A patient with bipolar I disorder is currently being managed with lithium, 60 mg q.h.s. along with quetiapine 300 mg daily. The patient presents today for follow-up and reports that her mood has been very stable. Her work as a pastry chef has been really stressful around the holiday season, but she has handled it well and has no concerns about any mood deviations, either manic or depressive. She is sleeping approximately 7 hours nightly. Her last blood work was 7 months ago, and at the time there were no alarm findings in her lithium level, renal function tests, TSH, or liver function tests. On physical examination the PMHNP appreciates a fine, symmetrical tremor of the hands that gets worse when the NP asks her to write her name. This finding was not present on previous examinations. 

The NP should take which of the following actions? 

A. Draw a TSH, lithium level, and metabolic panel with eGFR in the office today 

B. Instruct the patient to proceed to the emergency room immediately   

C. Hold the lithium and order a lithium level to be drawn in one week. 

D. Hold the quetiapine and order a metabolic panel with eGFR in one week. 

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YouTube: https://www.youtube.com/watch?v=EpZHxV2hSn4&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=108

A 27-year-old patient presents for evaluation at the suggestion of his intimate partner who thinks he might have depression. During the initial evaluation the patient admits that he is often “down,” has a really hard time feeling happy even when really good things happen. He denies any particular precipitating factor and in retrospect thinks he has been like this for “years.” He denies any difficulty sleeping, although says he never really wakes up feeling “well-rested and ready to go.” His appetite is fine, he denies any thoughts of death, suicide or self-harm, and denies a sense of hopelessness about life. 

He likes his job with a property management company, although he says it’s not especially exciting. He admits to generally having no mental or physical energy. Sometimes he wants to do things, but cannot get himself to do it. It is beginning to be a problem with his relationship, which is why he made the appointment. He has not medical conditions, takes no medications, and the rest of his history and ROS is within normal limits. 

What is the most likely diagnosis? 

A. Depressive mood due to substance use disorder 

B. Adjustment disorder with depressed mood 

C. Major depressive disorder, recurrent 

D. Persistent depressive disorder 

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YouTube: https://www.youtube.com/watch?v=WCrL3cdK4dM&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=107

The PMHNP is seeing a patient who has been struggling with a collection of anxiety and depressive symptoms. She is resistant to pharmacotherapy and prefers to begin with a psychotherapy approach. As it turns out, the primary source of her symptoms is that she is married to a spouse in the military and has had to move thousands of miles from home, friends and family. 

An attempt to implement solution-focused therapy would include which of the following techniques? 

A. Motivational interviewing 

B. Cognitive restructuring 

C. Social skills training 

D. The miracle question 

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YouTube: https://www.youtube.com/watch?v=60cxLyWFU4E&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=106

The PMHNP is interviewing a new patient, a 32-year-old single female who is presenting for evaluation of underlying anxiety. While collecting a social history the PMNP asks the patient if she has a boyfriend. The patient is uncomfortable with the question as she is lesbian and is now afraid that the PMHNP will not treat her fairly and with dignity. 

The PMHNP is most likely demonstrating which of the following? 

A. An appropriate approach to collecting social history

B.  A manifestation of implicit bias

C. An overt implementation of her value system 

D. A conscious disregard for alternative lifestyles 

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YouTube: https://www.youtube.com/watch?v=6kyWMh95t18&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=105

A 64-year-old patient presents with new onset anxiety. She denies any history of anxiety disorder or any psychiatric disorder previously in her life, but for the last 9 months she has been having episodes that she describes as “attacks.” Out of the blue she will develop a sense of racing heart, hyperventilation, numbness and tingling in her arms, and feeling lightheaded. She worries about this a lot, and now worries virtually all the time about why this is happening. It is causing difficulty with sleeping, and she finds herself being very irritable at home and at work. 

These episodes last for “a few minutes” and then subsides on its own. She takes medication for high blood pressure and high cholesterol, but otherwise reports being very healthy.  

What aspect of this scenario is suggestive that there might be an underlying organic cause of her symptoms? 

A. Age of onset

B. Character of episodes 

C. Medical history 

D. Duration of episodes 

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YouTube: https://www.youtube.com/watch?v=frd2lx7bb7o&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=104

The dopamine hypothesis of schizophrenia postulates an abnormality in which of the following dopamine pathway as the etiology of symptoms?  Select all that apply. 

A. The mesolimbic pathway

B. The mesocortical pathway

C. The nigrostriatal pathway 

D. The tuberoinfundibular pathway 

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YouTube: https://www.youtube.com/watch?v=oQ42kYfwJU4&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=103

The PMHNP is seeing a patient who presents with a chief complaint of feeling depressed. Further exploration reveals that while the patient does have several symptoms of a depressive episode, he does not quite meet criteria for any of the commonly encountered depressive disorders. The primary issue seems to center around the fact that the client feels as if his life has no meaning. He says he gets up, he gets dressed, goes to work, pays the bills, does all of the things he is supposed to do in life, but he struggles with the question, “what is the point? Why does any of it matter? 

The PMHNP recognizes that the patient might benefit from which of the following types of therapy? 

A. Cognitive behavioral therapy 

B. Behavioral therapy 

C. Psychodynamic therapy 

D. Existential therapy 

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YouTube: https://www.youtube.com/watch?v=5CwRoe9maZQ&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=102

The PMHNP is evaluating a 69-year-old patient who has self-referred for evaluation. The patient retired from his professional role as a CEO from a major fortune 500 company 8 months ago and admits that he feels himself sinking into an uncharacteristic depression. For most of his life he has been a high-achiever, and he retired 8 months ago with the intention of enjoying the wealth he worked so hard to build. While he did take some big trips and had a lot of fun at first, now he feels oddly empty and for no good reason feels himself sinking into depression. 

According to Erikson’s stages of psychosocial development this patient may be having maladaptive resolution of which stage? 

A. Identity versus role confusion 

B. Initiative versus guilt 

C. Generativity versus stagnation

D. Ego integrity versus despair

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YouTube: https://www.youtube.com/watch?v=8OBGbzW1HDc&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=101

Which of the following medical conditions should be considered when a patient presents complaining of new onset  episodes of anxiety-like symptoms including hypervigilance, tremulousness, tachycardia, and palpitations? 

A. Hypothyroidism

B. Insulinoma

C. Anemia 

D. Hepatitis 

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YouTube: https://www.youtube.com/watch?v=PgcoKYwUNMo&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=100

A PMHNP partners with a local women’s health practice to develop a program to screen pregnant women for depression in an effort to identify patients at high risk for post-partum depression and institute treatment as appropriate. This is an example of which level of prevention? 

A. Primary prevention 

B. Secondary prevention

C. Tertiary prevention 

D. Collaborative prevention

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YouTube: https://www.youtube.com/watch?v=QtlF5hZ5e0U&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=100