The PMHNP is called to the emergency room for a stat consult on a patient who reportedly was transferred in by ambulance after “acting weird at a party.” Upon arrival to the ED the NP finds the patient unresponsive. His respiratory rate is 7 bpm, his blood pressure is 70/48 mm Hg and pulse is 40 bpm. The skin is pale and clammy and his pupils are 1 mm. The most appropriate initial action is:

A. A CT scan of the head

B. Immediate administration of naloxone

C. Rapid infusion of IV crystalloids

D. Determination of medical history
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YouTube: https://www.youtube.com/watch?v=A8GD3jfcUHg&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=49

The PMHNP is evaluating a 14-year-old girl who is encouraged to care by her parents because they are concerned that she has an eating disorder. Physical examination reveals a cachectic female who, at 5’4” tall weighs 96 lbs for a BMI of 16.4. She appears clinically dehydrated, with poor skin turgor. Her vital signs reveal a temperature of 96.0o F, pulse of 48 bpm, respiratory rate of 20 bpm, and a blood pressure of 90/58 mm Hg. Suspecting a diagnosis of anorexia nervosa, the PMHNP orders a relevant laboratory assessment. Which of the follow abnormalities are most consistent with anorexia nervosa? 

A. Hypernatremia, hypokalemia, decreased BUN and creatinine

B. Polycythemia, leukocytosis, and metabolic acidosis

C. Elevated liver enzymes, hypoalbuminemia, and decreased LDL

D. Hypercholesterolemia, low TSH, Low T3, and anemia
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YouTube: https://www.youtube.com/watch?v=4aBsBqFjJ8E&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=48

A 51-year-old female is referred from her primary care provider. The patient had a 27-year-old son who died two years ago after inadvertently running in front of a car while intoxicated on hallucinogens. The patient continues to struggle with the loss of her son, and even two years later is preoccupied with thoughts of him on a daily basis. She is persistently talking about him, posting old pictures on social media, persists in talking about him at virtually every family gathering, and cannot seem to move on. When considering a diagnosis of prolonged grief disorder, the PMHNP evaluates the patient expecting to see any of the following symptoms except:

A. Identity disruption

B. Avoidance of reminders that the person is dead

C. Feeling that her purpose in life is to keep the memory alive

D. Emotional numbness
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YouTube: https://www.youtube.com/watch?v=WTc2VMSsl2I&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=47

An 82-year-old man with a long history of depression has been treated over the years with various pharmacologic agents with little improvement. Last week the PMHNP decided to try vortioxetine as the patient is clearly despondent, has not responded to several SSRI options, and is not interested in discussing ECT. At this visit the patient appears markedly brighter. He engages in conversation, has been more active with his peers at the assisted living facility, and overall seems much improved. He has no adverse effects and actually reports improved bowel motility.

The PMHNP considers that:

A. The SSRI/SPARI combination has improved the patient in a way that the SSRI alone did not.

B.  The patient may be planning suicide and a suicide screening should be implemented

C. It is likely a placebo effect from a new medication as it is unlikely therapeutic after one week

D. It may actually be an impending manic episode that has not been diagnosed previously
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YouTube: https://www.youtube.com/watch?v=apxLdU_UCFA&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=46

The PMHNP on call gets a call from the assisted living facility to advise that his 78-year-old patient is acutely confused. The patient, who is treated with mirtazapine for anxiety, insomnia, and decreased appetite, is normally oriented x 3. Today however, she does not recognize the staff at the facility and insists that she has to go home right now as her husband is waiting for her to cook dinner. She is agitated and the staff is asking for a sedative to calm her down. The PMHNP recognizes that the patient requires:

A. A non-benzodiazepine sedative for her safety

B. A medical evaluation including a urinalysis

C. Immediate transfer to the emergency department

D. An additional dose of mirtazapine with follow-up tomorrow
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YouTube: https://www.youtube.com/watch?v=pL8ZxcHOu_4&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=45

A 25-year-old female patient is being evaluated to rule out bipolar disorder. The PMHNP knows that all of the following are risk factors for bipolar disorder except: 

A. A history of depressive disorder in adolescence 

B. Low self-esteem 

C. Childhood adversity 

D. A first-degree relative with the disorder 
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Youtube: https://www.youtube.com/watch?v=vMQrrPDb1t8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=44

A 29-year-old pregnant woman is referred to the PMHNP for management of anxiety and depression. She has been taking paroxetine 40 mg daily as an outpatient for several years prescribed by her primary care provider. Upon learning that the patient was pregnant, the primary care provider insisted that the patient consult with mental health for continued management. The patient is clear that she needs to continue pharmacotherapy. She had a baby 3 years ago and tried to stop taking medication and her condition deteriorated rapidly.

The most appropriate approach for the PMHNP would be to:

A. Advise the patient that psychodynamic psychotherapy is her safest option

B. Continue the paroxetine as ordered

C. Reduce the paroxetine gradually to 20 mg daily for the duration of pregnancy

D. Stop the paroxetine and begin sertraline
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YouTube: https://www.youtube.com/watch?v=5g--quPOme0&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=43

A 42-year-old male presents for treatment of opioid use disorder. He has been taking 30 mg oxycodone tablets 4-6 times a day for over a year and both his personal and professional life are deteriorating. He has received several formal warnings at work about his absences and productivity, and his wife has been clear that she will need to move out with their children until he can get treatment. He seems sincere but is very concerned about whether or not he can do it. He has tried unsuccessfully to stop on his own and finally realized that he needs professional help so he made the appointment today. He is in which stage of the Transtheoretical Model of Change?

A. Precontemplative

B. Contemplative

C. Preparation

D. Action
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YouTube: https://www.youtube.com/watch?v=ICORO90EO6o&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=42

Suicide assessment should include an assessment of both risk factors and protective factors. Which of the following is a true statement with respect to suicide assessment?

A. Each protective factor mitigates a risk factor

B. Bonding with a pet is an internal protective factor

C. Strong sense of cultural identity is an external protective factor

D. There is no clear increase in suicidal rates with antidepressant use
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YouTube: https://www.youtube.com/watch?v=1vG6aYVNno8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=41

A 19-year-old male is in your office for evaluation of profound anxiety. He is in his first year of college and last week there was an active shooter on campus. Three people were killed. Although he didn’t know any of them, it was in the building where he has one of his classes and he is having severe anxiety and nightmares. He gets profoundly distressed when discussing this with anyone, he feels detached from his friends and even his family, is having trouble sleeping, and finds himself getting angry with everyone for no good reason. The PMHNP explores for additional symptoms to support a diagnosis of:

A. Post traumatic stress disorder

B. Acute stress response

C. Dissociative disorder

D. Panic disorder
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YouTube: https://www.youtube.com/watch?v=gvM_PjicmQI&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=40