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Domains 1 & 2
(1-Scientific Foundation= 30 Board Questions)
(2-Advanced Practice Skills= 38 Board Questions)
Link to Questions found in Review
https://quizlet.com/602022043/module-questions-from-fb-review-flash-cards/
https://quizlet.com/386361005/psych-np-review_ancc-questions-flash-cards/

TEST TAKING STRATEGIES

1. Read the entire questions carefully before answering and identify what the question is
seeking. Do not skim over the words or read them too quickly.
 When reading the question pay attention to keywords.
2. Do not read into the question. Only use the information provided by the examiner to
answer questions without making any assumptions or adding more information in the
question.
3. Read all of the answer choices.
 Partially correct answers are not the correct answer.
 Narrow down options to 2 possible right answers.
 When two answer choices are the opposite of one another, one is usually the
correct answer.
 The right answer option might have the same word (s) as the test question; it can
be the same word or a synonym of the word.
 When many response choices are remarkably similar, they are usually wrong.
 Be wary of absolutes; all, only, always, every, must, never, none, everything,
nothing, etc..--> usually wrong.
4. Questions that use adjectives like “priority”, “Initial action” test your ability to
prioritize.
 Airway, Breathing, Circulation
 Maslow’s Hierarchy of needs (physiologic needs (food, water, warmth, rest)
safety, and security, etc..).
 Nursing Process (Assessment before intervention). Assessment is collecting data
to support the problem towards a resolution.
5. Safety for the patient and others is usually the right answer.
6. Culture is important to be included in all nursing care.
7. Critical Thinking is important.
8. Interprofessional collaboration is encouraged.
9. Best Answer/Choice: Answers that acknowledge a patient’s feelings and makes the
patient feel heard.
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QUESTION
Your patient with bipolar disorder is admitted to a medical hospital. The internist contacts your
office and asks whether the lithium you prescribed him is affecting his electrocardiogram (ECG).
How do you respond?
a. Lithium can prolong the QT interval
b. Lithium has no effect on his ECG
c. Lithium can invert the T-waves
d. Lithium can shorten the PR interval

QUESTION
Mary a 45-year-old African American female who has been treated on Isocarboxazid (Marplan)
for over 6 years is going in for a surgical procedure. Which medication is strictly contraindicated
with Isocarboxazid?
a. Morphine
b. NSAIDs
c. Methylphenidate
d. Acetaminophen
Teratogenic risks of common psychiatric medications (Refer PB pg 118)
 Benzodiazepines: Floppy baby syndrome, cleft palate
 Carbamazepine (Tegretol): Neural tube defects
 Lithium (Eskalith): Ebstein anomaly (avoid in pregnancy, especially 1st trimester).
 Divalproex Sodium (Depakote): Neural tube defects, specifically spins bifida
Carbamazepine (Tegretol)
 Black box warning for carbamazepine: Agranulocytosis (decreased WBCs) and
aplastic amenia (pallor, fatigue, headache, fever, nosebleeds, bleeding gums, skin
rash, shortness of breath).
 Stevens-Johnson syndrome, particularly in Asian (screen for HLAB-1502 allele
before initiating.
 The HLA-B*1502 allele is highly associated with the outcome of
carbamazepine-induced Stevens-Johnson Syndrome.
Note:
 Check pregnancy status (human chorionic gonadotropin (HCG) before starting a
female patient of child-bearing age (12-51 years old) on a mood stabilizer.
 Folic acid- supports neural tube development during the first month that a woman
is pregnant.
o It is recommended that all women planning or capable of becoming
pregnant take 0.4mg-0.8mg of folic acid daily.
 Page |3

Clozapine
 Risk for neutropenia is monitored by the absolute neutrophil count (ANC) only, not in
conjunction with the white blood cell count.
 DC Clozaril at ANC less than 1,000 mm3 (because the risk of neutropenia).
 DC Clozaril at WBC of 2,000-3,000 (because the risk of agranulocytosis).
 Monitor patients for signs of infection (Sudden fever, chills, sore throat, weakness).
 During first 6 months: weekly; during second 6 months: every 2 weeks; then monthly if
ANC is normal.

Question
You are treating a client with schizophrenia who takes clozapine. What laboratory values will
indicate the client needs to discontinue treatment?
a. White blood cell count of less than 1,800/mm3 and absolute neutrophil count of less than
1,200/mm3
b. Absolute neutrophil count of less than 1,000/mm3
c. White blood cell count of less than 5,000/mm3
d. Absolute neutrophil count of less than 2,000/mm3

Question
If given during pregnancy sodium valproate can cause which of the following medical problems
in the baby?
a. Stevens-Johnson Syndrome
b. Ebstein’s anomaly
c. Spina bifida
d. Cleft palate
Question
Which mood stabilizer is associated with potential life-threatening rash in the Asian population?
a. Carbamazepine
b. Depakote
c. Lithium
d. Lamictal

BMI
Below 18.5= underweight
 Page |4

18.5-24.9= normal
25.0-29.9= overweight
30 and above= obese

BULIMIA NERVOSA
 BMI usually within normal range.
 Erosion of dental enamel
 Russel’s signs: scarring or calluses on the dorsum of the hand, secondary to self-induced
vomiting
 Hypertrophy of salivary glands
 Rectal prolapse
Pharmacological management
 Fluoxetine (Prozac) is FDA approved for bulimia nervosa.
 SSRIs and tricyclic antidepressants (TCAs) effective in reducing the frequency of
bingeing and purging.
ANOREXIA NERVOSA
 Low body mass index
 Amenorrhea
 Emaciation (being abnormally thin)
 Bradycardia
 Hypotension
 Inversion of T-waves
 Prolonged QT interval
 Hypertrophy of salvatory glands
 Russel’s signs
Pharmacological Management
 Medication management as adjunctive therapy to psychotherapy
 No specific medication therapy for anorexia nervosa
 Page |5

Nonpharmacological Management
 Multimodal treatment
o Medica and nutritional stabilization
o Weight restoration
o Correction of electrolyte imbalance
o Vitamin supplementation
o Nutrition counseling
Psychotherapeutic interventions
 Behavioral therapy
 Cognitive behavioral therapy
 Family therapy
 Group therapy
Question
Which of the following physical exam findings would help the PMHNP differentiate anorexia
nervosa from bulimia nervosa?
a. Russell sign
b. Low body mass index
c. Erosion of dental enamel
d. Hypertrophy of salivary glands
Refer PB pg 160
Depressed/Low energy/fatigue-Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)-
Wellbutrin
Bupropion (Wellbutrin) contraindication- Do not use bupropion if patient is bulimic, either
currently or in the past. Prohibition for use in eating disorders due to increased risk of seizures.
(Wellbutrin is good if sexual dysfunction)
 Page |6

Question
Which of the following medications has a unique mechanism that is both a norepinephrine and
dopamine reuptake inhibitor?
a. Bupropion (Wellbutrin)
b. Sertraline (Zoloft)
c. Clomipramine (Anafranil)
d. Duloxetine (Cymbalta)
Rationale
Bupropion- boots neurotransmitters norepinephrine/noradrenaline and dopamine
Duloxetine- Serotonin and norepinephrine reuptake inhibitors (SNRIs)- use this for neuropathic
pain and depression
Clomipramine- TCA
Sertraline- SSRI
INDUCERS AND INHIBITORS
 Clozapine (Clozaril) is an atypical antipsychotic drug that is metabolized to a major
extent by the cytochrome enzyme CYP1A2.
 Enzyme inducers can decrease the serum level of the other drugs that are substrates of
the enzyme, thus possibly causing subtherapeutic drug levels.
 Enzyme inhibitors can increase the serum level of the other drugs that are substrates of
that enzyme, thus possibly causing toxic levels.
 Page |7

MNEMONICS
INDUCERS: BullShit CRAP GPS INDUCES my rage!
Barbiturates
St. John’s wort
Carbamazepine
Rifampin
Alcohol (chronic)
Phenytoin
Griseofulvin
Sulfonylureas
Plus, cigarette smoking
Oral contraceptives

INHIBITORS: SICKFACES.COM
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol (acute)
Chloramphenicol
Erythromycin
Sulfonamide
Ciproflaxin
Omeprazole
Metronidazole
 Page |8

 Liver disease will affect liver enzyme activity and first-pass metabolism, possibly
resulting in toxic plasma drug levels.
 Kidney disease or drugs that reduce renal clearance, such as NSAIDs (ibuprofen,
Indocin), thiazides (hydrochlorothiazide), and ACE inhibitors (lisinopril) may increase
serum concentration are drugs that are excreted by the kidneys (such as lithium).
Older adults are more sensitive to psychotropics because of:
 Decreased intracellular water
 Decreased protein binding (with decreased protein available for binding , freer (active)
drug remains in the body which predisposes older adults to toxicity).
 Low muscle mass
 Decreased metabolism
 Increased body fat concentration
Question
Which cytochrome (CYP) enzyme is implicated as a tobacco inducer when an individual is
treated with clozapine?
a. 2D6
b. 1A2
c. 2C19
d. 2C9
Rationale
Clozapine (Clozaril) is an atypical antipsychotic drug that is metabolized to a major extent by the
cytochrome P450 enzyme CYP1A2. Smoking is a potent inducer of CYP1A2 enzyme activity,
resulting in significant lower clozapine serum concentration in smokers compared with non-
smokers, upon a given dose.
Question
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?
a. Decreased body fat
b. Increased liver capacity
c. Decreased protein binding
d. Increased muscle concentration
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Question
For 12 years, a 65-year-old patient with bipolar affective disorder has been taking lithium
(Eskalith) 900 mg daily. When oral hydrochlorothiazide (HCTZ) 12.5mg daily is added for
hypertension, the patient develops nausea, vomiting, ataxia, and muscle weakness and the
patient’s serum lithium level is 2.0 mEq/L. The interaction of the lithium and the thiazide
diuretic has induced:
a. Hypokalemia
b. Hyponatremia
c. Increased renal clearance of lithium
d. Reduced renal clearance of lithium

Neurotransmitters
 Norepinephrine: produced in the locus coeruleus and medullary reticular formation.
 Serotonin: Produced in the raphe nuclei of the brainstem.
 Dopamine: Produced in the substantia nigra, nucleus accumbens, and the ventral
tegmental area (VTA).
 Acetylcholine: Synthesized by the basal nucleus of Meynert.

 GABA (Gabba-aminobutyric acid) is the most abundant inhibitory neurotransmitter in the

brain. Decreasing GABA would increase anxiety.
o Benzodiazepines are used to bind with GABA receptors to [potentiate anxiolytic
(calming) effects of GABA.
 Glutamate- Is the most abundant excitatory neurotransmitter in the brain (increased levels
of glutamate will increase anxiety levels).
o Increased level of corticotropin releasing hormone in the amygdala, hippocampus
and locus coeruleus increases symptoms of anxiety.
Question
Serotonin is a neurotransmitter that is implicated in sleep and mood. What area of the brain has a
large majority of serotonin neurons?
a. Raphe nuclei
b. Nucleus Accumbens
c. Locus Coeruleus
d. Amygdala
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AUTISM SPECTRUM DISORDER

Persistent deficits in social communication and social interaction across multiple settings
associated with deficits in:
 Social reciprocity
 Nonverbal communication
 Developing, maintaining, and understanding relationships
 Restricted repetitive behavior
 Stereotyped or repetitive motor movements
 Insistence on sameness
 Highly restricted with food interests
 Hyper or hypo sensory input
Risk Factors
 Male gender
 Intellectual disability
 Genetic loading
Parents may report the following symptoms
 No response when called by name
 Little or no eye contact
 Children with autism often like to line up, stack, or organize objects and toys.
 No imaginary play
 Little interest in playing with other children
 Intense tantrum
 Extremely short attention span
 Self-injurious behavior
Screening
 Modified Checklist for Autism in Toddlers (M-CHAT)—ONLY TODDLERS
 Autism Diagnostic Observation Schedule- Generic (ADOS-G)
 Ages and Stages Questionnaires (ASQ)
Pharmacological management
 Antipsychotics are effective for symptoms such as tantrums; aggressive behavior; self-
injurious behavior; hyperactivity; and repetitive, stereotyped behaviors.

Question
 P a g e | 11

A 5-year-old boy shows no interest in playing with other children and ignores adults other than
his parents. He spends hours lining up his toy cars spinning their wheels. He rarely uses speech
to communicate, and his parents state that he has never done so. Physical examination indicates
his gait is normal. Which of the following is the most likely diagnosis for this boy?
a. Obsessive-compulsive disorder
b. Rett Syndrome
c. Autism
d. Tourette’s syndrome
PARTS OF THE BRAIN
Cerebrum
 Largest part of the brain, which is divided into two halves, the right and left cerebral
Hemispheres,
 Left hemisphere: Dominant in most people, controls most right-sided body functions
 Right Hemisphere: controls most left-sided body functions
 Normal functioning requires effective coordination of two hemispheres.
 Both hemispheres connected by a large bundle of white matter, the corpus
callosum, an area of sensorimotor information exchange between the two
hemispheres
 Each hemisphere is divided into four major lobes, which work in an
interactive and integrated manner, and each with a distinct function.

Lobes of the brain
 Photo of lobes of the brain PB pg 65
 Frontal lobe: Largest and most developed lobe.
 Seat of executive function: working memory, reasoning, planning,
prioritizing, sequencing, behavior, insight, flexibility, judgement, impulse
control, behavioral cueing, intelligence, and abstraction.
 Language (Broca’s areas): Expressive speech
 Personality variables: the most focal area for personality development
 Problems in the frontal lobe can lead to personality changes, emotional
and intellectual changes
 Parietal lobe
 Primary sensory area
 Sensory-perceptual disturbance
 Taste
 Reading and writing
 Problems in the parietal lobe can lead to sensory-perceptual disturbances
and agnosia (inability to interpret sensations)
Questions
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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:
a. Frontal lobe
b. Tempera; lobe
c. Parietal lobe
d. Occipital lobe
Clock Drawing test (CDT) The clock drawing test is a simple tool that is used to screen people
for signs of neurological problems, such as Alzheimer’s and other dementias.
 A is a very quick way to screen a person for possible dementia.
 It often requires only a minute or two for completion.
 Impairments on the CDT can be associated with damage to the right parietal lobe (right
hemisphere).
Limbic System
 Essential system for the regulation and modulation of emotions and memory.
 Hypothalamus: Plays key role in various regulatory functions such as
…sensory information to prevent overwhelming the cortex; regulates emotions, memory, and
related affective behaviors.
 Hippocampus: Regulates memory and converts short-term memory to long-term
memory.
o Regulates motivation, stress, emotion, and learning.
 Amygdala: Responsible for mediating mood, fear, anxiety, anger, stress, emotion, and
aggression.
Question
Which part of the brain is responsible for regulating emotions?
a. Wernicke’s area
b. Occipital lobe
c. Hippocampus
d. Parietal lobe
 P a g e | 13

Question
Which of these brain structures puts emotional meaning on a stimulus, forms emotional
memories, and is involved with rage and fear?
a. Hippocampus
b. Temporal lobe
c. Amygdala
d. Midbrain
Question
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?
a. Thalamus
b. Hypothalamus
c. Limbic System
d. Hippocampus
Question
Which serotonin receptor antagonism makes an antipsychotic “atypical”?
a. 5HT4A
b. 5HT2A
c. 5HT1A
d. 5HT3A
Rationale:
The mechanism of action that makes an antipsychotic medication “atypical” is related to the
5HT2A (serotonin) receptor antagonism.
Dopamine Pathways (watch Dirty Medicine video on YouTube)
Mesolimbic Pathway:
 Hyperactivity of dopamine in the mesolimbic pathway mediates positive psychotic
symptoms.
 Antagonism of D2 receptors in the mesolimbic pathway treats positive psychotic
symptoms.
Mesocorticol Pathway:
 Decreased dopamine in the Mesocorticol projection is postulated to be responsible for
negative and depressive symptoms of schizophrenia.
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Nigrostriatal Pathway:
 The nigrostriatal pathway mediates motor movements.
 Dopamine blockade in this pathway can lead to increased acetylcholine levels
 Blockade of dopamine (D2) receptors in this pathway can lead to EPS (dystonia,
parkinsonian symptoms, and akathisia.
 Long-standing D2 blockade in the nigrostriatal pathway can lead to tardive dyskinesia.
Tuberoinfundibular Pathway:
 Blockade of D2 receptors in this pathway can lead to increased prolactin levels leading to
hyperprolactinemia which clinically manifests as amenorrhea, galactorrhea (risperidone),
and sexual dysfunction, gynecomastia.
 Long-term hyperprolactinemia can be associated with osteoporosis.

Pseudo parkinsonism: Akathisia

Stopped posture restless (inability to remain still)
Shuffling gait trouble standing still-- paces the floor
Rigidity feet in constant motion-
Bradykinesia rocking back and forth
Tremors at rest NOTE: often makes for increased anxiety
Pill rolling motion of hands

Acute dystonia: Tardive dyskinesia

Facial grimacing protrusion and rolling of the tongue
Involuntary upward eye movement sucking and smacking movement of the lips
Muscle spasms of the tongue, face, chewing motion
--neck and back (back muscle spasms facial dyskinesia
--cause trunk to arch forward) involuntary movements of the body & extremities
Laryngeal spasms

 Other rare presentations of acute dystonia include oculogyric crises, which can lead to
permanent injury. On physical exam, patients in oculogyric crisis have prolonged
involuntary upward deviation of the eyes bilaterally.
 Cogentin (Benztropine)
 A commonly used rating scale for the measurement of akathisia includes the Barnes
Akathisia Rating Scale and Extrapyramidal Symptom Rating Scale.
 Treatment
o Betablocker
o Benztropine (Cogentin)
o Benzodiazepine
 P a g e | 15

Akinesia

Absence of movement, difficulty initiating motion, subjective feeling of lack of

motivation to move.
 Note: Often mistaken for laziness or lack of interest.
 TX: Cogentin (Benztropine)
Pseudo-Parkinsonian symptoms: Presence of symptoms of Parkinson's disease produced by
D2 blockade.
 Muscle rigidity
 Shuffling gait
 Motor slowing
 Mask-like facial expression
 Pill rolling tremors in fingers
 TX: Cogentin (Benztropine)
Tardive dyskinesia: Involuntary abnormal muscle movement of the mouth, tongue, face, and
jaw that may progress to limbs; can be irreversible.
 Protrusions and rolling of tongue
 Lip smacking and sucking
 Chewing motion
 Facial dyskinesia
 Treatment of tardive dyskinesia is either to reduce the dose, stop the offending
antipsychotic, or to switch to clozapine.

 Adjunctive treatments can be added, such as tetrabenazine, and with newer agents like
the VMAT-2 inhibitor Ingrezza.

 Cogentin should not be used as it could worsen symptoms:

 Can take up to 1-2 years to occur

 Can occur as an acute process at initiation of medications or as a chronic condition at

point in treatment.
Note: Reglan (metoclppramide) can cause tardive dyskinesia
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Question

A 45-year-old African American male diagnosed with schizophrenia arrives at your clinic for a
regular medication appointment. He is currently stabilized on chlorpromazine. You notice his
face appears mask-like, and he walks with a shuffling gait. Based on this information, what
extrapyramidal side effect would you suspect?

A. Akathisia
B. Akinesia
C. Dystonia
D. Pseudo-Parkinson's

Question

A patient has been treated for the past several years with fluphenazine (Prolixin). You notice that
he is drooling and has a tremor and slight pill-rolling movement of the fingers. These are the
extrapyramidal symptoms known as:

a) Anticholinergic effects
b) Pseudo parkinsonism
c) Tardive dyskinesia
d) Acute Dystonia

Question

A patient is diagnosed with schizophrenia. Which of the following would be the appropriate
question for the PMHNP to ask when assessing side effects produced by dopamine antagonism
in the nigrostriatal pathway?

a. Are you experiencing constipation?

b. Are you experiencing pill rolling tremors, shuffling gait, and masklike facial
expression?
c. Are you experiencing increased thirst?
d. Are you experiencing breast discharge?
 P a g e | 17

Question

Which of the following antidepressants is associated with the most cardiovascular adverse
effects?

a. Sertraline
b. Citalopram
c. Bupropion
d. Duloxetine
Question

The study of drug absorption, distribution, metabolism, and excretion is known as

A. pharmacotherapeutics
B. pharmacodynamics (what the drug does to the body)
C. pharmacokinetics (what body does to drug)
D. pharmacy
Medications that can cause mania and depression

Mania
 Steroids
 Disulfiram (Antabuse)
 Isoniazid (INH)
 Antidepressants in persons with bipolar disorder

Depression
 Steroids
 Isotretinoin (Accutane) (can also cause birth defects)
 Beta blockers
 Interferon
 Some retroviral drugs
 Antineoplastic drugs
 Benzodiazepines
 Progesterone
 Flonase/prednisone
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Question

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?

a. Omeprazole
b. Propranolol
c. Levothyroxine
d. Clarithromycin
Question

A patient with a known diagnosis of bipolar I disorder presents to your clinic complaining of
manic symptoms and insomnia. Your patient has been stable on lithium for the past six months.
To determine if a medication change or increase is warranted, it is important to gather more
information. You suspect a possible medication-induced manic episode when the patient
endorses what?

A. She was recently placed on a beta blocker for anxiety

B. She was recently prescribed a benzodiazepine by her primary care provider for panic attacks
C. She recently had an acute flare-up of her rheumatoid arthritis and received treatment
for one week for stabilization of symptoms (was probably a steroid—autoimmune disorder)
D. She recently began a new retroviral regimen for hepatitis

Question

John is a 58-year-old male patient with Bipolar I Disorder has been stable for 5 years on
valproate and Seroquel. He was recently started on Fluticasone (Flonase) by his primary care NP.
As the PMHNP treating John, you are concerned that the addition of the Fluticasone may cause

a. A hypertensive crisis
b. Steven-Johnson Syndrome
c. Neuroleptic Malignant Syndrome (INMS)
d. a manic episode
 P a g e | 19

Fragile X syndrome

Large, long head and ears, short stature, hyperextensible joints and post pubertal
macroorchidism (abnormally large testes).
Question

A 16-year-old boy presents with a long head, large ears, and hyperextensible joints
and starts rocking and flapping his hands when he is upset. Which of the following is the
likely diagnosis?

A. Tourette Disorder
B. Autism Spectrum Disorder
C. Fragile X syndrome
D. Rett disorder

Neuroleptic Malignant Syndrome (NMS)

 Caused by antipsychotics
 Extreme muscular rigidity
 Mutism
 Hyperthermia
 Tachycardia
 Diaphoresis
 Altered level of consciousness
 Elevated CPK (creatine phosphokinase)-muscle contraction/muscle destruction
 Myoglobinuria (Rhabdomyolysis)
 Elevated WBCs (leukocytosis)
 Elevated LFTs (liver function tests)

Treatment: supportive, dantrolene, dopamine producers, CNS depressants

 P a g e | 20

Question
What muscle relaxant is recommended to be used in the treatment of neuroleptic malignant
syndrome (NMS)?

a. Bromocriptine
b. Trihexyphenidyl
c. Dantrolene
d. Benztropine
Serotonin syndrome

 Caused by antidepressants
 Hyperreflexia
 Myoclonic jerks
 Agitation, restlessness
 Rapid heart rate and elevation in blood pressure
 Headache
 Sweating, shivering, and goose bumps
 Confusion, fever, seizures, unconsciousness

Treatment--> DC the offending agent-->Cyproheptadine

Drug combinations that can cause serotonin syndrome:

SSRI/TCA/MAOI/SNRI
 SSRIs and MAOIs
 Placing a patient on more than one SSRI
 Drug and herbal interactions
 SSRIs and St. John's wort
 When switching from an SSRIs to a MAOI wait 14 days.
 When switching from fluoxetine (Prozac) to MAOI wait 5-weeks
 When switching from an MAOI back to Prozac wait 2 weeks

Serotonin Discontinuation Syndrome (Refer PB pg 165)

 Flu-like symptoms (due to cholinergic rebound; particularly problematic with TCAs
 Fatigue and lethargy
 Myalgia (muscle soreness and achiness)
 Decreased concentration
 Nausea and vomiting
 Ataxia (unsteady gait)
 Impaired memory
 Agitation
> Don't D/C SSRIs/TCAs/MOAls abruptly
 P a g e | 21

Question

A week after raising the dose of clomipramine a patient treated for depression presents
the clinic with reports of acute change in mental status, fever, and hyperreflexia. As the
treating PMHNP, you know these symptoms are consistent with which of the following?

a. Extra Pyramidal Side Effect

b. Neuroleptic Malignant Syndrome
c. Serotonin syndrome
d. Hypertensive crisis

Question

A 24-year-old female attempts suicide by overdose with the monoamine oxidase inhibitor
phenelzine. She is stabilized at the hospital. Ten days later she is started on venlafaxine
becomes tachycardic and diaphoretic, and she develops myoclonic jerks. What condition

A. Neuroleptic malignant syndrome

B. Opisthotonos
C. Akathisia
D. Serotonin syndrome (didn’t wait 14 days after MAOI to give Effexor)

Question

A 17-year-old patient arrives at the emergency department with nonspecific complaints. The
patient's temperature is 100.8°F (38.2°C), pulse rate and blood pressure are elevated, and pupils
are dilated with decreased reaction to light. Two days ago, the patient began taking sertraline
(Zoloft) 50 mg daily for treatment of depression. The patient has a history of substance use and
smoked marijuana one week ago. The diagnosis is:

A. alcohol withdrawal.
B. infection affecting the central nervous system.
C. neuroleptic malignant syndrome.
D. serotonin syndrome.
 P a g e | 22

Question

Patient being treated for psychosis for 2 weeks develops symptoms of NMS. The following
factors help PMHNP to differentiate NMS from serotonin syndrome:

A. Autonomic instability, diaphoresis, tremors

B. Hyperthermia, leukopenia, tachycardia
C. Rigidity, hyperreflexia, orthostatic hypotension
D. Mutism, leukocytosis, myoglobinuria

Agonist effect: Drug binds to receptors and activates a biological response (opens the
ion channel).
 Inverse agonist effect: Drug causes the opposite effect of agonist; binds to same
receptor (closes the ion channel).
 Partial agonist effect: Drug does not fully activate the receptors
 Antagonist effect: Drug binds to the receptor but does not activate a biological
response
Question

When studying pharmacodynamics involving receptors, you know that an agonist

produces the following effect:

a. Does not fully activate the receptor and causes only limited actions. (Partial agonist)
b. Blocks the agonist from opening the channel and does not activate a biological
response. (antagonist)
c. Causes the opposite effect of agonist and causes the receptor to close the ion channel (inverse
agonist)
d. Activates a biological response and opens the ion channel.
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Delusion
 A false belief firmly maintained despite evidence to the contrary.
 Paranoia: Believing that people are out to get you.
Referential thinking:
>Patients may, for example, believe that certain news bulletins have a
direct reference to them, that music played on the radio is played for them, or that
car license plates have a meaning relevant to them.

Components
• Appearance
• Behavior
• Speech
• Mood
• Affect

• Thought process: Assesses the organization of the patient's thoughts and ideas.
 Normal: logical, linear, coherent, and goal oriented.
 Abnormal: associations are not clear, organized, or coherent.
 Tangentiality: Move from thought to thought that may or may not relate in some way
but never get to the point.
 Circumstantial: Provide unnecessary detail but eventually get to the point.
• Thought content: Refers to the themes that occupy the patient's thoughts and
perceptual disturbances. EX: suicidal ideations, homicidal ideation (SI or HI), plan,
visual
hallucinations, auditory hallucinations
Mini Mental Status Examination-MMSE (Folstein scale)
>Used in adults to quantify cognitive status
> Different components of the mini mental status exam
 I would like you to count backwards from 100 by sevens or do serial 7s-
concentration/attention/calculation
 What is the year? Season? Date? Day? Month? -Orientation
 Repeat the "no ifs and buts"/ Name a pencil and watch -language/speech
 Registration/ability to learn new material- bed, bad, ball
 Ask for the 3 objects repeated above- Recall(memory)
 Who is the president/governor? Fund of knowledge
Other instruments for assessing level of cognitive impairment
 Montreal Cognitive Assessment (MoCA)
 Mini-Cog
 St Louis University Mental Status Examination (SLUM)
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Question

During a follow-up assessment, a PMHNP ask patient to count backwards from 100 by
sevens. What aspect of mental status exam is being assessed?

a. Orientation
b. Language
c. Thought content
d. Concentration
Question

Appraisal of patient's SI, plan, method, intent, and access to implement plan would be
documented in which part of standard psychiatric evaluation?

a. Review of Systems
b. Diagnosis
C. Mental status exam
d. History of Presenting Illness
Suicide assessment
Risk factors for suicide
 Previous suicide attempt
 Ages 45 or older if male/Ages 55 or older if female
 Divorced, single, or separated
 White (Caucasian)
 Living alone
 Psychiatric disorder
 Physical illness
 Substance abuse
 Family history of suicide
 Recent loss
 Male gender
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Question

A 48-year-old Caucasian male patient presents for his therapy session. He is sad about losing his
wife recently to COVID-19. He reports feeling thoughts of hurting himself. He has a past history
of overdosing on propranolol several years ago. Which of the following places him at higher risk
for suicide?

a. Previous suicide Attempt

b. Age
C. Gender
d. Marital Status
Question

Which of the following patient is at a higher risk of suicide?

A. A 30-year-old married African American female with previous suicide attempt.

B. A 35-year-old single Asian male with previous suicide attempt.
C. A 38-year-old Single African-male who is manager of a bank.
D. A 68-year-old single Caucasian male with depression.
Question

A 64-year-old Caucasian male referred for treatment of refractory depression by his PCP reports
continued lack of purpose, insomnia, decreased energy, reduced interest in pleasurable activities
since losing his wife hit by a drunk driver 3 months ago. Which of the following is an
assessment priority?

a. Prior and current meds, dose, clinical response, side effects

b. Thoughts of self-harm, plan, intent, access
c. Extent of alcohol use and motivation to reduce to safe levels
d. Sleep patterns and hygiene
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Question

A married female patient has been in therapy with an adult psychiatric and mental health nurse
practitioner for three months. The patient's husband abuses alcohol and refuses treatment. The
night before the next scheduled appointment, the patient telephones the clinical nurse specialist
stating that her husband is drunk, violent, and threatening to kill her. The PMHNP's priority
intervention is to:

A. arrange for an emergency psychiatric evaluation.

B. arrange for the woman's safety.
C request a restraining order.
D. request to speak with the husband
------------------------------------------------------------------------------------------------------
 Acceptance
 Nonjudgmental
 Authenticity
 Empathy
 Respect
 Professional boundaries

Transference: Displacement of feelings for significant people in the client's past

onto the PMHNP in the present relationship.
Countertransference: The nurse's emotional reaction to the client based on her or his past
experiences.

Question

A client says to the PMHNP, "Some days life is just not worth 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:

a. "Do you mean that you are thinking about leaving your wife and moving out?"
b. "Tell me what you mean by 'it would be simpler if you just weren't there anymore."
c. "So you are thinking suicide might be an option for you?"
d. Remain silent
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Question

While working with an older male client, the nurse begins to think that the client reminds her of
her grandfather and responds as if she was the granddaughter. The nurse is developing which of
the following?

a) Empathy
b) Modeling
c) Transference
d) Countertransference
Neurocognitive Disorders
Delirium
 Acute onset
 Altered level of consciousness
 Inattention
 Changes in cognition (concentration)
 Poor prognosis: 1-year mortality rate of clients with delirium is up to 40%
Pharmacological Management
Symptomatic treatment
Agitation and psychotic symptoms
 Antipsychotic agents
 Haloperidol (Haldol): Haloperidol is the preferred treatment for agitated delirious
patients (as described by guidelines of the American Psychiatric Association).
 Atypical antipsychotic agents
 Anxiolytic agents for insomnia
 Avoid benzodiazepines unless the patient is at risk and has not responded
to haloperidol, as they tend to prolong delirium. The exception is alcohol-
or substance.
Nonpharmacological Management
 Monitor for safety needs
 Pay attention to basic needs
 It is helpful to have in the client’s room familiar people, familiar pictures or decorations;
a clock or calendar; and regular orientation to person, place, or time.
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Dementia

Dementia is a group of disorders characterized by gradual development of multiple

cognitive deficits:
 Impaired executive functioning
 Impaired global intellect with preservation of level of consciousness
 Impaired problem-solving
 Impaired organizational skills
 Altered memory

Dementia
Slow onset over months to years
Normal speech*
Conscious and attentive
Memory loss
Language difficulties
Hallucinations possible
Listless or apathetic mood most common; agitation also possible
Often no other signs of illness

Delirium
Sudden onset over hours to days
Slurred speech
In and out of consciousness,
inattentive, easily distracted
Memory loss
Language difficulties
Hallucinations common
Can be anxious, fearful, suspicious, agitated, or can seem to care less and react less
Signs of medical illness (eg, fever, chills, pain on urinating, etc) or drug side effects common

Dementia of Alzheimer's type (DAT)

 Most common type
 Classified as a cortical dementia
 Gradual onset and progressive decline without focal neurological deficits (a problem
with nerve, spinal cord, or brain function).
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Dementia due to HIV disease

 Classified as a subcortical dementia
 Early signs of HIV dementia: Cognitive decline, motor abnormalities (lack of
coordination), and behavioral abnormalities.
Clinical signs of late-stage HIV-related dementia
 Global cognitive impairment

Lewy body disease

 Presents with recurrent visual hallucinations

 Parkinson features (bradykinesia, cogwheel rigidity, tremor)
 Adversely react to antipsychotics

Vascular dementia (VD)

 Second most common type.

 Primarily caused by cardiovascular disease and characterized by step-type declines.
 Most common in men with preexisting high blood pressure and cardiovascular risk
factors.
Hallmarks: carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers

Pick's disease

 Also known as frontotemporal dementia/frontal lobe dementia

 More common in men
 Personality, behavioral, and language changes(slurred) in early stage
 Cognitive changes can occur in later stages

Huntington's disease
Subcortical type of dementia
 Characterized mostly by motor abnormalities (e.g., choreoathetoid movements
 Psychomotor slowing and difficulty with complex tasks
 High incidence of depression and psychosis

Etiology
 Diffuse cerebral atrophy and enlarged ventricles in dementia of Alzheimer's type (DAT)
 Decreased acetylcholine (ACh) and norepinephrine in DAT
 Genetic loading
o Family history of dementia in first-order relative
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Psychosis and agitation in Dementia

 Try nonpharmacological therapies first.
 Atypical antipsychotics should be used as first-line agents in patients with psychotic
symptoms of dementia.
 Use lowest effective dose and attempt to wean periodically.
 Benzodiazepines should be avoided, if possible, in most patients with dementia,
as they are particularly vulnerable to their adverse effects such as sedation, falls
and delirium.

Question

A 69-year-old man with a diagnosis of delirium has symptoms of psychosis which include
frightening auditory and visual hallucinations and paranoid delusions. Which of the following
medications should be chosen first for this man's symptoms?

A. Haloperidol
B. Quetiapine
C. Valium
D. Olanzapine

Question

An 81-year-old female with a history of vascular dementia is brought to the hospital for
increased agitation and urinary tract infection (UTI). Which of the following features most
distinguishes the effects of delirium from dementia?

A. Altered level of consciousness

B. Behavioral disturbances
C. Cognitive deficits
D. Language difficulties

Question
What is the best treatment for AIDS dementia complex?

a. Acetylcholinesterase inhibitors
b. Symptom-targeted pharmacologic treatments
c. Nonpharmacologic supportive care
d. Antiretroviral therapy
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Levels of Prevention

Primary prevention:
 Aimed at decreasing the incidence (number of new cases) of mental disorders.
 Example: Stress management classes for graduate students, smoking prevention classes

Secondary prevention:
 Aimed at decreasing the prevalence (number of existing cases) of mental disorder.
 Screening
 Example: Telephone hotlines, crisis intervention, disaster responses

Tertiary prevention:
 Aimed at decreasing the disability and severity of a mental disorder
 Rehabilitative services
 Avoidance or postponement of complications
 Example: Day treatment programs; case management for physical, housing, or vocational
needs; social skills training

Question

A patient who was diagnosed with Major depressive disorder comes to the clinic for a refill of
sertraline (Zoloft). The PMHNP explains that the medication is prescribed for:

A. Universal prevention
B. primary prevention.
C. secondary prevention.
D. tertiary prevention.
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Mental Status
MMSE (0=30) SLUM (0-30)
25 - 30 Normal 27-30 Normal
21=24 Mild 21-26 Mild
10-20 Moderate 0-20 Dementia
0 - 9 Severe

Depression

HAM D (0-76) PHQ-9 (0-27) Beck (0-63)

0 - 7 Normal 0-4 Normal 0-9 Normal
8- 13 Mild 5-9 Mild 10-18 Mild
14 - 18 Moderate 10-14 Moderate 19-29 Moderate
19-22 Severe 15-19 Moderate to severe 30-63 Severe
23»Very severe 20-27 Severe

Anxiety

HAM A (0-56) GAD (0-23)

<17 Mild 0-4 Normal
18 - 24 Moderate 5-9 Mild
25< Severe 10-14 Moderate
15-21 Severe
MILD ANXIETY/DEPRESSION – therapy, nothing
MODERATE/SEVERE- anxiety/depression- medications and/or therapy
Scoring on the depression falls on the severe range= Assess suicidal ideation
Screening Brief Intervention Referral for Treatment (SBIRT): screen for substance use disorders
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Assessment tools for substances use disorders

CIWA-AR: (Clinical Institute Withdrawal Assessment):

 Used to assess alcohol withdrawal (used to determine when to administer medications for
ETOH withdrawal)
 Treatment starts when score is greater or equal to 8 or higher -If ordered PRN only
(Symptom-triggered method).
 Total CIWA-Ar score 15 or higher if on Scheduled medication. (Scheduled + prn
method (Diazepam, Lorazepam, Librium).
 Three medications are approved by the FDA to treat alcohol use disorder (Alcohol
dependence): Acamprosate (Campral), disulfiram (Antabuse), and
naltrexone (Vivitrol).
 Acamprosate and naltrexone reduce alcohol consumption an increase abstinence rates.

Disulfiram (Antabuse) Refer PB pg 304

 Aversion Therapy for Alcohol use disorder
 Should not be taken for at least 12 hours after drinking alcohol.
 Advise client to refrain from using anything that contains alcohol (e.g., vinegar,
aftershave lotion, perfumes, mouthwash, cough medication) while taking disulfiram
and up to 2 weeks after discontinuing disulfiram.
 Disulfiram can elevate liver function tests, so monitoring is necessary.
Signs and Symptoms of alcohol withdrawal (Refer PB pg 303).
 Nausea and vomiting
 Tremors
 Paroxysmal sweats
 Tactile disturbances
 Auditory disturbances
 Visual disturbances
 Headaches
 Anxiety
 Agitation
 Altered sensorium
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Withdrawal
COWS (opioids) 7or more start treatment CIWA (alcohol) 8 or more start treatment
0-4 None 0-9 None
5-12 Mild- CLONIDINE 10-15 Mild
13-24 Moderate- BUPRENORPHINE 16-20 Moderate
25-35 Moderated to severe 21> severe
36 Severe DIAZEPAM, LIBRIUM, ATIVAN
15 requires scheduled meds

COWS (The Clinical Opiate Withdrawal Scale): For opioid withdrawal

Signs and Symptoms of Opioid withdrawal
 Yawning
 Irritability/anxiety
 Pupillary dilation (pinpoint pupils can indicate opioid intoxication
 Piloerection
 muscle aches
 Lacrimation
 Rhinorrhea
 Sweating
 Insomnia
 nausea, vomiting, diarrhea
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