The PMHNP is evaluating a patient who has presented for care repeatedly reporting that she is bipolar and has manic episodes. She has been medicated in the past with a number of mood stabilizers without any meaningful improvement. Today a more detailed history reports that what she is calling manic episodes are actually periods of dramatic responses to stressors. When she argues with her significant other, her mother, and even people at work she becomes very animated. In response to stressors she is very dramatic and defensive, will react in an erratic fashion, but then often within hours goes to extremes to try and explain her behavior and make amends. She clearly struggles with being alone. 

Which of the following diagnoses should be explored for this patient?  

A. Bipolar disorder with mixed episodes 

B. Schizoaffective disorder 

C. Adjustment disorder with anxiety features 

D. Borderline personality disorder

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YouTube: https://www.youtube.com/watch?v=dKMlovMXyVM&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=98

A 67-year-old female is being evaluated for complaints of depression. She has always struggled with times where she was down but never liked taking medication and has tried to treat herself with nutraceuticals. Her symptoms have gotten much worse lately because her husband died and she is struggling with that. She has been seeing a therapist for the last few months but is not feeling any real improvement.

When considering pharmacotherapy for her, which of the following medications should be avoided? 

A. Sertraline (Zoloft) 

B. Bupropion (Wellbutrin) 

C. Escitalopram (Lexapro) 

D. Citalopram (Celexa) 

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YouTube: https://www.youtube.com/watch?v=3R_9ZEV9B24&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=97

The PMHNP is evaluating a family at the request of county social services. A mother, father, 8-year-old and 2-year-old are present for the evaluation. The NP notes that the 2-year-old clings excessively to the parents, despite the fact that the parents do not seem to be particularly responsive to the child’s caution.  The 2-year-old does not exhibit typical curiosity about his new environment and does not express any curiosity about the PMHNP. 

These behaviors are consistent with:

A. Separation anxiety disorder 

B. Normal behavior

C. Autism spectrum disorder. 

D. Insecure-ambivalent attachment

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YouTube: https://www.youtube.com/watch?v=Q53ltO03TKU&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=96

A 78-year-old man presents for a follow-up visit. Two months ago he was started on sertraline  for major depressive disorder and has been titrated up to 100 mg daily. Today his daughter reports that she cannot really evaluate if his mood has improved because he seems to have become confused. The patient’s daughter reports a distinct new onset confusion and forgetfulness. 

The PMHNP considers the most likely cause of his confusion to be: 

A. Urinary tract infection. 

B. Hyponatremia

C. Alzheimer’s disease 

D. Depression 

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YouTube: https://www.youtube.com/watch?v=HGxzaaVSVxk&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=95

Cognitive assessment in children characterizes stages of development consistent with Piaget’s developmental theory. One of the cognitive principles typically developed during the sensorimotor stage is: 

A. Object permanence

B. Animalistic thinking

C. Phenomenalistic causality 

D. Learning without reasoning. 

YouTube: https://www.youtube.com/watch?v=AIZ5H14yUqI&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=94

A 12-year-old patient is being seen today in follow-up after being started on fluoxetine 1 month ago for a diagnosis of generalized anxiety disorder.  The patient and her father both report that while there does appear to be a mild improvement in anxiety, some adverse effects have developed about which they are concerned. 

Which of the following is not an expected adverse effect and is a cause for concern?  

A. Vivid nightmares 

B. Diaphoresis 

C. Restless legs 

D. Impulsivity

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YouTube: https://www.youtube.com/watch?v=6onROBl73UE&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=93

The PMHNP is evaluating a patient who presents complaining of panic attacks that occur for no identifiable reason. The patients has been treated for these previously with a variety of pharmacotherapies that did not provide any meaningful improvement. Upon further conversation, the NP learns that the patient experienced a near-fatal bicycle accident  4 years ago after being hit by a car. 

When considering a diagnosis of PTSD, the NP explores his history for all of the following diagnostic criteria except: 

A. Intrusion symptoms. 

B. Angry outbursts. 

C. Negative cognition 

D. Avoidance symptoms. 

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YouTube: https://www.youtube.com/watch?v=QQ-KgQYOuSg&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=92

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 

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YouTube: https://www.youtube.com/watch?v=GHa21K_Zprc&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=91

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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