Test Taking Strategies:

1. Read the entire question through

2. Pay attention to the key words
3. Read all answer choices before selecting an answer
4. The right answer option might have the same word as the question
5. Choose client focused answers
6. Always think safety
7. Priority or initial action questions usually want an assessment
8. When two answer choices are opposite of one another, one is usually the correct answer
9. Absolutes like “ all, never, only, always” are usually wrong
10. Culture is important to include in care of patient
11. If undecided, the umbrella answer is usually the best choice
12. Prioritize: Airway, Breathing, Circulation
Maslow's Hierarchy of needs
Nursing Process

THE PMHNP-BC EXAM INCLUDES 5 DOMAINS:

SCIENTIFIC FOUNDATION HAS 30 QUESTIONS AND IS 20% OF EXAM

ADVANCED PRACTICE SKILLS HAS 38 QUESTIONS AND IS 25% OF EXAM
DIAGNOSIS AND TREATMENT HAS 37 QUESTIONS AND IS 25% OF EXAM
PSYCHOTHERAPY AND RELATED THEORIES HAS 22 QUESTIONS AND IS 15% OF EXAM
ETHICAL AND LEGAL PRINCIPLES HAS 23 QUESTIONS AND IS 15% OF EXAM

Lithium
Therapeutic range 0.6 -1.2
Gold standard for treating manic episodes
Evidence of anti-suicidal effects ( Decrease Suicidal ideations)

Before starting lithium what baseline labs do you need?

-thyroid level (TSH)
-pregnancy test (HCG)
-Serum creatine (0.6-1.2)
- Blood urea nitrogen (10-20)
-ECG ( patients over 50)
-Important to check kidney levels prior to initiating because kidneys metabolize lithium
-Lithium is not recommended in pregnancy due to it causing Ebstein Abnormalities , especially
in the 1st trimester

What are the side effects of lithium ?

Endocrine
-hypothyroidism
-Central nervous system- fine hand tremors. Fatigue, mental cloudiness, headache, nystagmus,
coarse hand tremor ( with toxicity)
Dermatological
-maculopapular rash, pruritus, acne
Gastrointestinal
- GI upset, diarrhea, vomiting, cramps, anorexia
Renal
-polyuria with polydipsia, diabetes insipidus, edema, microscopic tubular changes
Cardiac
-T wave inversion, dysrhythmias
Hematological
-Leukocytosis ( increase WBC count )
-Lithium toxicity – want to discontinue if levels are 1.5 or above

What is a hypertensive crisis ?

-occurs when MAOIs are taken in conjunction with foods that contain tyramine, a dietary
precursor to norepinephrine
-life threatening and can not be reversed unless more MAO is produced by the body
Can occur with:
Meperidine , decongestants, TCAs, atypical antipsychotics, St. John's wart, L-tryptophan,
stimulants, asthma medications , Methylphenidate ( strictly contraindicated )

What are the symptoms of hypertensive crisis?

-sudden explosive like headache
-increased blood pressure
-facial flushing
- paeritations
-pupillary dilation
-diaphoresis
-fever
What is the treatment?
-Discontinue MAOI
-give phentolamine
-stabilize fever
-Re-evaluate person's diet and adherence to medication guidelines

Teratogenic risks of common psychiatric medications:

Benzodiazepines- floppy baby syndrome, cleft palate
Carbamazepine- neural tube defects
Lithium- Ebstein anomaly
Divalproex sodium- neural tube defects , SPINA BIFIDA
Lamictal- causes stevens johnsons syndrome

Signs and Symptoms of Stevens johnson syndrome

-severe rash
-fever-tongue swelling
-sore throat
- facial swelling
-malaise
-painful mucus membrane before rash occurs
-arthralgia
-skin sloughing
-Prodromal headaches

Carbamazepine/Tegretol
- StevenJohnson Syndrome particularly in Asianas
- Must screen all Asians for HLAB-1503 allele before initiating
- Discontinue if ANC (Absolute neutrophil count) is less than 1,000mm
- Monitor patients for signs of infections: sudden fever, chills, sore throat, weakness
- Aplastic anemia occurs with carbamazepine also signs of this include : pallor, fatigue,
headache, fever, nose bleed, bleeding gums, skin rash, and shortness of breath

Always check pregnancy test prior to starting a mood stabilizer!

Folic acid – supports neural tube development during 1st month pregnancy. Women on mood
stabilizers encouraged to take 0.4-0.8mg folic acid daily

Clozapine
-risk for neutropenia- monitor ANC, discontinue if less than 1,000
Monitor ANC :
-6 months weekly
-second 6 months- every 2 weeks
-monthly after that if ANC normal

Wellbutrin
-Norepinephrine dopamine reuptake inhibitor
-Helps with low energy/ fatigue
-no sexual side effects
- Do not use it with history of eating disorders it can lower seizure threshold.

Cymbalta (duloxetine)
- Serotonin norepinephrine reuptake inhibitor
- helps with depression and neuropathic pain

Bulimia
-BMI usually normal
-Russell's sign- scarring or calculus on dorsum of hand
-hypertrophy of salivary glands
-rectal prolapse
Treatment : Prozac is the only FDA approved for Bulimia
SSRI and TCA effective in binging and purging

Anorexia
-low body mass index
-emaciation
-amenorrhea
-inversion of T waves
- prolonged QT interval
-hypotension
-bradycardia

Know BMI
Inducers and Inhibitors
Clozapine- atypical antipsychotic drug metabolized by CYP1A2
Enzyme inducers- can decrease the serum levels of other drugs that are substrates of that
enzyme, thus possibly causing subtherapeutic drug levels

IMPORTANT INDUCERS- Bull Shit Crap GPS

Barbiturates
St. Johns wart
Carbamazepine
Rifampin
Alcohol
Phenytoin
Griseofulvin
Phenobarbital
Sulfonylureas
Oral contraceptive
Cigarette smoking

Enzyme Inhibitors- SICK FACES

Increase serum levels possibly causing toxic levels of drugs
Important Inhibitors
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Chloramphenicol
Erythromycin
Sulfonamide
Ciprofloxacin
Omeprazole
Metronidazole

Liver disease/ Liver levels

-liver disease will affect liver enzyme activity and first pass metabolism possibly resulting in toxic
plasma drug levels
-detoxing from alcohol and have liver disease ? – will give Ativan(lorazepam) because it has a
shorter half life than valium

Kidney
-kidney disease or drugs that reduce renal clearance such as:
NSAID (ibuprofen)
Thiazides ( hydrochlorothiazide)
ACE inhibitors ( Used in treatment of cardiac failure )
All may increase serum concentration of drugs

Older adults are more sensitive to drugs so start at the lowest most effective dose
possible :
-Older adults had decrease intracellular water
-deceased protein binding
-decreased metabolism
-low muscle mass
-Increase body fat concentration

Neurotransmitters
Norepinephrine- produced in Locus coeruleus and medullar reticular formations
Serotonin- produced in raphe nuclei of brainstem
Dopamine – produced in substantia nigra and ventral tegmental area
Acetylcholine- nucleus of meynert

GABA- most abundant inhibitory

-benzodiazepines and anxiolytics bind with GABA to produce a calming effect
-Decrease GABA = Increase anxiety

Glutamate -most abundant excitatory

-increase in levels of corticotropin releasing hormone in amygdala, hippocampus, and locus
coeruleus are responsible for increase in symptoms of anxiety
-Increase Glutamate = increase anxiety

Parts of the brain:

1. Cerebrum – largest part of the brain, which is divided into 2 halves, the right hemisphere
and the left hemisphere
1. Right hemisphere – controls L hemisphere, responsible for facial expressions,
music, and visual information
2. Left hemisphere- controls R hemisphere, dominant in most people
2. Corpus Callosum- connects R and L hemisphere , area of sensorimotor information
exchange between the two hemispheres
3. Prefrontal cortex- front part of the frontal lobe, involved in planning complex cognitive
behaviors, personality expression, impulse control, decision making, and social
behaviors. Also involved in executive function, focusing one’s attention, and modulating
pain and perception of pain.
4. Dorsolateral prefrontal cortex- top most part of the prefrontal cortex. Considered to have
overall management of cognitive processes. Involved in executive functioning, planning,
cognitive flexibility, and working memory
 5. Orbitofrontal cortex- ability to make decisions based on emotional information. Plays a
role in forming social relationships and regulating emotions
6. Ventromedial prefrontal cortex- regulates emotions especially in social situations
7. Frontal Lobe- largest most developed , considered seat of executive function. Regulates
impulse control, reasoning, planning, judgement, insight, language (Broca’s area).
Problems with the frontal lobe lead to personality changes, emotional changes, and
intellectual changes
8. Temporal lobe- Wernicke's area is located here, can lead to auditory hallucinations, aphasia,
and amnesia

9. Occipital lobe- visual field defects, blindness, and visual hallucinations

10. Parietal Lobe- sensory perception disturbances and agnosia (inability to interpret sensation)

11. Cerebellum- balance

Clock drawing test- R hemisphere and cerebrum affected if unable to draw

-simple tool used to screen for dementia and alzhemiers
-easy, fast

12. Limbic system- essential system for regulation and modulation of emotions and memory

13. Hypothalamus- appetite, sensation of hunger and thirst, changes in libido, circadian rhythm,
and hormones
14.
Thalamus- regulates emotions, memory, and related affective behaviors

15. Hippocampus- regulates memory and converts short term memory into long term memory.
Regulates motivation, stress, emotions, and learning

16. Amygdala- fear, anxiety, anger, stress, emotion, aggression, mood, rage

Dopamine Pathways
1. Mesolimbic- hyperactivity of dopamine in the mesolimbic pathway
1. Mediates positive symptoms of schizophrenia
2. An increase in dopamine in this pathway increases positive symptoms
3. Give antipsychotics to decrease D2 in this pathway, thus improving positive
symptoms
2. Mesocortical
1. Projects from VTA to prefrontal cortex
2. A decrease in D2 in this pathway cause worsening of negative symptoms
3. Goal is to increase D2 in this pathway
3. Nigrostriatal- mediates movement
 1. Blockade of dopamine receptors in this area can lead to EPS, dystonia,
parkinsonism symptoms, and akathisia
2. Dopamine blockade can lead to increase in acetylcholine
3. Long standing D2 blockade in nigrostriatal pathway can lead to tardive
dyskinesia
4. Tuberoinfundibular pathway
1. Blockade of D2 receptors can lead to increase prolactin levels, thus leading to
hyperprolactinemia, galactorrhea, sexual dysfunction, and gynecomastia
2. Long term leads to osteoporosis and hyperlactatemia

Extrapyramidal Side Effects

-Acute dystonia : painful muscle spasms of the face, neck, tongue. Often mistaken for agitation
-oculogyric crisis- can lead to permanent injury. On exam patients have prolonged involuntary
upward deviation of eyes bilaterally. Treatment: Cogentin (Benztropine)

-Akathisia: restless, inability to sit still, pacing, feet constantly in motion. Often mistake for
anxiety
- TREATMENT: 1. Beta Blockers- contraindicated in patients taking albuterol, can cause
bronchospasms
2. Cogentin
3. Benzodiazepines
Scales: Barnes Akathisia Rating Scale and Extrapyramidal Symptom Rating Scale

-Akinesia: absence of movement, difficulty initiating movement, often mistake for laziness
-TREATMENT: Cogentin
-Pseudo Parkinsonism Symptoms: produced by D2 blockade, shuffling gait, cogwheel rolling,
rigidity, mask like expressions
-TREATMENT: Cogentin
-Tardive Dyskinesia: involuntary movements of mouth, tongue, face, and jaw. Lip smacking,
tongue protrusion. IRREVERSIBLE.
-TREATMENT- stop antipsychotic, switch to Clozaril , NO COGENTIN!!
- Can occur as acute onset or 1-2 years later
-Can occur with Reglan also

Fetal Alcohol Syndrome

Signs and Symptoms – low birth weight, short palpebral fissure, midface hypoplasia, thin
upper lip, short philtrum, microcephaly

Fragile X syndrome- broad forehead, elongated face, large prominent ears and head, short
stature

Pharmacodynamics/ Pharmacokinetics
Pharmacodynamics- what the drug does to the body
Example- SSRI taken with NSAIDS causes increased risk of bleeding

Pharmacokinetics- what the body does to the drug

Citalopram- QTC prolonged on doses above 40mg and 20mg in older adults

Medications that can cause mania:

-Steroids
-disulfiram
-isoniazid
-antidepressants in patients with bipolar
-Flonase
Prednisone
-Will need increase in mood stabilizer dose

Medications that cause depression:

-retroviral
-antineoplastics
-beta blockers
-interferon
-accutane
-benzodiazepines
-progesterone
-will need to increase antidepressant

Neuroleptic malignant syndrome

-caused by antipsychotics
-extreme muscle rigidity
-mutism
-hyperthermia
-tachycardia
-diaphoresis
-Altered level of consciousness
-elevated CPK (creatine phosphokinase)
-Leukocytosis ( elevated white blood cell count)
- elevated liver enzyme test
TREATMENT: discontinue offending agent, dantrolene (muscle relaxant), and Bromocriptine
(dopamine agonist)

Autism spectrum disorder

-deficits in social communication and social interaction across multiple settings
-restricted repetitive behaviors
-repeated motor movements
-echolalia
-hyper/hypo sensory input
-no response when called by name
-little or no eye contact
-no imaginary play

Risk Factors:
Male
-intellectual disability
Genetic loading

Screening tools
-modified checklist for Autism in Toddlers (M-CHART)
-Autism Diagnostic Observations Schedule
-Age and Stages Questionnaire
Pharmacological management
-antipsychotics for tantrums, aggression, and self injuring behaviors (Risperdone)

Serotonin syndrome- caused by taking more than 1 antidepressant, taking SSRI & MAOI
together, drug/herbal interaction, when switching from SSRI to MAOI and not waiting 2 weeks.
When switching from Prozac to MAOI need to wait 5-6 weeks due to the long half life of Prozac.

Symptoms: hyperreflexia
Myoclonic jerk
Agitation
Restlessness
Headache
Sweating
Confusion
Fever

Tx: Discontinue offending agent and give cyproheptadine

Serotonin discontinuation syndrome- caused by abrupt stopping of an antidepressant (

SSRI, TCA, MAOI). Medications with shorter half lives more likely to experience ( Zoloft)

Symptoms:
Flu like symptoms
Decrease concentration
Fatigue
Lethargy
Impaired memory
Agitation
Nausea
Vomiting
Myalgia

Agonist effect- drug binds to receptors and activates a biological response, opens ion channels
Inverse agonist- causes opposite effect of agonist, binds to same receptor, closes ion channels
Partial agonist- drug does not fully activate receptors
Antagonist- binds to receptors but does not activate biological response

Delusion- false belief despite contrary evidence, do NOT clarify delusions

Paranoia- believing people are out to get you
Referential thinking- patients may believe certain news bulletins have direct reference to them
or that music played is for them.

Mental status exam

Thought process- abnormal: circumstantial, tangential, loose associations, flight of ideas

Tangential- ask a question and response is not appropriate, move from one thought to next but
never answer the question

Circumstantial- provide unnecessary information but eventually answer the question

Loosening of associations- thought disturbances demonstrated by speech that is disconnected

and fragmented with the individual jumping from one idea to another unrelated idea

Perseveration- repetition of a particular response regardless of the absence of a stimulus

Flight of ideas- continuous rapid speech that changes focus from moment to moment
Echolalia- meaningless repetition of another person's words. ( common in autism)

Thought content- themes that occupy patients thoughts and disturbancs ex: suicidal ideation,
homicidal ideation

Mini Mental status exam – used to quantify cognitive state, can be used to monitor progress
-count backwards from 100 by 7
-Registration- ask for 3 objects to be repeated in order

Other instruments for cognitive assessment:

-mini cog
-Montreal cognitive assessment
-St. Louis University Mental Health Assessment

Suicide assessment: Count the risk factors

-previous attempt
-male over 45 years of age
-female over 65 years of age
-divorced, single, separated
-white
-lives alone
-substance use
-physical illness
-recent loss/ death
-family history

Therapeutic relationship
● Focus on client and the needs and goals of said client
● Main attributes: acceptance, genuineness, non judgmental, respect, empathy
Transference- displacement of feelings for significant people in a client’s past onto the NP
Countertransference- NP emotional reaction to client based on a situation/ person in her past

Substance Use
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar): used to assess alcohol
withdrawal
Treatment starts when score is greater than or equal to 8- start with PRN only
If total score is 15 or higher client will receive scheduled medication and PRN medication
Scheduled meds: Ativan, Librium

Medications to help prevent alcohol relapse:

Acamprosate ( campral)
Disulfiram (Antabuse)
Naltrexone ( Vivitrol)

-acamprosate and naltrexone reduce alcohol consumption and increase abstinence rates

Disulfiram
-aversion therapy for alcohol use disorder
-should not be taken for at least 12 hours after drinking alcohol
-wait 2 weeks before using anything that contains alcohol when discontinued
-monitor LFTs

Signs and symptoms of alcohol withdrawal:

-tremors
Paroxysmal sweats
-tactile disturbance
-headache
-visual hallucinations
-nausea
-Vomiting
-anxiety
-agitation

Clinical Opiate Withdrawal Scale (COWS)- used for opioid withdrawal

Mild: 5-12= PRNs examples: clonidine, Imodium, Zofran

Moderate: 13-24 = scheduled and PRN

Examples of scheduled medications: Suboxone, Subutex, Methadone

Methadone can cause cardiac arrythmias so use other options if possible

Signs and symptoms of opioid withdrawal:

Yawning
Irritability
Pupil dilation
Anxiety
Piloerection
Muscle aches
Lacrimation
Rhinorrhea
Sweating
Insomnia
GI upset

KNOW ANXIETY AND DEPRESSION SCALES

Mild depression- therapy only

Neurocognitive Disorders

Delirium
-acute onset, usually associated with an illness ( UTI)
-altered level of consciousness
-inattention
-changes in cognition
-Poor prognosis- 1 YEAR MORTALITY RATE
Management- focuses on symptomatic treatment

Agitation and psychotic symptoms- start on antipsychotic ( Haldol, atypical antipsychotic)

Insomnia- anxiolytic
Avoid Benzodiazepines because they prolong delirium except for alcohol withdrawal
Monitor for safety
Pay attention to basic needs
Have clients room with familiar objects, people, decorations, clock, calendar, photos

Dementia
-group of disorders characterized by gradual development of cognitive deficits
-impaired executive functioning
-impaired global intellect
-impaired problem solving
-altered memory

Dementia of Alzheimer’s type- gradual onset, most common

Cortical dementia- memory and language mostly affected

-language effected
-memory impairment
-aphasia
-slurred speech
-amnesia

Subcortical Dementia- motor symptoms

-EPS
Dystonia
-increase muscle tone
-incoordination
-depression
Apathy
Dementia due to HIV- type of subcortical dementia

Early signs- cognitive decline, decrease concentration, decrease attention, motor abnormalities,
behavior abnormalities

Late signs- global cognitive impairment, mutism, seizures, hallucinations, depression, apathy,
mania

Lewy Body disease/ dementia

-recurrent visual hallucinations
-Parkinson features ( bradykinesia, cogwheel rigidity, tremors)
-adversely react to antipsychotics

Vascular dementia
-carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers
-most common in men with preexisting high blood pressure and cardiovascular risk factors
Pick's Disease
● Frontal lobe dementia/ frontotemporal dementia
● Common in men
● Personality, behavioral, and language changes in early stages of disease
● Cognitive changes in later stages of disease

Huntington's disease
-subcortical dementia
-motor abnormalities
- increase in incidence of depression and psychosis
Cause: cerebral atrophy and enlarged ventricles in dementia Alzheimer’s type
-decrease acetylcholine and norepinephrine
-family history
Psychosis and agitation in dementia
● Try nonpharmacological first
● Use antipsychotic agents for agitation and psychosis
● Use lowest dose and attempt to wean periodically
● Benzodiazepines should be avoided!!!

Levels of Prevention
Primary – decrease incidence of mental health disorders Example: stress management for
college
Secondary- aimed at decrease prevalence of disorders example: crisis hotlines, disaster
response
Tertiary- decrease the disability and severity of a mental illness example: rehab services

Tolerance- decreased effect of same dose of drug overtime

Kindling- seizure threshold is lowered, tendency of some regions of the brain to react to
repeated low levels of bioelectrical stimulant by progressively boosting synaptic discharges

Addiction- compulsive substance use despite consequences

Potency- amount of drug required to produce effect of given intensity

ADHD
Children must have at least 6 inattentive symptoms
Children must have at least 6 hyperactive symptoms

Dopamine, serotonin, and norepinephrine deficiency

Etiology- frontal cortex, basal ganglia, and reticular activating system.

Prefrontal cortex- regulates attention and executive function especially inattention
Dorsolateral Prefrontal cortex- regulates executive function, cognitive process, working memory,
problem solving, attention

Pharmacological management
-assess cardiac function and cardiac history prior to starting
-stimulants
-amphetamines approved in children 3 years and older
-methylphenidate approved in children 6 and older
-alpha agonist/ alpha 2 adherence example: Guanfacine (6-17 yrs old) Clonidine (6-17 yrs old)

Non pharmacological management

-behavioral therapy
-patient and parent cognitive behavioral training
-treat underlying learning disability

Signs and symptoms of stimulus abuse

-insomnia, tremors, agitation, anxiety, mood swings

Follow up care
-monitor clinical progress
-monitor growth and development
-Vanderbilt ADHD diagnostic scale
-Conner’s Parents and Teachers Scale

Borderline personality disorder

-impulsivity with self-damaging behaviors
-identity disturbance
-recurrent suicidal behavior
-chronic feeling of emps ness
-inappropriate or intensified anger
-efforts to avoid real or imagined abandonment
-unstable intense interpersonal relationships

Treatment:
SSRIs- used to treat impulsivity and suicidality in BPD
-Dialectic Behavioral therapy – Goal is to decrease self-damaging behaviors

Antisocial Personality Disorder

- Reckless disregard for the welfare of others
- Lack of remorse , indifference of feeling of others
- Disrespectful, lying
- -CAN'T DIAGNOSE UNTIL 18 years old
- In children it would be conduct disorder

Retts Syndrome
-Normal , active from birth until about 5-7 months old , then followed by development of specific
deficits such as :
-seizures, loss of purposeful hand skills, stereotypical hand movements, deceleration of head
growth
-typical in girls

Disruptive mood dysregulation disorder

-childhood depressive disorder
-must be older than 6 years old but less than 18 years old
-frequent intense anger outburst for no reason
-anger, severe irritability
Treatment- mood stabilizers

Intermittent explosive disorder

-involves repeated sudden episodes of impulsive, aggressive, violent behavior or angry verbal
outburst
-patient reacts grossly out of proportion to situation
-show remorse
Treatment: SSRIs, mood stabilizers, antipsychotics, cognitive behavioral therapy

Depression
-dysregulation of one or more -à dopamine, norepinephrine, serotonin
SIGE CAPS
-sleep disturbances
-interest reduced
-guilt self-blame
-energy loss/ fatigue
-concentration problems
-appetite changes
-psycho motor changes
-suicidal thoughts

-when patient is 65 years or older more likely to have concentration problems so do a cognitive
screening
-cognition and memory problems in older adults with Major depressive disorder are commonly
confused with dementia

Pseudo dementia- when adults present with cognitive and memory problems it can be
mistaken for dementia but is really MDD
Patients with dementia usually have a premorbid history of slowly declining cognition
In MDD cognitive changes have an acute onset and are significant when compared to
premorbid function

Pseudodementia:
-rapid progression
-sudden onset
-presence of insight
-provides general responses example: I don’t know ---dementia has lack of answers
-no night changes
-depressed mood

Management of Major Depressive Disorder

-antidepressants take 4-6 weeks
-need to continue them for 6-12 months
-antidepressant rebound is common if stopped abruptly

First line treatment

-SSRI- selective serotonin reuptake inhibitor
-serious side effects are rare
-much safer in overdose- less likely to cause heart arrythmias
- cause the 3 Ss side effects: sexual dysfunction, severe GI upset, and Serotonin syndrome

2nd Line
-TCA, MAOI
-EKG changes and dysrhythmias are more possible
-avoid with history of cardiac issues
-avoid abrupt withdrawal
-avoid with high risk suicide

Black box warning with all antidepressants about increasing suicidal thoughts

Nonpharmacological
-ECT
-Transcranial magnetic stimulation
-Cognitive behavioral therapy- increase sense of control, decrease negativity, and increase
coping skills, modify perception

Bipolar disorder
DIG FAST

D- distractibility
I – impulsivity
G – grandiosity
F – flight of ideas, racing thoughts
A – activities, psychomotor agitation
S – sleep disturbances, decrease need for sleep
T – talkativeness

Neurotransmitters involved in Bipolar- GABA, Dopamine, Serotonin, and Norepinephrine

It is important to rule out Bipolar disorder when diagnosing MDD because antidepressants can
cause mania

Treatment:
Lithium- neuroprotective treatment for bipolar, has a 2 week onset

Lamictal- Bipolar depression

Olanzapine- in combination with Prozac ( Symbyax) FDA approved for Bipolar depression

Lurasidone – Bipolar depression

Bipolar Mania- quetiapine ( Seroquel) and Lithium – WHY? Seroquel has faster onset

Non pharmacological
-Cognitive behavioral therapy
Behavioral therapy
Interpersonal therapy
Support group therapy

ECT
-used to treat MDD with psychotic features and treatment resistant depression
Contraindications
-cardiac disease, compromised pulmonary status

Adverse effects – cardiac, systemic (brain tumor), cognitive (stroke, memory loss), and fractures
( uncommon)

Thyroid
-When T3 and T4 are high, TSH is low= hyperthyroidism
-When T3 and T4 are low, and TSH is high= hypothyroidism

Normal levels
Free Thyroxine (T4) (0.8-2.8)
TSH (0.5-5.0)
Hypothyroidism
-mimics symptoms of unipolar mood ( depression)
-confusion
-decreased libido
-impotence
-weight gain
-decreased appetite
-lethargy
-headaches
-sensitive to cold
-constipation

Hyperthyroidism
-mimics mania
-motor restless
-compulsive movement
-tremor
-insomnia
-weight loss
-irritability
-sensitive to heat

Hepatic
Normal range:
AST: 5-40
ALT: 5-35

Liver disease related to alcohol you will see ALT is twice as high as AST. Also can happen post
myocardial infarction

Lab Findings in Alcoholic

-elevated: glutamyl transferase, mean corpuscular volume, prothrombin time, uric acid, total
cholesterol, triglycerides
-decreased: magnesium, calcium, potassium, hemoglobin and hematocrit, platelet count,
albumin

Oppositional Defiant Disorder

-enduring pattern of angry irritable mood and argumentative defiant and vindictive behavior

Criteria- behavior must last at least 6 months and client must have at least 4 of the following
symptoms:
-loss of temper
-touchy/ easily annoyed
-doesn’t comply with authority
-blames others
-no aggression !!
-deliberately annoys others
-spiteful/vindictive

Nonpharmacological management
-individual therapy
- family therapy with emphasis on child management skills and parent training
-Adolescent transition program

Conduct disorder
-aggression toward people and animals
-violation of social norms
-start fights
-destruction of property
-theft
- lies
-forces sexual activity
-LACK OF REMORSE FOR ACTIONS
-Diagnosed ages 6-17 years old

Treatment
-target mood and aggression
Aggression/agitation- antipsychotic
Mood stabilizers- SSRIs, alpha agonists (clonidine, guanfacine)
Behavioral therapy
Family and individual therapy

Conversion disorder
-person has blindness, mutism, paralysis, parathesis not explained by medical evaluation
-symptoms begin after a stressful experience

Factitious disorder- external agents that mimic disease. Person causes themselves to be sick
or injured

Adjustment disorder
-emotional/ behavioral reaction to stressful event or change
-reaction is considered unhealthy or excessive in response to event
-occurs within 3 months of stressor

Grief and Loss

-unlike MDD self-esteem is usually preserved in grieving person
-involve normative emotional, cognitive, and behavioral reactions to death and loss
Management:
-offer psychoeducation on grief reaction
-encourage expression
-support groups

Post-traumatic stress disorder

-reexperiencing of extremely traumatic event accompanied by symptoms of INCREASED
AROUSAL, AVOIDANCE, NIGHTMARES, FLASHBACKS

Treatment:
Prazosin for nightmares ( need to monitor BP)
Cognitive behavioral therapy
EMDR
Exposure therapy
Support group
SSRI and TCA
Benzodiazepines= NO!!

Obsessive compulsive disorder

-presence of anxiety- provoking obsession/ compulsions that decrease anxiety
Risk Factors- first degree relative

Treatment
-SSRIs usually need higher dose
-2nd generation antipsychotics and SSRI in combination
-TCA (Clomipramine)
-CBT and exposure therapy

PANDAS- pediatric acute-onset neuropsychiatric syndrome

-autoimmune disorder associated with streptococcal infections
-should be considered when sudden onset of OCD symptoms
- assess if child has had strep throat recently

Tourette’s Syndrome
● Two motor tics and one vocal tic that have been present for at least a year not
necessarily at the same time
● Tics may wax and wane
● Neurotransmitters involved- Dopamine, Serotonin, and norepinephrine
Treatment
-Atypical antipsychotics- FDA approved Haldol, Pimozide, Abilify
-Clonidine and Guanfacine can help with behavioral symptoms and rage attacks
-Prozac helps with anxiety and sadness
-CBT
-Behavioral therapy
-Deep Brain Stimulation
-NO STIMULANTS IN TIC DISORDERS!!

Variance- any event that alters patients progress toward their expected outcomes
Sources: provider behavior, severity of illness, practice patterns that inhibit/ expedite care

Schizophrenia
Age of onset:
18-25 years for male
25-35 years for female

Neurodevelopmental etiology
-Genetic defects:
Inadequate synapse formation
Excessive pruning of symptoms
Excitotoxic death of neurons

Intrauterine insults:
Prenatal exposures to toxins: viral, oxygen deprivation, maternal malnutrition

Positive symptoms
-Delusions, hallucinations, mania, hostility, disorganized behaviors, suspiciousness

Negative Symptoms
-flattening, alogia or poverty of speech, avolition, attention deficits

Neurobiological effects:
-Enlarged cerebral ventricles
-Everything else is decreased

Alterations in neurotransmitters
-excess dopamine in mesolimbic pathway
-excess glutamate
-decrease in GABA and serotonin

Preventative care for when patient is on antipsychotics

-monitor routine lab
-serum glucose
-lipid panel
-weight
-waist circumference
-liver function
-kidney function
-BMI
-CBC
-annual eye exam for atypical antipsychotics especially Seroquel

Non-Pharmacological
● Individual therapy
● group therapy
● Assertive community treatment
Clozaril- only antipsychotic that can reduce risk of suicide in schizophrenia

Schizoaffective disorder- psychotic symptoms usually continue in the nascence of prominent

mood symptoms ( Depression, bipolar)

Geodon- less likely to cause weight gain

2nd generation- cause weight gain ( olanzapine, clozapine, quetiapine, risperidone)

GALS- gals don’t like to gain weight

Geodon, Abilify, Lutuda- less likely to cause weight gain

Legal and Ethical

Scope of Practice
-determined by State legislative/ Board of Nursing
-Defines NP role
-Identifies competencies
-varies state to state

Standard of care
-determined by ANA
-PMHNP required by law to carry out care in accordance with what a reasonably prudent nurse
would do in the same situation
-provide way to judge nature of care provided
-legally describe care that must be provided consistent with established standards

Confidentiality
-clients rights to assume information given to provider will not be disclosed
-Two separate releases of information is needed for patients with Mental Health and Substance
Abuse
-Need informed consent to involve third party person , HIPAA does not allow

Exceptions to confidentiality
-information given to attorneys in litigation
-records for insurance
-court order
-meeting state requirements for mandatory reporting
-harm to self or others

Tarasoff Principle
-Duty to warn potential victim of imminent danger of homicidal client
-doesn’t apply in every state so need to check with state Board of Nursing

Informed consent
-process between provider and patient that results in client’s acceptance or rejection of
proposed treatment plan
-explanation of relevant information
-all adults and emancipated minors receive informed consent

Elements of informed consent

-decision capacity- ability to make decisions
-competency- legal term, not medical. Can clients make reasonable judgment regarding
treatment?

Disclosure- providers should disclose information on treatment, test, procedures including

expected benefits, risks, and likelihood they will occur

Comprehension- should be able to understand. Voluntarily give consent.

-provider must document in record informed consent
-if patient not able to – family, surrogate, court appointed guardian

Ethical Principles
1. Justice- doing what is fair in all aspects of care despite social/financial status
2. Non maleficence- doing no harm. IMMINENT DANGER is keyword
3. Beneficence – promote well being
4. Veracity- tell the truth about condition
5. Fidelity- being true and loyal- say you'll call them in 5 minutes and do it
6. Autonomy- doing for self. Allow patients to self determination. Allow NP to respect and
support patients decision
7. Respect- treat everyone with respect, used preferred pronoun

Case management
-system of controlled oversight and authorization services and benefits that are provided to
client consisting of coordination of care, monitoring plan of care, and advocacy

GOAL: promote quality cost effective outcomes

Stark Law- not allowed to refer a family member for treatment of your patients, seen as fraud

Research
PICOT:
Problem
Intervention
Comparison
Outcome
Time

Levels of evidence

Level 1
-evidence from systemic review or meta-analysis of ALL relevant random controlled trials or
evidence based practice guideline based on systemic review of RCT that have 3 or more good
qualities that have similar results

Level 2
-evidence obtained by at least 1 RCT

PMHNP interventions follow evidence based practice guidelines are always goal directed and
take into account clients ethnicity and culture

Key part of PMHNP work is to use empirical evidence in education client, families, and
communities about mental health

Education is the most effective way to decrease stigma – want to reach the largest audience
If you see literature search in question it means evidence based

Health Policy
4 Components of Health Policy:
1. Process- formulation, implementation, and evaluation
2. Policy reform
3. Policy environment
4. Policy makers – key players and stakeholders
Assess before meeting with stakeholders
You can implement change in policy without obtaining funding first

Patient Advocacy
-Help patient receive available services
-reduce stigma of mental health
-ensures patients autonomy and self-directedness
-promotes mental health by participating in organizations ( ANA, APNA, ISPN)

Just Culture- seeks to create and environment that encourages individuals to reports mistakes
or precursors to errors so that they can be better understood in order to fix
In just culture individuals are learning and designing a safe system and managing behavioral
choices
Holds people accountable for their behaviors and investigates errors

Habeas Corpus- person can report an unlawful hospitalization to court for the court to
determine whether it was required

American Disability Act of 1990

-prevents employees from discriminating against individuals with mental health disorders
-law mandates that reasonable accommodations are made

Quality Improvement – designed to improve the system, decrease cost, and improve
productivity. PLAN, DO, STUDY, ACT

Retrospective chart review- review quality initiative

Retrospective audit- go back and review charts of discharged patients that have already been
submitted

Reflective practice- review to improve practice

Failure modes and effective analysis- proactive method to identify what is most in need of
change

Root cause analysis- describe wide range of approaches, tools, and techniques used to uncover
cause of problem

Core competency- ability to practice nursing that meets clients needs by using logical thinking
and accurate nursing skills

Force field analysis- looks at forces either driving or blocking movement toward a goal

Risk Analysis- ongoing process that should provide an organization with a detailed
understanding of its risks and information necessary to address those risks in a timely manner

Patient centered care model

-understand education level, health, family patterns, and situation, traditions
-provide interpreter
-understand and consider culture

Erikson’s stages
1. Trust v mistrust
Birth to 1 year
Ability to form meaningful relationships, trust in others, and hope in future
 2. Autonomy v shame and doubt
1-3 years early childhood
-self control, self esteem, will power, sense of control/ adequacy

3. Initiative v guilt
3-6 years late childhood
-self directed behavior, goal formation, sense of purpose, ability to be a self-starter

4. Industry v inferiority
6-12 years school age
Ability to learn how things work, to understand, to organize. Ability to work, sense of
competency, and achievement
Unfavorable- lead to sense of inferiority

5. Identity v role confusion

12-20 years old, adolescence
-personal sense of identity, uniqueness

6. Intimacy v isolation
20-35 years old early adult
-committed relationship, capacity to love

7. Generativity v stagnation
35-65 years, middle adulthood
-able to care for others, able to give to others, and concerned for family and society. Parenting

8. Integrity v despair
Older than 65 years , late adulthood
- A sense of integrity, fulfillment and comfort in life, willingness to face death, balance life
events

Piaget’s stages

1. Sensorimotor ( 0-2 yrs)

-master object constancy and performance
Example- 2 year olds mom goes to work child won't cry because knows mom is coming back
2. Preoperational ( 2-6 yrs)
-uses language, symbols, words, and magical thinking

3. Concrete operational (7-11 yrs)

-able to understand conservation, reversibility, and egocentricity
Example: take water and freeze it and you get ice
 4. Formal operational (12- adult)
-abstract thinking, uses logic, idealistic, think like a scientist
Example- add and subtract, solve algebra, do a science project

Freud's psychosexual stages

Birth to 1 year= oral stage

Mouth is pleasure center

1 -3 years = anal stage

Bowel and bladder control

3-6 years= phallic stage

Genitals, play with genitals is normal at this age

6-puberty= latent stage

Libido inactive

Puberty- death = genital stage

Maturing sexual interest

Ego boundaries – concept of individuals are able to distinguish between self and not self

Idealization- way of coping with anxiety or ambivalence. Viewed as perfect or having

exaggerated positive qualities
Devaluation- person has negative qualities about themselves or objects

Motivational interviewing (p. 46)

-Builds on transtheoretical model of change
-asking open ended questions
-empathetic approach
-affirmations of patient’s positive traits
-reflective listening techniques
-non confrontational
-focus-goal directed therapy

Transtheoretical Model of Change

1. Precontemplation stage – person has no intention to change

1. Action step- provide information and feedback to raise the person's awareness of
problem and possibility of change. Don’t give prescriptive advice
2. Contemplation- person thinking about change is aware there is a problem but not
committed to change
 1. Action step- help person see benefits of change and consequences of not
changing
3. Preparation- help make steps for changes , person has decided to change
1. Action step- help find a change strategy that is realistic, acceptable, accessible,
appropriate, and effective
4. Action- person engaging in actual change
1. Action step- support, be advocate for patient
5. Maintenance- person is engaging in behavior to prevent relapse
1. Action step- help identify the possibility of relapse and what strategies are to
prevent that
6. Relapse- when was your last relapse, what led you to relapse, always assess!
1. Action step- help person holistically look at situation

TYPES OF THERAPY

Cognitive therapy- created by Aaron Beck (p.125)

Goal is to change client’s irrational beliefs, negative thoughts, faulty conceptions, and negative
cognitive distortions

Behavioral therapy (p. 126)

Focuses on changing maladaptive behaviors by participating in active behavioral techniques:
exposure therapy, problem-solving, role playing, and modeling

Dialectical Behavioral Therapy- created by Marsha Linehan

Used for Borderline Personality Disorder
GOALS: decrease suicide behavior
Decrease therapy interfering behavior
Decrease self-invalidation
Decrease emotional reactivity
Increase realistic decision making

Existential therapy (p.126)

-emphasizes accepting freedom and making responsible choices
-focus on the present and on personal responsibility
-understand patient’s subjective experiences

Humanistic therapy (p.126)

-Created by Carl Rogers
-Person- centered therapy
-concepts include self- directed growth and self-actualization

Interpersonal therapy (p. 127)

-focus on interpersonal issues that are creating distress
-goal is to help identify and modify interpersonal problems, to understand and manage
RELATIONSHIPS

EMDR - Eye movement desensitization and reprocessing

-form of behavioral and exposure therapy
-used in PTSD
-achieve adaptive resolution

Three phases of EMDR (DIB)

1. Desensitization phase
1. Client visualizes trauma, verbalizes negative thoughts of maladaptive behaviors
and remains attentive to physical sensations
2. Occurs for a limited time while client maintains rhythmic eye movement
3. Instructed to block out negative thoughts, breath deep, then verbalize what
thinking about, feeling, imagining
2. Installation phase
1. Client installs and increases strength of positive thoughts that are declared as
replacement of original negative thoughts
3. Body scan
1. Client visualizes the trauma along with positive thought and then scans his/her
body mentally to identify any tension in them

Biofeedback- used for stress related symptoms- pain, anxiety, insomnia

-Process providing a person with visual and auditory information about autonomic physiological
functions of his/her body such as blood pressure, brain, muscle tension

Family Therapies

Family Systems Therapy/ System Family Therapy (p.130)

-focus on chronic anxiety in families
-helps increase levels of self- differentiation
-Triangles/Triangulation/ Self-differentiation

Structural Family Therapy (p.130)

-type of family therapy that assess the subsystems, boundaries, hierarchies, and coalitions
within family and focuses on direct interaction between family members as primary method of
inducing positive change
-Main goals is to produce a structural change in the family organization to more effectively
manage problems
-GENOMES/HIERARCHIES

Experiential Therapy ( p.130)

-behavior is determined by personal experience and not by external reality
Strategic Therapy ( Paradoxical Strategic therapy)
-interventions are problem focused and symptom focused
-Uses paradoxical directives: a negative task that is assigned when family members are
resistant to change and member is expected to be non-compliant
Example: Worry really hard for 1 hour a day , and wont do it
-uses straightforwardness: tasks that are designed in expectation of family member compliance
-uses reframing belief systems: problematic behaviors are related to have more positive
meaning

Solution-focused therapy (p.131)

-focus on reworking situations that have previously worked for present situation
-uses miracle questions- “ if a miracles were to happen and your problem no longer existed”
-exception-finding questions
-scaling questions (0-10)

Acupuncture – used for pain and depression

Defense mechanisms- know with examples

Projection- you might hate someone but in your mind you tell yourself that the person hates you
because you know such hatred is unacceptable

Displacement- someone who might be frustrated at boss goes home and yells at their husband

Sublimation- redirecting unacceptable feelings into acceptable change

Example: mother of child killed by shooting tries to change gun laws

Intellectualization – concentrating on intellectual aspects to avoid emotional aspects of a difficult

situation
Example: patient diagnosed with cancer starts researching and learning about cancer

Rationalization- an attempt to logically justify generally unacceptable behaviors

Repression- involuntary ,
the action or process of suppressing a thought or desire in oneself so that it remains
unconscious

Suppression- voluntary

IRVIN YALOM( p.128)

Adverse childhood experiences (ACEs)

-potentially traumatic events that occur in childhood (0-17yrs)

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M.
P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many
of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
American journal of preventive medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-
3797(98)00017-8

Study found a relationship between adverse childhood experiences and the presence of adult
diseases including ischemic heart disease, cancer, chronic lung disease, skeletal
fractures, sexually transmitted disease, alcoholism, diabetes, unplanned pregnancy,
eating disorders, and liver disease.

Trauma informed care

-sexual, physical, psychological
-used if lived with person who was an alcoholic, had mental illness, committed suicide, mother
threatened violence, or member of household in prison
-memories buried in amygdala – need to induce arousal

Biopsychosocial framework of care (p.37)

Recovery model
-treatment approach which does not focus on full symptoms resolution but emphasizes
resilience and control over problems and life
-recovery model aims to help people with mental illness and distress look beyond mere survival
and existence
-supports view that they should get on with their lives and do things to develop relationships that
give life meaning
-recovery is not about “getting rid” of the problem but seeing beyond a person’s mental health
problems, recognizing, and fostering their abilities, interest, and dreams
-self direction
-individualized and person centered
-nonlinear- recovery is not a step-by-step process but one based on continual growth,
occasional setbacks, and learning experiences

Four dimensions of recovery

-health
-home
-purpose
-community

Assertive Community Treatment (ACT) (p.254)

-used for schizophrenia
-intensive integrated approach to community mental health services
-mental health services provided in community setting rather that more restrictive residential/
hospital setting for people with severe mental illness
-Primary goal: help people become independent and integrate into community as they
experience recovery. Reduce reliance on hospitals. Provide around the clock services.
-Treatment is centered around patient’s personal strengths, needs, and desires for future.
-ACT follows holistic approach for treatment

Other Important Information- Review the week of exam!

-When interviewing teenagers try to develop a therapeutic relationship. Tell them that what they
say is confidential but let them know the exceptions to confidentiality.
-Have parents sit in waiting room while interviewing them
-If dating someone their age no need to tell parents

-Culturally expected response to a stressor does not mean someone has a mental illness
-do a cultural assessment- what do these symptoms mean in your culture
-Cultural syndrome: something expected in that culture
-Offer BRIEF SUPPORTIVE THERAPY: can also be used if patient recently lost a job

Native Americans- believe mental illness is cause by imbalance of relationship with self and
world
They use healing sticks- let them keep these if in hospital
Highest rate of suicide
May want to integrate a traditional healer into treatment- you must have them sign a release of
information and get informed consent clearance

Providing an interpreter is culturally competent care

Education mental health in the community and people are of different ethnicity you need to
provide multicultural education and use ethno specific assessment parameters

Abilify is least sedating antipsychotic

Lamictal- mood stabilizer that causes the least weight gain

Interprofessional collaboration is encouraged “plan patient care” “call patient’s provider”

Completing a medical evaluation for a patient is out of scope of PMHNP practice

Patient goes to the ER during mental health intake- need to complete mental health assessment
in the ER, call ER

Important to know TSH range (0.5-5.0)

Valproic acid/Depakote can cause: spina bifida in babies , hepatotoxicity

-Can lead to disorientation, lethargy, confusion because ammonia levels can rise so check
ammonia levels, LFTs, and Depakote levels

Herbal Supplement KAVA KAVA can also cause hepatotoxicity so need to check LFTs. Also is
used for anxiety and insomnia so should not use if on benzodiazepines due to sedation risk.

TCAs can also cause hepatotoxicity

Lamictal- steven Johnson syndrome, severe rash, sudden onset of fever

Carbamazepine/Tegretol- can cause Steven Johnson Syndrome in Asian population so need to

screen for HLAB-1502 allele
Tegretol and Clozaril- can both cause agranulocytosis. Need to check ANC and discontinue at
less than 1,000. Monitor for signs of infection: sore throat, fever, chills, fatigue

Need to check a pregnancy test on every woman of child bearing age that is on a mood
stabilizer – HCG

Lithium- (0.6-1.2)
Toxicity at levels 1.5 and above
Signs/symptoms of toxicity- tremors, palpitations, mental cloudiness, severe GI upset, muscle
weakness, coarse hand tremors
Can cause Ebstein anomaly so don’t give in 1st trimester

Lithium can cause- hypothyroidism, increase white blood cell count, T wave inversion,
maculopapular rash, GI upset

Labs needed for lithium- TSH, creatine, BUN, urinalysis (check for protein in urine, normally
should not have protein in urine)
Lithium is neuroprotective treatment for Bipolar disorder, it is gold standard especially for manic
episodes and to decrease suicidal ideations

If a patient that is on Lithium says they will drink a lot of water and pack extra water on a hiking
trip this shows good understanding because lithium can affect sodium levels

Clozaril- best medication to decrease suicidal ideations in schizophrenia

Triptans (Sumatriptan) can cause serotonin syndrome so if patient is having migraines suggest
they use something else

If a patient has cancer and suffers from depression use escitalopram because less potential for
drug to drug interaction

It is important to assess every patient on SSRI for suicidal thoughts and self-harm thoughts but
especially important to assess a 16 year old that is on SSRI

Patients with schizophrenia have a very high risk of suicide more than someone with autism and
eating disorders
It is not recommended to give patients with schizophrenia stimulants because they potentiate
the dopamine release and increase positive symptoms

Assertive community treatment is used for patient with schizophrenia who have long history of
non-compliance

Social skills training is tertiary level of prevention

Refer schizophrenic patient to do exercise, specifically aerobics to improve cognition, quality of
life, and overall health

Abstraction- assess by having patient interpret a proverb

EPS is caused by increase acetylcholine and decrease dopamine

Risperidone can increase prolactin levels and cause breast discharge, normal levels: male less
than 20, female less than 25

Acute dystonia- painful, stiff neck, spasms, give Cogentin (benztropine)

Tardive dyskinesia- Reglan can cause TD, so discontinue Reglan if start with symptoms

Cigarette smoking can decrease levels of Clozaril so patient will need an increased dose of it

Erythromycin and clarithromycin can cause high levels of Tegretol

Accutane can cause birth defects

Steroids can cause psychosis so might need to increase antipsychotics

Neurotransmitter responsible in addiction are GABA and dopamine

Anorexia- you can have pain and bloating after eating. Can be caused by delayed gastric
emptying.

Antacids such as protonix and omeprazole can decrease absorption of psychotropic

medications so need to wait 2 hours after taking antacid before taking psych medications

SSRIs can cause increase anxiety in older adults

Paradoxical effect- give benzodiazepine to calm a patient down but causes opposite effect

Apoptosis- neuronal loss/ cell death

A patient has a genetic test done and shows that she is a carrier of a particular genetic variant it
can increase their risk of bipolar disorder
A pregnant client has bipolar disorder and does a genetic test on baby and it shows genetic
variant, baby can have increase risk of Bipolar

If patient presents with bipolar symptoms after the age of 45 years old suspect a medical illness
causing symptoms
Depakote is used for a patient with borderline personality disorder that is having mood swings

Patient with borderline personality disorder must journal and keep a diary in order to establish
BPD diagnosis

Adjustment disorder- occur as result of stressful experience, present with depression, anxiety,
or mixed depression and anxiety

Adjustment disorder with mixed disturbance of emotions and conduct- common in kids. Recently
moved out of state/ recent divorce, always crying, fighting, insomnia, truancy

Reactive attachment disorder- common in foster kids. Child comes back to live with biological
parents and is withdrawn, shows no emotion to them

ODD- defiant but show no aggression. Treat with family therapy with child management skills.
Set boundaries and give positive reinforcement

Clonidine – need to monitor blood pressure

Acute stress disorder- last less then 1 month

PTSD- last longer than 1 month

If patient comes in and says they just got out of the war and saw best friend killed and want to
start with psychotherapy- you need to assess first

Panic disorder- multiple panic attacks, feeling of impending doom

Tourette’s- dopamine(Hyperactivity), norepinephrine, and serotonin

It is normal for young children to have tics- as long as they don’t meet criteria they should
disappear into adulthood. Need to know if child is on stimulant because stimulants can cause
tics

ADHD-neurotransmitters involved- Dopamine, norepinephrine, serotonin

Brain- frontal cortex, basal ganglia, reticular activating system
Prefrontal cortex- regulates attention and executive function especially inattention

Client is at school and notice ADHD medications are wearing off, may need multiple doses
throughout the day

OCD- tic could be compulsive behavior

Treatment of OCD- children= Prozac
Adult= SSRI Zoloft, TCA clomipramine
PANDAS- recent strep throat think this

Nightmares in childhood need to assess can be genetic

Generalized anxiety disorder- have to last at least 6 months

UTI- can cause delirium in older female patient

Haldol- atypical antipsychotic for psychosis

Dementia- can lead to personality changes and irritability. Check vitamin B12 and folic acid
levels can cause memory problems

IV drug user presents with dementia symptoms need to do a HIV test

Treatment for HIV dementia- antiretrovirals

Autism- impaired social communication, poor social interaction, don’t respond when called by
name, no eye contact. Like to organize toys in long tidy rows and stack them up

Broken mirror theory of autism- mirror neuron dysfunction that’s why they have poor social
interaction/cognition

Anterior cingulate- cognitive functions, empathy, impulse control, decision making

Infant is about to die- give infant to parents to grieve

Osteoporosis risk factors- smoking, caffeine, lack of exercise, lack of diet rich in calcium and
vitamin D

Non-compliant with follow up care get involved, organize other ways to receive treatment
(example: outpatient clinic)

Group therapy- patient doesn’t feel comfortable to disclose problems in group therapy have
them continue group therapy and promote interpersonal learning but also offer individual
therapy

Cognitive therapy- help replace irrational thoughts with positive thoughts

Behavioral therapy- use techniques such as exposure therapy, problem solving, skills training

CBT- a patient is having negative thoughts tell them to write down the negative thoughts

Family systems therapy- self differentiation, triangles, triangulation

Interpersonal therapy- if patient has a lot of interpersonal issues affecting socialization and
relationships . lasts 12-16 weeks, used for marital conflicts

Meditation- uses muscle relaxation

When communicating with clients, convey empathy, use open ended questions. “ How has this
affected you?”

Closed ended questions- used when interviewing a child who can’t construct a narrative. Then
ask parents for clarification.

Have an appointment with a couple and only one person shows up need to reschedule for when
both parties can be there

Client moving out of state- give enough medication so they can establish a new provider

A mother calls you and says her 10 year old got raped by older brother, tell her not to leave the
10 year old alone with brother. Provider needs to contact CPS and set up crisis counseling

Rheumatoid arthritis- check ESR level

Evidence based care- read current journals

Level 1- systemic review or meta-analysis of many RCTs

Level 2- at least 1 RCT

Child presents with a shrill cry- suspect increased intracranial pressure

3-6 years old it is normal to play with genitals

It is normal for 9-16 year old boys to get tenderness and swelling under nipples- should
disappear in 6 months

Testosterone is involved in sex drive, decrease levels=decrease sex drive. Older people have
decrease levels of testosterone

Alcohol dehydrogenase- metabolizes alcohol. Women have decrease levels compared to men
so more likely to get drunk and have liver disease

Normalize grief response in children. Don’t tell them what to do or how to grieve. Offer inter
family system therapy and supportive group therapy

After care plan starts upon admission

If parent is anxious about teaching stop teaching and acknowledge anxiety before continuing

Normal reflexes and time frames:

Grasp/palmer = 5-6 months
Moro/startle= 5-6 months
Babinski/plantar= 2 years old

PDE5- medications for sexual dysfunction rapidly absorbed- short absorption (Viagra)

Anorexia – low BMI , not medically stable need to send to hospital for evaluation. If parents
refuse, they need to report to CPS.
Bulimia- will have normal BMI

You are reading a journal about ADHD and how patients with ADHD have higher substance
abuse risks. How would you apply this to practice? Screen all children with ADHD for substance
abuse

Adolescent reports feeling weird- can do a UDS

Acupuncture- used for pain and depression

Habeas corpus- protects against unlawful hospitalizations

Substance induced psychosis= increase risk of homicidal behavior

Disseminated encephalomyelitis- nervous system is affected , ASYMMETRICAL body

movements , complete a neuro exam

A patient can’t remember a specific timeline of events and ask questions to anchor their
memory. Example: What happened around your 20th birthday

Before starting on a medication first assess what a patient knows about medication before
educating them

Iatrogenic/ adverse effects- started patient on antipsychotic medication and develop tardive
dyskinesia could be considered Iatrogenic.

Assess what medications patient are taking and what have taken before

Advocating for policy change and need information from multiple nurse practitioners- post online
form/survey

Disclose benefits of policy change and how it is going to improve patient care
Trying to improve quality care at an outpatient clinic- develop instrument that can monitor
clinical outcomes

Autoimmune disorder- increase cytokine levels

Desmopressin- used for enuresis, reduces production of urine

-first try nonpharmacological treatment such as alarm clock

Started patient on medication can they call saying there is a new black box warning for it- you
need to research it before telling them to discontinue med

Risk factors for sleep apnea: excess weight, obesity, diabetes, smoking

Scales- Know moderates!

MMSE

Hamilton Depression Rating Scale (HAM-D)

PHQ-9
Beck

GAD
HAM-A

COWS
CIWA

If patient is withdrawing from alcohol and needs medication use lorazepam if they have liver
disease

Pregnant patient is abusing drugs need to send to hospital/ addiction specialist

Idealization- common in grief and loss- exaggeration of good qualities of the person or object
lost followed by acceptance of loss

Appreciative inquiry-is an approach to organizational change that focuses on strengths rather

than weakness

Reflective practice- debriefing strategies. Improve practice to look what was done good/bad

Start a patient on antidepressant and having insomnia- encourage them to take it in morning
before trying new medication
Professional organization- notice conflict of interest between pharmaceutical companies and
nurse practitioners, how do you assess? -Assess relationship between industry provided
samples and industry sponsored education

A patient is threatening suicide- call the police

Advocating for policy- through reading journals, join professional organizations, reach largest
amount of people

Preoperational stage- 2-7 years normal to use magical thinking

Formal operational- 12-adult, use logic, abstract thinking, think like a scientist

Industry v inferiority
Intimacy v isolation
Integrity v despair

Defense mechanisms- rationalization= trying to justify an unacceptable behavior

Intellectualization- goes and research diagnosis and reads book to understand diagnosis

Cortical dementia- memory and language mostly affected

-language effected
-memory impairment
-aphasia
-slurred speech
-amnesia

Subcortical Dementia- motor symptoms

-EPS
Dystonia
-increase muscle tone
-incoordination
-depression
Apathy

-Lewy body dementia- visual hallucinations

- Recovery is non linear its not a step by step process, will have occasional setback and
learning from experiences

-In a Just culture individuals are continually learning, developing safe systems, and managing
behavioral choices

Reduce stigma of mental illness by education- want to reach largest audience possible
-Antisocial personality disorder patients have the highest risk of homicidal ideations

-Acamprosate is not metabolized by the liver so safer to use than others in patients with liver
problems

-Signs of lead abuse- developmental delay, learning difficulties, irritability, loss of appetite,
weight loss, sluggishness, fatigue, abdominal pain, vomiting, constipation, hearing loss,
seizures, eating things that aren’t food (pica)

Neuroleptic malignant syndrome- occurs with antipsychotics, will see mutism, elevated CPK,
elevated WBC, elevated LFT, and myoglobinuria.

Why elevated CPK? - due to muscle contraction and destruction

TX: discontinue offending agent and give Dantrolene( muscle relaxant) or Bromocriptine
(dopamine agonist)

Serotonin syndrome- occurs with antipsychotics, will have hyperreflexia and myoclonic jerks
TX: cyproheptadine

Questions

A patient you recently started on Prozac after discontinuing Isocarboxazid (Marplan) reports
jerking movements of her arms and diaphoresis. What is this patient most likely experiencing?
And what is the treatment?

a. Neuroleptic malignant syndrome and Dantrolene

b. Serotonin syndrome and cyproheptadine
c. Serotonin discontinuation syndrome and monitor
d. Serotonin syndrome and bromocriptine

You have a patient that is on Haldol and states that they go to the gym everyday for 2 hours.
They started yesterday with muscle rigidity and cherry dark colored urine. What is this patient
must likely suffering from ?

a. serotonin syndrome
b. Hypertensive crisis
c. Neuroleptic malignant syndrome
d. kidney failure
What is the best treatment for neuroleptic malignant syndrome?

a.Cogentin/benztropine
b.Cyproheptadine
c.Bromocriptine
d.Valium

You have a patient that you are currently treating for bipolar disorder. The patient is prescribed
Lithium 300 mg PO tid. The patient tells you he has recently started taking ibuprofen up to four
times a day. What is your greatest concern with this medication?

a.Decrease lithium levels

b.Decrease potassium levels
c.Increase chance of bleeding
d.Reduced renal clearance

A patient presents with autonomic instability, fever, mutism, myoglobinuria, and increased WBC.
What do you suspect?

a.Neuroleptic malignant syndrome

b.Serotonin syndrome
c.Serotonin discontinuation syndrome
d.Hypertensive crisis

A patient has blood work done that shows TSH is 7.0 and T3 and T4 are low. They also
complain of cold intolerance. What do you suspect?
A.hyperthyroidism
B. hypothyroidism

You are trying to implement policy change across your organization. Steps to go about this
include all the following except:

a.Obtaining funding
b.Engaging stakeholders
c.Establishing what organizational barriers exist
d.Developing a tool to evaluate methods use

A mother presents with her 7 year old son for an evaluation and his 1 year old brother. You
notice the brother has a small head, small palpebral fissures, and smooth philtrum. You
suspect:
a.Fragile x syndrome
b.Fetal alcohol syndrome
 c.Premature birth
d.Rett’s syndrome

What are ACE inhibitors used for?

a.Congestive heart failure

b.COPD
c.Myocarditis
d.High cholesterol

A patient has been taking Zoloft for the past 6 months. She comes to the office today and
reports flu-like symptoms, mental cloudiness, nausea, and disequilibrium. You would most likely
suspect?

a.Serotonin syndrome
b.Serotonin discontinuation syndrome
c.Hypokalemia
d.Neuroleptic malignant syndrome

A NP goes to a clinic and provides parenting classes to expecting mothers. This is what level or
prevention?

a.Primary
b.Tertiary
c.Secondary

A patient presents with a 5-month history of nightmares and insomnia after being involved in a
serious car accident. He reports frequently waking up at night drenched in sweat and periods of
hyperarousal throughout the day. What would you prescribe for this patient?

a.Valium
b.Ativan
c.Clonidine
d.Prazosin

Who is at greatest risk of suicide?

a. 30 year old recently divorced female
b. 40 year old Asian male who recently lost his parents and has history of depression
c. A 63 year old Caucasion male that is divorced and has a previous suicide attempt
d. A 51 year old African American female with a history of bipolar disorder

A patient is being treated with haldol. What is the most common side effect of haldol?
 a. Increase waist circumference
b. Extrapyramidal side effects
c. Increased lipids
d. Metabolic syndrome

A patient of Native American descent presents to the unit for hospitalization. The patient is a
suicide risk. He has been having suicidal ideations without a specific plan for the past month.
The patient wants to keep his healing stick with him but the nurse takes it away. This is an
example of :

a. Malifeince
b. Autonomy
c. Not providing culturally competent care
d. Disrespect

A client tells you she has been working with her local government to get a stop sign put in near
where her 12 year old son died last year in a bike accident. This is what defense mechanism?

A. Repression
B. Sublimation
C. Intellectualization
D. Projection

You have been treating a patient with major depressive disorder for the past year on
Zoloft(sertraline). She recently tells you that she feels like her depression has worsened and
that her medication does not seem to be as effective. Her depression screen using the PHQ-9
was a 17. She reports she recently started taking Protonix for GERD. What is the primary action
of the nurse practitioner?

A. Increase Zoloft dose from 50mg to 100mg

B. Ask the client when she takes the Zoloft and the Protonix

C. Change the clients antidepressant to Paxil

D. Ask the client if she has been sleeping okay at night

Answers:

1. B
2. C
3. C
4. D
5. A
6. B
7. A
8. B
9. A
10. B
11. A
12. D
13. C
14. D
15. C
16. B
17. B