants to improve quality, reduce errors to promote safety. What concept is Mary employing?
Just Culture.
In completing the PMHNP assessment for Mrs. Shea, the most appropriate lab test for the PMHNP to order in the context of TCA administration is:
Liver function tests.
A 74-year-old married white woman was referred to you by her primary care provider for a psychiatric evaluation. She had a normal medical and neurological examination in the last 2 months. The client presents with her husband of 45 years who states, "My wife is just not the same anymore, she is irritable and asks the same question several times, even though I've answered it many times." The client responds, "Oh, Henry, you do the same thing, it's just a normal part of getting older, and the kids think everything is fine." During the assessment you compete the mini mental status examination (MMSE) and the client scores 18. As the PMHNP treating the client, you know the results of her MMSE indicate which level of cognitive impairment?
Moderate cognitive impairment.
You are a PMHNP working in a hospitalist role on an acute inpatient psychiatric unit at a local hospital. As you make rounds, the registered nurse informs you that a 32-year-old client who was admitted for alcohol detox has a score of 17 on the Clinical Institute Withdrawal Assessment for Alcohol. What phase of withdrawal is this client in?
Moderate withdrawal.
Which defense mechanisms are commonly used by persons with obsessive-compulsive personality disorder?
Rationalization, isolation, and intellectualization.
You have been working with a 54-year-old man who has been treated for schizophrenia since age 19. He has limited social interactions, likes to be alone, and has never dated nor had a desire to date. His symptoms are best explained by which of the following?
Negative symptoms.
The PMHNP working at a student mental health clinic has now been working with a freshman student for several weeks. The PMHNP learns that the student considers himself shy. He tells the NP that he has always felt uncomfortable in social situations or when he has to do oral presentations in class. He had few friends up until his senior year of high school when he discovered he could enjoy himself if he "had a couple drinks before going out." He has continued this pattern in college and now occasionally drinks "2 to 3 beers" on weekends as well. According to the DSM-V, does the student have a mental disorder?
No, at this point, the student does not meet criteria for a mental disorder.
Mr. D. is a 35-year-old, married, high-tech industry executive who is referred to the PMHNP for "insomnia." Mr. D. reports that he falls asleep quickly, but has difficulty staying asleep. He wakes several times during the night, and believes he tosses and turns even when he is sleeping. He wakes up feeling exhausted and drinks "a pot of coffee" to stay awake and concentrate during his long work day. He drinks 1 glass of wine most evenings. He denies any illicit substance use. He denies any symptoms of a mood or anxiety disorder, but is feeling increasingly frustrated and concerned about his sleep. Which of the following is the most likely contributing factor to Mr. D.'s ongoing middle insomnia?
Obstructive sleep apnea (OSA).
Which of the following interventions by the PMHNP for a person experiencing ataque de nervios demonstrates culturally-informed care?
Offering brief supportive psychotherapy.
A client comes into the clinic with a longstanding history of depression and chronic renal failure. He is on an antidepressant and a diuretic and complains of increased depression, mild confusion, irritability, and overall apathy from being too tired to do anything. The best initial PMHNP action to take at this time is:
Order a comprehensive metabolic panel.
In considering whether to order an MRI of the head for a client, which of the following would be a contraindication to this diagnostic test?
Pacemaker.
Primary prevention care practices are an essential aspect of the PMHNP role. Which of the following is the best example of a primary prevention care strategy for community behavioral health?
Parenting skills classes for pregnant adolescents.
The study of what the body does to drugs is called:
Pharmacokinetics.
A community has an unusually high incidence of depression and drug use among the teenage population. The public health nurses decide to address the problem, in part, by modifying the environment and strengthening the capacities of families to prevent the development of new cases of depression and drug use. What is this an example of?
Primary prevention.
You are asked by a church organization to work with members within your health system to develop a flu vaccination program. According to public health principles, this is an example of what level of prevention?
Primary.
Sarah presents for her initial intake appointment with complaints of depression. She is being treated for hypertension and asthma by her primary care provider. Knowing that certain medications can cause or exacerbate depression, you obtain a complete medication history. Which of the following medications is known to exacerbate or cause depression?
Propranolol.
The trend in legal rulings on cases involving mental illness over the past 25 years has been to:
Protect the person's freedoms or rights when he or she is committed to a mental hospital.
Mr. Smithers, an involuntary hospitalized patient experiencing psychotic symptoms, refuses to take any of his ordered medication because he believes "Jesus Christ tole me I am the prophet and must fast for a year." Your actions should be based on your knowledge of which of the following:
Psychiatric clients can refuse treatment.
Mr. Thompson has been forgetful lately, for example, forgetting where he has placed his keys or what time appointments are scheduled, and he has stated that he thinks these are just random behaviors that have no particular meaning. Which Freudian-based psychodynamic principle assumes that all behavior and actions are purposeful?
Psychic determinism principle.
The chief nursing officer of a large behavioral health system approached the PMHNP to discuss the new Healthcare Effectiveness Data and Information Set (HEDIS) behavioral health measures and specifications. The PMHNP is asked to do a retrospective chart review of all hospital discharge clients who received a follow-up visit within 7 days of discharge and within 30 days of discharge. The PMHNP has been asked to engage in which of the following?
Quality improvement initiative.
Dialectical behavioral therapy (DBT) affirms dialectical thinking, which involves examining and discussing opposing ideas to find the truth. This philosophy is a supportive principle of DBT training. The central dialectical pattern emphasized in DBT involves the tension between:
Radical acceptance and change.
Serotonin is produced in which of the following locations:
Raphe nuclei.
Which communication technique is the PMHNP using in the following situation? Client: "Sorry I was late. I didn't realize what time it was." PMHNP: "This is the third time now that you have been late for our sessions. I am wondering how committed you are to our working on your problems."
Recognizing.
A mother brings in her 7-year-old son for a psychiatric follow-up visit with the PMHNP. This is the fourth visit the PMHNP has had with the client, his mother, and his younger sister, Renee, now 7 months old. You notice that she ahs a decrease in head growth, along with stereotypic motions of the hands, often licking and slapping. Renee has also lost her language skills. What medical condition do you suspect Renee has developed?
Rett syndrome.
As a PMHNP working on the consult liaison team, you know the importance of preventing delirium due to which of the following?
Risk of 1-year mortality rate.
Which of the following is the best reason for considering the SSRI among the first-line drug choices for treating major depression?
Safe use in suicidal overdose clients.
As a PMHNP working in a crisis evaluation center, you are aware that the initial focus of a crisis assessment is on which of the following?
Safety of the client and others.
Following evidence-based practice (EBP), which laboratory screening tests and assessments should be completed prior to placing a person on a second-generation ("atypical") antipsychotic medication?
Serum glucose or hemoglobin A1c, lipid profile, weight, body mass index, blood pressure, waist circumference, and family history of cardiovascular disease.
A client returns for a follow-up appointment 3 weeks after starting on fluoxetine 20mg. During this appointment you notice that her speech is a little rapid, in marked contrast to the psychomotor retardation and paucity of spontaneous speech she displayed on her first visit. Instead of looking at the floor, she now makes eye contact. Her affect has gone from constricted to expansive. She continues to have difficulty sleeping, but her energy has improved and she states she feels "so much better!" What should you conclude about the shift in the client's presentation?
She is becoming hypomanic.
Samantha is a 26-year-old partnered woman who works full time as a teacher. She is in a long-term relationship with Mary and they are getting along well, and doing well financially. They have two children, ages 2 and 6. Samantha is seeing the PMHNP to address her concerns that she is feeling down and sad for no reason and states, "I know my life is going well but I just don't feel happy. I have always worried a lot and have been sad most of my life." As the PMHNP trained in transactional analysis (TA), you understand that personality is multifaceted and wonder if which of the following is affecting her ability to experience happiness:
She likely had a traumatic event in her childhood and her throughs and feelings related to the event are locked together in her brain and cannot be accessed.
Dialectical behavioral therapy (DBT) draws on cognitive theory and behavioral theory, along with other theories. Elements of behavioral theory in DBT include which of the following?
Skills training and exposure.
In an attempt to bring the client toward the goal he or she is working on, you ask the client, "If a miracle were to happen tonight while you slept, and you awoke in the morning and the problem no longer existed, how would you know, and what would be different?" This technique is used in which type of therapy?
Solution-focused therapy.
When working with a dysfunctional family, you find that the father, Jim, worries excessively and is resistant to change. You give Jim a paradoxical directive to worry extremely well for 1 hour per day, knowing that he will likely be non-compliant, and thus change will occur. With this technique, you are using which type of therapy?
Strategic therapy.
You are working with a family: mother, father, and two biological children. Sam, the father, is very rigid and controlling, which seems to be out of fear that something might happen to his family. He worries daily and it affects his family relationships. You give Sam a paradoxical directive and instruct him to intensely worry about everything he can think of for 1 hour a day. Using a paradoxical directive is part of which therapy?
Strategic.
Dopamine is produced in which of the following locations:
Substantia nigra.
Tina is a 54-year-old single white woman who has been a Psychiatric-Mental Health Nurse Practitioner for over 20 years. She is considering making application to a Doctor of Nursing Practice (DNP) program but states "if a DNP is required to practice I'll get grandfathered in, no need for me to go back to school." Following the 2008 License, Accreditation, Certification, and Education (LACE) Consensus Model for Advanced Practice Registered Nurse Regulation, which statement is correct?
The DNP is an academic terminal degree and there will not be an opportunity for Tina to be grandfathered in a DNP.
Your client Sam is being treated for panic disorder with agoraphobia. He currently is being prescribed paroxetine (Paxil CR, 37.5mg q.d.) and clonazepam (Klonopin, 0.5mg q.d., p.r.n.). He has been on clonazepam for 2 years and admits to needing 4 pills to achieve the same effect that 1 pill initially produced. This is possibly an example of which process?
Tolerance.
In assessing a client, you ask him the meaning of the proverb "People who live in glass houses shouldn't throw stones." He replies, "Because it will break the windows." The correct interpretation of this finding is:
Unable to interpret the finding without knowing the client's age.
Ms. Thomas has been diagnosed with major depressive disorder (MDD) and is placed on fluoxetine 20mg for her depression. For the PMHNP to effectively monitor her use of the medication, which of the following actions should be part of ongoing care?
Use of a standardized rating scale of depression.
Defense mechanisms are best viewed as a function of the ego:
Used to resolve a conflict.
A new client reveals to the PMHNP that her boyfriend screams at her and has repeatedly slapped and pushed her in front of her 3-year-old son. She goes no to say that the boyfriend has thrown things at her and on one occasion threw a glass of water at her that hit her son in the back. Should the PMHNP report this to child protective services (CPS)?
Yes, the PMHNP has a duty to report.
