J.B. is a 41-year-old female patient who is being managed for obsessive compulsive disorder. She has been in exposure response therapy (ERT) for several months with marginal improvement, but she has never approached true remission. At one time she was on fluvoxamine with notable improvement, but after a few months it ceased to produce any notable impact and after conferring with her therapist she was converted to fluoxetine 20 mg qd. After two months she was still struggling with symptoms, so two months ago her dose was increased to 40 mg qd. Today she presents for follow-up, reporting no notable improvement with pharmacotherapy. She continues to engage in psychotherapy but at this point is becoming very frustrated.  

The appropriate approach at this point would be to: 

A. Continue fluoxetine 40 mg daily for one more month and reassess 

B. Convert the patient to therapy with a tricyclic antidepressant 

C. Continue fluoxetine at 40 mg daily and consider a change in therapy. 

D. Increase the fluoxetine to 60 mg daily and reassess in four to eight weeks 

The PMHNP is evaluating a patient with significant anxiety and depressive symptoms. In the course of the evaluation the NP further appreciates that the patient is having hypnopompic hallucinations, and that the patient is very concerned about this because his uncle has schizophrenia. 

The PMHNP advises the patient that: 

A. There are a variety of pharmacologic options that can be helpful. 

B. The hallucinations are benign and not a cause for concern.

C. There is no need for intervention unless they are accompanied by sleep paralysis.

D. The sensory systems involved will dictate the need for further evaluation and treatment.

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YouTube: https://www.youtube.com/watch?v=K-RKNH9QqU0&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=90

A.J. is an 8-year-old male who is under the care of the PMHNP for ADHD.  His symptoms are profound, and the recommendation is to begin psychostimulant therapy along with behavioral therapy.  The parents are concerned because they have read that psychostimulant therapy can impact growth and final adult height if the child starts taking it before the growth spurt of adolescence.

The most appropriate response to the parents is to say that: 

A. The impact on growth can be minimized by taking breaks from the medication on weekends and over the summer

B. This concern is not supported by the evidence and that there is no impact on growth when appropriately prescribed 

C. The impact on growth can be significant and the best management for this patient is likely a non-stimulant option 

D. The cardiovascular consequences are  actually the bigger concern. 

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YouTube: 

A 14-year-old patient has been managed for the last year with fluoxetine 40 mg daily for a diagnosis of generalized anxiety disorder. She had been doing well, but today her mother reports that ever since returning to school after the summer break she has been distant, sullen, argumentative and defiant. She has been spending time with new friends from school and is always out somewhere with them.

The PMHNP recognizes that today’s appointment should include use of which of the following objective tools?  

A. The AIMS tool 

B. The BPRS 

C. The MDQ 

D. The CRAFFT tool

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YouTube: https://www.youtube.com/watch?v=jQmzYmvXL-o&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=88

PMHNP is asked to evaluate a 71-year-old male patient who is reportedly having visual hallucinations. His adult daughter accompanies him to the appointment and reports that he was diagnosed with Parkinson’s disease approximately 2 years ago. It began with the classic motor symptoms, but over the last year he has developed more and more difficulty with memory loss, difficulty with decision making, and episodes of depression and apathy. Sinemet has helped his motor symptoms, but he has not responded well to medications for cognitive symptoms.  A few months ago he started having visual hallucinations. At first it was a sense of things moving in his peripheral vision, but lately he is seeing people who are not there, or interpreting inanimate objects as people. 

Which of the following is the most appropriate medication for this patient? 

A. Bupropion (Wellbutrin)

B. Pimavanserin (Nuplazid)

C. Quetiapine (Seroquel) 

D. Sertraline (Zoloft)

A 71-year-old patient with neurocognitive disorder due to Lewy Body disease presents for a routine follow-up.  His wife reveals that he seems to be hallucinating, sometimes at night becoming very agitated as a result of visual hallucinations, and she is afraid for his safety. The patient himself does not really seem to understand that there is a problem, but his wife is very concerned and firm that he seems to have visual hallucinations more and more frequently. 

Which of the following medications would be most appropriate? 

A. Risperidone 

B. Olanzapine 

C. Haloperidol

D. Quetiapine

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YouTube: https://www.youtube.com/watch?v=dtthgQAXpes&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=86

A.G. is a 51-year-old female patient who is being managed for a variety of mental health conditions including bipolar disorder, opioid use disorder, generalized anxiety disorder, and adjustment disorder.  Her medication regimen includes a buprenorphine-based medication for OUD, an antipsychotic, an SSRI, and antihistamine. 

The physical examination documentation for each encounter should include a(n) :

A. A PHQ-9 

B. An AIMS score 

C. A GAD-7 

D. An ORT 

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YouTube: https://www.youtube.com/watch?v=MYOGl9FLV40&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=85

A 31-year-old Middle Eastern female presents to establish care. She recently relocated to the United States with her husband and is struggling with living in an environment so different from that in which she grew up. She shares that her husband seems more comfortable because he is working and integrating outside of the home, but she does not have that experience and feels very isolated from everything she knows. She is in her first trimester of pregnancy with their first child, and clearly struggling with the cultural shift  of living in the United States. 

The PMHNP recognizes that the best approach to this patient includes: 

A. Assisting with the integration of her cultural values into her those of her new home

B. Encouraging the patient that maintenance of her native cultural values should remain the mainstay of her life 

C. Referring the patient to a culturally-similar therapist who can help her maintain her cultural identity 

D. Facilitating her shift into the cultural mores and folkways most compatible with her new living circumstances 

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YouTube: https://www.youtube.com/watch?v=If3UC_jLRhs&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=84

The PMHNP is conducting a new patient assessment with a patient who has self-referred for treatment of her panic attacks. The patient relates that she has had anxiety for years, and that she has episodes during which she gets very agitated, she can feel her heart pounding, feels as if she cannot breathe, feels very shaky, and has to sit down and wait for it to pass. These episodes can last for more than 15 minutes until she starts to calm down. 

Which of the following is inconsistent with diagnostic criteria of a panic attack?  

A. The duration is too short 

B. The duration is too long 

C. There is no report of worrying in between episodes 

D. There is no report of intense fear

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YouTube: https://www.youtube.com/watch?v=Fgx3jTEMvEk&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=83

A 22-year-old female patient is transferred to your care after another provider in the practice retired. She has been managed for bipolar I disorder for 3 years and has had some challenging extremes of exacerbation. She is currently taking a mood stabilizer, an antipsychotic, and an antidepressant. Today she reports a worsening of her depression, admitting to true hopelessness about the future, worsening malaise to the extent that she is not attending to basic hygiene, and for the first time reporting passive suicidal ideation. While her ideation does not rise to the level of hospitalization, it is a new and concerning symptom. 

Which of the following is the most appropriate adjustment to the plan of care? 

A. Ensure that the patient is seeing a therapist. 

B. Adjust the medication regimen to include lithium.

C. Increase the dose of the antidepressant.

D. Change to a different antidepressant. 

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YouTube: https://www.youtube.com/watch?v=FHFskPi8cz8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=82