Boardvitals (PMHNP) Flashcards

Question

What is the prevalence of borderline personality disorder among patients in psychiatric inpatient facilities? A. 1.6% B. 6% C. 10% D. 20%

Answer 1

Correct Answer: D. 20% The prevalence of borderline personality disorder in the population is estimated to be from 1.6% to 5.9%. The prevalence of borderline personality disorder among patients in psychiatric inpatient facilities is 20%. The prevalence of borderline personality disorder at primary care clinics is estimated to be about 6%, and at outpatient psychiatric clinics is estimated to be about 10%. Borderline personality disorder has been associated with depressive and bipolar disorders, posttraumatic stress disorder, substance use disorders, attention-deficit hyperactivity disorder, and eating disorders. The primary treatment for borderline personality disorder is psychotherapy, but medications can be utilized to target symptoms. For impulsive aggression can utilize fluoxetine, fluvoxamine, olanzapine, and divalproex. For affective dysregulation can use an SSRI or venlafaxine. Incorrect Answers: A. The prevalence of borderline personality disorder in the population is estimated to be from 1.6% to 5.9%. B. The prevalence of borderline personality disorder at primary care clinics is estimated to be about 6% C. The prevalence of borderline personality disorder at outpatient psychiatric clinics is estimated to be about 10%. Vital Concept: Estimates of borderline personality disorder prevalence include 6% at primary care clinics, 10% at outpatient psychiatric clinics, and 20% at psychiatric inpatient facilities.

Answer 2

Correct Answer: B. Schizotypal personality disorder There is evidence that patients with schizotypal personality disorder have abnormalities in the temporal lobe, striatal nuclei, and thalamic nuclei on MRI. In studies on patients with schizotypal personality disorder MRIs have shown the superior temporal gyrus to have decreased volume. The thalamic nucleus, pulvinar, had decreased volume, which plays a role in visual processing. Also found on MRI smaller putamen volume. The putamen is a part of the dorsal striatum (putamen, globus pallidus and caudate nucleus), which participates, in cognitive and motor activity. Incorrect Answers: A. In patients with borderline personality disorder MRIs have shown decreased limbic volumes, particularly in the hippocampus and amygdala. C. In patients with narcissistic personality disorder there has been some evidence showing right prefrontal and bilateral medial prefrontal decrease in grey matter. D. In patients with antisocial personality disorder there has been insufficient evidence of brain structural changes. Vital Concept: There is evidence that patients with schizotypal personality disorder have abnormalities in the temporal lobe, striatal nuclei, and thalamic nuclei on MRI.

Answer 3

Correct Answer: D. Giving a personal home number in case of a crisis It is important to maintain a positive attitude, find support from peers and supervisors for advice or consultation, and establish rules for therapy concerning what the patient should do in a crisis situation and how frequently he or she should receive therapy. Therapists must also respect personal boundaries and avoid relating personal problems to the patient or giving the patient their home phone number. Incorrect Answers: A, B, and C. These are appropriate and effective therapy provider techniques and boundaries

Answer 4

Correct Answer: D. Quick decision-making without consideration of consequences or preparation Antisocial personality disorder is characterized by: consistent ignorance and abuse of surrounding people’s rights that begins by age 15 as evidenced by at least three of the following: - dishonesty in the form of defrauding, deceiving, or misleading others for individual gain - an agitated and sometimes hostile nature with a history of numerous altercations - a lack of personal accountability as evidenced by a failure to fulfill financial responsibilities or deliver professionally when promised - lack of concern regarding social norms or laws, with repeated arrests or undetected breaches of the law - quick decision-making without consideration of consequences or preparation - lack of concern about the well-being or security of others or oneself - an inability to feel guilty or personally responsible following the harm, deception, or abuse of another person The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder. Conduct disorder must be diagnosed or evident prior to age 15, but antisocial PD is not to be confirmed in an individual under 18. Incorrect Answers: A. Challenges starting tasks due to a lack of self-assurance in skill or decision-making is a characteristic of dependent personality disorder, not antisocial. B. Overly sensual or erotic communication is characteristic of histrionic personality disorder, not antisocial. C. Repeated discussions, attempts, or contemplations of suicide or intentional self-harm are characteristic of borderline personality disorder, not antisocial. Vital Concept: Quick decision-making without regard for consequences or proper preparation is characteristic of antisocial personality disorder, as well as borderline personality disorder.

Answer 5

Correct Answer: A. Antisocial Personality Disorder The patient described meets the criteria for APD by: 1. Pervasive pattern for disregard for others since age 15 as indicated by (at least 3 of 7 criteria): - breaking the law - impulsivity - aggressiveness - lack of remorse 2. Individual is at least 18 3. There is evidence of conduct disorder with onset before age 15. Incorrect Answers: B. Histrionic Personality Disorder (HPD) is a pervasive pattern of excessive emotionality and attention seeking beginning in early adulthood and present in a variety of contexts. C. Oppositional Defiant Disorder (ODD). ODD is a pattern of angry/irritable mood, argumentative /defiant behavior, or vindictiveness lasting at least 6 months. ODD does not include aggression towards people or animals, destruction of property, or a pattern of theft or deceit. D. Intermittent Explosive Disorder is recurrent behavioral outbursts representing a failure to control aggressive impulses. Physical aggression may result in damage or destruction of property and/or physical injury to animals or other individuals.

Answer 6

Correct Answer: A. A patient with antisocial personality disorder Patients with antisocial personality disorder who do not have depression are least likely to achieve meaningful improvement with psychotherapy alone. Treatment for aggression may include the use of antipsychotic medication. Treatment for impulsivity may include the use of anticonvulsants. Those with comorbid ADHD may be managed with bupropion or atomoxetine. Incorrect Answers: B. Patients with borderline personality disorder generally respond to psychotherapy, potentially in combination with other treatments. C. Patients with narcissistic personality disorder generally respond to psychotherapy, potentially in combination with other treatments. D. Patients with histrionic personality disorder generally respond to psychotherapy, potentially in combination with other treatments. Vital Concept: Antisocial personality disorder does not have a clearly identified treatment algorithm. It is least likely to improve with psychotherapy.

Answer 7

Correct Answer: D. Psychotherapy Psychotherapy, specifically dialectical-behavioral therapy (DBT), has been shown to cause lasting changes in a person’s character structure. Medications are an essential part of treating the symptoms of borderline personality disorder, but psychotherapy will target the root cause of the disorder. Borderline PD is likely secondary to many factors (i.e. genetic, neurobiological, and psychosocial). However, specific genetic risk factors have not been identified. Some studies have indicated that impulsive-aggressive behavior is related to low CNS serotonin levels. Specific brain abnormalities include reduced volume in the amygdala and hippocampus, altered amygdala activation, and hippocampal hypometabolisim. Other findings include abnormalities in the prefrontal, corticostriatal, and limbic networks, which could be related to low serotonin neurotransmission and behavioral disinhibition. The primary treatment for borderline PD is psychotherapy and medications to target symptoms. Most patients will need long-term therapy to see benefits in interpersonal relationships, changes in personality, and an improvement in overall functioning. Psychodynamic, dialectical-behavioral, transference-focused therapy (TFP), interpersonal therapy, and CBT have been shown to be effective. Family therapy or couples therapy alone is not effective. Fluoxetine, fluvoxamine, olanzapine, and divalproex reduce impulsive aggression and depressive symptoms. Affective dysregulation is treated with an SSRI or venlafaxine, and TCAs have had inconsistent results. Benzodiazepines should be used sparingly, as research on their use with BPD is limited, and they carry more substantial risks in this population. MAOIs show strong empirical support, but their side effect profiles make them second-line. Mood stabilizers are second-line as well since few studies support their efficacy in this population. Patients with borderline PD are unlikely to respond to ECT. Impulsive-behavioral dyscontrol symptoms that present serious risk to the patient (e.g. aggression, self-mutilation, or self-damaging behaviors like reckless spending, promiscuous sex, and substance abuse) are best treated by adding an antipsychotic to the SSRI. Other alternatives include adding lithium or switching to an MAOI. A few studies support the use of valproate or carbamazepine to treat impulsive aggression. Cognitive-perceptual symptoms (paranoid ideation, derealization, depersonalization, or hallucinations) respond best to low-dose antipsychotics. Incorrect Answers: A. No need for antipsychotics as there are no psychotic symptoms B. No need for anticonvulsants as there are no symptoms C. Mood stabilizers are second line

Answer 8

Correct Answer: D. Grandiose sense of self-importance Narcissistic personality disorder involves a grandiose sense of self-importance. Incorrect Answers: A. Affective lability or emotional instability is a symptom of borderline personality disorder (BLPD). B. Feelings of emptiness occur in BLPD. C. Inappropriate anger, including recurrent fights, is a symptom of BLPD.

Answer 9

Correct Answer: D. Projective identification Projective identification is seen in this patient and is common in borderline personality disorder. Projective identification has three steps: 1) patient assigns a component of himself or herself to another individual 2) patient manipulates this individual into integrating this component into his or her consciousness 3) this process leads to an increased feeling of closeness between the parties Incorrect Answers: A. Countertransference is the analyst's emotional response to a patient. B. Splitting is when a patient tends to identify aspects as either completely good or completely bad. C. Dissociation is a mental process that gives rise to a lack of connection in the patient's thoughts, memory, and sense of identity.

Answer 10

Correct Answer: C. Schizoid personality disorder Schizoid personality disorder is defined as a pattern of detachment from social relationships and restricted expression of emotions in interpersonal settings. This personality disorder typically presents by the patient’s ‘20s and is evidenced by at least four of the following: · consistently picks actions or events that are performed alone · does not enjoy most (or any) events, actions, or hobbies · appears unaffected by people’s positive or negative opinions of them · does not want or like to be emotionally close to people, including family members · minimal (or no) desire to have a sexual relationship with someone else · has very few (or no) people that they are emotionally close to outside of family · appears to display minimal attachment, emotion, or responsiveness The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder, autism spectrum disorder, or other medical condition. Incorrect Answers: A. Schizotypal personality disorder is often confused with schizoid personality disorder. Schizotypal personality disorder is defined as a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior. Those with schizotypal personality disorder try and want to be “typical” but are odd and awkward and are unsuccessful. In contrast, patients with schizoid personality disorder do not want any relationships and are content loners. B. Paranoid personality disorder is defined as a pervasive pattern of distrust and suspiciousness of others so that their motives are interpreted as malevolent. This condition begins in early adulthood and presents in a variety of contexts. James is not described as being suspicious or paranoid but as a content loner. D. Autism spectrum disorder has some unique characteristics to distinguish it from a schizoid personality disorder, including stereotypies, repetitive self-soothing, highly perseverative or unusual interests, concrete thought processes, and difficulties with social pragmatics. Patients with autism spectrum disorder are generally interested in social interactions, compared to patients with schizoid personality disorder who are aloof and indifferent to social interactions. Typically, patients with autism spectrum disorder want relationships but have trouble initiating and maintaining them. Patients with autism spectrum disorder also will have a much stronger reaction to praise or criticism. Autism spectrum traits are observed much earlier, typically in early childhood, and can be associated with some developmental delays. Vital Concept: Schizoid personality disorder is defined as a consistent lack of attachment to others and a limited display of emotions when interacting with others.

Answer 11

Correct Answer: C. Fluoxetine SSRIs like fluoxetine may be helpful in this regard. Incorrect Answers: A, B, and C. These aren't useful for reducing the need for perfectionism and the development of unnecessary rituals

Answer 12

Correct Answer: A. Agree that there may be some truth to his claims. It is to the benefit of the patient to enter his world of paranoia by agreeing that there may be some truth to his claims. The therapist should not outright agree with or affirm these paranoid ideas, however, as this may seem patronizing and may alienate the patient. Incorrect Answers: B. It benefits the patient to enter his world of paranoia; so denying the claims is a poor move by the therapist C. It benefits the patient to enter his world of paranoia; so explaining why they're wrong is a poor move by the therapist D. It benefits the patient to enter his world of paranoia; so disproving the claims is a poor move by the therapist

Answer 13

Correct Answer: B. .5-2% Women with antisocial personality disorder (ASPD) comprise 0.5-2% of individuals in community settings. In clinical settings, this percentage is much higher (ranging from 3-30%). By contrast, the prevalence of ASPD in the general population is roughly 6% in males. The Epidemiologic Catchment Area (ECA) survey of five United States cities found that 2 to 4 percent of men and 0.5 to 1 percent of women met these criteria. Two nationally representative surveys of US adults, the National Comorbidity Study and the NESARC study, estimated prevalence rates of 3.5 and 3.6 percent, respectively; the latter survey found a rate of 5.5 percent for men and 1.9 percent for women. Incorrect Answers: A. This figure is too low — the prevalence of antisocial personality disorder in women in the community is 0.5-2%. C. The prevalence of ASPD is less than 3-5% amongst females in the US. D. The estimated prevalence of ASPD amongst men in the US is 6%. Vital Concept: The prevalence of antisocial personality disorder (ASPD) is roughly 3-5 times higher in males than females.

Answer 14

Correct Answer: D. 10% The prevalence of borderline personality disorder is 1.6-5.9% in the general population, 6% in primary care patients, 10% in psychiatric outpatients, and 20% in psychiatric inpatients. Diagnosis of borderline personality disorder includes 5 or more of the following criteria: frantic avoidance of abandonment, unstable relationships, disturbances of identity, recurrent suicidality, unstable mood/affect, a chronic feeling of emptiness, intense bouts of difficult-to-control anger, and transient paranoia or dissociation (see table below). Incorrect Answers: A, B, C. These prevalence percentages are all below the actual prevalence Vital Concept: Estimates of borderline personality disorder prevalence include 6% at primary care clinics, 10% at outpatient psychiatric clinics, and 20% at psychiatric inpatient facilities.

Answer 15

Correct Answer: A. Obsessive-compulsive personality disorder Patients with obsessive-compulsive personality disorder (OCPD) are characterized by strict adherence to rules and a lack of adaptability. OCPD is not associated with the intrusive thoughts and ritual performance that characterize obsessive-compulsive disorder (OCD). These people would colloquially be called anal or "control freaks." This patient also demonstrates intellectualization and isolation of affect, which are 2 common defense mechanisms seen in OCPD. Incorrect Answers: B. OCD is associated with intrusive thoughts and ritual performance to relieve the anxiety from intrusive thoughts. These patients do not present with the same extreme rule-following. C. Narcissistic personality disorder does not present with a focus on rule-following. These patients are much more focused on themselves. D. Schizoaffective disorder patients would present with signs of schizophrenia with a depressive component, which is not seen in this patient.

Answer 16

Correct Answer: B. Avoidant and dependent Dependent and avoidant personality disorders commonly co-occur with generalized anxiety disorder (GAD), although personality disorders may result from GAD. GAD is also commonly comorbid with other anxiety and unipolar depressive disorders. In males with GAD, there is also comorbidity with substance use disorders. Dependent personality disorder is characterized by a need to be cared for, resulting in clingy and obedient behavior. It is commonly comorbid with depressive disorders, anxiety disorders, and adjustment disorders. It also commonly co-occurs with other personality disorders, including borderline, avoidant, and histrionic. Patients with avoidant personality disorder often feel inadequate, hypersensitive to rejection/criticism, and avoid social interactions. It is commonly comorbid with depressive, bipolar, and anxiety disorders. It also commonly co-occurs with other personality disorders, including dependent, borderline, paranoid, schizoid, and schizotypal. Incorrect Answers: A. Borderline personality disorder is associated with depressive and bipolar disorders, posttraumatic stress disorder, substance use disorders, attention-deficit hyperactivity disorder, and eating disorders. Histrionic personality disorder has been associated with somatic symptom disorder, functional neurological symptoms disorder, and major depressive disorder. C. Histrionic personality disorder has been associated with somatic symptom disorder, functional neurological symptoms disorder, and major depressive disorder. Dependent PD is often comorbid with GAD. D. Borderline personality disorder is associated with depressive and bipolar disorders, posttraumatic stress disorder, substance use disorders, attention-deficit hyperactivity disorder, and eating disorders. In some cases, schizoid personality disorder can be premorbid to schizophrenia and delusional disorder. Vital Concept: GAD is characterized by pervasive concern or worry and is often comorbid with dependent and avoidant personality disorders.

Answer 17

Correct Answer: B. 15% Epidemiological surveys show that 9-16% of the general population meets criteria for at least 1 personality disorder. Incorrect Answers: A. This percentage prevalence is too low (actual is 15%) B., D. These percentage prevalences are too high (actual is 15%)

Answer 18

Correct Answer: A. 5-HIAA Impulsive offenders who have a tendency to behave aggressively, especially while intoxicated, had low CSF 5-HIAA. Another study demonstrated that impulsive violent offenders possessed lower concentrations of CSF 5-HIAA than non-impulsive violent criminals. Furthermore, a meta-analysis of 20 studies also found significantly reduced levels of 5-HIAA in the CSF of antisocial individuals compared to controls. Incorrect Answers: B, C, and D. These aren't found in lower concentrations in impulsive, violent criminals' CSF.

Answer 19

Correct Answer: C. Onset of conduct disorder before age 15 Antisocial personality disorder is characterized by: - consistent ignorance and abuse of surrounding people’s rights that begins by age 15 as evidenced by at least three of the following: - dishonesty in the form of defrauding, deceiving, or misleading others for individual gain - an agitated and sometimes hostile nature with a history of numerous altercations - a lack of personal accountability as evidenced by a failure to fulfill financial responsibilities or deliver professionally when promised - lack of concern regarding social norms or laws, with repeated arrests or undetected breaches of the law - quick decision-making without consideration of consequences or preparation - lack of concern about the well-being or security of others or oneself - an inability to feel guilty or personally responsible following the harm, deception, or abuse of another person The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder. Conduct disorder must be diagnosed or evident prior to age 15, but antisocial PD is not to be confirmed in an individual under 18. Incorrect Answers: A. Desperate attempts to prevent actual or perceived rejection or desertion by others are associated with borderline personality disorder. B. Patients with narcissistic personality disorder are somewhat preoccupied with jealousy and envy- of others or suspicion of others directed at them. D. Patients with paranoid personality disorder may experience an unfounded belief that people are trying to take advantage of them, lying to them, or otherwise hurting them. Vital Concept: A prior history of conduct disorder before the age of 15 is characteristic of antisocial personality disorder.

Answer 20

Correct Answer: B. Schizoid Schizoid personality disorder is defined as a pattern of detachment from social relationships and restricted expression of emotions in interpersonal settings. This personality disorder typically presents by the patient’s ‘20s and is evidenced by at least four of the following: · consistently picks actions or events that are performed alone · does not enjoy most (or any) events, actions, or hobbies · appears unaffected by people’s positive or negative opinions of them · does not want or like to be emotionally close to people, including family members · minimal (or no) desire to have a sexual relationship with someone else · has very few (or no) people that they are emotionally close to outside of family · appears to display minimal attachment, emotion, or responsiveness The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder, autism spectrum disorder, or other medical condition. Incorrect Answers: A. Paranoid personality disorder is diagnosed when someone is distrustful and suspicious of others without reason. C. Schizotypal personality disorder is defined by social isolation related to social anxiety and difficulty interacting. These patients can have odd behaviors and appearances. D. Obsessive-compulsive personality disorder is characterized by perfectionism, rigidity, and a consistent fascination with control, flawlessness, and organization. Vital Concept: Schizoid personality disorder is defined as a consistent lack of attachment to others and a limited display of emotions when interacting with others.

Answer 21

Correct Answer: D. Cognition, affectivity, interpersonal functioning, impulse control Diagnosing a patient with a general personality disorder requires consistent thoughts, feelings, and actions that are significantly varied from those of the individuals around them. This must be observed in at least of the categories of thought (cognition), emotion (affectivity), interactions with others (interpersonal functioning), and the ability to manage inner desires (impulse control). Incorrect Answers: A. Perceptions aren't one of the four areas B. Dysphoria isn't one of the four areas C. Occupational functioning isn't one of the four areas Vital Concept: Cognition, affectivity, interpersonal functioning, and impulse control comprise Criteria A for personality disorders.

Answer 22

Correct Answer: D. 5-10% Lifetime obsessive-compulsive personality disorder has a prevalence of approximately 7.8% in the general population. It is less common in younger adults and in Asians and Hispanics. Incorrect Answers: A, B, C. These prevalence percentages are all too low

Answer 23

Correct Answer: A. Lithium Borderline PD is thought to be secondary to many factors, including genetic, neurobiological, and psychosocial influences. However, specific genetic risk factors have not been identified. Specific brain abnormalities include reduced volume in the amygdala and hippocampus, altered amygdala activation, and hippocampal hypometabolism. Other findings include abnormalities in the prefrontal, corticostriatal, and limbic networks, which could be related to low serotonin neurotransmission and behavioral disinhibition. The primary treatment for borderline PD is psychotherapy and medications to target symptoms. Most patients will need long-term therapy to see improved interpersonal relationships, personality changes, and overall functioning. Psychodynamic, dialectical-behavioral, transference-focused, interpersonal, and cognitive-behavioral therapies have been effective. Family therapy or couples therapy alone has not been effective. Mood stabliizers reduce impulsive aggression and depressive symptoms. Affective dysregulation is treated with an SSRI or venlafaxine, but TCAs have had inconsistent results. Benzodiazepines should be used sparingly, as research on their use with BPD is limited, and they carry more substantial risks in this population. MAOIs show strong empirical support, but their side effect profiles make them second-line. Patients with borderline PD are unlikely to respond to ECT. Impulsive-behavioral dyscontrol symptoms that present serious risk to the patient (e.g. aggression, self-mutilation, or self-damaging behaviors like reckless spending, promiscuous sex, and substance abuse) are treated by adding an antipsychotic to an SSRI. Other alternatives include switching to an MAOI. A few studies support the use of lithium, valproate or carbamazepine to treat impulsive aggression. Cognitive-perceptual symptoms (paranoid ideation, derealization, depersonalization, or hallucinations) respond best to low-dose antipsychotics. Incorrect Answers: B. Fluoxetine. Fluoxetine is not first line treatment for impulsitiviy or affective dysregulation in borderline PD. C. Isocarboxazid. MAOIs show strong empirical support, but their side effect profiles make them second-line. D. Lorazepam. Benzodiazepines should be used sparingly, as research on their use with BPD is limited, and they carry more substantial risks in this population. Vital Concept: The primary treatment for borderline personality disorder is psychotherapy but medications can be utilized to target symptoms. For impulsive aggression, mood stabilizers are recommended. For affective dysregulation, use an SSRI or venlafaxine.

Answer 24

Correct Answer: B. Pervasive pattern of social inhibition The diagnostic criteria for avoidant PD are: A consistent finding of feelings of deficiency, highly touchy when presented with constructive feedback, and shyness or self-consciousness. This personality disorder typically presents by the patient’s ‘20s and is evidenced by at least four of the following: - resistance to interacting with others unless acceptance is guaranteed prior - consistent distraction by the prospect or threat of being disparaged or excluded - a self-image that includes being substandard, socially awkward, and unlikable - avoids functions or get-togethers that include interacting with others out of concern for reproach or censure - is hesitant in romantic or close friendships due to concern for being judged or mocked - is reserved early on in relationships due to a sense of deficiency - is highly resistant to trying new things or taking risks due to a fear of humiliation Incorrect Answers: A. This is a criterion for paranoid personality disorder. C. This is a criterion for dependent personality disorder. D. This is a criterion for obsessive-compulsive personality disorder. Vital Concept: The criteria for avoidant personality disorder include behaviors that avoid social interaction, activities, or relationships out of fear that they are not good enough or will not be liked.

Answer 25

Correct Answer: B. Carbamazepine First-line pharmacotherapy for aggression due to seizure activity involves carbamazepine. The second-line option would be benzodiazepines. Incorrect Answers: A. Antipsychotics are contraindicated in the treatment of aggressive personality changes due to epilepsy. C. D. These drugs are neither contraindicated nor recommended for use in managing aggression due to seizures.

Answer 26

Correct Answer: D. Psychodynamic therapy In psychodynamic psychotherapy, the therapist works with the patient to recognize his or her unconscious or conscious motivations for making these decisions. It is especially interested in the dynamic relations between conscious motivation and unconscious motivation. No substantial treatment research exists for histrionic personality disorder (HPD), although 2 meta-analyses of psychotherapeutic treatments for personality disorders suggest that these conditions respond to both psychodynamic therapy and cognitive-behavioral therapy. Interpersonal therapy (IPT) focuses on improving relationships in the present. IPT is particularly accessible to patients who find dynamic approaches confusing or the "homework" demands of cognitive-behavioral therapy too daunting. Incorrect Answers: A, B, C. These aren't indicated for treating patients with histrionic personality disorder.

Answer 27

Correct Answer: A. Level of impairment in personality functioning The alternative model in Section III of the DSM-5-TR classifies personality disorders by personality functioning impairment and pathological personality traits. This section includes a scale for measuring the level of impairment, ranging from 0 (no impairment) to 4 (extreme impairment). A diagnosis of a personality disorder would require at least a level 2 (moderate impairment) and at least one pathological personality trait. Impairment in personality functioning predicts the presence of the personality disorder and the impairment severity predicts if the patient has multiple personality disorder or more severe personality disorders. This model is only applied to the following personality disorders: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal. Incorrect Answers: B. The impairment must be stable over time with onset in adolescence or early adulthood. C. There is no assessment in the alternative model for personality disorders, DSM-5-TR section III, for degree of introversion versus extraversion. D. Both DSM-5-TR sections II and III require stability of personality traits over time in order to receive a diagnosis of a personality disorder. Vital Concept: The alternative model in Section III of the DSM-5-TR classifies personality disorders by personality functioning impairment and pathological personality traits.

Answer 28

Correct Answer: C. An inability to feel guilty or personally responsible following the harm, deception, or abuse of another person Antisocial personality disorder (ASPD) is characterized by: consistent ignorance and abuse of surrounding people’s rights that begins by age 15 as evidenced by at least three of the following: - dishonesty in the form of defrauding, deceiving, or misleading others for individual gain - an agitated and sometimes hostile nature with a history of numerous altercations - a lack of personal accountability as evidenced by a failure to fulfill financial responsibilities or deliver professionally when promised - lack of concern regarding social norms or laws, with repeated arrests or undetected breaches of the law - quick decision-making without consideration of consequences or preparation - lack of concern about the well-being or security of others or oneself - an inability to feel guilty or personally responsible following the harm, deception, or abuse of another person The symptoms must be present outside of and notwithstanding a diagnosis of bipolar disorder, schizophrenia, or some other psychotic disorder. Conduct disorder must be diagnosed or evident prior to age 15, but antisocial PD is not to be confirmed in an individual under 18. Incorrect Answers: A. Self-harm is associated with borderline personality disorder. B. Conduct disorder is diagnosed in children and adolescents with a repetitive and persistent pattern of behavior violating basic rights of others or major societal norms or rules. While the majority of children with conduct disorder do not develop adult ASPD, they are at risk to do so, with an estimated 25 percent of girls and 40 percent of boys eventually developing ASPD D. Patients with borderline personality disorder may experience short-term thoughts of persecution/victimhood or severe derealization or depersonalization. Vital Concept: Antisocial personality disorder should not be diagnosed in a patient under the age of 18, but a portion of the criteria stipulates that conduct disorder must have been diagnosed or obvious prior to age 15.

Answer 29

Correct Answer: B. Antisocial Antisocial personality disorder occurs more frequently in men. Borderline personality disorder and histrionic personality disorder occur more commonly in women, while dependent and avoidant also show a slight female predilection in some studies and gender neutrality in others. Schizoid personality disorder occurs relatively equally among the genders with a slight male predilection suggested by some sources. Incorrect Answers: A and D. These are diagnosed more often in women C. This shows a slight female predilection in some studies, and gender neutrality in others

Answer 30

Correct Answer: C. Rapprochement Mahler’s theory is based on psychoanalytic work from observation of children ages 6 months to 3 years. The autistic phase occurs during the first weeks of life and is characterized by total detachment and self-absorption, as the infant spends most of his or her time sleeping. The symbiotic phase occurs until about 5 months of age. The infant recognizes his or her mother but lacks a sense of individuality. Separation-individuation has 3 phases: 1) hatching, in which the infant shows increased interest in the outside world 2) practicing (9-16 months), in which the infant develops the physical ability to separate from the mother 3) rapprochement (15-24 months), in which the infant explores the outside world but requires that the mother is present and able to support the child appropriately and emotionally in completing the task Mahler’s work has been expanded by other theorists to understand the basis of personality disorder. Disturbance of the rapprochement subphase is associated with a persistent longing for and dread of fusion with the object that is thought to be secondary to aggression or withdrawal in the mother. Disruption of the rapprochement subphase is thought to contribute to the development of borderline personality disorder. Narcissistic personality disorders are likely due to inadequate soothing during the symbiotic phase and inadequate refueling during separation-individuation. Object constancy describes the child’s understanding that his or her mother is a separate individual and that he or she is also separate. Object constancy leads to the formation of internalization, which will allow the child to have an internal representation of mother, in turn allowing healthy separation, exploration, and the development of self-esteem. Incorrect Answers: A. This isn't one of Mahler's stages of infant development B, and D. These stages of Mahler's stages of infant development aren't disrupted in children who develop borderline personality disorder

Answer 31

Correct Answer: D. Avoidant personality disorder Avoidant personality disorder is characterized by a consistent and nearly debilitating fear of rejection. These patients often desire close relationships with others, but their rumination on rejection prevents them from interacting with others. Incorrect Answers: A. People with antisocial personality disorder can be extroverted and superficially liked; however, they tend to be misanthropic in their actions and show little to no adherence to laws or social standards. There is often a marked legal history with these individuals. B. Schizotypal personality disorder describes difficulty with socializing combined with a pattern of strange thinking. C. Schizoid personality disorder is demonstrated in patients who do not form close relationships but generally have little to no desire to socialize or form relationships with others. Vital Concept: Avoidant personality disorder is characterized by a consistent and nearly debilitating fear of rejection. Patients with this condition often desire close relationships with others, but can't interact with others due to their rumination on rejection.

Answer 32

Correct Answer: B. Avoidant personality disorder Avoidant personality disorder belongs to the Cluster C group, which shares the common features of being anxious and fearful. Incorrect Answers: A. Antisocial personality disorder is a cluster B disorder, characterized by drama, emotion, and impulsivity. C. Borderline personality disorder is a cluster B disorder. D. Histrionic personality disorder is a cluster B disorder. Vital Concept: Cluster C disorders all present with fear and anxiety. Avoidant PD, dependent personality disorder, and obsessive-compulsive personality disorder are all cluster C disorders

Answer 33

Correct Answer: C. Mood stabilizers Mood stabilizers are considered first-line agents for treating impulsive-behavioral symptoms, such as impulsivity, self-injury, theft, and aggression/interpersonal conflict, in personality-disordered patients. By contrast cognitive-perceptual symptoms, such as hallucinations and delusions/paranoia are treated with a low-dose of antipsychotic medication Affective dysregulation, which may present with depressed or anxious mood, lability, or anger, is also treated with either a low-dose antipsychotic medication or a mood stabilizer. Incorrect Answers: A and B- MAOIs and TCAs have many adverse side effects and are not considered first-line treatment. TCAs can also be fatal in overdose. D- SSRIs are not first-line therapy for impulsive-behavioral symptoms in patients with personality disorder. Vital Concept: Personality disorders are typically treated nonpharmacologically with psychotherapy. If symptoms significantly impair function, some symptoms may be managed with medication. Mood stabilizers are often used for impulsive-behavioral symptoms or affective dysregulation.

Answer 34

Correct Answer: A. Schizotypal This patient exhibits odd beliefs, paranoid ideation, an "off" appearance, a lack of close friends, and social anxiety secondary to paranoid fears. These features are consistent with schizotypal personality disorder. Incorrect Answers: B. This patient's behavior doesn't exhibit the aggression that'd be seen in antisocial disorder C. This patient isn't overly dramatic or emotional, as you'd see in a patient with histrionic disorder D. There's no evidence of unreasonable suspicion, as you'd see in paranoid disorder

Answer 35

Correct Answer: D. No FDA-approved medications for any personality disorder Currently, there are no FDA-approved medications for any personality disorder. Psychotherapy is the mainstay of personality disorder treatment at this time. Medications can be used in combination with psychotherapy in severe cases and based on specific symptoms present that could justify adding an antipsychotic, antidepressant or anti-anxiety medication. Incorrect Answers: A. There are no FDA-approved medications for schizotypal personality disorder. B. There are no FDA-approved medications for paranoid personality disorder. C. There are no FDA-approved medications for borderline personality disorder. Vital Concept: Psychotherapy is the mainstay of personality disorder treatment. There are no FDA-approved medications for any personality disorder.

Answer 36

Correct Answer: D. Subjectively altered sense of time is common. Common symptoms of depersonalization/derealization disorder include a subjectively altered sense of time, subjective difficulty in vividly recalling past memories, vague somatic symptoms, and fear of irreversible brain damage. There is an association with childhood interpersonal trauma, and it can be precipitated by severe stress or illicit drug use (most notably hallucinogens, ketamine, MDMA, and salvia). Marijuana can precipitate new-onset panic attacks and depersonalization/derealization disorder at the same time. Incorrect Answers: A. Symptoms can wax and wane, but in some cases, there is an unwavering, persistent course. B. The average age of onset is 16 years, and <20% of patients experience onset after age 20 (and 5% after age 25). C. DDD is equally prevalent in men and women. Vital Concept: DDD is often associated with a subjectively altered sense of time.

Answer 37

Correct Answer: D. Use of inanimate objects for sexual stimulation Fetishism is characterized by feelings of sexual excitement related to inanimate objects or nonsexual body parts. This occurs over a period of 6 or more months, with associated daydreams and desires. The inanimate objects cannot be limited to articles of clothing involved in dressing as the opposite gender or those designed for sexual gratification (e.g., vibrator). The patient has either followed through with their desires or describes them as leading to substantial anguish or dysfunction. Incorrect Answers: A. This describes voyeuristic disorder. B. This describes exhibitionistic disorder. C. This describes frotteuristic disorder. Vital Concept: Fetishism is characterized by feelings of sexual excitement related to inanimate objects or nonsexual body parts.

Answer 38

Correct Answer: B. Lithium Not all medications are safe during pregnancy. They are classified according to the level of evidence of their teratogenicity (i.e. birth anomaly induction). The older classification was Class A means no known adverse effects, Class B: no risks have been identified in human beings, Class C: drug safety is unknown due to lack of sufficient research, Class D: research has shown adverse effects in humans, Class X: should be completely avoided in pregnancy. Due to the confusing nature of this system, the FDA required that it be replaced with a narrative section and subsection. Those sections are pregnancy, with risk summaries, registries of cases, clinical data, and clinical considerations. Another section involves lactation, also containing data relevant to the drug’s effect on lactation, clinical considerations, and a synopsis of the adverse effects. The last section deals with the female and male reproductive systems, with subsections dealing with contraception, infertility, and pregnancy testing. The mother has a history of bipolar disorder-type I. Therefore, suspicion for pharmacotherapy should be present. Commonly, bipolar disorder is treated with Lithium. Lithium causes Ebstein anomaly, which is atrialization of the right ventricle by which the tricuspid valve moves towards the apex of the heart, thus enlarging the right atrium and shrinking the right ventricle. Ebstein anomaly is highly specific for Lithium use during pregnancy. This anomaly leads to poor pulmonary circulation and, consequently, poor blood oxygenation; poor oxygenation leads to tachypnea and tachycardia. Incorrect Answers: A. Valproate: it is an anticonvulsant that is used mainly to treat epilepsy, mania, and migraines. It is recommended not to use valproate in women of reproductive age unless it’s absolutely necessary. Its use during pregnancy has been correlated with neural tube defects (such as spina bifida) and low IQ scores. Therefore, it is absolutely contraindicated for migraine prevention in pregnant women and it is highly recommended against for other conditions in the same population. In women of childbearing age using valproate, contraception is usually instituted concurrently. C. Fluoxetine: it is a Selective Serotonin Reuptake Inhibitor (SSRI) that is used as an antidepressant. Its main use is for depressive disorders, obsessive compulsive disorder, and bipolar type I in combination with olanzapine for treatment-resistant cases. It is a class C in the old classification system, which means that adverse events may have been noticed in animals during gestation. Human results have not been conclusive. SSRIs may be used during pregnancy on individual basis. However, no SSRI has been associated with the Ebstein anomaly. Therefore, this answer choice is incorrect. D. Cocaine: it is an indirect sympathomimetic. It works by blocking the re-uptake of the catecholamines at the synaptic cleft, thus strengthening their effects. Epinephrine binding to alpha-1 receptors on blood vessels causes vasoconstriction. Cocaine use during pregnancy has been associated with Intra-Uterine Growth Restriction (IUGR), and Placental Abruption. Babies born to mothers who used cocaine during pregnancy are susceptible to being small for gestational age (SGA). However, the newborn in the clinical vignette has a cardiac anomaly that has not been shown to be associated with cocaine use.

Answer 39

Correct Answer: C. Lithium Data suggests that all psychotropic medications (including antipsychotic agents, antidepressant agents, lithium carbonate, and benzodiazepines) are excreted into breast milk. Concentrations of these agents in breast milk can vary considerably. Lithium is relatively contraindicated in breastfeeding; if a mother is taking lithium, breastfeeding is only feasible with rigorous monitoring. Weight should be monitored closely, as well as signs of dehydration, lethargy, and feeding concerns. Laboratory monitoring should include a lithium level, CBC, BUN/Cr, and TSH. Incorrect Answers: A. Clinical exposure via breast milk is generally considered to be clinically insignificant. Infants whose mothers took an antipsychotic during pregnancy are generally encouraged to continue this during pregnancy. the infant should be monitored for extrapyramidal symptoms (EPS). B. Trazodone levels in breastfed infants is relatively low and not expected to cause adverse effects. D. Paroxetine use during breastfeeding is a low-risk option, with no detectable serum levels of the drug found in breastfed infants and minimal side effects. Vital Concept: Of the medications listed, lithium is the most concerning to be administered to a breastfeeding mother.

Answer 40

Correct Answer: D. Cognitive behavioral therapy and SSRI CBT alone or CBT plus an SSRI is considered adequate treatment for bulimia nervosa. The only SSRI currently FDA-approved for bulimia is fluoxetine. Studies are also suggesting topiramate for use in bulimia. Incorrect Answers: A. An SSRI alone isn't considered adequate for bulimia treatment. B. An antipsychotic won't help treat bulimia, as it doesn't treat the issue at hand. C. A mood stabilizer alone won't help treat bulimia, as there's also a behavioral component that needs to be addressed. Vital Concept: Bulimia is often comorbid with bipolar and substance use disorders. The most effective treatment for bulimia overall is CBT. An SSRI alone is not considered adequate treatment for this condition.

Answer 41

Correct Answer: A. Increased risk of cardiac malformation Antenatal lithium exposure is thought to cause teratogenic effects, especially in the heart and when used during the first trimester. This may include Ebstein anomaly (abnormalities of the tricuspid valve and right ventricle), right ventricular outflow tract obstruction defects, coarctation of the aorta, and mitral atresia. Incorrect Answers: B. Antepartum exposure to lithium has not been proven to dramatically affect perinatal mortality, as the research seems contradictory and unclear. C. Lithium use may be associated with a slightly increased birth weight, but this is often not clinically significant. D. Lithium exposure during pregnancy has been associated with nephrogenic diabetes insipidus, not diabetes mellitus. Vital Concept: The potential risks associated with lithium use during pregnancy are significant and should be explored and explained to all patients of childbearing age.

Answer 42

Correct Answer: C. There is a correlation between virilization degree and gender dysphoria. The degree of virilization (graded on the Prader scale) is correlated with the development of gender dysphoria and homosexuality. Incorrect Answers: A. Females with congenital adrenal hyperplasia (CAH) have a virilized clitoris. Boys with classic CAH have normal-appearing genitalia. B. A higher rate of homosexuality has been reported in individuals with CAH, which correlates with the degree of virilization. D. Successful HRT, while helpful, does not eliminate psychological issues with gender in intersex patients such as females with CAH.

Answer 43

Correct Answer: D. Planning appropriate limit-setting It is not ideal for these parents to have their 2-year-old sleeping in their bed, especially since they have disagreements over it. The parents should agree on appropriate bed time and bedtime rituals, which must be enforced by both parents with equal rigor. Incorrect Answers: A. The child does not have trouble sleeping when in the right environment, which is also the wrong environment for the parents. B. Putting the child to sleep when awake and drowsy, but not yet sleeping, is helpful but unlikely to solve the problem in this case. C. Extinction of the behavior may work, and it could be tried in addition to appropriate limit-setting.

Answer 44

Correct Answer: D. Younger patients with shorter illness Family therapy is most helpful in younger patients with a short duration of illness. Incorrect Answers: A. Family therapy can be useful for patients who are younger with shorter illness. B. Older patients with longer illness likely won't see much benefit from family therapy. C. Older patients with shorter illness likely won't see much benefit from family therapy.

Answer 45

Correct Answer: C. In response, the patient will attempt to avoid an increase in weight through purging, which may include exercise, vomiting, fasting, or the use of medications to empty the gut, such as laxatives or diuretics Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise, are features of bulimia nervosa. The DSM-5-TR diagnostic criteria include: Binge eating is the ingestion of a much bigger quantity of food within a window of time (i.e., typically no more than 2 hours) than a typical person would ingest at the same time, with the perception of not being able to regulate the quantity or selection of food consumed during the occurrences. In response, the patient will attempt to counteract the eating occurrences described above and avoid an increase in weight through purging, which may include exercise, vomiting, fasting, or the use of medications to empty the gut, such as laxatives or diuretics. The eating occurrences and purging are experienced once or more per week for 12 weeks or more. The patient’s body weight and size directly inform their self-regard and self-esteem. The symptoms do not coincide with occurrences of anorexia nervosa. Incorrect Answers: A. Binge eating is the ingestion of a much bigger quantity of food within a window of time (i.e., typically no more than 2 hours) than a typical person would ingest, not over 2 weeks. B. Binge eating occurs with the perception of not being able to regulate the quantity or selection of food consumed during the occurrences D. The symptoms should not coincide with occurrences of anorexia nervosa. Vital Concept: Episodes of binge eating with repeated compensatory behaviors to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise, are features of bulimia nervosa.

Answer 46

Correct Answer: C. Have a supervisor watch them for 2-3 hours after every meal Patients with these disorders rarely feel comfortable self-inducing vomiting in front of another person. Having them supervised for 2-3 hours after the meal ensures that the food is digested before they would purge it. The goal is to stop the cycle of binging and purging altogether. DSM-5-TR criteria for anorexia include limitation of caloric intake resulting in a markedly decreased body mass index (BMI) or weight as compared to similar individuals of the same sex, age, or height. extreme dread of an increase in weight or of being overweight, or actions that prevent weight gain, despite being severely underweight distorted perception of their own body and their weight, an exaggerated impact of their weight on their self-regard, or a consistent disregard or lack of awareness of the consequences of their health condition or their behavior Incorrect Answers: A. Having another person portion out their meals would not help these patients to avoid purging. B. Stopping the entire cycle is needed; it is insufficient to avoid binge eating. The patient may also need assistance to avoid purging after typical-sized meals. D. While it is important to facilitate the recognition of triggers and urges, this alone won't necessarily stop the targeted behavior Vital Concept: A patient that is struggling to avoid purging may find it beneficial to have accountability through supervision for 2-3 hours after eating a meal.

Answer 47

Correct Answer: D. Temperature <97.0°F Incorrect Answers: A. This is a normal resting heart rate (60-100bpm is normal range), so it's not an indication for admission. B. This is a normal glucose reading (70-130 mg/dL is normal range), so it's not an indication for admission C. Potassium has to be below <3mEq/L to be an indication for admission — this is above that threshold.

Answer 48

Correct Answer: D. 3A7 Clearance is the volume of plasma from which a drug is removed per unit of time. Most psychotropic drugs are eliminated by hepatic metabolism followed by renal excretion. Hepatic metabolism is broken into Phase I and Phase II reactions. Phase I reactions involve the formation of a more polar metabolite that can be eliminated renally or further metabolized by Phase II conjugation. Phase I reactions include oxidation, reduction, and hydrolysis. Most Phase I oxidation reactions are carried out by the hepatic cytochrome P450 system. The CYP enzymes most involved in the metabolism of drugs are CYP 1A2, 2C9, 2C19, 2D6, and 3A4. Adult values for the cytochrome P450 enzymes are generally achieved by 1 year of age. CYP3A7 is the predominant P450 enzyme at birth, but its levels fall quickly and are undetectable in most adults. Because psychotropic medications are not generally prescribed to children under the age of 5, CYP3A7 is the enzyme that is least important in the metabolism of psychotropic drugs of the enzymes listed. Incorrect Answers: A. CYP1A2 is the last cytochrome to develop. B. C. CYP3A4, 2D6, and 2C enzymes are present in newborns at very low concentrations but surge quickly to about 20-30% of adult values within the first week of life.

Answer 49

Correct Answer: D. They are almost never diagnosed in females. Paraphilias are almost never diagnosed in females, though there are case reports of some. Incorrect Answers: A. The chapter on paraphilic disorders in DSM-5-TR includes 8 conditions: exhibitionistic disorder, fetishistic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder, and voyeuristic disorder. B. People often do act out their fantasies on willing or unwilling/unknowing victims. C. They are rarely diagnosed in the clinical setting but are likely quite prevalent. Vital Concept: Paraphilic disorders are rarely diagnosed in females and are predominantly diagnosed in males.

Answer 50

Correct Answer: B. Dissociative amnesia with dissociative fugue This is dissociative amnesia with a dissociative fugue (DSM-5-TR). Dissociative amnesia with dissociative fugue criteria includes an inability to recall autobiographical information and apparently purposeful travel associated with amnesia. The 12-month prevalence for dissociative amnesia is approximately 1.8% (1% for men, 2.6% for women). Onset is usually sudden, and memory loss may be refractory. There is a significantly elevated suicide risk in patients with dissociative amnesia, particularly when amnesia remits. Dissociative fugue is present If the patient presents with intentional travel or dazed roaming to uncover lost memories and information. Incorrect Answers: A. Depersonalization/derealization disorder is often characterized by the patient as feeling detached from their body. They often describe the experience as if they are watching from outside the body. There is no associated memory loss or change in personality or behavior. C. Transient global amnesia is a temporary episode of memory loss that is not associated with a neurological cause. The onset is sudden, and the person is unable to recall who there are, how they got there, or what they were doing. D. A transient ischemia attack (TIA), often referred to as a ministroke, produces effects similar to a stroke, but they resolve rapidly. This may include motor or sensory deficits. There is no associated change in memory or personality. Vital Concept: Dissociative amnesia is associated with generalized, localized, or selective memory loss.

Answer 51

Correct Answer: A. 2 Gender identity usually begins to form by 18-24 months and is extremely unlikely to change after that point. Gender identity becomes rigid/inflexible around the ages of 5–7 years, and socially defined gender roles relax somewhat after that age. Incorrect Answers: B. C. These aren't meaningful ages in terms of gender identity development. D. This is the age at which gender identity starts becoming rigid/inflexible. Gender identity becomes rigid/inflexible around ages 5-7.

Answer 52

Correct Answer: D. Address relationship-related stressors contributing to eating disturbance Interpersonal psychotherapy normalizes the disturbed eating behavior, decreasing the number of binge-purge episodes by addressing interpersonal sources of stress believed to precipitate or promote the behavior. This therapy is also effective in patients with binge-eating disorder. Incorrect Answers: A. Interpersonal psychotherapy doesn't encourage patients to enjoy food. B. Interpersonal psychotherapy doesn't correct patients' beliefs about themselves or their bulimia disorder. C. Interpersonal psychotherapy doesn't alter patients' response to extreme stress or anxiety

Answer 53

Correct Answer: C. Hypotension Hypotension, hypothermia, severe starvation, weight loss, and electrolyte imbalance are the main indications for hospitalization. Incorrect Answers: A. Nausea doesn't indicate inpatient treatment — but it might be a sign of starvation or electrolyte imbalances, and may worsen those imbalances B. Vomiting doesn't indicate inpatient treatment — but it might be a sign of starvation or electrolyte imbalances, and may worsen those imbalances D. Depression on its own doesn't indicate inpatient treatment — only depressed patients with eating disorders with suicidal ideations or psychosis are indicated for inpatient treatment

Answer 54

Correct Answer: B. Fluoxetine In general, any SSRI can be considered for treatment of bulimia, but only fluoxetine is FDA-approved. TCAs should be avoided due to their potential to increase cardiac toxicity. MAOIs should be avoided in these patients. Bupropion should be avoided in all eating disorder patients due to seizure risk. Incorrect Answers: A Mirtazapine is an atypical antidepressant. It is not FDA approved for the treatment of bulimia. C. Amitriptyline is a tricyclic antidepressant; these should be avoided in bulimia patients because of their potential to increase cardiac toxicity. D. Bupropion should be avoided in all eating disorder patients due to seizure risk. Vital Concept: Fluoxetine is the only medication approved by the FDA for the treatment of bulimia nervosa.

Answer 55

Correct Answer: A. Object permanence Object permanence is the ability to understand that objects have an existence independent of the child’s involvement with them. Reversibility is the realization that one thing can turn into another and back again. Conservation is the ability to recognize that although the shape of an object may change, it will still maintain characteristics that enable it to be recognized as that object. Incorrect Answers: B. This is the realization that things can turn into each other and back again; it doesn't apply here. C. This is the ability to recognize that although an object's shape may change, it will maintain characteristics that allow it to be recognized as that object; it doesn't apply here. D. This is the first of Piaget's four stages of cognitive development. It doesn't explain Christopher's understanding of the toy still being there.

Answer 56

Correct Answer: D. Smaller hippocampal volume Structural differences in the hippocampus have been well documented, showing smaller volumes of the hippocampus with similar volumetric changes within the medial temporal and prefrontal lobes. The lateral ventricles may also be enlarged. Schizophrenia affects 1% of the population worldwide. It is characterized by positive symptoms (hallucinations, delusions, and disorganized speech and behavior) and negative symptoms (flattened affect, alogia), as well as other symptoms, including inattentiveness. Some patients with schizophrenia also lack insight regarding their condition. There is usually significant impairment in their social, occupational, and interpersonal function. To diagnose schizophrenia, symptoms must be present for at least 6 months, including at least 1 month of positive or negative symptoms. The diagnosis of schizophrenia has expanded in the DSM-5. Criterion A now includes five items: delusions; hallucinations; disorganized speech (e.g., frequent derailment or incoherence); grossly disorganized or catatonic behavior; and negative symptoms (diminished emotional expression or avolition). At least 2 of the 5 symptoms must be present for at least 1 month, and 1 of the 2 symptoms must be delusions, hallucinations, or disorganized speech. Negative symptoms, which impair function the most, are now officially included. Continuous signs of disturbance must be present for at least 6 months with at least 1 month of the symptoms listed above. Incorrect Answers: A. The lateral ventricles are generally enlarged, not smaller, as the hippocampus atrophies. B. The hippocampal volume is typically decreased in patients with schizophrenia. C. Smaller volume is evident in the medial temporal lobe, not the lateral temporal lobe. Vital Concept: Consistent changes have been observed in patients with chronic schizophrenia, such as enlarged lateral ventricles and decreased volume in the hippocampus, medial temporal, and prefrontal lobes.

Answer 57

Correct Answer: A. Normal developmental process of separation anxiety Separation anxiety is a normal developmental process. It is most commonly seen at 10-18 months of age. Incorrect Answers: B. C. Nothing in this scenario indicates insecure attachment to the mother (since the child is comforted and shows a positive response when the mother returns) or abuse or maltreatment by the neighbor. D. Stranger anxiety is typically seen around 8 months of age and would be unlikely, as the baby is familiar with the neighbor.

Answer 58

Correct Answer: D. Partialism Partialism or oralism is when an individual is only aroused by and can only achieve orgasm through a single type of sexual contact, usually relegated to a specific anatomical location. These individuals may even attempt to avoid penetrative sex due to a lack of interest. This is a type of paraphilia. Incorrect Answers: A. While SSRIs like paroxetine can have sexual side effects, these are mostly manifested as delayed ejaculation or difficulty maintaining an erection. Although this patient reports difficulty maintaining arousal, his difficulty is isolated to penetrative sex and is not present when engaging in oral sex. Additionally, the patient’s first depressive episode occurred 6 months ago, and the medication was likely started at that time. The patient reports a lack of interest in vaginal intercourse consistently since his first sexual encounter. B. The patient reports a lack of interest in penetrative sex persistently since age 16. Because his lack of interest is not temporally correlated with his and his wife’s attempts to conceive, this is unlikely the explanation. C. Frotteurism is a paraphilic disorder characterized by arousal by or orgasm from touching or rubbing against a fully clothed sexual partner or a non-consenting individual in a public place.

Answer 59

Correct Answer: D. Frotteuristic disorder Frotteuristic disorder is characterized by feelings of sexual excitement related to coming into contact with or brushing up against an individual without their knowledge. This occurs over a period of 6 or more months, with associated daydreams and desires. The patient has either followed through with their desires or describes them as leading to substantial anguish or dysfunction. Incorrect Answers: A. Fetishistic disorder is the sexual use of non-living objects. B. Exhibitionistic disorder involves exposing one's genitals to a stranger. C. Pedophilic disorder is sexual activity with a prepubescent child. Vital Concept: Frotteuristic disorder is characterized by feelings of sexual excitement related to coming into contact with or brushing up against an individual without their knowledge.

Answer 60

Correct Answer: D. Personality disorder Patients who have factitious disorder by proxy (Munchausen syndrome) are more likely to have personality disorders and other psychiatric disorders. Incorrect Answers: A. B. They are not likely to have a disorder involving psychosis. C. A major medical condition may or may not be present in a person with factitious disorder by proxy.

Answer 61

Correct Answer: D. Major depressive disorder Correct Answer: D. Major depressive disorder Major depressive disorder has a female-to-male predominance of 1.5:1 to 3:1 in some studies, beginning in early adolescence. Incorrect Answers: A. Bipolar I disorder has a male-to-female ratio of 1.1:1. B. ADHD is more frequent in males. C. Schizophrenia is generally considered to have a male-to-female ratio of 1.4:1, but this differs across samples depending on the emphasis on negative symptoms and poorer outcomes (male predominance) versus inclusion of more mood symptoms and brief presentations (equal predominance 1:1 for both sexes). Vital Concept: Depression affects roughly twice as many women as it does men according to most prevalence studies.

Answer 62

Correct Answer: D. Illness anxiety disorder In the DSM-5-TR, the category "somatic symptom and related disorders" includes the diagnoses of somatic symptom disorder (SSD), illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder. All of the disorders in this chapter share the prominence of somatic symptoms associated with significant distress and impairment. Incorrect Answers: A. B. and C. These have all been removed from the DSM-5, and many of the individuals who'd previously been diagnosed with one of these disorders can now be diagnosed with somatic symptom disorder (SSD), which is part of the category of somatic symptom and related disorders. Vital Concept: Somatic symptoms and related disorders includes somatic symptom disorder (SSD), illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder.

Answer 63

Correct Answer: A. Hypokalemic alkalosis Hypokalemic alkalosis is most likely due to the daily use of laxatives and diuretics. Diarrhea associated with chronic laxative abuse is rich in potassium and chloride (70–90mEq/L), in combination with increased renal-bicarbonate reabsorption and volume contraction due to a profound loss of sodium and water, resulting in hypokalemia and a saline (chloride)-responsive metabolic alkalosis. Diuretics also cause metabolic alkalosis, likely derived from multiple contributing mechanisms. Secondary hyperaldosteronism often develops due to volume depletion, renal chloride loss, or a contraction alkalosis. Chloride-unresponsiveness may also develop due to a profound K depletion from either chronic thiazide or loop-diuretic exposure. Patients might also have leukopenia with relative lymphocytosis, elevated bicarbonate, and hypochloremia. These electrolyte abnormalities can cause cardiac arrhythmias and even death from cardiac arrest. Incorrect Answers: B. Acute diarrhea usually produces a hyperchloremic metabolic acidosis from bicarbonate losses in stool, but diarrhea associated with chronic laxative abuse is rich in potassium and chloride (70–90mEq/L), resulting in hypokalemic alkalosis. C. Acute diarrhea usually produces a hyperchloremic metabolic acidosis from bicarbonate losses in stool, but diarrhea associated with chronic laxative abuse is rich in potassium and chloride (70–90mEq/L), resulting in hypokalemic alkalosis. D. Hyperkalemic alkalosis may occur with certain endocrine disorders (e.g., Cushing's syndrome) and conditions affecting the renal system (e.g., Barrter's and Gitelman's). Vital Concept: A patient utilizing laxatives and diuretics daily as a component of a pathological eating disorder or body dysmorphia will most likely present with hypokalemic alkalosis due to the loss of potassium, chloride, and water.

Answer 64

Correct Answer: D. DID usually occurs with comorbid psychiatric conditions Dissociative identity disorder criteria was updated in the DSM-5. Criterion A was expanded to include some possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. Also, Criterion A specified that transitions in identity may be observable by others or self-reported. Lastly, according to Criterion B, individuals with dissociative identity disorder may report recurrent gaps in recall of everyday events, not just of traumatic experiences. The diagnostic criteria in the DSM-5-TR now include: The presence of more than two distinct personalities that disrupt an individual's identity or sense of self (some cultures refer to this as being possessed). Symptoms that are reported by the individual or observed by others include changes in: - cognition - emotional response - conduct - sensory-motor functioning - alertness or awareness - memory or recollection - awareness or perception Symptoms affect the individual's social and professional functioning. There are recurrent gaps in memories that cannot be attributed to forgetfulness. The symptoms cannot be attributed to a cultural or religious practice; in children, the symptoms are not explained by expected imaginative play for their age. Symptoms cannot be attributed to a medical condition or the use of mind-altering substances. Incorrect Answers: A. DID has a prevalence among psychiatric inpatients of approximately 3%. DID is present in 1% of the general population and comprises around 10% of dissociative disorders. B. DID is a chronic and recurrent disorder. C. Patients with DID typically have issues recalling events after they have occurred. Vital Concept: Patients with DID often present with comorbid depression, anxiety, substance abuse, self-injury, and non-epileptic events.

Answer 65

Correct Answer: C. 2 years Pharmacokinetics refers to the rates of absorption, distribution, metabolism, and elimination of drugs. Bioavailability, volume of distribution, half-life, and clearance dictate how much exposure a patient will have to a drug at a particular dose. At birth, the absorption and transport of drugs are affected by a high gastric pH, slowed gastric emptying, and irregular peristalsis. By 24 months, these processes have matured enough to be comparable to adult metabolism, albeit somewhat slower. The immaturity of drug metabolizing enzymes in the newborn can lead to a higher bioavailability of drugs that are extensively metabolized by first-pass metabolism. Topical administration of drugs to infants can also result in higher plasma concentrations because infants have a thinner skin (specifically the outermost layer of the epidermis), greater hydration of the epidermis, and a much higher ratio of surface area to body mass. Incorrect Answers: A. Gastric pH reaches adult values around 2 years of age. B. Glomerular filtration rate increases rapidly after birth and reaches adult values around 1 year of age. Adult values for the cytochrome P450 enzymes are also generally achieved by this age. D. There are few clinically significant differences in the volume of distribution between older children and adults. Psychotropic medications are not generally prescribed to children under the age of 5; by this time, the process of drug metabolism has matured sufficiently. Dosing medication in older children and adolescents mainly relies on differences in body size between child and adult dosing.

Answer 66

Correct Answer: B. Abnormality of locus coeruleus Fear triggers the amygdala that activates the sympathetic nervous system and the hypothalamic pituitary adrenal (HPA) axis. The sympathetic nervous system activates the locus coeruleus and adrenal medulla (increases epinephrine and norepinephrine). The locus coeruleus is a nucleus in the pons of the brainstem and produces norepinephrine . The HPA axis releases corticotropin releasing factor (CRF) activating secretion adrenocorticotropic hormone (ACTH) causing secretion of cortisol. Incorrect Answers: (A) Decreased catecholamines in the central nervous system. With panic attacks get increased catecholamines in the CNS including epinephrine and norepinephrine released from the adrenal medulla. (C) Respiratory acidosis. Hyperventilation during panic (causing decreased CO2) can cause respiratory alkalosis, not respiratory acidosis, and hypocapnia (D) Activation of the parasympathetic nervous system. Panic attacks activate the sympathetic nervous system, not parasympathetic, stimulating the flight or fight response.

Answer 67

Correct Answer: D. Allow patient to return home, as risk of imminent danger is low A patient with anorexia nervosa presenting to a physician should only be admitted against his or her will when there is a risk of probable death from complications of malnutrition. This patient's labs and vital signs are normal. The advice of an ethics committee is not required. Do not threaten the patient with abandonment or refer her, as these actions do not address her problem. Incorrect Answers: A. Patients with anorexia should only be admitted against their will when there's a risk of probable death from malnutrition complications — this case doesn't reach that standard. B. The ethics committee isn't needed to weigh in on this case. C. Refusing to treat the patient doesn't address her problem.

Answer 68

Correct Answer: D. Dopamine Dopamine, serotonin, and noradrenaline have all been suggested to play some role in social phobia. Dopamine is thought to mediate social interest, gregariousness, confidence, and sensitivity to rejection. People with low levels of dopamine in the CSF and Parkinson's disease are more likely to be introverted and to have social phobia as well. Incorrect Answers: (A) Cortisol. Cortisol does not play the most significant role in social phobia but does in stress response and panic disorder. (B) Gamma-aminobutyric acid (GABA). Reduced GABA has been associated with panic disorder and depression. (C) Glutamate. Glutamate impairment has been associated with anxiety disorder but dopamine is the best answer choice for playing the most significant role in social phobia.

Answer 69

Correct Answer: C. Hemoglobin A1C It does not require fasting and is very accurate in evaluating overall glucose metabolism. In most labs it is readily available the same day. Incorrect Answers: A. Random glucose. A random glucose is a glucose level that can be drawn at any time. It can be helpful depending on the level, but is not as accurate. A fasting glucose would be needed to support the diagnosis of metabolic syndrome. B. Random cholesterol. A random cholesterol is a cholesterol that can be drawn at any time. The patient’s appointment is at 1pm; therefore the patient should be instructed to have the labs drawn the next day after fasting 8-10 hours. In addition to a fasting cholesterol, a High Density Lipid (HDL) is another indicator for the diagnosis of metabolic syndrome. If the HDL is <40 in a male patient (<50mg/dL in females), the HDL can be a positive indicator of metabolic syndrome and further follow up will be required. D. Fasting glucose. A fasting glucose would be helpful in evaluating this patient’s glucose, but it requires the patient be NPO for 8-10 prior to testing. The patient’s appointment is at 1pm; therefore the patient should be instructed to have the labs drawn the next day. If the fasting glucose is >110 mg/dL, that is a positive indicator of metabolic syndrome and further follow up will be required. Vital Concept: A Hemoglobin A1C measures the concentration of glucose over 120 days in red blood cells.

Answer 70

Correct Answer: B. Male sex assignment and female gender identity The four interrelated psychosexual factors are sexual identity, gender identity, sexual orientation, and sexual behavior. Sexual identity reflects inborn biological sexual characteristics: chromosomes, genitalia, hormones, etc. Gender identity reflects a person’s individual sense of being male or female. It is generally set by age 3 and very difficult to change. This child's sex assignment is male, but they associate with the female gender. Thus, the child's sexual identity is male, but their gender identity is female. In DSM-5-TR, people whose gender at birth is contrary to their identified gender leading to anguish and dysfunction are diagnosed with gender dysphoria. While sexual orientation is not necessarily fully revealed in early childhood, both sexual and gender identities are present early in development. Incorrect Answers: A. The boy saying "because I am a girl" indicates female, not male, gender identity. C. D. As the child has male genitalia, they have a male, not female, sex assignment. This means that the child was assigned dmale sex at birth. Vital Concept: Gender dysphoria describes a misalignment or disagreement between the patient’s identified gender and anatomical sex.

Answer 71

Correct Answer: C. When considering underlying disorders contributing to malingering behaviors, antisocial personality disorder is a common feature. Malingering, especially in criminal cases where persons are trying to get out of criminal charges by feigning mental illness or other illness, can be associated with antisocial personality disorder. Patients are diagnosed with a factitious disorder or malingering because they are “faking” or even creating symptoms that have no real pathological basis. Differentiation between factitious disorder and malingering involves determining the patient’s motivation. In malingering, there is some secondary gain (e.g. getting out of a crime by “pleading insanity," making money). In factitious disorder or factitious disorder by proxy, the patient wants to assume the “sick role” (such as in Munchausen syndrome). The 2 disorders require different treatments. Treatment of these disorders is tricky, and the physician must be sure that no real pathology is causing the symptoms first in order to avoid medico-legal consequences. Factitious disorder by proxy is considered child maltreatment and needs to be reported to the authorities. Incorrect Answers: A. As stated above, malingering is the condition involving secondary gain as motivators. B. This is associated with factitious disorder. D. Factitious disorder does not involve motives of secondary gain.

Answer 72

Correct Answer: D. Systematized amnesia: loss of memory relating to a particular category of information Systematized amnesia is the loss of memory relating to a particular category of information. Previously referred to as psychogenic amnesia, the DSM-5-TR describes it as a type of dissociative amnesia where the patient has no memory of a specific event or grouping of information or the memories are fragmented (e.g., the individual remembers the home they grew up in but does not remember the presence of a specific room of the house). Individuals rarely discuss these symptoms with others and attempt to justify or downplay the loss of particular memories. Incorrect Answers: A. Localized amnesia is the lack of memories from a circumscribed period of time, usually immediately following a traumatic event. B. In selective amnesia, the person can recall some but not all events from a particular time period. C. Generalized amnesia is the lack of memory of the patient’s entire life. Vital Concept: Systematized amnesia is the loss of memory relating to a particular category of information.

Answer 73

Correct Answer: C. Physical disability Prematurity, developmental disability, and physical disability are risk factors for abuse. Children with any of these factors are more likely to be abused. Other factors that make a child more likely to be abused include age younger than 3 with less than 1 being the highest group that is victimized and being male. Incorrect Answers: A. Children with difficult temperaments tend to be abused more frequently than their peers. B. Male children have a higher risk of child maltreatment than female children. Female children are more likely to experience neglect. D. Only children do not have an increased risk of child abuse. Vital Concepts: Age under 3, prematurity, and developmental disability or physical disability are risk factors for abuse.

Answer 74

Correct Answer: B. Voyeuristic disorder Voyeuristic disorder involves feelings of sexual excitement related to viewing an individual while undressing, undressed, or having sex without their knowledge. This occurs over a period of 6 or more months, with associated daydreams and desires. The patient has either followed through with their desires or describes them as leading to substantial anguish or dysfunction. The patient must be at least 18 years old Incorrect Answers: A. Fetishistic disorder is sexual excitement related to inanimate objects. C. Frotteuristic disorder involves sexual excitement related to rubbing against non-consenting people. D. Pedophilic disorder involves sexual excitement related to prepubescent children. Vital Concept: Voyeuristic disorder involves feelings of sexual excitement related to viewing an individual while undressing, undressed, or having sex without their knowledge.

Answer 75

Correct Answer: B. Scars and abrasions on hands from using them to induce vomiting Russell’s sign refers to the scars and abrasions found on the hands of anorexic and bulimic patients who induce vomiting. Russel's sign Incorrect Answers: A. Tooth decay and tooth sensitivity are common in patients who vomit frequently. C. Parotid gland enlargement and elevated amylase levels are also common in patients who induce emesis. D. Other sequelae of self-induced purging include hypokalemic alkalosis, elevated bicarb, hypochloremia, and dehydration. Electrolyte imbalances can cause cardiac arrhythmias and sudden cardiac death. Ipecac intoxication can cause cardiomyopathy and subsequent cardiac failure and death. Vital Concept: This type of scarring is considered one of the physical indicators of a mental illness, and Russell's sign is primarily found in patients with an eating disorder such as bulimia nervosa or anorexia nervosa. However, it is not always a reliable indicator of an eating disorder; there are many more factors associated with it. Bulimics who are capable of "handsfree purging", or the induction of vomiting by the willful opening of the esophageal sphincter in a manner similar to belching, while contracting the stomach muscles, do not have Russell's sign.

Answer 76

Correct Answer: B. Fluoxetine Fluoxetine is the only medication approved by the FDA for the treatment of bulimia nervosa. In general, any SSRI should be considered first-line in treating bulimia. TCAs should be avoided due to their potential to increase cardiac toxicity. MAOIs should be avoided in these patients. Bupropion should be avoided in all eating disorder patients due to seizure risk. Incorrect Answers: A. The patient displays bulimia nervosa, and needs to be treated for it. C. Bupropion shouldn't be used in eating disorder patients, as there's seizure risk. D. Paroxetine, as an SSRI, is considered first-line treatment for treating bulimia, but isn't FDA-approved as fluoxetine is.

Answer 77

Correct Answer: D. 2 hours Patients should be observed for a minimum of 2 hours after eating, even if this requires attendants to follow them to the bathroom. The primary purpose of the observation is to prevent purging of the meal. Incorrect Answers: A. B. and C. These durations are all too short.

Answer 78

Correct Answer: D. Docusate Patients with anorexia nervosa who are hospitalized for a treatment program may complain of constipation. This symptom is usually relieved when they begin to eat normally. Never give these patients laxatives; stool softeners are permissible. Lactulose, senna, magnesium hydroxide, and bisacodyl all have laxative activity. Docusate is a stool softener and not a laxative. It may be given in this setting. Incorrect Answers: A. B. and C. Lactulose, senna, and magnesium hydroxide are all laxatives, which shouldn't be given to patients with anorexia nervosa.

Answer 79

Correct Answer: D. Borderline Approximately 25% of bulimia patients have borderline personality disorder. Just over 40% of bulimic patients also have suffered from an affective disorder at some point, and approximately 20% have a substance abuse history. Incorrect Answers: A, B, and C. These other personality disorders aren't as common as borderline personality disorder in bulimia patients.

Answer 80

Correct Answer: D. Phenytoin Phenytoin is an anti-epileptic that is known for causing fetal hydantoin syndrome, which is characterized by short limbs and phalangeal hypoplasia. Phenytoin has also been known to cause neural tube defects. Folate is necessary to prevent such defects, and it is recommended for all pregnant women. Higher doses of folate are recommended for women taking anti-epileptics, such as phenytoin or valproate. Therefore, in women whose risk of developing serious seizures outweighs the benefits of stopping the antiepileptic, it is necessary to ensure that higher doses of folate are administered. Incorrect Answers: A. Citalopram: it is another Selective Serotonin Reuptake Inhibitor (SSRI) used for the treatment of depressive disorders. Evidence using Citalopram during pregnancy has not been very clear, and a clinician should always weighs the risks and benefits of using an SSRI during pregnancy. However, phalangeal hypoplasia has not been associated with SSRIs. B. Lithium: bipolar disorder is treated with Lithium. Lithium causes Ebstein anomaly, which is atrialization of the right ventricle by which the tricuspid valve moves towards the apex of the heart, thus enlarging the right atrium and shrinking the right ventricle. Ebstein anomaly is highly specific for Lithium use during pregnancy. This anomaly leads to poor pulmonary circulation and, consequently, poor blood oxygenation; poor oxygenation leads to tachypnea and tachycardia. C. Lorazepam: Lorazepam is a benzodiazepine (BDZ). BDZs are a group of drugs that bind to the GABA receptors in the Central Nervous System, and induce relaxation and sedation. Lorazepam is routinely given to abort seizures and to avoid severe alcohol withdrawal symptoms in patients with chronic alcohol use disorder. BDZs are not associated with fetal hydantoin syndrome when taken during pregnancy. BDZs have not been shown to cause teratogenicity in most studies.

Answer 81

Correct Answer: A. Somatopsychological differentiation Infantile anorexia is characterized by food refusal by the infant, which can lead to malnutrition. The disorder usually occurs between 6 months and 3 years of age and can vary between meals and feeders. The parent may resort to bribery, distraction, or force-feeding. The infant's feeding is directed by his or her emotional needs instead of physiological sensations of hunger and satiety, and he or she fails to develop somatopsychological differentiation, which is the ability to differentiate sensations in the body. The best way to address infantile anorexia and to restore normal growth is by helping the parents reduce stress and control issues around mealtimes. Infantile anorexia must be differentiated from posttraumatic feeding disorder (PTFD), which usually has a sudden onset after a traumatic event like choking or the insertion of a gastric tube. Incorrect Answers: B. C. and D. These developmental events aren't affected by infantile anorexia.

Answer 82

Correct Answer: B. Lanugo Medical complications associated with anorexia include (but are not limited to) bradycardia, pancytopenia, lanugo, osteopenia, metabolic encephalopathy, arrhythmias, elevated LFTs, elevated BUN, decreased T3 and T4, parotid gland enlargement, seizures, and peripheral neuropathy. Ankylosing spondylitis, selective IgA deficiency, Sjogren's syndrome, and ulcerative colitis are autoimmune diseases. Incorrect Answers: A. C. and D. These are all autoimmune diseases, and as such aren't associated with anorexia nervosa (which is an eating disorder).

Answer 83

Correct Answer: C. Major depressive disorder Major depressive disorder is the most commonly comorbid condition in patients with anorexia nervosa. A nationally representative survey found 56% of anorexic patients had comorbid psychiatric diagnoses. Unipolar major depression was the most prevalent comorbid disorder (39%), followed by alcohol use disorders, specific phobias, and social anxiety disorder (each in approximately 25% of anorexic patients). In the clinical setting, unipolar depression is seen in up to 71% of anorexics, and obsessive compulsive disorder is also common (up to 35% of anorexic patients). Incorrect Answers: A. B. and D. These are less commonly comorbid with anorexia nervosa as compared to major depressive disorder.

Answer 84

Correct Answer: B. Patient is at increased risk for seizures. The patient is demonstrating signs concerning for anorexia, as indicated by excessive exercise and distorted self-perception. The DSM-5-TR includes extreme actions that prevent weight gain and distorted perception of their own body and their weight within the diagnostic criteria for anorexia. Patients with eating disorders are at increased risk for seizures, and bupropion further lowers a patient’s seizure threshold. Using bupropion in a patient with an eating disorder is relatively contraindicated. Incorrect Answers: A. MAOIs are associated with the risk of a tyramine crisis. Neither of these medications is an MAOI, and bupropion is a commonly used and safe augment to SSRIs. C. Bupropion is not contraindicated for use in children, but like most other psychiatric medications, it may require closer monitoring and slower titration. D. Patients often respond differently to different medications, even if they are in the same class (i.e., patients who do not improve sufficiently with one SSRI may find success with another SSRI). This is often true if switching classes. If a patient does not see improvement with sertraline, an SSRI, then trialing bupropion, an NDRI, is a reasonable next step. Vital Concept: This patient is displaying indicators of a possible eating disorder, which increases their risk of seizures. Bupropion is relatively contraindicated in this patient as it also lowers the seizure threshold.

Answer 85

Correct Answer: C. Sexual urges or fantasies cause substantial or interpersonal problems. Exhibitionistic disorder is characterized by feelings of sexual excitement related to showing private parts of their body to an individual without their prior knowledge or consent. This occurs over a period of 6 or more months, with associated daydreams and desires. The patient has either followed through with their desires or describes them as leading to substantial anguish or dysfunction. Incorrect Answers: A. Exhibitionism needs to occur over at least 6 months to be diagnosed. B. Onset is usually before age 18. D. When exhibitionists act on their urges, they generally don't make attempts to have further sexual activity with the stranger(s) to whom they expose themselves. Vital Concept: In exhibitionistic disorder, the patient has either followed through with their desires or describes them as leading to substantial anguish or dysfunction.

Answer 86

Correct Answer: B. Androphilic The use of homosexual and heterosexual designators in transgender individuals is problematic. Historically, most medical professions classified orientation based on the individual’s genetic/assigned sex; the individual, however, defined it with regard to his or her perceived gender. Androphilia describes sexual attraction to men or masculinity; gynephilia describes the sexual attraction to women or femininity. Ambiphilia describes the combination of both androphilia and gynephilia. Incorrect Answers: A. Gynephilic means attracted to women. C. Analophilic means asexual (attracted to neither men nor women). D. Asexual is synonymous with analophilic.

Answer 87

Correct Answer: C. Alcohol dependence (alcohol use disorder) The patient is suffering from alcohol use disorder (formerly alcohol dependence), and her baby has congenital abnormalities due to fetal alcohol syndrome (FAS), which is a complication of prolonged alcohol use by the mother. No amount of alcohol can be considered safe during pregnancy. About 5% of mothers with chronic alcohol use disorder give birth to children with FAS. Intellectual disability (formerly mental retardation) is common, and 44% of children with fetal alcohol syndrome have an IQ of 79 or below. Other congenital defects include wide-set eyes, short palpebral fissure, a short and broad-bridged nose, hypoplastic philtrum, thinned upper lip, and flattened mid-face. Maternal alcohol use with breastfeeding has been shown to impair a child's motor but not mental development. Incorrect Answers: A. Bipolar disorder is associated with mood swings involving an irritable or elated mood and dysphoria. B. Major depression is an unlikely diagnosis in a female who has no previous episode of low mood or other biological and depressive symptoms associated with depression. D. This female has alcohol dependence with complication development, making illness anxiety disorder unlikely.

Answer 88

Correct Answer: C. Anorexia nervosa, binge-eating/purging type In the DSM-5-TR, the diagnosis of anorexia nervosa no longer requires irregular menses in postmenarcheal females. This patient should be diagnosed with anorexia nervosa, binge-eating/purging type in the DSM-5-TR. The criteria include limitation of caloric intake resulting in a markedly decreased body mass index (BMI) or weight as compared to similar individuals of the same sex, age, or height. extreme dread of an increase in weight or of being overweight, or actions that prevent weight gain, despite being severely underweight distorted perception of their own body and their weight, an exaggerated impact of their weight on their self-regard, or a consistent disregard or lack of awareness of the consequences of their health condition or their behavior Incorrect Answers: A. Although the patient engages in purging behavior, the presence of anorexic behaviors eliminates a sole diagnosis of bulimia nervosa. B. D. Unspecified eating disorder is not appropriate in this case, given that they meet the diagnostic criteria for anorexia Vital Concept: This patient appears to satisfy the criteria for anorexia nervosa.

Answer 89

Correct Answer: D. Admit to hospital This patient suffers from anorexia nervosa and needs admission because her blood pressure is <80 systolic and her weight is 30% below expected. While a blood draw in a week, a referral to a nutritionist, and psychotherapy may at some point play a role in her care, this ill patient requires hospitalization. She is at considerable risk for developing cardiac arrhythmias, an EKG is warranted. Other criteria often used for admission are: <75% ideal body weight or ongoing weight loss despite intensive management, refusal to eat, body fat <10%, heart rate <50bpm daytime or <45bpm nighttime, systolic pressure <80, orthostatic changes in pulse (increased >35bpm) or blood pressure (decreased >10 mmHg), hypothermia and arrhythmia. Incorrect Answers: A. The patient can't be discharged, as her blood pressure and weight are too low. While a blood draw in a week might be required later, she needs hospitalization now. B. A referral to a nutritionist may be needed later, but hospitalization is needed now. C. Psychotherapy may be needed later, but hospitalization is needed now.

Answer 90

Correct Answer: D. Dissociative amnesia Dissociative (psychogenic) amnesia includes loss of autobiographical memory, sometimes with preserved ability for new learning. Incorrect Answers: A. Wernicke’s encephalopathy, which results from thiamine (vitamin B1) deficiency, occurs in malnourishment such as in chronic alcohol use disorder. It is defined by the triad of confusion, ataxia, and ophthalmoplegia. B. Korsakoff’s disease, the chronic phase of thiamine deficiency, presents with anterograde and retrograde amnesia. It is classically associated with confabulation as a result of the poor memory. C. Transient global amnesia leads to anterograde amnesia, the inability to encode new memories. The patient retains immediate recall as well as remote memory. The remainder of the neurological exam is normal.

Answer 91

Correct Answer: B. Cognitive behavioral therapy This patient has bulimia nervosa, an eating disorder characterized by consuming an abnormally large amount of food followed by compensatory behaviors, which may include exercise, vomiting, diuretics, emetics, and laxatives. The Diagnostic and Statistical Manual, 5th Edition (DSM-V) set diagnostic criteria for bulimia nervosa as follows: Recurrent episodes of binge eating Recurrent compensatory behaviors Binge eating and compensatory behavior each happen at least once per week for three months Self-evaluation unduly influenced by body shape and weight Does not happen exclusively during episodes of anorexia nervosa Cognitive-behavioral therapy (CBT) is the first-line therapy for bulimia nervosa. CBT seeks to correct the inappropriate thoughts bulimic patients have regarding themselves and their disorder. CBT can reduce the number of binge-purge episodes and is also effective for patients with binge-eating disorders. Incorrect Answers: A. Family-based therapy is one of the treatment options of choice for children and adolescents with anorexia nervosa. It requires that the patient lives in a household where parents or family members can consistently enforce specific eating behaviors before eventually transitioning back to more autonomous eating by the patient. This patient does not have anorexia nervosa, and living alone would make this treatment option logistically very challenging. C. Biofeedback therapy can effectively reduce the symptom burden of panic disorder but does not have a role in treating bulimia nervosa. D. Food journals are not a component of treatment for any eating disorder. Instead, they may inappropriately cause fixation on food intake and encourage disordered eating behaviors. Vital Concept: Cognitive-behavioral therapy (CBT) is the first-line therapy for the treatment of bulimia nervosa and aims to change the way the patient thinks about themselves and their disorder.

Answer 92

Correct Answer: B. Td booster A tetanus booster shot is recommended every ten years for everyone. The current recommendation is to give Tetanus, diphtheria, and acellular pertussis (Tdap) once for patients 11 years or older who have not received Tdap or whose immunization status is unknown, and then to use the Tetanus diphtheria (Td) or Tdap vaccine every 10 years as a booster. This patient is due for her booster tetanus shot. Incorrect Answers: A. Pneumococcal vaccine is indicated for individuals 65 years or older or those ages 19-64 years with chronic medical conditions. C. Human Papilloma Virus (HPV) vaccine is indicated for patients ages 9-26, and has been approved up to age 45 years. There are two types of the vaccine (HPV 4 or HPV 2, containing 4 and 2 strains of the virus, respectively). A complete series consists of 3 doses of either HPV 2 or HPV 4 vaccines, with the 2nd dose administered at 4-8 weeks after the 1st one, and the third dose at 24 weeks after the 1st one (16 weeks after the 2nd ). This patient is older than the recommended age. Therefore, the HPV vaccine is not indicated at this time. D. The Center for Disease Control recommends annual influenza vaccine for all patients aged 6 months or older. Most patients receive the inactivated, intramuscular influenza vaccine. The intranasal, live attenuated influenza vaccine is not as commonly administered as the inactivated one. Most patients receive the flu vaccine in the fall season. The patient in this vignette is visiting in June and she is up-to-date on all her vaccines (except HPV and Td). The flu vaccine is not indicated at this visit. Vital Concepts: The current recommendation is to give Tetanus, diphtheria, and acellular pertussis (Tdap) once for patients 11 years or older who have not received Tdap or whose immunization status is unknown, and then to use the Tetanus diphtheria (Td) or Tdap vaccine every 10 years as a booster.

Answer 93

Correct Answer: C. 16 Pedophilic disorder criteria: Feelings of sexual excitement involving prepubescent children (typically under the age of 14). This occurs over a period of 6 or more months, with associated daydreams and desires. The patient has either followed through with their desires or describes them as leading to substantial anguish or dysfunction. The patient must be at least 16 years old, with at least a 5-year age gap May specify if the intended individual is a male, female, or both, and whether the patient is exclusively attracted to children or also attracted to adults Incorrect Answers: A. The person must be 16 years or older and at least 5 years older than the child sexually interested in. This question asked how old the person has to be for a diagnosis of pedophilic disorder, not how much older than the child the person has to be. B. The child/children of interest are typically prepubescent child/children (13 years or younger). D. An individual must be 16 years or older to be diagnosed with pedophilic disorder, not 18 years old. Vital Concept: Must be 16 years or older and at least 5 years older than the child sexually interested in to be diagnosed with pedophilic disorder.

Answer 94

Correct Answer: A. Dissociative episode Amnestic disorders are secondary syndromes caused by systemic medical or primary cerebral diseases, substance use disorders, or medication adverse effects, as evidenced by findings from clinical history, physical exam, or laboratory data. In contrast to transient global amnesia, dissociative amnesia typically does not involve deficits in learning and recalling new information. Instead, patients present with a circumscribed inability to recall previously learned information but continue to function normally in the present. The dissociative disorders can sometimes be difficult to differentiate from the amnestic disorders. Patients with dissociative disorders are more likely to have lost their orientation to self and may have more selective memory deficits than patients with amnestic disorders. For example, patients with dissociative disorders may not know their names or home addresses but are able to learn new information and remember selected past memories. Dissociative disorders are also often associated with emotionally stressful life events involving money, the legal system, or troubled relationships. Episodes of psychogenic amnesia end abruptly and are typically associated with an awareness of having no memories for the time period of the amnestic or fugue state. Incorrect Answers: B. Transient ischemic attack (TIA). A TIA is like a stroke but only last for a few minutes and does not cause lasting damage. These few minutes consist of physical symptoms, such as weakness, numbness, slurred speech, or change in vision. C. Transient global amnesia. Transient global amnesia typically involves deficits in learning and recalling new information. D. Cardiovascular accident. A cardiovascular accident (CVA), a stroke, presents with physical symptoms in addition to confusion, such as weakness, numbness, slurred speech, or change in vision.

Answer 95

Correct Answer: A. Anti-hypertensives - impaired vaginal lubrication due to antiadrenergic effects Anti-hypertensives cause erectile dysfunction and impaired vaginal lubrication secondary to antiadrenergic effects. Incorrect Answers: B. Antipsychotics cause erectile dysfunction and impaired vaginal lubrication secondary to anticholinergic as well an alpha 2 receptor effects. In addition, there is impaired arousal and orgasm through dopamine-blocking. C. TCA and MAOI antidepressants can cause erectile dysfunction and impaired vaginal lubrication secondary to anticholinergic effects. SSRIs can cause inhibition of arousal and orgasm by increased serotonergic activity. D. Spironolactone, estrogen, and steroids cause decreased sexual desire secondary to decreased testosterone.

Answer 96

Correct Answer: B. Calcium 7.9 mg/dl Calcium normal range is 8.6-10.2 mg/dl. Several factors can cause hypocalcemia, including primary hypoparathyroidism and surgical hypoparathyroidism. Hypocalcemia is associated with thyroid and parathyroid surgery. Numbness and tingling of finger, toes and circumoral region are signs of hypocalcemia. Additional signs of hypocalcemia include: confusion, muscle spasms/cramps, weak nails, hallucinations, and depression. Hypocalcemia can be verified by a positive Chvostek's sign or Trousseau's sign in addition to obtaining a serum calcium level. In the case of this patient, the parathyroid was removed along with the thyroid. Incorrect Answers: A. Creatinine 0.7mg/dl. Creatinine normal values are 0.5-1.5 mg/dl and monitors kidney function and is not associated with the parathyroid. C. Chloride 100 mEq/L. Chloride normal values are 96-106 mEq/L. This is a normal value, however, hypochloremia is most often associated with severe vomiting and diarrhea, gastric surgery and GI tube drainage/gastric suctioning. D. Magnesium 2.0 mEq/L. Magnesium normal values are 1.5-2.5 mEq/L. While this is a normal magnesium level, hypomagnesemia is most often associated with nasogastric suction, diarrhea or fistulas. Chronic alcohol abuse is also a major cause of hypomagnesemia. Clinical symptoms present as ataxia, dizziness, depressed mood, insomnia, increased deep tendon reflexes and confusion. Hypermagnesemia is most associated with renal failure and clinical manifestation includes flushing, hypotension, muscle weakness, hypoactive reflexes, depressed respirations and diaphoresis. Vital Concepts: The calcium normal range is 8.6-10.2 mg/dl. Several factors can cause hypocalcemia, including primary hypoparathyroidism and surgical hypoparathyroidism Signs of hypocalcemia include: numbness and tingling of fingers or toes, confusion, muscle spasms/cramps, weak nails, hallucinations, and depression

Answer 97

Correct Answer: D. 265-800 ng/dl 265-800 ng/dl is the level of testosterone for males in Tanner Stage V (i.e., adult genitalia). Conceptually, pubertal maturation can be described in terms of sequence, timing, and tempo. Puberty consists of a series of predictable events, and the sequence of changes in secondary sexual characteristics has been categorized by several groups. The staging system utilized most frequently is that published by Marshall and Tanner and the sequence of changes, commonly referred to as “Tanner stages”. A testosterone level above 300ng/dL is considered normal for an adult male Incorrect Answers: A. 2-23 ng/dl is the testosterone level for Tanner Stage I (i.e., prepubertal). B. 5-70 ng/dl is the testosterone level for Tanner Stage II (i.e., enlargement of scrotum and testes; scrotum skin reddens and changes in texture). Early puberty levels may range from 30-100 ng/dL. C. 15-280 ng/dl is the testosterone level for Tanner Stage III (i.e., enlargement of penis [length at first] and further growth of testes). Testosterone levels in mid to late puberty may range from 100-300 ng/dL. Vital Concept: The testosterone levels can be used to assess a patient's expected (and corresponding) stage of physical pubertal development.

Answer 98

Correct Answer: D. Lithium The approximate incidence of major congenital anomalies in children of pregnant women treated with lithium in the first trimester is 4-12%. Ebstein’s anomaly is considered the most common fetal cardiac defect caused by lithium, occurring in approximately 1/1000, compared to the general population incidence of 1/20,000. Ebstein anomaly is when the tricuspid valve and right ventricle develop abnormally. Lithium during the second and third trimesters can result in neonatal lithium toxicity. Lithium remains a category D drug during pregnancy. Incorrect Answers: A. Hospitalization. Severely depressed, actively psychotic, or suicidal patients need to be hospitalized. However, this alone doesn't cause fetal cardiac malformations. B. Antipsychotic agents. Most studies have shown that second-generation antipsychotics do not increase the risk of major physical malformations above general population rates. Quetiapine, olanzapine, and risperidone are among the antipsychotics that have the most safety data in pregnancy, although they all remain category C. C. Electroconvulsive therapy. Electroconvulsive therapy can be utilized for severe depression and mania in pregnant women. Two reviews of ECT during pregnancy note the efficacy and safety of this procedure. ECT may also be considered as an alternative to pharmacotherapy for women who seek to avoid exposure to psychotropic medications during pregnancy or for women who do not respond to standard treatments.

Answer 99

Correct Answer: D. Hippocampus On MRI, the hippocampus of dissociative identity disorder patients was smaller than healthy volunteers. Incorrect Answers: A. Pons and cortex is incorrect as the recent research shows the hippocampus of dissociative identity disorder patients was smaller than healthy volunteers. B. Amygdala and corpus callosum is incorrect as the recent research shows the hippocampus of dissociative identity disorder patients was smaller than healthy volunteers. C. Frontal cortex is incorrect as the recent research shows the hippocampus of dissociative identity disorder patients was smaller than healthy volunteers.

Answer 100

Correct Answer: C. Ziprasidone Absorption of Ziprasidone after oral administration is significantly more rapid when administered within 1 hour of a meal compared to fasting. A fatty meal increased total absorption compared to fasting by 68% and decreased the serum half-life from 6.6 hours to 4.7 hours. Incorrect Answers: A, B, D. None of these is affected by food in the stomach.

Answer 101

Correct Answer: B. AUDIT-C AUDIT-C is a three-item version of AUDIT that can be used in an effort to allow cooperation with a client who is acutely ill or otherwise poorly disposed to speaking with a provider. AUDIT-C has nearly identical sensitivity to the full AUDIT. Incorrect Answers: A. AUDIT, Alcohol Use Disorders Identification Test, consists of 10 multiple-choice questions regarding the quantity and frequency of a patient’s alcohol consumption, drinking behavior, and alcohol-related problems. AUDIT is the gold standard for screening. C. CAGE is four-item screening tool with a 50-75% sensitivity and specificity of about 80%. The questions begin with “Have you ever….” C-thought you should cut back, A –felt annoyed by others criticizing your drinking, G-felt guilty or bad about your drinking, E-had a morning eye-opener. D. MAST Michigan Alcohol Screening Test is a 25 question screening tool that has simple yes and no answers.

Answer 102

Correct Answer: B. 1,500 ANC must be >1,500 to initiate treatment with clozapine. Patients usually recover from clozapine-induced agranulocytosis within 14-24 days of stopping the drug, but rechallenge with clozapine is not recommended if the ANC drops below 1,000 because of the very high rate of recurrence, unless the physician determines that the benefit outweighs the risk. An exception is made for patients with benign ethnic neutropenia. Incorrect Answers: A. This level is too low; the baseline ANC is 1,500 to initiate treatment with clozapine. C, D. These levels are too high; the baseline ANC is 1,500 to initiate treatment with clozapine. References:

Answer 103

Correct Answer: C. Meaningful Use The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the “meaningful use” of certified EHR technology. This program includes incentives for participation, demonstrated by meeting certain requirements over three stages. Incorrect Answers: A. HITECH refers to the Health Information Technology for Economic and Clinical Health Act. This act was enacted under the American Recovery and Reinvestment Act of 2009 to promote and expand the adoption of health information technology. B. HIPAA refers to the Health Insurance Portability and Accountability Act, enacted in 1996. This act ensures equal access to certain health and human services and protects the privacy and security of health information. D. ACA refers to the Affordable Care Act, designed to provide increased access to health care for all Americans. Vital Concepts: The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the “meaningful use” of certified EHR technology. This program includes incentives for participation, demonstrated by meeting certain requirements over three stages. References:

Answer 104

Correct Answer: B. Cognitive-behavioral Cognitive-behavioral therapy is the most widely used brief psychotherapy. Incorrect Answers: A. Eclectic brief psychotherapy is the second most popular psychotherapy. It's made up of an integration of multiple techniques. The most popular version, proposed by Budman and Gurman, emphasizes the three dimensions of mental life: interpersonal, developmental, and existential. C. Psychodynamic therapy is the third most popular psychotherapy. It focuses on unconscious conflicts, repressed feelings, and early relationships. D. Interpersonal is the fourth most popular psychotherapy. It's primarily used to treat depression and focus on current relationships. Its four core issues are grief, role transition, role dispute, and interpersonal deficits. References:

Answer 105

Correct Answer: D. Shift to right When tolerance develops, higher doses are required to achieve the same effect. In a graph with the dose on the X axis and the response on the Y axis, tolerance corresponds with a shift to the right. While tolerance can develop due to pharmacokinetic effects, pharmacodynamics effects, or both, the shift in the curve is to the right regardless. Incorrect Answers: A. The rightward shift occurs regardless of the cause of the tolerance B. The shape of the curve doesn't change — only its position on the X axis C. A shift to the left would indicate decreased tolerance, which isn't correct References:

Answer 106

Correct Answer: A. Naltrexone FDA-approved medications for alcohol use disorder include naltrexone, acamprosate, and disulfiram. Naltrexone is approved for treatment of opioid use disorder and can be considered in patients with comorbid alcohol use disorder. However, patients must be detoxified from opioids and committed to abstaining, as use of opioids while taking naltrexone may precipitate opioid withdrawal. Incorrect Answers: B. Acamprosate can be given for alcohol use disorder but does not have additional benefits for opioid use. C. Gabapentin can be used for pain and treatment of withdrawal symptoms in opiate withdrawal. It is also an off-label treatment for ETOH use disorder. D. Naloxone does not have an FDA-approved indication for the treatment of alcohol use disorder. References:

Answer 107

Correct Answer: B. Bargaining According to Kubler-Ross, bargaining involves thinking in "what-if" statements, such as "what if we had seen the doctor sooner." Incorrect Answers: A. In the acceptance stage of grief, the individual is resolved to their condition and accepts that nothing they can do will change the outcome. C. Denial involves resisting or refusing to remember information that has been supplied. D. Depression involves being tearful or withdrawn from the situation. Vital Concepts: According to Kubler-Ross, bargaining involves thinking in "if-then" terms. If we change practitioners, then my loved one will not die. References:

Answer 108

Correct Answer: C. Benzodiazepine intoxication When benzodiazepine dependence arises during therapeutic treatment, a predictable clinical course often occurs, especially during long-term treatment of a generalized anxiety disorder, panic disorder, or severe insomnia. When treatment is started, patients often have initial side effects such as drowsiness, psychomotor impairment, or memory impairment. Benzodiazepine intoxication ranges from mild to severe. Mild symptoms include agitation, confusion, drowsiness, blurred vision, and dizziness. Severe symptoms include respiratory depression, unresponsiveness, and coma. New symptoms, particularly alterations in sensory perception, suggest the beginning of a withdrawal syndrome. Incorrect Answers: A. Panic attack. Physical symptoms of a panic attack can include chest pain, palpitations, difficulty breathing, dizziness, sweating, and paresthesias. The key symptom of panic is hyperventilation. Patient feels like they are “going crazy” or having a “heart attack," but the only symptom present is sinus tachycardia. B. Benzodiazepine withdrawal. Signs of withdrawal include anxiety, tremors, nightmares, insomnia, anorexia, nausea, vomiting, postural hypotension, seizures, delirium, and hyperpyrexia. Abrupt discontinuation of sedative-hypnotics in patients who are severely physically dependent on them can result in serious medical complications and even death. D. Delirium. Withdrawal delirium may include confusion and visual and auditory hallucinations. Delirium generally follows a period of insomnia. Some patients may have only delirium, others may have only seizures, and others may have both. References:

Answer 109

Correct Answer: B. Diagnosis-related groups Diagnosis-related groups (DRGs) are groups related to a diagnosis with a fixed reimbursement amount. Adjustments are based upon the severity of the case, teaching costs, and area of service (rural/urban/regional). Hospitals receive a set dollar amount for each client based upon the DRG, regardless of the client’s length of stay or use of services. Incorrect Answers: A. This is used for coding and classifying mortality data from death certificates. C. This is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. D. This is the process of using universal medical alphanumeric codes to document healthcare diagnosis, procedures, medical services, and equipment. Vital Concepts: Diagnosis-related groups (DRGs) are groups related to a diagnosis with a fixed reimbursement amount. References:

Answer 110

Correct Answer: A. Medicare typically covers the cost of SNF care. A skilled nursing facility can submit bills to Medicare for skilled nursing and physician/medical care. However, CMS does limit the number of days it will cover. Incorrect Answers: B. Skilled nursing care is the primary reason that a patient is admitted to a SNF rather than a nursing home or long term care facility. Surgery is generally not performed at a SNF. C. Custodial care is typically done in a nursing home. Without the need for more advanced care, a patient will usually not be sent to a SNF. D. A SNF will provide appropriate physical and occupational therapy but most do not offer psychiatric therapy services. Vital Concepts: A skilled nursing facility can submit bills to Medicare for skilled nursing and physician/medical care. However, CMS does limit the number of days it will cover. References:

Answer 111

Correct Answer: A. Sedatives/hypnotics Sedative-hypnotics are used for rapid/acute treatment. The faster they are absorbed, the more effectively and quickly the drugs can begin to work. SSRIs and SNRIs can be affected by food in the stomach. However, these drugs are generally beneficial over a long treatment period, and their efficacy is more dependent on the built-up concentration of the compounds in the system, which is unlikely to be affected by occasionally taking the drug with food. Incorrect Answers: B, C. While SSRIs and SNRIs can be affected by food in the stomach, their efficacy is more dependent on the built-up concentration of the compounds in the system; so occasionally taking the drug with food is unlikely to affect the effects D. This should only be taken with meals References:

Answer 112

Correct Answer: B. Clozapine Clozapine is the most studied treatment for drug-induced psychosis in patients with Parkinson’s disease; olanzapine is a close second. Incorrect Answers: A. C. Risperidone has the greatest number of parkinsonian side effects, followed by olanzapine and finally clozapine. Use of clozapine is limited due to significant hematological, cognitive, metabolic, cardiac, and neurological side effects. There is little clinical data supporting the use of ziprasidone or aripiprazole in dementia. D. Quetiapine is often used anecdotally, but there is a lack of evidence for its use at this time. References:

Answer 113

Correct Answer: A. Genotyping The child is likely a poor metabolizer. Many psychotropic medications are metabolized by CYP2D6; over 70 different mutated alleles described in research. Nonfunctional or reduced function alleles occur in approximately 25-30% of Caucasians, resulting in about 5-10% of the population having the poor metabolizer genotype. Under 2% of Asians have the poor metabolizer genotype, and the frequency among African Americans is somewhere between. Poor metabolizers at CYP2D6 taking a substrate of CYP2D6 can be at significantly increased risk of adverse events and are much more likely to discontinue treatment because of the side-effect burden. Atomoxetine is a substrate of CYP2D6; poor metabolizers can develop plasma concentrations of atomoxetine 10x higher than unaffected individuals. Genotyping might help establish the presence of a nonfunctioning allele and confirm the poor metabolizer phenotype. Incorrect Answers: B. Urine toxicology may establish illicit drug use but would not explain current or previous instances of sensitivity to particular medications. C. D. Renal and hepatic impairment can affect drug metabolism but are less likely to be the culprit in a healthy 10-year-old. References:

Answer 114

Correct Answer: C. Agoraphobia Panic disorder is most commonly associated with anxiety disorders such as agoraphobia. In addition to other anxiety disorders, panic disorder has a higher prevalence in individuals with major depression, bipolar disorder, and possibly mild alcohol use disorder. Incorrect Answers: A. Although patients with posttraumatic stress disorder can also have panic disorder, it is more commonly found with agoraphobia. B. Impulse control disorders include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, kleptomania, and pyromania. They can occur in patients with other psychiatric disorders and/or substance use disorders, but are not commonly found with panic disorder. D. Psychotic disorders are not comorbid with panic disorder. Vital Concept: Panic disorder is most commonly associated with mood and anxiety disorders. References:

Answer 115

Correct Answer: B. Licensure Licensure is a legal requirement to practice as a nurse practitioner. Incorrect Answers: A. Certification is a voluntary process granted by a nongovernmental association or organization, and certification is now mandated in most states in the United States as a condition of licensure. C. A collaborative agreement refers to a written agreement between a supervising physician and nurse practitioner that outlines the nurse practitioner’s role and responsibility in clinical practice. Many states have granted NPs full practice authority and no longer require a collaborative practice agreement. D. A National Provider Identification Number (NPI) is required for billing. Vital Concepts: Licensure is granted by a governmental agency, the state board of nursing. To become licensed, a nurse must meet minimal educational and clinical requirements. References:

Answer 116

Correct Answer: D. Politely decline their offer because it is unethical. It is unethical for a healthcare provider to enter into a sexual relationship with a former patient, even when the patient initiates the contact, particularly if the healthcare provider uses or exploits emotions, trust, influence, or knowledge derived from the past provider-patient relationship. The extent of the previous provider-patient relationship, degree of emotional dependence on the healthcare provider, the extent to which the patient has confided private or personal information to the healthcare provider, and extent of the provider’s general knowledge about the patient’s life may contribute to the intimacy of the provider-patient relationship and render a romantic or sexual relationship with a former patient unethical. However, the healthcare provider should not reprimand the patient but should simply explain the situation. Incorrect Answers: A. This is not true, it's still unethical. B. There's nothing a patient can sign to release you from your ethical obligations. C. You shouldn't reprimand the patient. Vital Concept: It is unethical for a healthcare provider to enter into a sexual relationship with a former patient, even when the patient initiates the contact, particularly if the healthcare provider uses or exploits emotions, trust, influence, or knowledge derived from the past provider-patient relationship. References:

Answer 117

Correct Answer: D. Somatic symptom disorder SSD diagnosis does not require that somatic symptoms are medically unexplained. In other words, symptoms may or may not be associated with another medical condition or diagnosis. To meet the criteria for SSD, patients must have: At least one somatic symptom that substantially impacts the patient’s daily functioning or leads to anguish The patient then develops extraordinary actions, emotions, or ruminations regarding the symptom(s) or related medical condition(s), as evidenced by one or more of the following: · consistent worry or concern about their physical wellbeing · extraordinary devotion of resources (e.g., energy, time) to the symptom(s) or related medical condition(s) · ruminations that are consistent and unbalanced regarding the gravity and meaning underlying these symptoms These conditions persist for at least 6 months, although the specific symptom of focus may vary or shift during that time Specifiers include: · with prominent pain if the symptoms involve physical discomfort · persistent if the symptoms are severe, enduring (greater than 6 months), and cause substantial dysfunction · mild/moderate/severe based on the number of symptoms listed above that are present (1/2/2+ multiple symptoms) Incorrect Answers: A. Functional neurological symptom disorder (FNSD) requires the presence of one or more voluntary motor or sensory symptoms that are incompatible with known neurological or medical conditions. B. There's no evidence that the patient is faking their condition to assume the role of the patient, which is the underlying motivation in factitious disorder. C. Illness anxiety disorder is characterized by a preoccupation with having or acquiring an illness and the presence of a high level of anxiety regarding one’s health despite no somatic symptoms present (or only mild in intensity). Vital Concept: Somatic symptom disorder (SSD) is a disease with somatic symptoms that must be significantly distressing or disruptive to daily life and must be accompanied by excessive thoughts, feelings, or behaviors. References:

Answer 118

Correct Answer: A. Sertraline SSRIs like sertraline have been associated with hyponatremia and SIADH, particularly in elderly females. Incorrect Answers: B. MAOIs like selegiline are usually not associated with hyponatremia, but may cause dizziness in some patients. MAOIs are not used as first-line treatment for depression, especially with this patient’s multiple medical comorbidities. Although MAOIs can be used in treatment refractory depression, this patient has only been experiencing depression for the past 3 months, which is not enough time for adequate trials of first-line treatment options. C. Buprenorphine is used in the treatment of opioid use disorder and is not used to treat depression. D. Zolpidem is a sleep aid; it is not used in the treatment of depression. References:

Answer 119

Correct Answer: B. Inflammatory response Apoptosis is genetically programmed cell death. It is an active process that requires RNA and protein synthesis and is characterized by cytoplasmic shrinkage, chromatin condensation, and degradation of DNA into oligonucleosomal fragments. Reactive oxygen species at intermediate concentrations can trigger apoptosis, as can a deprivation of neurotrophic factors like nerve growth factor (NGF). Reactive oxygen species at higher concentrations can induce necrotic cell death. Evidence accumulated since the 1990s suggests that apoptosis may actually be the default program for most cells and that the continual presence of survival signals is necessary to prevent widespread cell suicide. Unlike necrosis, the process of apoptosis does not stimulate an inflammatory response. In necrosis usually get a disruption of the cell membrane resulting in cell death products being released into the extracellular space triggering the inflammatory response. Incorrect Answers: (A) Phagocytosis by macrophages. Phagocytosis by macrophages occurs in both necrosis and apoptosis. In apoptosis phagocytosis can also occur by adjacent cells. (C) Membrane blebbing. Membrane blebbing occurs in both necrosis and apoptosis. However, loss of membrane integrity is only in necrosis, not apoptosis. (D) Degradation of DNA. Degradation of DNA occurs in both apoptosis and necrosis. In necrosis the digestion of DNA is random and has postlytic DNA fragmentation. In apoptosis there is prelytic DNA fragmentation. References:

Answer 120

Correct Answer: B. Lithium Several studies demonstrate that women with histories of bipolar disorder or peripartum psychosis benefit from prophylactic treatment with lithium instituted either before delivery (at 36 weeks of gestation) or no later than the first 48 hours following delivery. Prophylactic lithium appears to reduce relapse rates significantly and diminish the severity and duration of postpartum illness. Incorrect Answers: A. Valproic acid use during the first trimester increases the risk of neural tube defects. Lithium, not valproic acid, has been studied as the preferred prophylactic treatment either before delivery or no later than the first 48 hours following delivery to reduce relapse rates in bipolar disorder. C. There have been no studies demonstrating prophylactic treatment with quetiapine instituted either before or after delivery that reduces relapse rates in bipolar disorder. D. There have been no studies demonstrating prophylactic treatment with aripiprazole instituted either before or after delivery that reduces relapse rates in bipolar disorder. Vital Concept: Lithium has been shown to reduce relapse rates and decrease the severity and duration of illness when given to women with a history of bipolar disorder before or within 48 hours of delivery. References:

Answer 121

Correct Answer: C. Atypical antipsychotics should be tapered slowly. Atypical antipsychotics should be tapered slowly to allow adjustment to the lowered dose and to prevent withdrawal akathisias. Aripiprazole (in 6-17 years old) and risperidone (in 5-16 years old) are FDA approved for irritability in autism (6-17 years old). Most atypical antipsychotics are used off-label for behavioral disturbances in children and adolescents. Clozapine is not due to side effect profile. Pimavanserin is not because it is only utilized for patients with Parkinson’s disease hallucinations. Incorrect Answers: A. Psychosocial/educational intervention and appropriate pharmacotherapy of primary psychiatric disorder should be optimized prior to atypical antipsychotics use. B. Tardive dyskinesia, involuntary movements, is seen after months to years on antipsychotic therapy, not upon initiation. D. Sedation is seen primarily with the initiation of therapy, not after months. Vital Concept: Atypical antipsychotics should be tapered slowly to allow adjustment to the lowered dose and to prevent withdrawal akathisias. References:

Answer 122

Correct Answer: C. Competitive inhibitor of acetylcholinesterase Galantamine has a dual mode of action. First, it acts as a reversible competitive inhibitor of acetylcholinesterase (AChE). Second, it is an allosteric modulator of nicotinic acetylcholine receptors (nAChRs). Galantamine can improve and stabilize cognitive performance, activities of daily living, and behavioral symptoms of dementia. The efficacy and tolerability of galantamine are comparable to other cholinesterase inhibitors. Memantine is an antagonist at glutamatergic NMDA receptors. Incorrect Answers: A. Monoamine oxidase inhibitors (MAOIs) are a class of drugs that inhibit the activity of one or both monoamine oxidase enzymes: monoamine oxidase A (MAO-A) and monoamine oxidase B (MAO-B). B. This is the MOA of memantine. D. Selective Serotonin Reuptake Inhibitors (SSRIs) increase serotonin levels in the brain. References:

Answer 123

Correct Answer: D. Children with posttraumatic stress disorder (PTSD) may have generalized nightmares of monsters, rescues, and threats rather than recurring dreams of traumatic events. Children with PTSD may have generalized nightmares of monsters, rescues, and threats rather than recurring dreams of the traumatic event. Additionally, children with PTSD may also exhibit fear of betraying adults and may resist descriptions of traumatic events. Incorrect Answers: A. Separation anxiety is a normal part of child development, particularly at ages 8-10 months and 18-24 months. About 2-5% of children develop separation anxiety to the extent that they may display excessive anxiety when going to school, going to sleep, or if separated from a parent when he or she is going on an errand. B. Children with OCD may not acknowledge their symptoms or may fail to recognize them as abnormal or unreasonable. C. Somatic complaints are more common than worries and fears in children with GAD. Vital Concept: The nightmares and flashbacks in children with PTSD may be generalized and not specific to their history of trauma. References:

Answer 124

Correct Answer: B. Bupropion dose was increased by his primary care doctor. Common anticholinergic side effects of the tricyclic antidepressants (TCAs) (e.g. amitriptyline) are blurred vision, urinary retention, constipation, and dry mouth. Primarily CYP2D6 and 1A2 enzymes metabolize amitriptyline. Bupropion is a strong inhibitor of the CYP2D6 enzyme and can increase levels of amitriptyline. Increasing the level of bupropion would slow the metabolism of amitriptyline and increase anticholinergic side effects. Incorrect Answers: A. Patient has developed benign prostatic hyperplasia (BPH). This is a distracter. BPH does cause urinary retention but does not account for blurred vision. Increasing bupropion leading to a higher concentration of the TCA would account for both symptoms. C. Bupropion dose was decreased by his primary care doctor. Bupropion, is an inhibitor of the CYP2D6 system which decreases the metabolism of TCAs like amitriptyline increasing TCA blood levels. Decreasing bupropion would lead to increased metabolism resulting in a lower TCA level. This would not cause the anticholinergic side effects this patient is experiencing. D. Patient is experiencing adverse effects of bupropion. TCAs have significant anticholinergic activity versus bupropion does not have anticholinergic activity. References:

Answer 125

Correct Answer: B. Modafinil Inhibitors include Clarithromycin, fluconazole, and ketoconazole. Inducers include phenobarbitol, St. John's Wort, and dexamethasone. Incorrect Answers: A. Clarithromycin is a CYP3A4 inhibitor, not inducer C. fluconazole is a CYP3A4 substrate, not inducer. D. ketoconazole is a CYP3A4 inhibitor. References:

Answer 126

Correct Answer: D. Emotional abuse or neglect Although further testing should be completed to rule out endocrine or metabolic causes of weight loss (e.g., diabetes, celiac disease, or adrenal insufficiency), toxic exposures such as lead, and other organic causes of weight loss, the most likely causes of weight loss/failure to gain weight, in this case, are emotional abuse and neglect. Emotional neglect of children can result from parents with substance use disorders and severe mental health disorders. Domestic violence and intimate partner violence increase the risk of emotional neglect for children. Incorrect Answers: A, C, and E. While neoplastic disease, infections (including parasitic infections or viral infections such as HIV), and anemia can result in weight loss or failure to gain weight, these are not the most likely causes of this patient’s low weight. B. Eating disorders usually affect older children and adolescents. Vital Concept: Emotional abuse or neglect in children can have physical, developmental, and psychological consequences. Weight loss in young children may indicate neglect. References:

Answer 127

Correct Answer: D. Latino combat veterans experience a higher rate of PTSD than their African American and Euro-American counterparts. This is especially true for Puerto Rican combat veterans. Incorrect Answers: A. Native Americans have a rate of violent victimization that is 2x the national average. B. PTSD rates among Native Americans is 3x higher than the national average. C. African American combat veterans experience higher rates than European Americans. This may be related to a higher rate of traumatic early experiences, as more African Americans live in urban environments that have more violence. References:

Answer 128

Correct Answer: C. Methadone Management of acute opioid withdrawal involves a combination of general supportive measures in conjunction with pharmacotherapy. Treatment consists of short-term detoxification and long-term maintenance. Methadone, clonidine, buprenorphine, and clonidine-naltrexone are used for detoxification, while methadone, buprenorphine, and naltrexone are used for maintenance therapy. Another less-recommended option is the use of ultra-rapid opioid detoxification. This method uses general anesthesia with propofol or conscious sedation with midazolam as well as naltrexone (or naloxone), ondansetron (an antiemetic), octreotide (an antidiarrheal), clonidine, and other benzodiazepines. Incorrect Answers: A. Lithium is the drug of choice for bipolar disorders. B. Chlordiazepoxide is a benzodiazepine used in alcohol withdrawal. D. Haloperidol is an antipsychotic drug that is useful for psychotic episodes and uncontrolled agitated behavior. References:

Answer 129

Correct Answer: D. Delusional disorder To meet the criteria for delusional disorder, a patient must have one or more delusions for at least a month in the absence of other prominent mood or psychotic symptoms. Delusions are defined as a fixed false belief; in this case, the patient believes they're being monitored by government agencies. To make a diagnosis of delusional disorder, other causes must be excluded, including medications or illicit drug use, certain medical conditions, and psychiatric disorders such as schizophrenia. Delusional disorder is relatively rare, with a lifetime estimated prevalence of 0.2 percent. There are multiple subtypes of delusional disorder, including persecutory (which is the subtype applicable in this case), grandiose, jealous, somatic, erotomanic, and mixed. Mood disorders are common comorbid conditions, particularly depression; a family history of paranoid personality disorder is a risk factor. Patients with delusional disorder often present in their 30s and 40s and do not have functional impairments outside of their delusions. They often insist their delusions are true and do not accept treatment. Antipsychotics are recommended. Although no randomized controlled trials have been completed for this disorder, case series and open-label studies have demonstrated the efficacy of this treatment with varied response rates. A strong therapeutic alliance between the physician and the patient is an essential part of treating delusional disorder because patients lack insight and may resist treatment. Incorrect Answers: A. Paranoid personality disorder is characterized by suspicion of other people and distrust of their motives. Individuals with paranoid personality disorder may develop delusional disorder. This patient is unlikely to have paranoid personality disorder, as the symptoms only appeared a few weeks ago, and they only endorse a single specific delusion rather than more generalized mistrust and suspicion. B. To meet the criteria for schizoaffective disorder, a patient must have features of both schizophrenia and a major mood disorder. C. Although this patient has a specific delusion, a diagnosis of schizophrenia requires at least two characteristic symptoms (including hallucinations, disorganized speech, and negative symptoms) that persist for a month, evidence of impaired functioning since the onset of symptoms, and at least 6 months of continuous signs of the disturbance. E. This patient does not currently endorse any symptoms of depression, making major depression with psychotic symptoms unlikely. Vital Concept: Delusional disorder is characterized by at least one delusion lasting for at least one month in patients who otherwise lack functional impairments and have no other medical, substance-induced, or psychiatric reason for their symptoms. Patients with this rare disorder often lack insight into their disease. Treatment with antipsychotics is recommended. References:

Answer 130

Correct Answer: B. Validity The validity of a quality measure refers to how well it addresses the purpose chosen by the user and is a function of how the measure is built. The user should consider how well the intended use matches the intent of the developer of the measure, which is identified in the NQMC summary section called State of Use of the Measure. The NQMC summary of a measure includes six fields intended to answer these questions. They include these questions: * How strong is the scientific evidence supporting the validity of this measure as a quality measure? * Are all individuals represented in the denominator equally eligible for inclusion in the numerator? * Is the measure result under control of those whom the measure evaluates? * How well do the measure specifications capture the subject of the measure? * Does the measure provide for fair comparisons of performance of providers, facilities, health plans, or geographic areas? * Does the measure allow for adjustment to exclude patients with rare performance-related characteristics when appropriate? Incorrect Answers: A. Reliability is the overall consistency of a measure. C. Sensitivity is the ability of a test to correctly identify those with the disease (true positive rate), whereas test specificity is the ability of the test to correctly identify those without the disease (true negative rate). Vital Concepts: The validity of a quality measure refers to how well it addresses the purpose chosen by the user and is a function of how the measure is built. References:

Answer 131

Correct Answer: D. Health literacy This is the definition of health literacy and it is important to know the meaning of all the answers. It is a common theme in healthy people 2020. Incorrect Answers: A. Understanding of the objective reality of the situation coupled with the motivational and emotional impetus to master the situation or change behavior is true insight. B. The form of thinking that is logical, organized, reality oriented, and influenced by the demands of the environment is second process thinking. C. Unconscious defense mechanism in which a person attributes to another these unconscious ideas, thoughts, and feelings, impulses that in themselves is a form of protection from anxiety. References:

Answer 132

Correct Answer: C. Carbamazepine Valproate metabolism may be induced by other anticonvulsants, including carbamazepine, phenytoin, primidone, and phenobarbital, resulting in an increased total clearance of valproate. Incorrect Answers: A. B. D. Drugs that may increase valproate levels include cimetidine, macrolide antibiotics (e.g. erythromycin), and felbamate. References:

Answer 133

Correct Answer: B. Cardiovascular abnormalities The approximate incidence of major congenital anomalies in children of pregnant women treated with lithium in the first trimester is 4-12%. Ebstein’s anomaly is considered the most common fetal cardiac defect caused by lithium, occurring in approximately 1/1,000, compared to the general population incidence of 1/20,000. Ebstein’s anomaly is when the tricuspid valve and right ventricle develop abnormally. Lithium remains a category D drug during pregnancy. Have to weigh the risks and benefits. If have bipolar disorder and discontinue lithium during pregnancy there is a 70% risk of mania relapse. It is recommended to monitor lithium levels monthly in pregnancy until 34 weeks then monitor weekly. During first and second trimester there is a decrease in lithium blood levels due to increased total body water, plasma volume and GFR. Lithium during the third trimester returns back to preconception levels and therefore can result in lithium toxicity. Incorrect Answers: A. There has been no association with fetal exposure to lithium and gastrointestinal abnormalities. C. There has been no association with fetal exposure to lithium and pulmonary abnormalities. D. There has been no association with fetal exposure to lithium and ocular abnormalities. Vital Concept: The most congenital malformations from neonatal lithium exposure is cardiovascular abnormalities, in particular Ebstein's anomaly. References:

Answer 134

Correct Answer: C. Verify that the caller has a need to know the information. The NP must determine if the caller on the phone is the physician of record or has a need to know the information. Incorrect Answers: A. Until the NP determines that the caller has a true need to know the information, results should not give out the information. B. The caller may be the physician of record and may have a need to know the information, so the NP should not refuse to give out the information until caller identity is identified. D. Unless the NP cannot confirm the identity of the caller, there is no need to require the physician to come to the unit to access the information. Vital Concept: To ensure protected health information (PHI), verification of the identity of the caller is important to remain in compliance with HIPPA. References:

Answer 135

Correct Answer: B. 1940s The first use in the U.S. of electroconvulsive therapy (ECT) was in the 1940s. ECT had been used for several years prior in Europe. ECT has FDA indications to treat catatonia and treatment-resistant or severe depression (unipolar or bipolar). ECT is used off label for psychotic depression, suicidality, severe schizophrenia, and neuroleptic malignant syndrome. ECT has also been used as last resort treatments in OCD, dyskinesias, Gilles de la Tourette syndrome, epilepsy and Parkinson’s disease. ECT produces a generalized seizure, usually 30-60 seconds in duration, with an unknown mechanism of action for these indications. Treatments are 3 days per week and vary from 7-12 treatments in an acute series. Most common side effects include acute confusion, memory loss, headaches, jaw pain and nausea. Incorrect Answers: A. ECT was first used in the U.S. in the 1940s, not 1920s. C. ECT was first used in the U.S. in the 1940s, not 1970s. D. ECT was first used in the U.S. in the 1940s, not 1990s. Vital Concept: The first use in the U.S. of electroconvulsive therapy (ECT) was in the 1940s. References:

Answer 136

Correct Answer: B. Balanced Budget Act of 1997 The Balanced Budget Act of 1997 was signed into law by President Bill Clinton and allowed direct reimbursement of nurse practitioners by Medicare. Nurse practitioners can be directly reimbursed by Medicare Part B, Medicaid, Tricare, and some health insurance plans. Medicare permits NP reimbursement at 85% of the usual and customary fee, referring to the fee paid to a physician. The NP must file charges under his or her name or provider number for reimbursement. Prior to this act, only NPs who practiced in certain designated or rural areas in the US were permitted to bill Medicare directly. Incorrect Answers: A. The Affordable Care Act went into effect in 2014 and is intended to broaden healthcare access. C. COBRA stands for Consolidated Omnibus Budget Reconciliation Act, which provides for continuation of an employer's preexisting group health insurance for a fixed period for an individual who loses coverage. D. CMS refers to the Centers for Medicaid and Medicare Service. Vital Concepts: The Balanced Budget Act of 1997 was signed into law by President Bill Clinton and allowed direct reimbursement of nurse practitioners by Medicare. Nurse practitioners can be directly reimbursed by Medicare Part B, Medicaid, Tricare, and some health insurance plans. References:

Answer 137

Correct Answer: C. There is often a disconnect between peer-based support services and traditional diagnostic-driven programs. Peer-based programs tend to focus on supporting individuals' return to independent living. Incorrect Answers: A. There are a variety of peer-based service models (including self-help groups, face to face, or Internet), peer-delivered services, peer partnerships, and peer employees. B. Peer-based programs do have benefit, but further studies are needed to characterize their benefit. D. Peer-based programs tend to focus on supporting individuals' return to independent living rather than diagnostic labels. References:

Answer 138

Correct Answer: C. Explain to the patient that her condition will not be discussed with anyone without her permission. A clinician may not disclose a patient’s medical condition to anyone, even a spouse, without the patient’s permission. The provider can encourage the patient to reveal her medical condition to her husband and offer to meet with them jointly to address any questions or concerns. Some individuals may prefer limited or no disclosure of information to family members. The patient’s confidentiality should be respected unless a third party is at risk of harm. Incorrect Answers: A and D. A clinician may not disclose a patient’s medical condition to anyone without the patient’s permission. B. Regardless of whether the patient agrees to marital counseling, the clinician may not disclose her medical condition to her spouse without her permission. Vital Concept: A clinician may not disclose a patient’s medical condition to anyone without the patient’s permission. References:

Answer 139

Correct Answer: B. No, continue to use universal precautions; you are not required to disclose your status to patients. Healthcare workers should use universal precautions at all times. Whether an infected physician should disclose the condition depends on the likelihood of risk to the patient and the relevant regulations, but if it becomes clear that the risk to a patient associated with contact or a procedure is high despite appropriate preventive measures, physicians should remove himself/herself from care. If a clinically significant exposure occurs, the physician is obligated to disclose the condition after the fact. A healthcare worker with a blood-borne illness has an ethical obligation to notify the hospital or employer, but this information cannot be used to terminate his/her employment. Incorrect Answers: A. There is no requirement of an infected physician to disclose if they have a communicable disease unless there is a high likelihood of risk to the patient. C. The physician is obligated to disclose HIV status to the hospital but not to the patients. D. There is no requirement of an infected physician to disclose if they have a communicable disease unless there is a high likelihood of risk to the patient regardless if it is HIV+ versus AIDS-defining illness. Vital Concept: A healthcare worker with a blood-borne illness has an ethical obligation to notify the hospital, but not their patients. The healthcare worker should use preventive measures and avoid contact/procedures that puts the patients at high risk despite the preventative measures. References:

Answer 140

Correct Answer: A. Displacement and repression The man is demonstrating displacement by focusing his anger toward his boss even though he admits his productivity is down at work and his boss is having a reasonable reaction. He's also demonstrating repression by not connecting his exhaustion and sleeping issues with his marital problems. Incorrect Answers: B. The man isn't giving false reasons to show why he can't be bothered, which would be rationalization. He also isn't demonstrating suppression, which is when emotions are recognized but they're not thought about it, as he's focusing on the situation. C. The man isn't demonstrating suppression, which is when emotions are recognized but they're not thought about it, as he's focusing on the situation. He is demonstrating repression by not connecting his exhaustion and sleeping issues with his marital problems. D. The man is demonstrating displacement by focusing his anger toward his boss even though he admits his productivity is down at work and his boss is having a reasonable reaction. He isn't giving false reasons to show why he can't be bothered, which would be rationalization. References:

Answer 141

Correct Answer: C. Selegiline MAOIs like selegiline increase norepinephrine, serotonin, and dopamine (see table below). Bupropion has a slight dopamine increase as well. Most SSRIs increase serotonin predominantly, and TCAs generally increase serotonin and norepinephrine. Incorrect Answers: A, B, C. Do not increase dopamine References:

Answer 142

Correct Answer: D. Alcohol use disorder Comorbid disorders with social phobics include other anxiety disorders, posttraumatic stress disorder, major depressive disorder, bipolar disorder, body dysmorphic disorder and substance use disorder. The lifetime prevalence of social phobia is around 13%, and it is slightly more common in women. Other factors that increase risk are Native American heritage, younger age, and low socioeconomic status. Factors that decrease risk are Asian, black, or Latino heritage and living in an urban setting. Onset is usually in adolescence or early adulthood. Psychological theories of the development of social phobia indicate that being exposed to a traumatic social situation in the past or seeing others experience such an event can impart social phobia. Children who are not exposed to social situations and whose parents are controlling and overprotective have a higher likelihood of developing the disorder as well. Incorrect Answers: (A) Schizophrenia. Psychotic disorders have not been associated as comorbid with social phobia. (B) Borderline personality disorder. Borderline personality disorder has not been associated as comorbid with social phobia. (C) Gender dysphoria. Gender dysphoria has not been associated as comorbid with social phobia. References:

Answer 143

Correct Answer: C. Wernicke's encephalopathy This patient with chronic alcohol use disorder has developed ataxia, ophthalmoplegia, fever, and confusion. His symptoms worsened after glucose administration. Wernicke's encephalopathy is the most likely diagnosis. Bilateral hyperintensity of the mammillary bodies are involved in most cases. Incorrect Answers: A. Central pontine myelinolysis due to hyponatremia -Patients with chronic alcohol use disorder may present with altered mental status and falls secondary to low sodium. This is described in the literature as beer potomania. Clinically, Wernicke’s encephalopathy and osmotic demyelination syndrome can be distinguished by ocular involvement and progression when glucose is given without thiamine. The MRI of a patient with osmotic demyelination syndrome classically shows pontine myelinolysis. B. Brain tumor is incorrect. The triad of confusion, ophthalmoplegia, and ataxia worsening after administration of glucose suggest Wernicke’s encephalopathy. Symmetrical, bilateral lesions on MRI are more specific to an encephalopathy, and the onset of symptoms are rapid onset for a tumor. D. Encephalitis (viral) often is displayed as changed in mental status changes in deep tendon reflexes and are often confused and agitation. The above patient meets criteria for Wernicke's encephalopathy References:

Answer 144

Correct Answer: C. It is diagnosed with onset at any age. In the DSM-5-TR, the diagnostic criteria do not specify the age of onset. Also, a duration criterion of "typically lasting for 6 months or more" has been added for adults to minimize the overdiagnosis of transient fears. Social anxiety disorder (social phobia) DSM 5-TR criteria include: · Terror or significant concern about a certain environment that exposes the patient to potential judgment by the public or individuals. This may be when being watched (e.g., during observations, dining in public spaces), presenting (e.g., public speaking), or socializing (e.g., talking or interacting with new people). · The patient is concerned that they will behave poorly and be judged by others (i.e., they will be rejected, mortified) · The patient reports sudden terror or significant concern every time they are exposed to the certain environment · The patient evades the certain environment · The actual risk or threat posed by the environment is insignificant in comparison to the patient’s emotional response and concern · The terror or concern is consistent for at least 6 months · The terror/concern or active evasion of the environment leads to dysfunction (academic, professional, social, or otherwise) or substantial anguish · The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern. The concern is not due to a more appropriate psychiatric condition such as autism spectrum disorder, panic attacks (i.e., panic disorder), past trauma (i.e., post-traumatic stress disorder), separation from a loved one (i.e., separation anxiety disorder), a specific trigger (i.e., specific phobia), physical judgment (i.e., body dysmorphic disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). · In pediatric patients, the terror/concern must be present when interacting with peers (not only grown-ups) and may present as dependence, immobility, mutism, outbursts, or fits · The terror/concern is disproportionate or unconnected in those with a physical attribute that causes them discomfort (e.g., significant scars, facial or other obvious physical difference · May specify performance only if applicable Incorrect Answers: (A)There is no age of onset requirement for a diagnosis of social anxiety disorder. (B) Social anxiety disorder is classified as an anxiety disorder. (D) Social anxiety disorder (social phobia) is a DSM diagnosis. Vital Concept: Social anxiety disorder is characterized by excessive fear or embarrassment and humiliation in social situations, causing significant distress and impaired function. References:

Answer 145

Correct Answer: B. Generalized tonic-clonic seizures ECT causes generalized tonic-clonic seizures by using alternating-current electrical pulses via scalp electrodes under general anesthesia. Without causing a seizure, ECT has not been found to be effective, so the electrical input must be sufficient to cause a seizure. Incorrect Answers: A. ECT indicates generalized tonic-clonic, not partial complex, seizures C. ECT indicates generalized tonic-clonic, not atonic, seizures D. ECT induces generalized tonic-clonic, not myoclonic, seizures References:

Answer 146

Correct Answer: B. Meperidine Serotonin syndrome is an adverse event, resulting from serotonin excess from the use of serotonergic medication. Clinical signs of serotonin syndrome include confusion, hyperthermia, myoclonus, tachycardia, and hyperreflexia. Severe sequelae can include rhabdomyolysis, metabolic acidosis, and renal failure. Meperidine can cause serotonin syndrome in patients taking serotonergic medications. Dextromethorphan also exhibits this effect. Pain medications like fentanyl, tramadol, and cyclobenzaprine also are associated with serotonin syndrome, and propoxyphene has some weak serotonergic activity. Other medications associated with serotonin syndrome include amphetamine, analgesics, buspirone, lithium, monoamine oxidase inhibitors, SSRIs, SNRIs, antiemetics, ergot alkaloids, triptans, valproic acid, linezolid, and tryptophans. Incorrect Answers: A. Marijuana does not predispose patients to serotonin syndrome. C. Phenytoin does not predispose patients to serotonin syndrome. D. Haloperidol does not predispose patients to serotonin syndrome. Haloperidol has the potential to cause neuroleptic malignant syndrome (NMS). NMS can be confused with serotonin syndrome because they both cause mental status change, fever, and autonomic changes. Important in distinguishing NMS from serotonin syndrome are neuromuscular findings and reflexes. Serotonin syndrome is associated with myoclonus and hyperreflexia versus NMS is associated with diffuse rigidity and hyporeflexia. Vital Concept: Meperidine can cause serotonin syndrome in patients taking serotonergic medications. Clinical signs include confusion, hyperthermia, myoclonus, tachycardia, and hyperreflexia. References:

Answer 147

Correct Answer: A. Naltrexone maintenance dose is usually 50mg once daily. When treating alcohol use disorder, the general consensus is that in a patient without a psychiatric comorbidity, the evidence for pharmacological treatment is less robust than for psychotherapist interventions. Adequately treating any psychiatric condition, if medication is indicated, will help prevent relapse. Naltrexone is given at 25mg initially (with 1-hour observation for reactions), then 50mg once daily starting on day 2. It can also be given at 380mg IM every 4 weeks for maintenance of abstinence. Incorrect Answers: B. Naltrexone is an opioid blocker. Studies providing much psychosocial support and additional treatment resources have shown modest results, while other trials have shown no significant difference. Side effects include GI upset, elevated LFTs, and mild dysthymia. C. Acamprosate structurally resembles GABA and is possibly an NMDA antagonist. Doses are around 2000mg/day. Most trials show modest efficacy in comparison to placebo. Side effects are mild and include stomach upset. Some trials indicate that combining acamprosate and naltrexone may be more beneficial than taking either drug alone. D. Disulfiram is an aldehyde dehydrogenase inhibitor prescribed at about 250mg daily. The patient should wait at least 24 hours (but up to 5 days in some cases) to resume drinking, as doing so earlier may induce nausea, diarrhea, and raise blood pressure. Double-blinded studies have not convincingly shown its efficacy. However, when used appropriately, the medication does have clinical efficacy. References:

Answer 148

Correct Answer: C. Isotretinoin This includes taking isotretinoin in any amount even for a short period of time. It must abruptly be stopped. Anticonvulsants like Depakote (valproate) should not be discontinued abruptly because of the possibility of increasing seizures or even status epilepticus. It should be tapered and transitioned to a new medication. Incorrect Answers: A. While there's still debate over whether valproate is safe for women of childbearing age and the UK has recently banned valproate use in women not in a pregnancy prevention program, there's still no clinical consensus on not giving women valproate while pregnant B. This is harmless, and can be continued during pregnancy D. Pregnant women should take multivitamins (ideally prenatal vitamins) References:

Answer 149

Correct Answer: D. Act During the “act” phase of the PDSA (Plan Do Study Act) cycle, a change that has been made is modified based on results from a test of the change. Further modifications are made as needed and preparations are made for the next test. Incorrect Answers: A. During the "plan" phase, the change is identified, with ideas for its implementation. Specific measurable objectives are developed with a hypothesis. B. During the “do” phase of a PDSA cycle, a test of a change is carried out in a pilot study and observations, including notation of obstacles, are documented. Preliminary analysis of data begins during this stage. C. During the “study” phase, data are analyzed and compared to the hypothesis. The team gathers together to summarize the results and consider the implications of the findings. Vital Concepts: During the “act” phase of the PDSA (Plan Do Study Act) cycle, a change that has been made is modified based on results from a test of the change. Further modifications are made as needed and preparations are made for the next tes. References:

Answer 150

Correct Answer: B. The efficiency and outcome of care by an organization, including patient satisfaction From the perspective of the Institute of Medicine, a recognized leader and advisor on improving the nation’s healthcare, quality in healthcare is defined as a direct correlation between the levels of improved health services and desired health outcomes. It is defined by an organization’s efficiency and outcome of care, and by patient satisfaction. Incorrect Answers: A. An organization’s current system incorporates how things are done now. C. Resources, activities, and results that make up a healthcare delivery system are also called inputs, processes, and outcomes. D. Activities within a healthcare organization can be addressed to improve quality by addressing what care is provided and how, when, and by whom the care is delivered. Vital Concepts: Quality in healthcare is defined as a direct correlation between the levels of improved health services and desired health outcomes. It is defined by an organization’s efficiency and outcome of care, and by patient satisfaction. References:

Answer 151

Correct Answer: C. While controversial, a normal MRI or CT can exclude some treatable causes of psychosis and support diagnosis of schizophrenia The value of CT or MRI in suspected schizophrenia is controversial. Accessing head imaging is common in new onset psychosis to rule out organic causes. A normal MRI or CT would support a diagnosis of schizophrenia. Incorrect Answers: A. Ordering head imaging can have value. A normal MRI or CT supports the diagnosis of schizophrenia. B. Head imaging is controversial; it does have value but is not considered highly valuable. Also the testing is not preformed upon patient request, it is preformed if a doctor suspects other possible causes of psychosis. D. Ordering head imaging can have value. A normal MRI or CT supports the diagnosis of schizophrenia. Vital Concept: While controversial, a normal MRI or CT can exclude some treatable causes of psychosis and support diagnosis of schizophrenia. References:

Answer 152

Correct Answer: C. The use of a separate psychiatric system and a medical system within a hospital does not protect the privacy of psychiatric patients and is not helpful to patients C. Some hospitals have implemented systems in which the protected health information of psychiatric patients is limited to psychiatric staff, who can access both psych and medical records. This has been shown to harm patients, compared to systems where medical doctors also have full access to both psychiatric and medical protected health information. Incorrect Answers: A. Administrators should be able to view who has logged in and viewed a patient's medical record. B. De-identified data can be distributed without significant limitations. D. HIPAA tries to limit unauthorized release of protected health information to facilities that are not “Covered Entities,” "Business Associates,” or "Subcontractors." Vital Concepts: A streamlined system that contains psychiatric and medical information has been shown to be safer for patients. References:

Answer 153

Correct Answer: E. Cyclothymic disorder Cyclothymic disorder is diagnosed when there are multiple periods of hypomanic symptoms (yet insufficient to meet criteria for a hypomanic episode) and then periods of depressive symptoms (yet insufficient to meet criteria for a major depressive episode). The diagnostic criteria state: Symptomatic periods fluctuate between those included in the diagnostic criteria for a hypomania episode and those for major depressive episode (MDE), but insufficient to meet the full criteria for either In adults, symptoms must persist for 24 months or more (12 months in children and adolescents) and must remain present during at least half of that time; there are no asymptomatic periods that last longer than 8 consecutive weeks The patient has never reported symptoms sufficient to meet the criteria for: major depressive episode, manic episode, hypomanic episode The symptoms result in substantial dysfunction (professional, interpersonal, academic) or anguish for the patient These symptoms are not more appropriately attributed to a substance of abuse or another mental health condition, such as another mood disorder or psychotic disorder Incorrect Answers: A. Malingering refers to exaggerating or feigning illness for secondary gains, such as in order to escape duty or work. B. There is no mention of associated symptoms necessary for the diagnosis of a major depressive episode, such as anhedonia, suicidal ideation, guilt, decreased psychomotor activity, energy, concentration, appetite, or sleep. C. For a diagnosis of bipolar I disorder, the criteria for a manic episode would need to be met. This simply describes periods of happiness and increased energy without the need for hospitalization or symptoms of psychosis that would indicate mania. D. Borderline personality disorder diagnosis does not include hypomanic symptoms or depressive symptoms. Symptoms of borderline personality disorder include inappropriate anger, impulsivity, unstable relationships, and unstable self-image or sense of self. Vital Concept: Cyclothymic disorder is diagnosed when there are multiple periods of hypomanic symptoms and periods of depressive symptoms without meeting DSM criteria for either. Symptoms must be present for over 2 consecutive years and not symptom-free for more than 2 consecutive months. References:

Answer 154

Correct Answer: C. There is wide variation in normal language development at this age. Wide variation in normal language development is influenced by environmental factors, including the amount of language a child is exposed to, how much caregivers engage a child in language, and how much they encourage the child to speak. Incorrect Answers: A. Childhood-onset fluency disorder (formerly stuttering) occurs in 3% of children at this age. Often, it will resolve over time. Chronic or severe stuttering may require special speech and language services. B. Word articulation typically lags behind vocabulary. Many preschoolers will make articulation errors, including dropping, altering, or shortening speech sounds. D. Most articulation errors end by age 4, and people outside of their immediate environment can understand their speech. References:

Answer 155

Correct Answer: C. Independent variable In an experimental study design, the variable is a characteristic, object, or event that is being measured. The independent variable is the variable that is not affected by the other variables. It is the variable that is manipulated, in this case, the medication. The dependent variable is the variable that changes in responses to the manipulation of the independent variable. The control refers to the non-treatment group, or the group that receives a current standard treatment when testing another group with a new treatment. Incorrect Answers: A. The control is the non-treatment group B. This is the variable being measured in response to manipulation of the independent variable (active medication) D. This is a variable that moves consistently in relation to another variable Vital Concepts: The independent variable is the variable that is not affected by the other variables. It is the variable that is manipulated, in this case, the medication. References:

Answer 156

Correct Answer: A. Renal side effects Lithium causes polyuria due to decreased resorption of fluid from the distal tubules of the kidney. Amiloride blocks lithium entry through the sodium channel, reducing the resultant nephrogenic diabetes insipidus. Incorrect Answers: B, C, and D. These aren't side effects of lithium, so amiloride wouldn't be used to treat them as lithium side effects References:

Answer 157

Correct Answer: B. Stop dialysis. When a competent adult decides to stop life-sustaining treatment, the provider must comply with the patient’s decision. Incorrect Answers: A. If the patient is competent, the provider cannot declare that patient incompetent by virtue of a decision to stop treatment. C. With respect to patient autonomy, withdrawing care is no different from withholding care. D. Family members cannot give consent for treatment when a competent patient refuses a medical intervention. If the decision appears to be the result of depression, a psychiatric consultation should be obtained. Vital Concepts: When a competent adult decides to stop life-sustaining treatment, the provider must comply with the patient’s decision. References:

Answer 158

Correct Answer: B. Reframing The therapist has reframed the situation to make the patient feel better. The statement by the therapist might also be considered "reducing distortion," as the therapist changes the patient's statement from "every job" to "fewer jobs." Incorrect Answers: A. Rationalizing by a therapist involves a comment that explains unacceptable impulses or behavior. C. Minimization is a strategy the therapist uses to allow the patient to acknowledge some affect. D. Projection is a primitive defense mechanism put forth by ego psychology. References:

Answer 159

Correct Answer: C. Major depression increases in prevalence with age. Major depression increases in prevalence with age. Based on epidemiological studies and estimates, the prevalence is about 0.3% in preschoolers, 2% in children, and 1.5-9% in adolescents. Incorrect Answers: A. ADHD is the most prevalent childhood psychiatric disorder. Data collected from a variety of sources from 2005-2011 show that children ages 3-17 years had ADHD (6.8%), behavioral or conduct problems (3.5%), anxiety (3.0%), depression (2.1%), autism spectrum disorders (1.1%), and Tourette syndrome (0.2% among children ages 6-17 years). Adolescents ages 12-17 years demonstrated illicit drug use disorder in the past year (4.7%), alcohol use disorder in the past year (4.2%), and cigarette dependence in the past month (2.8%). B. Generalized anxiety disorder is seen more frequently in girls than boys. D. Autism spectrum disorder is three to four times more common in boys than girls. References:

Answer 160

Correct Answer: C. Partial agonist at alpha4beta2 and full agonist at alpha7 Varenicline (Chantix) is a partial agonist at alpha4beta2 and a full agonist at alpha7. It binds to receptors avidly but stimulates receptors more weakly than nicotine, reducing cravings but also limiting the pleasurable effects of smoking. Incorrect Answers: A. Bupropion (Wellbutrin, Zyban) is a norepinephrine/dopamine reuptake inhibitor that also acts as a nicotinic acetylcholine antagonist. B. Nicotine, the addictive substance found in cigarettes, is a nicotine receptor agonist. Nicotine replacement therapies (gums, patches, etc.) use this route to aid in smoking cessation. D. Dopamine receptor antagonists include neuroleptics as well as antiemetic drugs such as metoclopramide. References:

Answer 161

Correct Answer: D. Health belief model The Health Belief model predicts health behavior with the understanding that a person takes a health action to avoid negative consequences, if the person believes the action prevents negative outcomes. Incorrect Answers: A, B, and C. These options are incorrect. Vital Concepts: The Health Belief model predicts health behavior with the understanding that a person takes a health action to avoid negative consequences, if the person believes the action prevents negative outcomes. References:

Answer 162

Correct Answer: A. Generativity vs. Stagnation This woman is struggling with generativity vs. stagnation, she wishes to be able to give her children more. Although her career has always defined her she is growing and changing with her life shown by the desire to quit working to provide more of her time to her children. Intimacy vs. isolation has to do with committed relationships and the capacity to love which does not pertain to her. (C) (D) These are not developmental tasks developed by Erikson. Incorrect Answers: B. This is related to committed relationships and the capacity to love, which doesn’t apply to this woman, and she has a good home life and family. C, D. These aren't developmental tasks developed by Erikson. References:

Answer 163

Correct Answer: C. The claim will be covered Occurrence-based malpractice coverage is a type of malpractice insurance that is not affected by retirement or job changes. Under this type of policy, all claims derived from the period the policy is in effect will be covered. If she had a claims-made policy, the claim would not be covered after she left that employment and policy, unless she purchased “tail coverage.” A nurse can be sued in another state over actions that took place in that state. Incorrect Answers: A. The claim will be covered B. Tail coverage isn't needed for those with occurrence-based coverage D. A nurse can be sued in another state over actions that took place in that state Vital Concepts: Occurrence-based malpractice coverage is a type of malpractice insurance that is not affected by retirement or job changes. Under this type of policy, all claims derived from the period the policy is in effect will be covered. If she had a claims-made policy, the claim would not be covered after she left that employment and policy, unless she purchased “tail coverage.” A nurse can be sued in another state over actions that took place in that state. References:

Answer 164

Correct Answer: A. Integrity vs. Despair This patient is struggling with integrity vs. despair which is evidenced by her anger, bitterness, regret, and alienation. Incorrect Answers: B. A patient struggling with this would be emotionally isolated. However, this stage doesn't explain the patient's anger, bitterness, and regret. C. This relates to work and family. It doesn't relate to this patient's current state. D. This relates to learning the pleasure of applying oneself to tasks. It doesn't relate to this patient's current state. Vital Concept: Fulfillment of integrity vs despair is evidenced by comfort with life, willingness to face death, insight and balanced perspective on life’s events. Those struggling with the developmental task of Intimacy vs. isolation results in emotional isolation, this is not the correct answer because of the other attributes of this patient including, anger, bitterness, and regret. Choices C and D are not appropriate for this patient. References:

Answer 165

Correct Answer: B. Recidivism commonly occurs in the termination process of therapy and she should be allowed to express her thoughts and feelings while continuing your plan to terminate as previously discussed. This is a common occurrence due to the bond and trust one may have built with the therapist. This is also a time where the patient is challenged to use the new skills they have developed in treatment. The literature states some psychotherapist use PRN follow-ups every 3 months and some state this may be harmful. Overall, this is not a reason to stop the discharge plan. Incorrect Answers: A. This answer is incorrect because it is common for patients to develop these feelings at the end of therapy, especially if there were dependent/abandonment issues. Extending the therapy will just continue this cyclic process. The risk of suicide may always be there with her history, so it is important not to let this be the sole reason to change her discharge plan. C. EDMR has nothing to do with this question. This is a treatment usually used for PTSD and has a set number of visits. The patient developing these symptoms at the end of treatment is not uncommon and could be part of the natural termination process. D. Nothing in this question reveals and clues that this may be her diagnosis. Although these patients may be a challenge to work with, this would not be a reason to change her treatment and discharge plan. References:

Answer 166

Correct Answer: B. Formal operations Billy is demonstrating abstract thinking by making analogies which is developed during Piaget’s formal operations stage. Preoperational, Sensorimotor, and concrete operations, are not applicable in this scenario. Incorrect Answers: A. This is ages 2-7 and involves perception-dominated thinking; he's too old for this stage. C. This is ages 0-2 years and involves interacting with the environment; he's too old for this stage. D. This is ages 7-11.5 years and involves only applying logical reasoning to objects that are real or can be seen; he's too old for this stage. References:

Answer 167

Correct Answer: C. The physician must be present in the physical location for immediate assistance to allow the physician to bill for NP care under “incident to” model Medicaid may pay from 75% to 100% of the physician fee with additional payment for rural areas. Medicare will only reimburse a physician practice 85% of the physician fee if an NP bills using her own Medicare provider ID. As a result, this encourages the use of billing “incident to” for NP services, for which the practice will receive 100% of the physician fee schedule. However, billing “incident to” has several requirements, including the provision that services must be initiated and performed under physician supervision and the physician must be present in the physical location for immediate assistance. This type of billing system does not allow tracking and evaluation of NP care and it limits the public’s right to see quality care indicators for providers who actually deliver the care. Incorrect Answers: A. B. Billing this way doesn't allow NP care evaluation D. Medicaid pays 75-100% Vital Concepts: Medicaid may pay from 75% to 100% of the physician fee with additional payment for rural areas. Medicare will only reimburse a physician practice 85% of the physician fee if an NP bills using her own Medicare provider ID. As a result, this encourages the use of billing “incident to” for NP services, for which the practice will receive 100% of the physician fee schedule. References:

Answer 168

Correct Answer: C. 22-25% The lifetime suicide attempt rate in patients with body dysmorphic disorder has been estimated at 25%. The annual suicide attempt rate is approximately 3-12 times greater than in the general population. Incorrect Answers: A. Patients with body dysmorphic disorder do not attempt suicide at a rate of 2-5% annually. B. Patients with body dysmorphic disorder do not attempt suicide at a rate of 12-15% annually. D. Patients with body dysmorphic disorder do not attempt suicide at a rate of 32-35% annually. Vital Concept: Patients with body dysmorphic disorder are at increased risk for suicidal ideations and attempts, often attempting suicide multiple times. References:

Answer 169

Correct Answer: D. Cyclophosphamide and carbamazepine Both Cyclophosphamide and carbamazepine auto-induce their own respective metabolisms. Other drugs that induce their own metabolism are theophylline, ifosfamide, and aminoglutethimide. Incorrect Answers: A. Cyclophosphamide is an auto-inducer, but valproic acid is an INHIBITOR. B. Although rifampicin is an inducer, but it is not an auto-inducer. Isoniazid is an INHIBITOR. C. Although carbamazepine is an auto-inducer, ethanol is not auto-inducer. Remember in chronic dosing of ethanol = induction, but in acute, binge doses = inhibition. References:

Answer 170

Correct Answer: D. Ask the parents and teachers to complete the Vanderbilt ADHD Rating Scale Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that appears in early childhood. It is characterized by inattention, hyperactivity, and impulsivity that is developmentally abnormal. Boys are more commonly diagnosed than girls. There is no single test that can establish the diagnosis of ADHD. Information should be gathered directly from both parents and teachers on how the child’s behavior impacts the ability to function at home, at school, and with other children. The inattentive, hyperactive, and impulsive behaviors must cause significant impairment in two separate environments to make a diagnosis. Validated rating measures such as the Conners-3 and the Vanderbilt ADHD Rating Scale (VARS) can help make the diagnosis. Incorrect Answers: A. A complete blood count (CBC) is a good screening test for anemia. Anemia should be in the differential diagnosis of disorders that can cause symptoms like ADHD. No specific values on the CBC would confirm a diagnosis of ADHD. B. Interviewing the parents is a great first step toward diagnosing ADHD, but input is needed from multiple adults in a minimum of two situations to confirm the diagnosis. C. This child is more likely to have ADHD if a parent or sibling also has the diagnosis. There is a high concordance of ADHD in identical twins, and multiple different genes contribute to the disorder. There is no specific genetic test currently for ADHD. Vital Concept: ADHD is characterized by the onset of limited attention span or impulse control that starts before the age of 12 and last for more than 6 months. There must be impairment in more than one setting (e.g., at school and at home). Symptoms often persist into adulthood. Treatment includes stimulant medications or non-stimulant medications and cognitive behavioral therapy. References:

Answer 171

Correct Answer: C. The information can't be used in the case. You cannot ethically use any information obtained from your patient in the legal case. The information was discussed confidentially, and using or acquiring information for such use is unethical. Incorrect Answers: A, B. and D. You can't ethically use any information obtained from your patient in the legal case. This information was disclosed confidentially, and using or acquiring information for your personal use in the lawsuit is unethical.

Answer 172

Correct Answer: D. Routine random audits should be conducted to identify potentially inappropriate access Compliance with hospital privacy regulations and policies should be enforced by routine random audits. If potentially inappropriate access is identified, an EMR system can identify the name of the person who gained access, and information about the time, date, screens, and duration of access, which can determine if the access was an error or if it was an unauthorized review of protected health information. Incorrect Answers: A. Patients have the right to a log of all individuals who have accessed their personal health record. B. Although the use of EMR by creates special issues with respect to privacy, there are safeguards to limit the content and recipients of released data, such as a telefax report. C. Legal action can be the outcome of any privacy and confidentiality violations, so in addition to creating a policy, the facility must be diligent in enforcement of the policy through monitoring and follow-up. Vital Concepts: Health care providers should only be accessing necessary information about their patients in order to continue providing care for them. Any additional access can be potentially inappropriate and in violation of the patient's privacy.

Answer 173

Correct Answer: C. 1 year Symptoms must be present for a year in children and adolescents, as opposed to two years in adults. According to the DSM-5-TR, symptoms in adults must persist for 24 months or more (12 months in children and adolescents) and must remain present during at least half of that time; there are no asymptomatic periods that last longer than 8 consecutive weeks. About 15-50% of these patients later develop bipolar disorder (I or II). Incorrect Answers: A. Symptoms must be present for 12 months, not one month, in children and adolescents to be diagnosed with cyclothymic disorder. B. Symptoms must be present for 12 months, not six months, in children and adolescents to be diagnosed with cyclothymic disorder. D. Symptoms must be present for one year in children and adolescents to be diagnosed with cyclothymic disorder, as opposed to two years in adults. Vital Concept: The minimum duration of symptoms in children and adolescents to meet the diagnostic criteria for cyclothymic disorder is 12 months.

Answer 174

Correct Answer: B. Semiformal Semiformal support systems provide physical and emotional assistance. They include organizations and agencies in the community that provide goods and services. Incorrect Answers: A. Formal support is regulated by laws or statutes. Formal social support is provided by social workers, financial support by Social Security, and medical support provided by Medicare. C and D. Informal support derive from the social network, includes family, and friends, but only those who actually provide assistance in some way. Vital Concept: Semiformal support systems provide physical and emotional assistance. They include organizations and agencies in the community that provide goods and services.

Answer 175

Correct Answer: C. Killing neighborhood cats Cruelty to or killing of animals is strongly tied to the diagnosis of conduct disorder. Childhood animal cruelty is one of the earliest and most specific symptoms of conduct disorder. Other criteria include other aggression towards animals or people, destruction of property, deceitfulness or theft, and serious rule/law violations. Many children diagnosed with childhood-onset conduct disorder also have comorbid ADHD or other neurodevelopmental diagnoses, and those with these comorbidities have poorer outcomes. Patients diagnosed in childhood as opposed to adolescence are more likely to have persistent conduct disorder into adulthood. Substance misuse and suicidal ideation are also more common in those diagnosed with conduct disorder. The prevalence of conduct disorder ranges from 2-10% (median is 4%). Risk factors include neglect, physical or sexual abuse, large family size, parental criminality, and a family history of substance use disorders. Incorrect Answers: A. While familial arguments are unpleasant, they don't support a conduct disorder diagnosis in a child. B. While disrespectful behavior is rude, it doesn't support a conduct disorder diagnosis in a child. D. Bullying classmates, while unkind, does not rise to the level of criminality or cruelty to support a conduct disorder diagnosis in a child. Vital Concept: Conduct disorder is a diagnosis provided in children and adolescents and is defined by incessant or repetitive actions that infringe on the fundamental rights of others or go against what is considered a societal norm or established law. Animal cruelty in childhood is an early and specific symptom of conduct disorder.

Answer 176

Correct Answer: C. Ketoconazole Drugs that induce CYP3A4 enzyme are carbamazepine, dexamethasone, ethosuximide, glucocorticoids, griseofulvin, phenytoin, primidone, progesterone, rifabutin, rifampin, nafcillin, nelfinavir, nevirapine, oxcarbazepine, phenobarbital, phenylbutazone, rofecoxib (mild), St. John’s wort, sulfadimidine, sulfinpyrazone, and troglitazone. Drugs that inhibit CYP3A4 enzyme are amiodarone, anastrozole, azithromycin, cannabinoids, cimetidine, clarithromycin, clotrimazole, cyclosporine, danazol, delavirdine, diethyldithiocarbamate, diltiazem, dirithromycin, disulfiram, entacapone (high dose), erythromycin, ethinyl estradiol, fluconazole, fluoxetine, fluvoxamine, gestodene, grapefruit juice, indinavir, isoniazid, ketoconazole, metronidazole, mibefradil, miconazole, nefazodone, nelfinavir, nevirapine, norfloxacin, norfluoxetine, omeprazole, oxiconazole, paroxetine (weak), propoxyphene, quinidine, quinine, quinupristin and dalfopristin, ranitidine, ritonavir, saquinavir, sertindole, sertraline, troglitazone, troleandomycin, and valproic acid. Incorrect Answers: A. B. and D. These drugs are all CYP3A4 inducers.

Answer 177

Correct Answer: D. Ketamine - cat valium Ketamine is commonly referred to on the street as "cat valium,” "special K," "vitamin K," "kit kat," and “honey oil.” Ketamine is a derivative of PCP that was first developed in 1965. It is less potent and shorter-acting and is used as a dissociative anesthetic in humans. Incorrect Answers: A. MDMA (methylenedioxymethamphetamine) is referred as “ecstasy,” “Adam,” “club drug,” “disco biscuits,” and “love drug.” B. Cocaine is referred as “crack,” “coca,” “freeze girl” and “happy dust” on the streets. Crack is the hardened form of cocaine. C. Methamphetamine is referred as “crank,” “crystal,” “ice,” “speed”, and “crystal meth” on the streets.

Answer 178

Correct Answer: D. A recovery-oriented mental health system In 2003, a recovery-oriented mental health system was published in the landmark report: Achieving the Promise: Transforming Mental Health Care in America. The report was an Executive Summary with the vision statement: “We envision a future when everyone with a mental illness will recover, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports-essentials for living, working, learning, and participating fully in the community”. Incorrect Answers: A. Quality care for individuals with mental and substance abuse disorders is addressed in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equal Act of 2008. B. Expanded healthcare coverage is the goal of the Patient Protection and Affordable Care Act and was signed into law in 2010. C. In 2010, The Substance Abuse and Mental Health Services Administration contributed mental health initiatives in support of the PPACA, to promote awareness, acceptance and adaptation of recovery-based practices; however, this was in support of the recovery model, not the initial sensitization.

Answer 179

Correct Answer: C. Discontinue treatment For discontinuation of therapy that does not result in an immediate or imminent threat to the life of a minor, the caregivers’ wishes should be respected. The caregivers of a child have the right to refuse treatment, including treatments strongly recommended by the healthcare provider, unless refusal of treatment results in a serious and immediate risk to the life or health of the child. In this case, although it would be inappropriate (and illegal) to try to force the use of antiepileptic drugs, it would be appropriate to intervene if the child was in status epilepticus, which is an immediate threat. Incorrect Answers: A. This case is a good example of the difference between "immediate threat to life and limb" and a refusal of maintenance therapy to prevent seizures at some distant point in the future. Given that there is not an immediate risk to the patient, obtaining a court order would not be appropriate. B. There must be an immediately compelling reason to override the wishes of the patient and/or the patient’s caregivers. In this situation, there is not imminent danger to the patient so reporting the caregivers to child protective services would not be appropriate. D. Although a healthcare provider has the right to terminate a relationship with a patient, they must not abandon the patient. In general, the patient and/or parents must be given adequate opportunity to arrange a continuation of care with another healthcare provider. Vital Concept: For discontinuation of therapy that does not result in an immediate or imminent threat to the life of a minor, the parents’ wishes should be respected. The parents of a young child have the right to refuse treatment, including treatments strongly recommended by the healthcare provider, unless refusal of treatment results in a serious and immediate risk to the life or health of the child. In this case, although it would be inappropriate (and illegal) to try to force the use of antiepileptic drugs, it would be appropriate to intervene if the child was in status epilepticus, which is an immediate threat.

Answer 180

Correct Answer: B. Reflective practice Reflective practice is the process of thinking through an experience to develop a greater understanding of the link between theory and practice by consideration of the process of thinking, including preconceptions, beliefs, and evidence underlying the thought process. Incorrect Answers: A. Modeled learning is a form of non-reflective learning in which the practitioner does not reflexively consider their actions or their knowledge or the patient, but imitates the actions carried out by the teacher or supervisor. C. Espoused theories are theories enshrined within protocols and procedures of how practice should proceed, as opposed to theories in use, developed from application and reflection. D. Transitional space refers to a space in which a practitioner is able to explore, develop, and grow, using reflective practices. Vital Concepts: Reflective practice is the process of thinking through an experience to develop a greater understanding of the link between theory and practice by consideration of the process of thinking, including preconceptions, beliefs, and evidence underlying the thought process.

Answer 181

Correct Answer: B. 5-HT1D and 5-HT1B agonist Sumatriptan is a 5-HT1D and 5-HT1B agonist. Incorrect Answers: A. Sumatriptan is a 5-HT1D, not 5-HT1A, agonist. It's also a 5-HT1B agonist. C. D. Aripiprazole is a 5-HT2C agonist and a weak partial agonist at 5-HT7.

Answer 182

Correct Answer: C. 1 month Several criteria must be met to receive a diagnosis of acute stress disorder. They include: The symptoms are related to a prior experience of potential or genuine fatality, severe harm, or sexual assault. The patient may have been a participant, victim, or witness/bystander. Alternately, in the case of violent acts, the patient may have learned about a loved one’s experience as a victim or participant or had recurrent professional experiences with unsettling or unpleasant details (e.g., law enforcement officers, social workers, first responders, etc.). Professional incidents typically occur first-hand, not through images, videos, etc. The patient must endorse the onset of symptoms following the initial traumatizing experience, with at least nine of the following potential effects categorized as follows: · Affective/mood a consistent paucity of desirable feelings (e.g., joy, love, contentment) · Intrusive repetitious nightmares associated with the initial traumatizing experience significant psychological reactions or physical responses to environmental or inner triggers associated with the initial traumatizing experience recollections of the initial traumatizing experience that are repeated, compulsory, and anguishing/unpleasant (in older pediatric patients, this may include play scenarios resembling the experience in some aspect) flashbacks, during which the patient temporarily mentally disconnects from their current environment and reality and has the sensation that the initial traumatizing experience is happening again · Dissociative a lack of memory regarding a crucial portion of the initial traumatizing experience a distorted perception of oneself or one’s environment (e.g., a lack of attachment to their own body or thoughts as if watching from a distance, belief that the patient’s experienced environment is not real) · Arousal cantankerous disposition with frequent gratuitous fits of rage exhibited as loud outbursts or outwardly aggressive behavior challenges maintaining focus poor ability to initiate or maintain adequate sleep behavior that is overly cautious and alert extreme edginess or jumpiness · Avoidance Preventing exposure to things (e.g., locations, items, persons) that may provoke thinking, feeling, or remembering the initial traumatizing experience Not allowing oneself to think, feel, or remember the initial traumatizing experience or things related to the experience The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise The symptoms must persist for 3 or more days but not more than 30. For patients with symptoms persisting longer than 30 days, please see the diagnostic criteria for posttraumatic stress disorder (PTSD). Incorrect Answers: A. Symptoms for acute stress disorder are present for at least 3 days and up to a month, not only one week. B. Symptoms for acute stress disorder are present for at least 3 days and up to a month, not only two weeks. D. If symptoms persist for longer than one month (e.g. 6 months) then consider a PTSD diagnosis. Vital Concept: In acute stress disorder, 9 or more symptoms occur for at least 3 days and up to a month after a traumatic experience. If symptoms persist for longer than one month then consider a PTSD diagnosis.

Answer 183

Correct Answer: C. Regression The 8-year-old is showing regression by talking in a baby voice when her mother is breastfeeding the infant. Denial, projection, and repression are not appropriate answers for this question. Incorrect Answers: A. The 8-year-old isn't denying the baby's presence or pretending it doesn't exist. B. The 8-year-old isn't seeking to attribute a quality in themselves to someone else. D. The 8-year-old isn't trying to ignore distressing memories, thoughts, or feelings related to the baby.

Answer 184

Correct Answer: B. Witness who has knowledge about details of a case A fact witness's testimony consists of facts or events as opposed to an expert witness, whose testimony consists of the presentation of an opinion or a diagnosis. Incorrect Answers: A. An expert witness has specialized knowledge and assists a court in making a decision in a case. C. The focus of the best interests of the child standard is to fulfill the basic and developmental needs of the child. D. Privilege is the legal rule that protects certain information from being shared in open court. The individual possesses privilege, not the physician.

Answer 185

Correct Answer: D. Naltrexone is available as once daily oral dosing or once monthly injection. If a patient is not achieving abstinence on oral naltrexone, they may be switched to monthly injectable naltrexone for better adherence. Incorrect Answers: A. Naltrexone may be started while the patient is still drinking. B. Naltrexone is metabolized in the liver and should be avoided in patients with hepatitis or liver failure. C. Acamprosate is taken three times daily, but naltrexone is once daily.

Answer 186

Correct Answer: B. Serotonin syndrome This patient’s symptoms indicate serotonin syndrome, which is characterized by brisk reflexes. NMS is characterized by rigidity. She likely used MDMA (ecstasy) at the party, which resulted in serotonin syndrome. This is a known risk of intoxication with MDMA because the mechanism of action involves the release of serotonin. Incorrect Answers: A. The patient doesn't display the symptoms of high fever, confusion, rigid muscles, variable blood pressure, sweating, and fast heart rate that would raise suspicion of this. C. The patient doesn't display the symptoms of delusions, hallucinations, disorganized speech, disorganized behavior or lack of normal behaviors (the "negative" symptoms, including lack of emotional expression, interest, or speech) that would raise suspicion of this. D. The patient doesn't display the symptoms of headaches, nausea, tremors, anxiety, hallucinations, or seizure that would raise suspicion of this. Incorrect Answers: A. This is characterized by high fever and confusion — neither of which is present C. Serotonin is an amino acid that helps regulate blood pressure, not a condition D. Anxiety, headaches, nausea, or shaking hands would happen if this were the case.

Answer 187

Correct Answer: A. Polydipsia and water intoxication are associated with heavy cigarette use. Polydipsia (water intake > 3L/day) and water intoxication are also associated with high antipsychotic dosages, moderate anticholinergic dosages, and extended hospitalization. Nicotine causes the release of antidiuretic hormone (ADH), which fuels thirst. Up to 70% of people with psychogenic polydipsia are cigarette smokers. Incorrect Answers: B. Polydipsia can occur before antipsychotic medications are used. C. Polydipsia is associated with severe hypernatremia. Polydipsia is associated with severe HYPOnatremia (serum sodium < 130 mmol/L), not hypernatremia. Hyponatremia is also associated with calcium antagonists, diuretics, selective serotonin reuptake-inhibitors, tricyclic antidepressants, and venlafaxine. D. Management involves sodium restriction and water replacement to prevent seizures. Polydipsia is associated with severe hyponatremia requiring sodium replacement not restriction. Polydipsia is a result of water intoxication and management would include water restriction, not replacement. Untreated polydipsia and water intoxication results in severe hyponatremia and associated with cerebral edema, delirium, seizures, coma, and death. Medical differential diagnoses of polydipsia include cancer, diabetes mellitus, diabetes insipidus, end-stage renal disease, hypocalcemia, hypokalemia, and lung disease.

Answer 188

Correct Answer: A. Acute alcohol ingestion may be the culprit Acute alcohol ingestion is known to inhibit CYP450 activity, which leads to substrate accumulation and an increase in the incidence of the adverse effect profile of CYP450-dependent drugs. Topiramate is one such drug, and one of its side effects is kidney stone formation. It is likely that the patient may have acutely increased his alcohol intake, leading to CYP450 inhibiting and topiramate accumulation. Consequently, the patient developed kidney stones. Incorrect Answers: B. St. John’s wort induces CYP450 activity, thus leading to increased clearance of Topiramate, and decreases the chance of developing kidney stones. This is not the case with our patient in this clinical vignette. C. D. Phenytoin, Phenobarbital, and Carbamazepine are all anti-epileptics that induce CYP450 activity. Initiating either one would have caused an increase in Topiramate clearance, thus decreasing its concentration in the blood and decreasing the adverse effect profile. This patient developed kidney stones due to a sudden increase in Topiramate concentration.

Answer 189

Correct Answer: C. Yohimbine The adrenergic agonist yohimbine has been reported to help SSRI-induced sexual dysfunction. Unfortunately, yohimbine is also an anxiogenic for some patients, and this effect tends to be counterproductive. A study also showed that switching to or adding bupropion at 75-150mg/day to the SSRI regimen was useful in some cases. However, a dose of 300mg or more is also effective. Incorrect Answers: A. Cyproheptadine at dosages of 4-12mg/day may reverse some dysfunction, but unfortunately, cyproheptadine may also reverse the antidepressant or anti-obsessive effects of SSRIs. B. The use of sildenafil (Viagra) has been more effective than placebo in men with SSRI-induced sexual dysfunction. Sildenafil has been reported to increase overall sexual satisfaction in both men and women.

Answer 190

Correct Answer: B. To contribute information and experience Each team member responsible for the work involved in improving a specific process or outcome has the responsibility of focusing on the team objective, contributing information, sharing experiences, perspective, and ideas, and making decisions to develop an improvement plan. Team members should be involved in the process that is being improved. The team leader facilitates team members through a process of building consensus for decisions. The leader should have a positive attitude and enthusiasm, confidence in the team’s work, appreciation for the contribution of all team members, and logical, analytic thinking. A facilitator often assists the team leader, but is not a member of the team. The facilitator is a person outside the group who serves as a coach or consultant and assists the team leader to provide instruction on use of tools and methods in the QI process. Facilitators should not be involved in the process the team is working to improve, but should be selected on the basis of analytical abilities and problem-solving skills. They should stay objective and neutral, should help coordinate ideas and introduce problem-solving tools; guide the team in data collection; and help the team follow a logical problem-solving model while staying on track. They are uninvolved in content but help facilitate the process. Incorrect Answers: A. Team members should be involved in the process that's being improved (not objective/neutral) C. A facilitator outside the team provides analytical abilities and problem-solving skills D. The facilitator should introduce problem-solving tools Vital Concepts: Each team member responsible for the work involved in improving a specific process or outcome has the responsibility of focusing on the team objective, contributing information, sharing experiences, perspective, and ideas, and making decisions to develop an improvement plan. Team members should be involved in the process that is being improved. The team leader facilitates team members through a process of building consensus for decisions.

Answer 191

Correct Answer: D. Lorazepam Lorazepam is a benzodiazepine that can be used for alcohol detox. In patients requiring alcohol detox who have evidence of liver disease or impairment, as evidenced in this patient by his elevated liver transaminases, lorazepam would be a good option. Lorazepam metabolism does not produce active compounds, and it is cleared from the patient’s system more rapidly than other benzodiazepines, making it a preferable choice in patients with liver dysfunction. The other medications are benzodiazepines and can protect against alcohol withdrawal symptoms; however, in patients with liver dysfunction, lorazepam is preferred for alcohol detox. Incorrect Answers: A, B, and C. These benzodiazepine medications can protect against alcohol withdrawal syndromes. However, for patients with liver dysfunction, lorazepam is preferred for alcohol detox.

Answer 192

Correct Answer: B. At least 2 people should be present, 1 to interview the mother and the other to observe interactions. It is suggested that 2 people are present to achieve a more objective view. Incorrect Answers: A. and C. Restraining the mother or taking the child away could cause the woman to panic and leave. It is important to keep the woman calm so that the true diagnosis can be reached and the child can be protected. D. Two people should be present to give more insight into the situation.

Answer 193

Correct Answer: C. Can be done concurrently or retrospectively The timing of the PI process will depend on when the issue is identified. Therefore, the initiative can be carried out concurrently or retrospectively. Incorrect Answers: A. The PI project should include all of the people involved in the process, including Quality, unit managers, and clinicians. It is important that all groups participate to ensure buy-in on the end product. B. Unless specific patients will be identified, IRB approval is NOT required. Since PI results are meant to improve internal processes, this is rarely required. D. Typically, there is no fixed endpoint. Instead, processes are implemented and tested, issues with the new process are identified, and new processes are put into place. This makes the PI process a continuous, cyclical process. Vital Concept: The timing of the PI process will depend on when the issue is identified. Therefore, the initiative can be carried out concurrently or retrospectively.

Answer 194

Correct Answer: B. Reaction formation Reaction-formation involves the conversion of unconscious wishes into their opposites. The behavior is the opposite of what one really desires or feels. Incorrect Answers: A. Identification is the unconscious modeling of one’s self on another person’s character and behavior. C. Repression involves avoiding pleasurable instincts or drives due to the threat of suffering if the drive is satisfied. D. Displacement is the shift of a sexual or aggressive drive to a more acceptable target.

Answer 195

Correct Answer: D. The team leader should summarize key decisions and actions at the close of the team meeting Before the close of each team meeting, the team leader should summarize key decisions and actions taken, and action items that need to be taken. Time, place, and agenda for next meeting should be addressed as well. Incorrect Answers: A. During the initial phases of team development, typical behaviors include being polite and masking feelings of reluctance or insecurity. Groups of individuals who initially gather as a team often need time and effort to gain acceptance and build trust, which will allow progression to team functioning. Team members may be cautious in communication until they gain a clearer understanding of their roles on the team and a sense of trust with other team members. Trust-building activities include asking team members to share something about themselves or asking members to share what strengths they bring to the team. B. In the first few meetings, a set of ground rules that govern how meetings are run and how members interact with each other should be established, and the rules can be changed as the work of the team progresses and new issues arise. Some issues addressed in ground rules include attendance; meeting location, time and frequency; expectation of participation in the meeting, including basic conversational courtesy; and expectation for timely completion of any tasks that are assigned for completion outside of the meeting time. C. Productive meetings are ideally team meetings that last for 30 minutes to one hour weekly or every other week and are scheduled at a regular day and time. Meetings should have an agenda and should start and end on time. Vital Concepts: Before the close of each team meeting, the team leader should summarize key decisions and actions taken, and action items that need to be taken. Time, place, and agenda for next meeting should be addressed as well.

Answer 196

Correct Answer: A. Protriptyline Protriptyline does not cause sedation like the other listed drugs. Other sedating antidepressants include imipramine, trazodone, nefazodone, mirtazapine, and amoxapine. Unique among the TCAs, protriptyline tends to be energizing instead of sedating and is sometimes used for narcolepsy to achieve a wakefulness-promoting effect. Incorrect Answers: B, C, and D. These antidepressants all have sedation effects.

Answer 197

Correct Answer: C. Expression of understanding Expression of understanding helps to assure the patient that the therapist is listening (e.g. seeking clarification when a patient’s statement is unclear). Incorrect Answers: A. Expression of interest, such as accurately recalling details from previous sessions, helps to build trust B. Expression of empathy, which could involve agreeing with the patient's feelings, is a way to assure the patient that the patient is listening D. Maximization is a cognitive error where a part of a situation is picked out and exaggerated; it's not a technique for building a therapeutic alliance

Answer 198

Correct Answer: D. 6 To qualify for the “severe” subclassification of a substance use disorder, 6 of the 11 criteria must be met. A minimum of 2-3 criteria must be present for "mild," and 4-5 criteria are required for "moderate" substance use disorders. The criteria include: A destructive repetition or habit of ingesting/administering an intoxicating substance that causes substantial anguish or drastically affects the patient’s ability to function professionally, socially, or otherwise. These effects are evidenced by two or more of the conditions listed here within one year: · ineffective attempts to reduce the use of the substance or a wish to do so · an intense need or impulse to use the substance · a persistent ingestion/administration of the substance even though they have experienced repeated relational challenges (i.e., with surrounding friends and family members) related to its use · a persistent ingestion/administration of the substance in environments where it is unsafe · the development of tolerance, which is a gradual reduction in the physical impact/effect of a given substance when administered at a consistent dose or amount, requiring an increase in dose or amount to achieve the prior effect · a persistent ingestion/administration of the substance for a longer time and at a higher dose or amount than planned · a considerable investment of time related to the substance, procuring it, ingesting/administering it, or recuperating from the consequences of its use. · a persistent ingestion/administration of the substance, interfering with significant responsibilities and commitments (i.e., academic, professional, or familial) · a decrease in attendance or participation in significant events at work, at home, or with friends/family due to the use of the substance · a persistent ingestion/administration of the substance even though they are aware of a significant challenge directly related to the substance use · the development of withdrawal as evidenced by the signs and symptoms of withdrawal syndrome for that particular substance or the use of the substance to prevent these symptoms. This disorder may be graded as mild (two or three symptoms), moderate (four or five), or severe (at least six symptoms). The disorder may be considered in early (3 or more months) or sustained (12 or more months) remission when all of the above symptoms have resolved, except for an intense need or impulse to use the substance. This may also be qualified in a controlled environment if the patient is currently without access to the substance. Incorrect Answers: A. 2-3 is considered mild. B. 2-3 is considered "mild" classification C. Meeting 4-5 criteria meets the "moderate" classification Vital Concept: Substance use disorders are defined by issues with impaired control of use, risky use, tolerance and withdrawal, and social impairments. The frequency and intensity of substance use are not independent criteria for diagnosing a substance use disorder. Meeting 6 of the 11 criteria suggests that the condition is severe.

Answer 199

Correct Answer: A. Workarounds Workarounds occur when clinicians encounter problems in delivering care and devise a quick way to solve the problem. Workarounds leave systems problems untreated and may cause errors. An example would be bypassing a safety system like the barcoding procedure for medication because it is perceived to have too many steps. Incorrect Answers: B. Having the patient's family involved may improve care. C. Having observers for procedures is an important part of medical teaching and doesn't affect safety. D. Updated technology should improve patient safety. Vital Concepts: Workarounds occur when clinicians encounter problems in delivering care and devise a quick way to solve the problem. Workarounds leave systems problems untreated and may cause errors. An example would be bypassing a safety system like the barcoding procedure for medication because it is perceived to have too many steps. References:

Answer 200

Correct Answer: B. Nurse-managed health centers (NMHC) were funded in the first year The Patient Protection and Affordable Care Act (PPACA) was passed in 2010 in an attempt to reform the health care system in the United States, with an emphasis on effectiveness, access, and care quality. With full implementation, the demand for primary care was expected to increase, offering an opportunity for nurse practitioners to contribute significantly to delivery of primary care services. The PPACA legislation created more leadership opportunities for nurse practitioners, in part by provision of funding of $50 million for Nurse-Managed Health Centers in the first year of the project. However, although there is increasing support and leadership opportunities for nurse practitioners, there was no mandate for 100% reimbursement by Medicare for advanced nurse practitioners. Medicare was to reimburse a 10% bonus for services through January 1, 2016, for NPs practicing in professional shortage areas. Incorrect Answers: A. There was NO mandate for 100% reimbursement by Medicare for advanced nurse practitioners. C. Medicare was to reimburse a 10% bonus for services through January 1, 2016, for NPs practicing in professional shortage areas, not 15%. D. With full implementation of the PPACA, the demand for primary care was expected to increase, not decrease. Vital Concept: The Patient Protection and Affordable Care Act (PPACA) was passed in 2010 and created more leadership opportunities for nurse practitioners, in part by provision of funding of $50 million for Nurse-Managed Health Centers in the first year of the project. References:

Answer 201

Correct Answer: B. Withdrawal syndrome following abrupt discontinuation of TCA results from cholinergic rebound. TCAs can cause withdrawal syndrome following abrupt discontinuation. This is the result of cholinergic rebound. Incorrect Answers: A. Quinidine also prolongs cardiac intervals. When taken concomitantly with a TCA, it can result in significant cardiac interval prolongation. Serotonin syndrome occurs when SSRIs are used in combination with other pro-serotonergic agents such as MAOIs and TCAs. This syndrome includes confusion, agitation, neuromuscular excitability, and seizures. C. Withdrawal syndrome associated with abrupt discontinuation of TCAs includes malaise, nausea, muscle aches, chills, diaphoresis, and anxiety. D. Adverse effects of TCA overdose include severe sedation, hypotension, and anticholinergic delirium. References:

Answer 202

Correct Answer: C. Adjustment disorder Head and neck surgery patients frequently (about 1 in 6) get adjustment disorder. This patient's anxiety and frustrations with the surgeons seem to have created a maladaptive response. Adjustment disorder occurs when one develops an emotional or behavioral response to a stressor within 3 months. This response causes either marked distress or impairs functioning. In this patient it was causing marked distress. Incorrect Answers: A. None of the symptoms point toward a brief psychotic episode. Patient does not appear to be experiencing delusions, hallucinations, or disorganized speech/behavior. B. Cocaine withdrawal would likely make this patient irritable and perhaps somewhat depressed. There is no reason to suspect cocaine use from the history. D. The patient's symptoms do not point toward illness anxiety disorder. Somatic symptoms are not typically present in this disorder. The patient is not performing excessive health-related behaviors. Also illness preoccupation has to be present for at least 6 months for a diagnosis of illness anxiety disorder to be made. References:

Answer 203

Correct Answer: A. 4 days According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), a hypomanic episode is a specific stage of consistent and significant alteration in: a mood that is elated, capacious, or cantankerous behavior that is energetic, dynamic, and lively At least three of the following must occur to a substantial level, concurrently with the mood and behavior symptoms described above, and indicate a significant deviation from the patient’s typical comportment (if the mood is cantankerous, four of the following is required) the ability to function on three hours of sleep without feeling tired/fatigued thoughts that move at an accelerated pace without the ability to sustain focus a significant elevation in movement or to become more active, with or without purpose an exaggerated self-regard or concept of self-worth speaking more than baseline or is typical for the individual difficulty focusing due to frequent distractions, either subjective or objective consistent participation in behaviors with an increased risk for negative results or effects A hypomanic episode is defined as lasting 4 or more days, with symptoms obvious nearly all day, every day. The symptoms must affect the patient’s ability to function professionally or socially but do not result in an inpatient admission, and psychosis is NOT present. A hypomanic episode is distinguished from a manic episode in that hypomania does not have any psychotic features. Also, a hypomanic episode is severe enough to cause impairment in social or job functions but does require hospitalization. To make a diagnosis of bipolar II disorder, a single hypomanic episode is not sufficient; the diagnosis requires at least one hypomanic and at least one depressive episode. If a patient has a manic episode, a diagnosis of bipolar I disorder is made. Importantly, a single manic episode is sufficient to make the diagnosis of bipolar I disorder. Incorrect Answers: B. 1 week is the minimum duration of symptoms for diagnosing a manic episode. C. 2 weeks is the minimum duration of symptoms for diagnosing a major depressive episode. D. 4 weeks is the minimum duration of symptoms for diagnosing a delusional disorder. Vital Concept: To diagnose a hypomanic episode the patient must experience symptoms for at least 4 consecutive days. References:

Answer 204

Correct Answer: B. Interpretation An interpretation is a statement made to promote an insight, which is the conscious realization of unconsciousness conflict. Incorrect Answers: A. Exhortation is a therapeutic technique from interpersonal individual psychotherapy. C. A countertransference reaction is the therapist’s reaction to a patient or the patient’s behavior. D. An observation offers a connection between statements or behaviors but does not explain motivation. References:

Answer 205

Correct Answer: D. When selecting changes, use ideas from team members who work within the system, or ideas derived from change theories, brainstorming, or the success of others When implementing a quality improvement strategy and initiating a Plan-Do-Study-Act cycle, it is important to determine what change must be accomplished, who will work toward the goal, and what measures will be necessary to improve the organization. When establishing measures of quality improvement, after the determination of the most useful tools for measurement of change, the same tools should be used throughout each PDSA cycle to ensure continuity. Incorrect Answers: A. When forming the team, it is important to recruit people critical to the success of the project. Leaders should be involved, but each team member’s strengths (and weaknesses) should be identified. The team should be built to meet the specific needs of the organization or the project. B. When setting goals, they should be specific and directed at the affected population. C. When establishing measures, they should be targeted at measurable goals, with deadlines established. All team members should understand the aims and measures of the team. Vital Concepts: When establishing measures of quality improvement, after the determination of the most useful tools for measurement of change, the same tools should be used throughout each PDSA cycle to ensure continuity. References:

Answer 206

Correct Answer: B. Adjustment disorder with depression Adjustment disorder with depression is the most common psychiatric disorder among cancer patients, and up to 50% of all cancer patients have a comorbid psychiatric disorder. This condition often manifests with self-harm. Adjustment disorder occurs within 3 months of a stressor and ceases within 6 months of a stressor ending. Has a change in emotional or behavioral symptoms that are out of proportion to severity of stressor and/or causes impairment. The symptoms should not be better explained by another psychiatric disorder. Specifiers of adjustment disorder include the following: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, unspecified. The specifier "with depressed mood" consists of predominant tearfulness, low mood and hopelessness. Incorrect Answers: A. Major depressive disorder (MDD). This patient's symptoms do not meet criteria for MDD. MDD would involve at least 2 weeks of depressive feelings most days; while she does feel depressed, she has no suicidal ideation reported and has an event that appears to correlate with the focus of symptoms. C. Adjustment disorder with dementia. Dementia is unlikely, as this woman has otherwise normal mentation. Also "with dementia" is not a specifier of adjustment disorder. D. Persistent depressive disorder. Her symptoms have not lasted long enough to qualify as persistent depressive disorder (previously dysthymia), as 2 years duration is needed for this diagnosis. References:

Answer 207

Correct Answer: D. Transitional objects are physical reminders of a mother's presence. Winnicott hypothesized that children choose a transitional object as a physical representation of their mother at a time when they have not yet internalized their mother. Incorrect Answers: A. Transitional objects usually have an association with the mother. B. Transitional objects are usually soft items such as a stuffed animal or blanket that help soothe a toddler. C. Children usually surrender their transitional object by age 5, although there is considerable variation. References:

Answer 208

Correct Answer: A. Fluoxetine Long-acting SSRIs like fluoxetine can decrease symptoms of discontinuation. The other options are shorter-acting SSRIs, which should be tapered over several weeks to decrease symptoms of discontinuation. Incorrect Answers: B, C, and D. These are all shorter-acting SSRIs. They should be tapered over several weeks to decrease symptoms of discontinuation. References:

Answer 209

Correct Answer: C. Plan-do-study-act cycle The plan-do-study-act cycle is a scientific method used in the model by the Institute for Healthcare Improvement to accelerate the process of bringing quality care to patients. Incorrect Answers: A. Meaningful use refers to utilizing electronic health record technology to improve quality, safety, and efficiency and to reduce health disparities. It is intended to engage patients and families and to improve care coordination and public health. B. The scientific method consists of systematic observation, measurement, and experimentation. Using the scientific method, hypotheses are formulated, tested, and modified. D. Reflexive thinking refers to active thinking that involves the use of higher-order thinking skills, which encourages learners to think in both abstract and conceptual terms, apply specific strategies to problems, relate new knowledge to prior understanding, and examine their own thinking, learning strategies, and assumptions. Vital Concepts: The plan-do-study-act cycle is a scientific method used in the model by the Institute for Healthcare Improvement to accelerate the process of bringing quality care to patients. References:

Answer 210

Correct Answer: D. >75% Most patients will relapse within a year, and almost all will relapse within 2 years. Around 80% will relapse by 5 years after antipsychotics are discontinued. Interestingly, a longer treatment period prior to discontinuation does not reduce the relapse rate. Even with re-introduction of antipsychotic treatment after relapse, treatment failure may emerge in up to 1 out of 6 patients. Recent evidence suggests that the very high relapse rates and abrupt re-emergence of psychotic symptoms indicate a reduced threshold for psychotic decompensation once a first episode has occurred. Incorrect Answers: A. B. C. These percentage bands are all too low. Around 80% of schizophrenic patients relapse within five years of discontinuation of treatment following their initial episode. References:

Answer 211

Correct Answer: C. The elderly man should get the treatment he has decided upon An elderly patient who is competent mentally has the right to make decisions on his or her own healthcare preferences. Competence is a legal term, but in practice, if the patient can understand the risks and benefits of a treatment, they can make the decision. This is the ethical principle of autonomy. If a patient is incapacitated mentally, such as a patient in a coma or a patient with dementia, then a surrogate will be designated. An individual may appoint a healthcare surrogate while they are well, in which case that person can make decisions in the patient’s best interests. Incorrect Answers: A. The father is competent his wishes should be respected B. While getting a power of attorney may be useful, and an individual can designate this while well, they don't have to do so D. The father is responsible for this decision, not the daughter Vital Concepts: An elderly patient who is competent mentally has the right to make decisions on his or her own healthcare preferences. Competence is a legal term, but in practice, if the patient can understand the risks and benefits of a treatment, they can make the decision. This is the ethical principle of autonomy. If a patient is incapacitated mentally, such as a patient in a coma or a patient with dementia, then a surrogate will be designated. References:

Answer 212

Correct Answer: B. Use of service Use of service refers to the provision of a service to, on behalf of, or by a group of persons identified by enrollment in a health plan or through use of clinical services. These measures can assess encounters, tests, or interventions that are not supported by evidence for appropriateness of the service for the specified individuals. Incorrect Answers: A. Management quality measures refer to measures that assess administrative activities that are important to health care but not part of a direct interaction between individual patients and health care professionals. C. Efficiency measures are measures of the relationship between a specific level of quality of health care service and the resources used to provide that care, typically the cost of care. D. Patient experience refers to a measure characterized by a patient or enrollee’s report of observations and participation in health care, or any assessment of the resulting change in their health. Vital Concepts: Use of service refers to the provision of a service to, on behalf of, or by a group of persons identified by enrollment in a health plan or through use of clinical services. These measures can assess encounters, tests, or interventions that are not supported by evidence for appropriateness of the service for the specified individuals. References:

Answer 213

Correct Answer: A. The Nurse Practice Act of each state will help define the NP scope of practice based on state legislation The nurse practitioner’s scope of practice represents the full range of practice privileges allowed by certification and licensure. Each state’s Nurse Practice Act will help to define an individual NP’s scope of practice based upon the legislation in that state. Incorrect Answers: B. Standards of practice refer to the clinical aspects of patient care. C. National guidelines for clinical care may be incorporated into the standard of practice for a nurse practitioner. They are often recommendations by government agencies or professional organizations that are made after a review of research and the harms and benefits of a particular treatment. D. NPs have the authority to prescribe Schedule II controlled medications in many states, but other states limit prescribing of controlled substances by NPs or may require cosignature by a collaborating physician. Vital Concepts: The nurse practitioner’s scope of practice represents the full range of practice privileges allowed by certification and licensure. Each state’s Nurse Practice Act will help to define an individual NP’s scope of practice based upon the legislation in that state. References:

Answer 214

Correct Answer: D. Nonneural tissues can be affected. Variant forms of rabies may have a different course, requiring minimal inoculums and causing infection in nonneural tissues. The virus travels inwards from the peripheral nerves to infect the CNS. The time course of the onset of symptoms is dependent on the bite location, inoculum, and host immunity. Once the virus reaches the CNS, the patient will experience physical agitation, episodic confusion, psychosis, and combativeness. Incorrect Answers: A. Paralytic rabies occurs in 20% of patients. B. The more aggressive and rapidly progressing form is furious rabies, and it is determined by psychosis, bizarre behavior, biting, anxiety, agitation, hydrophobia, and autonomic dysfunction. C. Vocal cord paralysis often occurs. References:

Answer 215

Correct Answer: C. Avoidance There are emotional as well as rational reactions to conflict resolution. Emotional reactions include avoidance, competition, and giving up. Rational reactions include accommodation, compromise, and collaboration. The avoidance approach to conflict resolution results in both sides “losing.” The collaborative approach gives greater weight to achieving the goal of optimal workplace results than to effective concerns and results in a win-win situation. Incorrect Answers: A. Avoiding the physician means competition can't be the approach B. Not working with the physician means collaboration isn't the approach D. Not giving in to the physician's contacts means accommodation isn't the approach Vital Concepts: The avoidance approach to conflict resolution results in both sides “losing.” The collaborative approach gives greater weight to achieving the goal of optimal workplace results than to effective concerns and results in a win-win situation. References:

Answer 216

Correct Answer: D. It bypasses the gastric tract, so no need for dietary restriction MAOI users usually need strict dietary guidelines, but because of the delivery system in the patch, the digestive system is bypassed. For doses greater than 9 mg/24 hr, tyramine may need to be avoided in the diet due to limited safety data. Incorrect Answers: A. This route will bypass the GI tract, allowing no limitations at lower doses to food options, unlike the oral tablets. B. It is an MAOI medication and needs to have restrictions on tyramine in the diet is incorrect as the patch bypasses GI tract. C. Higher doses of selegiline patch can be used to treat Parkinson's disease is incorrect. At lower doses, it is considered an MAOB and is used for Parkinson's disease but at higher doses, it acts as an MAOI. References:

Answer 217

Correct Answer: A. Clozapine (Clozaril) The patient is showing frequent relapse due to treatment resistance to medications. Clozapine is an oral atypical antipsychotic that has strong evidence as being helpful for treatment-resistant psychosis. Alternatives include lamotrigine, topiramate, and minocycline. Nonpharmacological options include ECT and repetitive transcranial magnetic stimulation (rTMS). Incorrect Answers: B. This patient has already attempted risperidone orally and IM without success. C. D. Another first-generation antipsychotic is unlikely to be helpful, as haloperidol has been tried twice with poor response. Vital Concept: Treatment-resistant schizophrenia is challenging. Clozapine is the medication that has proven to be most effective in these cases. References:

Answer 218

Correct Answer: D. Role reversal Role reversal is used in some forms of family therapy. Incorrect Answers: A. Grief or complicated bereavement is 1 of the 4 specific problem areas declared by individual interpersonal psychotherapy. B. Role transition is 1 of the 4 specific problem areas declared by individual interpersonal psychotherapy. C. Role dispute is 1 of the 4 specific problem areas declared by individual interpersonal psychotherapy. References:

Answer 219

Correct Answer: D. Fetal alcohol syndrome The key is to identify the facial anomalies in the premaxillary zone, which are characteristic of fetal alcohol syndrome. These anomalies include a flat upper lip, flattened philtrum, and flat midface. Fetal alcohol syndrome can also be associated with multiple other birth defects (cardiac, skeletal, renal, ocular, and auditory), as well as behavioral and learning problems. Incorrect Answers: A. Down syndrome facial features include upslanting palpebral fissures, a suggestion of epicanthal folds, and a flat nasal bridge. B. Williams syndrome facial features include a broad forehead, a short nose with a broad tip, full cheeks, and a wide mouth with full lips. C. Prader-Willi syndrome facial features include a narrow forehead, almond-shaped eyes, and a triangular mouth. Vital Concept: The physical and facial features described here are characteristic of fetal alcohol syndrome, which classically presents with short palpebral fissures, thin vermillion border, and smooth philtrum. References:

Answer 220

Correct Answer: A. Risperidone The latest studies have found no increase in the risk of typical and atypical antipsychotics with any form of birth defects, except for risperidone. The small increase in risk for risperidone should be studied further. There is a likely possibility that this increase in risk is simply the result of chance alone and will require confirmation. Typical and atypical antipsychotics may be used in pregnancy, and withdrawing these medications during this period is not necessary. Incorrect Answers: B, C, and D. The latest studies have found that these are all safe to use in pregnant women. References:

Answer 221

Correct Answer: C. Inform the patient in writing that care will be provided only until an alternative provider is identified. After accepting a patient into a medical practice, healthcare providers are under legal and ethical obligation to provide services to the patient as long as the patient requires those services. If circumstances render the healthcare provider unable to continue the relationship, he or she must give the patient reasonable notice and sufficient opportunity to make alternative arrangements for care. Failure to pay a bill does not end the healthcare provider-patient relationship, which is based on fiduciary responsibility, not financial responsibility. Written notice should be given, preferably by certified mail, with a brief explanation for termination of the relationship and an agreement to continue to provide treatment and access to services for a reasonable length of time (30 days) to allow the patient to secure care from another provider. The healthcare provider should also provide resources to help the patient locate another healthcare provider and offer to transfer the patient’s medical records after execution of a signed authorization. Incorrect Answers: A. and B. The patient needs to be given adequate notice and opportunity to make alternate arrangements for care --- so these aren't viable in the current situation. D. False; the provider can terminate the relationship in writing. Vital Concepts: After accepting a patient into medical practice, healthcare providers are under legal and ethical obligation to provide services to the patient as long as the patient requires those services. If circumstances render the healthcare provider unable to continue the relationship, he or she must give the patient reasonable notice and sufficient opportunity to make alternative arrangements for care. Failure to pay a bill does not end the healthcare provider-patient relationship, which is based on fiduciary responsibility, not financial responsibility. References:

Answer 222

Correct Answer: D. Bupropion is often used for patients with ADHD and other comorbidities. Bupropion has been studied in small groups of adolescents with ADHD and substance use disorders, nicotine dependence, conduct disorder, and depression. Incorrect Answers: A. Bupropion is a unicyclic aminoketone and an antidepressant. It is also used in smoking cessation. B. Bupropion modulates both norepinephrine and dopamine. C. Bupropion is associated with a higher rate of drug-induced seizures than other antidepressants. References:

Answer 223

Correct Answer: C. Advocacy offers the nurse practitioner the chance to have broader control over patient care and outcomes. Nurses and NPs are often aware of the challenges faced by patients and providers in the quest for quality healthcare and improved outcomes. Issues that nurses often see include problems with access to services, health disparities, patient safety and satisfaction, and clinical outcomes. When NPs choose to become a policy advocate for change, they may be required to move out of their comfort zone of their practice area. However, this element of professional practice can reward them with the opportunity to make a positive change and participate in the creation of a better healthcare system. Incorrect Answers: A. Political advocacy often requires that nurse practitioners move out of their comfort zone and look beyond their own patients and their own organization. B. Nurse practitioners often find political advocacy adds a new dimension to their professional identities. The ANA states that advocacy is "a pillar of nursing". D. Nurse practitioners may become involved in political advocacy for change that will result in better outcomes but should be aware that change often presents challenges. The nurse practitioner should approach any potential conflict thoughtfully and should communicate honestly within the healthcare organization. Vital Concept: The ANA considers legislative and political advocacy "a pillar of nursing" and is no less important than advocating for a patient. References:

Answer 224

Correct Answer: B. Releasing information to a patient’s spouse Patient confidentiality is breached when medical information is given to any person, including a spouse, without the patient's permission. Patient consent is not required to release medical information to a health plan or insurance company that is paying for medical care; a third party or business associated hired by the insurance company or doctor’s office to assist in billing or collections; collection agencies for unpaid bills; health care operations; victims of abuse, neglect, or domestic violence; required reporting; legal subpoenas. Incorrect Answers: A. Patient consent is not required to release medical information in response to a legal subpoena. C. Patient consent is not required to release medical information to a health department for purposes of required reporting. D. Patient consent is not required to release medical information to a health plan or insurance company that is paying for medical care. Vital Concept: Patient consent is not required to release medical information to a health plan or insurance company that is paying for medical care References:

Answer 225

Correct Answer: D. OCD Use of quetiapine to treat OCD is an off-label use. Incorrect Answers: A, B, and C. Quetiapine is FDA-approved for the treatment of these conditions. References:

Answer 226

Correct Answer: B. Special protections and additional informed consent requirements are necessary when studying prisoners Informed consent is required for almost all types of biomedical and behavioral research in the United States. Some groups are considered “vulnerable populations” and have additional requirements for consent. Additional paperwork is typically required. These groups include infants and children under the age of 18 years; pregnant women; prisoners; persons at risk of suicide; and persons with impaired decision-making capacity (those with cognitive delay; the demented elderly). When performing research on human subjects, nurse practitioners should follow the principles in the Belmont report, a paper that outlines important ethical principles that should be followed when performing research involving human subjects. This paper was issued by a national commission of experts in 1978. Incorrect Answers: A. Informed consent is needed for almost all biomedical and behavioral research in the U.S., and because the prison population is a "vulnerable population" additional paperwork is needed C. This isn't true, as the U.S. prison population is large enough to create a large, random sample D. Appropriate study design depends on the study aims Vital Concepts: Some groups are considered “vulnerable populations” and have additional requirements for consent. Additional paperwork is typically required. These groups include infants and children under the age of 18 years; pregnant women; prisoners; persons at risk of suicide; and persons with impaired decision-making capacity (the mentally retarded; the demented elderly). References:

Answer 227

Correct Answer: C. Operant conditioning Operant conditioning takes place when reinforcement or punishment is used to modulate the frequency of a particular behavior. In this case, timely arrival has been reinforced by a negative reinforcer (taking away time with a physician). Incorrect Answers: A. Trial and error learning refers to the type of action, not the mechanism by which learning occurs. A rat may pick the exit to the maze through trial and error, but when the rat is rewarded with freedom, this learning is reinforced through operant conditioning. B. In classical conditioning, a conditioned stimulus elicits a conditioned response due to its proximity to an unconditioned stimulus and unconditioned response. D. Much learning takes place secondary to the unexpected consequences of behavior, but coincidental learning is not a learning modality. Vital Concept: Conditioning in behavioral psychology is a theory that the reaction, called a response, to an object or event, called a stimulus, can be modified through learning, or conditioning. References:

Answer 228

Correct Answer: C. At least 24 months What was referred to as dysthymia in DSM-IV is now termed persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. The DSM-5-TR diagnostic criteria include: · A poor disposition characterizes this disorder, present most days for most of the day for 24 months or more in adults. · This should not include any asymptomatic periods lasting longer than 8 weeks. · The disposition may be cantankerous and crabby in teens and pediatric patients for 12 months or more. · In addition to the poor disposition, at least two of the following co-occur: changes in sleep, resulting in poor sleep or excessive sleep a decreased sense of self-worth and self-regard a sense that nothing good will happen and that the current situation will never improve changes in food intake or interest, resulting in no desire to eat or eating significantly more than typical a sense of being tired or worn out despite adequate rest or sleep, without much drive or vigor poor decision-making or an inability to maintain focus · The patient should not exhibit symptoms meeting the diagnostic criteria for a manic or hypomanic episode. · The patient may exhibit symptoms meeting the diagnostic criteria for a major depressive disorder for 24 months. A separate diagnosis of MDE or MDD should also be documented in this case. A specifier should be added to the persistent depressive disorder of with persistent major depressive episode or with intermittent major depressive episodes, with/without current episode. · The symptoms are not more appropriately due to another condition, such as a psychotic disorder (e.g., schizophrenia, schizoaffective DO, delusional disorder). · The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern · The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise · The following specifiers may be added: Mild/moderate/severe With anxious distress With atypical features Early onset (prior to age 21) Late onset (after age 21) In partial/full remission Incorrect Answers: A. At least one month is incorrect as this does not meet the "At least 2-year requirement" of s/s that is required to have dx of PDD. B. At least 12 months is incorrect as this does not meet the "At least 2-year requirement" of s/s that is required to have dx of PDD. D. At least 5 years exceeds the amount of "At least 2-year requirement" of s/s that is required to have dx of PDD. The question asks for the "least" amount of required time. E. At least 10 years exceeds the amount of "At least 2-year requirement" of s/s that is required to have dx of PDD. The question asks for the "least" amount of required time. Vital Concept: The condition involves a depressed mood that occurs for most of the day, for more days than not, and for at least 2 years (at least 1 year for children and adolescents). Major depression may precede persistent depressive disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder with persistent major depressive episode. References:

Answer 229

Correct Answer: C. 13% Schizophrenia has a polygenetic mode of inheritance. The risk of schizophrenia increases in occurrence with greater closeness in the family tree. The lifetime risk in the general population is just below 1%. It is 6.5% in first-degree relatives of patients and rises to >40% in monozygotic twins of affected people. With a parent affected, the risk is about 13%. If both parents are affected, the risk is nearly 50%. Incorrect Answers: A. This is the risk of schizophrenia in monozygotic twins of schizophrenics B. This is the risk of schizophrenia when both parents have schizophrenia D. This is the risk of schizophrenia when a first-degree relative has schizophrenia References:

Answer 230

Correct Answer: B. People who feel they have control over their coping in response to traumatic events are less likely to suffer from disorders in response to trauma. Albert Bandura developed social Cognitive Therapy (SCT) in the 1960s. SCT emphasizes learning from social context with a reciprocal relationship between the person, behavior and environment. For example, how the patient's social environment responded to a past behavior influences this patient's reinforcement expectations for future behaviors. SCT is composed of six components including self-efficacy, expectations, reinforcements, observational learning, behavioral capability, and reciprocal determinism. Self-efficacy theory discusses the effects of patients’ confidence in their ability to do a behavior successfully. In order to change “self-efficacy,” people must give themselves the credit for coping well rather than giving credit to other people or factors. People who feel they have control over their coping in response to traumatic events are less likely to suffer from disorders in response to trauma. Incorrect Answers: A. People who are able to care for themselves are less likely to suffer from mental illness or to suffer from disorders in response to trauma is not a part of the self-efficacy theory C. People who are independent are more efficient at dealing with stress is not a part of the self-efficacy theory. D. People who live independently are less efficient at dealing with stress is not a part of the self-efficacy theory. Vital Concept: Social Cognitive Therapy (SCT) emphasizes learning from social context with a reciprocal relationship between the person, behavior and environment. Self-efficacy theory is part of SCT that discusses the effects of patients’ confidence in their ability to do a behavior successfully. References:

Answer 231

Correct Answer: A. Student's t-test A student’s t-test is used to compare the means of 2 independent sample populations. Incorrect Answers: B. A paired t-test is used to compare the means of 2 related (“paired”) sample populations. An example would be a twin study. C. A z-test is similar to a t-test, but the z-test requires either a large sample or a known population variance. D. A chi-square test is used to compare samples with non-measurable nominal/categorical variables (as opposed to ordinal or interval measurements). References:

Answer 232

Correct Answer: B. Methamphetamine Selegiline is metabolized by the body into l-methamphetamine and l-amphetamine. The drug's package insert is meant to alert users that this is a likely side effect of being on this drug. If they test positive for the other drugs on the list, it is more likely a positive drug test. Selegiline is a substituted phenethylamine used for the treatment of early-stage Parkinson's disease, depression, and dementia. In normal clinical doses, it is a selective irreversible MAO-B inhibitor. However, in larger doses it loses its specificity and also inhibits MAO-A. Other psychotropics that can cause a false positive for amphetamines are promethazine, chlorpromazine, bupropion, fluoxetine and trazodone. Incorrect Answers: A. Lysergic acid diethylamide (LSD). Amitriptyline, fluoxetine, sertraline can lead to false positives for LSD. C. Phencyclidine (PCP). Thioridazine, mesoridazine, and venlafaxine can lead to false positives for PCP. D. Methadone. Quetiapine, chlorpromazine, thioidazine, clomipramine, and diphenhydramine can lead to false positives for methadone. Vital Concept: Psychotropics that can lead to a false positive for amphetamines are selegiline, promethazine, chlorpromazine, bupropion, fluoxetine and trazodone. References:

Answer 233

Correct Answer: A. Anxiety, insomnia, tremor, confusion, nausea, and vomiting Gamma Hydroxybutyrate (GHB) withdrawal shares features of both alcohol withdrawal and benzodiazepine withdrawal and is rare due to the rapid elimination of the drug. Withdrawal may take place in certain chronic GHB users who consume the drug every 3-4 hours. Earlier symptoms may include anxiety, insomnia, tremor, confusion, nausea, and vomiting. Later symptoms include disorientation, hallucinations, agitation, and possibly combative behavior. Incorrect Answers: B. There is an associated autonomic instability that is similar to alcohol withdrawal, manifesting as tachycardia, hypertension, tremor, and diaphoresis. C. Hypothermia and seizures with a delirium tremens-type picture are more consistent with ethanol withdrawal. D. Fatigue, dysphoria, depression with loss of appetite, and trouble concentrating describes the withdrawal picture for MDMA. References:

Answer 234

Correct Answer: C. Supportive group This describes supportive group therapy. Incorrect Answers: A. The goal of a psychodynamic group is to reconstruct personality dynamics. B. The goal of a cognitive-behavioral group is to relieve specific psychiatric symptoms. D. The goal of a day hospital group is to reconstitute defenses. References:

Answer 235

Correct Answer: A. Human chorionic gonadotropin Human chorionic gonadotropin is a hormone produced by the placenta after implantation, and HCG is tested to determine if a patient is pregnant. Before starting a medication that can have negative effects on a fetus, it is best to rule out pregnancy and have a discussion about pregnancy prevention during the period of time the medication is taken. Depakote (valproate) can cause major congenital malformations, particularly neural tube defects. Also before starting treatment should order a complete blood counts, liver function tests and coagulation tests. Incorrect Answers: B. Creatinine. Depakote is metabolized by the liver not the kidneys. It is not necessary to order a comprehensive metabolic panel (CMP) prior to starting Depakote. C. Potassium. Depakote does not affect potassium levels. It is not necessary to order a comprehensive metabolic panel (CMP) prior to starting Depakote. D. Sodium. Depakote does not affect sodium levels. It is not necessary to order a comprehensive metabolic panel (CMP) prior to starting Depakote.

Answer 236

Correct Answer: C. As old as formal nursing and began with Florence Nightingale The theoretical basis for nursing practice began with Florence Nightingale and has been used for practice and research for over a century. Incorrect Answers: A. B. D. Nursing theories are specifically developed for nursing. These options are not correct.

Answer 237

Correct Answer: A. Convulsions and coma Clomipramine is a TCA and blocks the reuptake of norepinephrine or 5-HT. Incorrect Answers: B, C, and D. These symptoms aren't characteristic of clomipramine toxicity.

Answer 238

Correct Answer: D. Role models The IDE perspective doesn't include role models. It includes losses, developmental dyssynchronies, interpersonal conflicts, symptomatic presentations, and personality disorders. Incorrect Answers: A, B, and C. These are all included in the IDE perspective. The major focus of the IDE perspective includes losses, developmental dyssynchronies, interpersonal conflicts, symptomatic presentations, and personality disorders. The eclectic brief therapy of Budman and Gurman focuses on the reason that the patient seeks therapy now. A characteristic feature of their therapy is the belief that maximal benefit occurs early and is the opportune time for change.

Answer 239

Correct Answer: A. Prospective cohort study This is a prospective cohort study, which follows similar individuals over time with respect to certain variables to determine how those variables will impact the rate of a certain outcome. Prospective cohort studies may have errors that result from patients who are lost to follow-up, but a prospective study generally has fewer sources of bias when compared to a retrospective cohort design. All cohort studies measure outcomes after exposure. They require large numbers of subjects to yield statistically significant rates of true incidence and relative risk. Incorrect Answers: B. A clinical trial is a study based on therapeutic intervention. It is designed to answer a specific question about the intervention and is always a prospective study. C. A case-control study is usually retrospective and compares patients with a disease or condition to patients who do not have the disease or condition. Subjects are identified by known outcomes, and investigators look back to identify risk factors and exposures. D. Retrospective cohort studies identify patients with a certain outcome and look back at exposure or risk factors to identify associations. Vital Concepts: This is a prospective cohort study, which follows similar individuals over time with respect to certain variables to determine how those variables will impact the rate of a certain outcome. Prospective cohort studies may have errors that result from patients who are lost to follow-up, but a prospective study generally has fewer sources of bias when compared to a retrospective cohort design.

Answer 240

Correct Answer: C. Smoking ban at nursing home Tobacco use and smoking are potent inducers of CYP1A2 enzymes, which processes clozapine. At the state hospital, surprisingly, many individuals can smoke even while taking antipsychotics. The patient likely had a stable amount of clozapine in his system and was utilizing a higher amount of medication than what he would normally need if he had not used tobacco daily at the hospital. Daily tobacco use induced enzymes, causing clozapine to be cleared more quickly and necessitating a higher dose of clozapine. New restrictions at his nursing home stopped his inducing agent (tobacco) and led to supratherapeutic levels of clozapine, causing his seizure. Clinicians must be very cautious when patients start or stop smoking, as it can drastically affect medication levels in the body. Incorrect Answers: A. St. John’s wort (Hypericum perforatum) is an inducing agent for CYP3A4 and CYP3A5. Substrates affected by this herbal supplement include alprazolam, amlodipine, atorvastatin, diazepam, cyclosporine, and many other commonly prescribed medications. When St. John’s wort is taken with these medications, they will be metabolized more quickly and be less effective. In other words, there will be lower levels of the alprazolam, amlodipine, and atorvastatin when they are co-administered with St. John’s wort. However, this inducing agent does not affect the metabolism of clozapine. B. Cruciferous vegetables induce the metabolism of CYP1A2. Increasing consumption of this inducing agent would lower clozapine levels in the patient’s system (i.e. clozapine is metabolized more quickly). This lower level of clozapine would make the patient more psychotic and not increase his risk for a seizure. D. This is a distractor.

Answer 241

Correct Answer: C. Inattention Children diagnosed with ADHD, combined type, tend to exhibit fewer impulsive-hyperactive symptoms as they grow older. Inattention is the symptom which may persist (disorganization is considered a symptom of inattention). Oppositional behavior is not a symptom of ADHD. Incorrect Answers: A. Impulsivity in ADHD-diagnosed children tends to go down as they grow older B. Disorganization is considered a symptom of inattention, not a symptom in itself D. Hyperactivity in ADHD-diagnosed children tends to go down as they grow older

Answer 242

Correct Answer: A. Nefazodone Caution should be used in prescribing nefazodone for AIDS patients taking protease inhibitors (e.g. ritonavir, saquinavir), as nefazodone may increase the serum concentration of ritonavir. . Tranylcypromine, phenelzine, sertraline, and bupropion are not known to cause interactions with protease inhibitors. Incorrect Answers: B, C, and D. These medications aren't known to cause interactions when taken with protease inhibitors.

Answer 243

Correct Answer: B. Short sentences and a matter-of-fact manner. The NP must ensure they communicate with a patient in withdrawal in a matter-of-fact manner using short sentences. This patient may be disoriented and anxious, so sentences must be kept short and to the point. Incorrect Answers: A. An overly cheerful tone and humor may lead to the patient feeling like the staff member is laughing at themm, which may lead to dysfunctional communication. C. A loud voice may make the patient feel as though they're being yelled at or chastised. Alcohol withdrawal does not affect a patient's ability to hear. D. A patient in withdrawal will typically not be able to follow extensive explanations, so sentences should be kept short and to the point. Vital Concept: he NP must ensure they communicate with a patient in withdrawal in a matter-of-fact manner using short sentences. This patient may be disoriented and anxious, so sentences must be kept short and to the point.

Answer 244

Correct Answer: D. Separation from family Panic disorders tend to begin with a panic attack that is seemingly out of the blue. This usually occurs when people are young adults (average is 30s) but can appear later. Although the person thinks the first panic attack is completely out of the blue and unrelated to the activity he or she was engaging in, there is often a correlation with some type of life event (including serious illness of a family/friend, an accident, loss or major change in relationship, or separation from family in some way like moving for a new job). It is also not uncommon for the first panic attack to occur postpartum or while abusing substances. Incorrect Answers: (A) Prior fasting. Prior fasting has not been correlated with onset of first panic attack. There is often a correlation with some type of life event; including serious illness of a family/friend, an accident, loss or major change in relationship, or separation from family. (B) Recently return from vacation. Prior fasting has not been correlated with onset of first panic attack. There is often a correlation with some type of life event; including serious illness of a family/friend, an accident, loss or major change in relationship, or separation from family. (C) Sleep-deprivation. Sleep-deprivation has not been correlated with onset of first panic attack. There is often a correlation with some type of life event; including serious illness of a family/friend, an accident, loss or major change in relationship, or separation from family.

Answer 245

Correct Answer: D. Respiratory depression Opiate use may result in respiratory depression. The remaining options describe the sequela of cocaine use, including hallucinations, paranoia, euphoria, increased energy, hypersexuality, and irritability. With heavy cocaine use, patients can experience a shower of lights in their central vision, as well as visual hallucinations of black dots on their skin and in the environment (coke bugs). Incorrect Answers: A. B. C. These are all potential consequences of cocaine use. Significant appearance of lights in the central vision field is a potential consequence of heavy cocaine use.

Answer 246

Correct Answer: A. It can cause spina bifida. Valproate and carbamazepine are known for being teratogenic. Specifically, they have been shown to be associated with neural tube defects, such as spina bifida. It is thought that the mechanism of the neural tube defects is related to folate antagonism. Therefore, it is advised to abstain from valproate during pregnancy. However, if that was not possible, it would be recommended to give the mother a significantly higher dose of folate daily during pregnancy. Incorrect Answers: B. Fetal hydantoin syndrome is characterized by short limbs and phalangeal hypoplasia, which has been associated with maternal use of Phenytoin during pregnancy. Valproate has not been shown to cause this syndrome. C. Valproate is an antiepileptic, which means that it functions to dampen seizure activity. It is a known teratogen, which maybe the reason to terminate it during pregnancy. However, continuing Valproate should not worsen seizure activity during pregnancy. D. Even though increasing folate supplementation during pregnancy when valproate is used has been shown to decrease the incidence of neural tube defects, it is still not completely safe to use it during pregnancy.

Answer 247

Correct Answer: A. 12 hours after last dose For an accurate plasma level of lithium during therapy, obtain the blood sample 12 hours after the last dose. This ensures that the steady-state concentration has been achieved and that absorption variations have been surpassed. Incorrect Answers: B. This is 2x too long to wait. C. This is 3x too long to wait. D. This is 6x too long to wait. Vital Concepts: For an accurate plasma level of lithium during therapy, obtain the blood sample 12 hours after the last dose.

Answer 248

Correct Answer: D. Bupropion Bupropion is a better choice than an SSRI for a patient diagnosed with SAD who wishes to avoid certain side effects, such as sexual dysfunction. Incorrect Answers: A. Fluoxetine is an SSRI. It is used to treat SAD, but SSRIs do have side effects, including sexual dysfunction and weight gain. B and C. Clonidine and buspirone are not first-line for treatment of SAD. Vital Concept: SSRIs are first-line for treatment of SAD. However, buproprion is a good choice for patients wishing to avoid sexual dysfunction associated with SSRIs.

Answer 249

Correct Answer: B. High rates of smoking, substance use disorders, obesity, and low socioeconomic status are related to poor prenatal care and outcomes in pregnant patients with schizophrenia. High rates of smoking, substance use disorders, obesity, and low socioeconomic status are independently related to poor outcomes such as low birth rate and increased stillbirth. Incorrect Answers: A. Mood stabilizers and benzodiazepines are more closely associated with fetal malformations and neonatal behavioral effects than antipsychotics. There is a secondary effect of low folate intake with increased risk of neural tube defects with second-generation antipsychotics. Antipsychotics are not generally associated with fetal malformations. C. Periods of high risk for the fetus include the first trimester of pregnancy and time of delivery. Pregnant women with schizophrenia rarely have early entry to prenatal care, so the first time of risk cannot readily be managed by coordinated obstetric and psychiatric care; drug withdrawal risk is highest at the time of delivery but can be managed. D. Although pregnancy is a time of decreased symptoms, pregnant women with schizophrenia need coordinated obstetric and psychiatric care.

Answer 250

Correct Answer: C. Naloxone Naloxone is the drug of choice for the acute treatment of opiate overdose. Patients addicted to opioids should be withdrawn gradually over time. Drugs often used for this include methadone, naltrexone, buprenorphine, and clonidine. Incorrect Answers: A. This is used to help prevent relapses into alcohol or drug abuse, but doesn't reverse overdoses. B. This is used to treat narcotic drug addiction through medication-assisted treatment, but doesn't reverse overdoses. D. This can be used to treat addiction to opioids, but doesn't reverse overdoses.

Answer 251

Correct Answer: D. Standard usage of psychotropics for children in state custody may require a legal hearing, although emergency use is permitted. Consent to use psychotropic medications should be obtained from a parent or legal guardian after a thorough discussion of the indications, risks, and benefits of the medication with the patient and parent or legal guardian. If a child is in state custody, permission to utilize standard doses of psychotropic medications must be obtained from the state. In some cases, this may require a legal hearing. Incorrect Answers: A. The FDA does allow off-label use of medication and use of medication in age groups not studied. B. Pharmacotherapy is part of a comprehensive treatment plan, including individual and family psychotherapy and educational and behavioral interventions. C. Combined pharmacotherapy often achieves more targeted treatment and efficacy with fewer side effects and lower doses. Vital Concept: Consent for children's psychotropic medications should be obtained from the parent, legal guardian, or from the state (if in state custody). References:

Answer 252

Correct Answer: A. Females are often diagnosed in their late 20s. Peak ages of diagnosis are early to mid-20s (18-25) for males and late 20s/early 30s (25-35) for females. An episodic course is more common in females. Long-term prognosis is better for women than it is for men. Men have poorer premorbid functioning, social functioning, educational achievements, and outcomes. Men also have more negative symptoms and cognitive decline, while women tend to display more mood and psychotic symptoms. Women also tend to experience a second peak of symptoms (especially psychotic) later in life that may be related to hormonal shifts during menopause. Incorrect Answers: B. Schizophrenia has roughly equal prevalence in males and females, but early onset is seen in males with poor prognosis, and late onset is seen in females with good prognosis. The prevalence is 1.4:1 (men:women) worldwide. C. Negative and deficit symptoms are predominant in males. D. Social functioning is better in females. Vital Concept: Men have an earlier schizophrenia onset than women and a poorer prognosis. References:

Answer 253

Correct Answer: C. A "tail" policy is recommended if the NP changes coverage “Claims made” coverage refers to malpractice insurance that only covers claims if the NP is enrolled with the same insurance company at the time the claim is filed in court. If an NP drops coverage and is sued for an event that happened during the period of coverage, the NP will not be covered unless he or she has purchased a “tail coverage.” If the NP has claims-made coverage and decides to change insurers or to retire, it is advisable to buy “tail coverage” insurance that will cover the NP for any future claims filed against him or her that result from patient encounters during the period of coverage. The other type of malpractice insurance is “occurrence” insurance. An occurrence-based policy is unaffected by job changes or retirement. If an NP had an occurrence-based policy during the time of a patient encounter that later resulted in a lawsuit, the policy would cover that claim. No tail is necessary with occurrence coverage. Incorrect Answers: A. The NP won't be covered if she drops her coverage, unless she has purchase a "tail coverage" B. The NP won't be covered for future claims made with this type of coverage D. An occurrence-based policy is unaffected by job changes and retirement; but this policy is affected Vital Concepts: If an NP drops coverage and is sued for an event that happened during the period of coverage, the NP will not be covered unless he or she has purchased a “tail coverage.” If the NP has claims-made coverage and decides to change insurers or to retire, it is advisable to buy “tail coverage” insurance that will cover the NP for any future claims filed against him or her that result from patient encounters during the period of coverage. References:

Answer 254

Correct Answer: B. Respect the patient’s wishes Explain the risks and benefits of long-acting contraceptives and the risks of engaging in unprotected sex. If the patient still declines the contraceptive, her wishes should be respected. There are several areas in which minors have rights to treatment or to refuse treatment. These areas include contraception, abortion, prenatal care, drug, alcohol, and mental health services. Intellectual disability and other limitations of decision making capacity, are not an absolute indication to deny the patient her reproductive rights, particularly when there is no substantial evidence to suggest that harm will come to the patient or to her child. Incorrect Answers: A. The patient's wishes should be respected — minors have the right to treatment and to refuse treatment in contraception C, D. Neither is warranted without substantial evidence to suggest harm will come to the patient Vital Concepts: Explain the risks and benefits of long-acting contraceptives and the risks of engaging in unprotected sex. If the patient still declines the contraceptive, her wishes should be respected. References:

Answer 255

Correct Answer: C. Bias The clients are not randomized to different samples, so bias can occur, primarily as a result of self-selection. As an example, clients who are more gregarious may choose a group exercise class. The difference seen in their moods may be a result of differences in their personalities, not the result of the specific effects of the type of exercise. Incorrect Answers: A. Classes aren't anonymous. B. Classes aren't randomized. D. Sample size is sufficient at 10% of the population. Vital Concepts: The clients are not randomized to different samples, so bias can occur, primarily as a result of self-selection. References:

Answer 256

Correct Answer: B. Topiramate At dosages < 200mg, topiramate as daily monotherapy in healthy volunteers did not have a significant interaction with oral contraceptives but did at 200 mg or more. Incorrect Answers: A. Carbamazepine is associated with neural tube defects (1% of cases) and neurodevelopmental problems. Carbamazepine is associated with decreased levels of oral contraceptives. C. Lithium does not decrease the efficacy of oral contraceptives, but should be avoided in patients who are trying to get pregnant due to the risk posed to the developing fetus (see chart below). Lithium is associated with Ebstein's abnormality and other cardiovascular defects, as well as neonatal goiter. Lithium should be avoided in the first trimester if possible. D. Oxcarbazepine may decrease the serum concentration of oral contraceptives leading to contraceptive failure. References:

Answer 257

Correct Answer: A. Cannabis-induced psychotic disorder In the DSM-5-TR, substance-induced mental disorders are named by the causative agent. The diagnostic criteria for psychosis related to a substance include that the patient must have at least one of the following symptoms: illusions or perceived experiences that do not exist (e.g., sounds, voices, smells, visions, feelings, etc.) a misconception, belief, or thought that is firmly held despite not being grounded in reality The patient’s symptoms must become apparent in the midst of or following withdrawal or intoxication related to a substance or following the administration of a medicine. The implicated medicine/substance has been known to cause the patient’s signs and symptoms Symptoms cause substantial dysfunction in at least one environment (work, home, social settings) The patient’s symptoms are not due to a more appropriate psychiatric condition, as evidenced by the satisfaction of the following features: initial symptom presentation prior to substance exposure symptom duration for longer than expected (e.g., 4 weeks) a past episode of similar symptoms not associated with substance use Symptoms are not only present with acute delirium If the hallucinations/delusions are mild and clinically insignificant, a diagnosis of substance intoxication or withdrawal may be more clinically appropriate Incorrect Answers: B. The DSM-5-TR does not include the psychotic disorder NOS diagnosis. C. Withdrawal from cannabis is not typically associated with psychotic symptoms. D. Schizophreniform disorder is not diagnosed when the cause of symptoms is related to a substance. Vital Concept: The diagnosis of psychosis related to a substance requires that the symptoms present during intoxication or withdrawal of the implicated substance. References:

Answer 258

Correct Answer: D. Screening mammograms Secondary prevention strategies refer primarily to detection of a disease early in its course, leading to early treatment and improved outcomes. Secondary prevention strategies are used to identify and treat asymptomatic individuals who do not yet show clinical signs or symptoms of a disease. Secondary strategies also refer to identification and treatment of individuals with certain risk factors. Screening mammography is an example of a secondary prevention strategy for breast cancer. Primary prevention strategies are designed to prevent the onset of a particular condition or disease. Examples of primary preventive strategies include weight loss in obese women to reduce the risk of development of breast cancer. Tertiary prevention strategies are strategies of management of existing diseases or conditions that are designed to restore the individual with the disease to optimal function, to reduce disease related complications, and to eliminate or reduce negative consequences of a disease. Radical mastectomy, when indicated, is a tertiary prevention measure against spread or recurrence of breast cancer. Incorrect Answers: A. This is a healthy lifestyle habit. B. A primary prevention strategy only for obese women. C. Tertiary prevention measure. Vital Concepts: Secondary prevention strategies refer primarily to detection of a disease early in its course, leading to early treatment and improved outcomes. Secondary prevention strategies are used to identify and treat asymptomatic individuals who do not yet show clinical signs or symptoms of a disease. References:

Answer 259

Correct Answer: C. Reactive attachment disorder This child has a classic history for and displays several features of reactive attachment disorder (formerly reactive attachment disorder, inhibited type), including repeated changes in caregiver, history of neglect, avoidance of social interaction, and resistance to comforting from others. The diagnostic criteria for reactive attachment disorder: The symptoms described must be obvious prior to age 5, and the patient’s development age must be 9 months or older Actions that indicate a lack of attachment to caregiving adults, as evidenced by both of the following: · the child does not consistently want to be comforted by the caregiver when upset · the child does not react to being comforted by the caregiver when upset A consistent interpersonal or psychological dysfunction, as evidenced by two or more of the following: · minimal display of positive emotional response · periods of cantankerous mood, unhappiness, or fear when around caregiving adults without provocation · limited response to people on a social or psychological level Historically, the child has endured poor care that preceded the symptoms described, such as one or more of the following: · an inability to form a solid relationship with caregiver(s) due to recurrent switches in primary caregivers · caregiving adults that failed to meet the child’s emotional needs (e.g., love, consolation, encouragement) · being raised in an institutional or otherwise non-conventional environment that significantly prevents selective attachment (e.g., too few caregivers available for the number of children The child does not meet the established criteria for autism spectrum disorder (ASD) If symptoms have persisted for at least a year, the disorder is considered persistent If all symptoms can be identified in one patient, the disorder is considered severe Incorrect Answers: A. There are no indications of developmental delay related to communication, obsessive interests, or repetitive behaviors that would raise suspicion of autism. B. There's no mention of difficulty speaking in select social settings, which is what selective mutism is. D. Disinhibited social engagement disorder presents with excessive indiscriminate sociability and lack of selectivity in attachment figures. Vital Concept: Reactive attachment disorder is characterized by actions that indicate a lack of attachment to caregiving adults, as evidenced by the child not consistently wanting to be comforted or not reacting to being comforted by the caregiver when upset. References:

Answer 260

Correct Answer: A. Integrity vs. Despair This patient is struggling with integrity vs. despair which is evidenced by her anger, bitterness, regret, and alienation. Incorrect Answers: B. A patient struggling with this would be emotionally isolated. However, this stage doesn't explain the patient's anger, bitterness, and regret. C. This relates to work and family. It doesn't relate to this patient's current state. D. This relates to learning the pleasure of applying oneself to tasks. It doesn't relate to this patient's current state. Vital Concept: Fulfillment of integrity vs despair is evidenced by comfort with life, willingness to face death, insight and balanced perspective on life’s events. Those struggling with the developmental task of Intimacy vs. isolation results in emotional isolation, this is not the correct answer because of the other attributes of this patient including, anger, bitterness, and regret. Choices C and D are not appropriate for this patient. References:

Answer 261

Correct Answer: C. Intellectualization This patient is demonstrating intellectualization. They're attempting to avoid dealing with their alcoholism by studying their family heritage. Intellectualization is characterized by excessive thinking and analyzing as a way of avoiding discussing and dealing with emotions and feelings. Incorrect Answers: A. The patient isn't trying to ignore a factual reality by focusing internally, which would be denial. Denial is also considered a primitive defense mechanism, not higher level. B. The patient isn't trying to use faulty logic to explain their behavior or reactions, which would be rationalization. D. The patient isn't demonstrating sublimation by trying to transform a socially unacceptable impulse (drinking alcohol) into a socially acceptable action or behavior (focusing on hydration). Vital Concept: This patient is using thinking and analyzing as a defense mechanism to distance himself from his feelings and emotions, termed intellectualization. References:

Answer 262

Correct Answer: D. Oxazepam In general, long-acting benzodiazepines with active metabolites (e.g. diazepam and clonazepam) are preferred due to a smoother course with less chance of recurrent withdrawal or seizures. However, their metabolites stay longer in the liver. These drugs should not be used in patients with liver disease. Intermediate- and short-acting benzodiazepines, including lorazepam and oxazepam, are often used in elderly patients or those with liver damage, as they are renal excreted and lack metabolites. Lorazepam or oxazepam is preferred for the treatment of patients with advanced cirrhosis or acute alcoholic hepatitis due to the shorter half-life of lorazepam and the absence of active metabolites with oxazepam. Incorrect Answers: A. Chlordiazepoxide has a long half-life and is a cost-effective medication for treating alcohol withdrawal, but it is metabolized by the liver. As a result, it is used rarely in patients with impaired liver function or in the elderly. B. Clonazepam should be avoided in this patient. C. Carbamazepine’s role in treating alcohol withdrawal has yet to be delineated fully. References:

Answer 263

Correct Answer: C. Tell the patient about her biopsy results unless she has requested otherwise and has provided written consent for release of information. All medical information (like results of laboratory testing or a biopsy) must be delivered to the patient, not to the family. Unless the patient has provided specific instructions to the contrary, the family should never receive the patient’s confidential medical information. The only exceptions are when a patient is not competent or when the patient has a psychiatric disturbance that may be exacerbated by news of a serious medical condition, resulting in a suicide attempt. Therapeutic privilege refers to withholding relevant health information from a patient if disclosure of the information is medically contraindicated, but the therapeutic privilege is rarely invoked, and consideration of therapeutic nondisclosure should only occur after consultation with a colleague. A thorough review of the risks and benefits to the patient and an ethical justification of non-disclosure are required. Incorrect Answers: A. A patient's spiritual beliefs have no bearing on the obligation to deliver all medical information to the patient unless the patient has provided specific instructions to the contrary, is incompetent, or has a psychiatric disturbance that might be exacerbated by news of a serious medical condition. B. and D. All medical information (such as biopsy results) must be delivered to the patient, not the family unless the patient has provided specific instructions to the contrary, is incompetent or has a psychiatric disturbance that might be exacerbated by news of a serious medical condition. Vital Concepts: All medical information (like results of laboratory testing or a biopsy) must be delivered to the patient, not to the family. Unless the patient has provided specific instructions to the contrary, the family should never receive the patient’s confidential medical information. The only exceptions are when a patient is not competent or when the patient has a psychiatric disturbance that may be exacerbated by news of a serious medical condition, resulting in a suicide attempt. References:

Answer 264

Correct Answer: D. Keep the patient in your office and have a nurse call the police and the intended targets; the police will arrive and take over Although the right to confidentiality is a critical ethical concept in medicine, it is not an absolute right. When the possibility of harm to an innocent party exists, the health care provider must report the threat to the person and to the authorities. The duty is not only to report but to act to prevent harm. This may include keeping the patient in the office until authorities arrive, or warning the threatened person. If a clinician obtains information from a patient that an identified victim is at risk, it is the duty of the healthcare personnel to warn the intended victim, even if it will break confidentiality (Tarasoff I). Tarasoff II extended this mandate to a duty to include a duty to protect that supersedes the duty to warn, which means that a warning may not by itself be sufficient to protect the patient. The healthcare staff should call the police and should also try in every way to notify the potential victim of danger. The patient who is making the threat should be detained, then the police must be called. Finally, notification and warning of the potential victim should occur after these protective measures are in place. All three actions should be attempted. Incorrect Answers: A. This is inadequate to protect the intended victim. B. The intended victim AND the law enforcement authorities should be notified. C. Confidentiality is not absolute if an innocent victim is in harm's way. Vital Concepts: Although the right to confidentiality is a critical ethical concept in medicine, it is not an absolute right. When the possibility of harm to an innocent party exists, the health care provider must report the threat to the person and to the authorities. References:

Answer 265

Correct Answer: D. Parietal lobe The temporal lobes are the key areas of the brain for hearing, naming, and visual recognition. The frontal lobe is primary in executive function, social conduct, judgment, insight, and some motor function. The occipital lobe is vital for visual functions. The parietal lobes are key areas for sensory integration and somatosensory function. Incorrect Answers: A. Medulla - Responsible for autonomic (involuntary) functions B. Occipital lobe- Responsible for visual functions C. Frontal lobe-Responsible for executive function, social conduct, judgment, insight, and some motor function References:

Answer 266

Correct Answer: B. Cross-sectional study Cross-sectional studies analyze a population (or representative subset) at a single point in time (a cross-section) to assess disease incidence and prevalence. Incorrect Answers: A. Case-control studies analyze a known outcome by looking back in time to assess exposure. C. An RCT is an experiment/clinical trial that studies the effect of an intervention by comparing the treatment to a placebo in 2 equivalent groups separated by randomization. D. A cohort study follows a group of similar individuals (a cohort) without a disease over time to determine the risk of developing the disease. References:

Answer 267

Correct Answer: D. Natural environment Specific phobia is diagnosed when there is fear about a specific situation/object and that stimulus always provokes an immediate response. Criteria for diagnosis include · Terror or significant concern about a certain condition or item (small spaces, spiders, heights). · The terror or concern is consistent for at least 6 months. · The patient evades the condition or item. · The terror/concern or active evasion of the condition or item leads to dysfunction (academic, professional, social, or otherwise) or considerable anguish. · The patient reports sudden terror or significant concern almost every time they are presented with the certain condition or item. · The actual risk or threat posed by the condition or item is insignificant compared to the patient’s emotional response and concern. · The patient’s symptoms are not due to a more appropriate psychiatric condition such as panic attacks (i.e., panic disorder), past trauma (i.e., post-traumatic stress disorder), gaining weight (i.e., eating disorders), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). · In pediatric patients, phobias may manifest as dependence, immobility, outbursts, or fits. Specific subtypes include: animal (fear that relates to animals or insects) natural environment (fears of things like heights, lightning, or bodies of water) blood-injection injury (fear of blood, medical procedures, needles, etc.) situational (fear of situations such as being in an elevator, tight spaces, driving, or airplanes.) other (fear of choking or vomiting, loud sounds, costumed characters) Incorrect Answers: A. Food-related is not a subtype of specific phobia. B. Social is not a subtype of specific phobia. Social anxiety disorder is a separate diagnosis. C. Clown is not a subtype of specific phobia, but could be considered an 'other' subtype. Vital Concept: Subtypes of specific phobia in the DSM-5-TR include animal, natural environment, blood-injection injury, situation, and other. References:

Answer 268

Correct Answer: D. Greater than 65 years The 2010 census showed that the population 65 and older is the largest in terms of size and percent of the population. There were 40.3 million people over the age of 65, representing an increase of 5.3 million since the 2000 census. The population aged 65 and older grew faster than the total population, growing 15.1 percent, compared to total population growth in the US of 9.7 percent. Within the older population, 85- to 94-year-olds experienced the fastest growth between 2000 and 2010, 29.9 percent, representing an increase from 3.9 million to 5.1 million. Incorrect Answers: A. B. and C. These groups are growing more slowly than the 65+ population. References:

Answer 269

Correct Answer: B. 80-year-old White male Older people, particularly Caucasian men >75, have the highest rates of suicide in the U.S. In fact, white males ages 85 and older have the highest suicide rate of any age and ethnic group. Nearly 70% of older suicide victims visit their primary care physician within the month of their death, and many did not tell their doctors they were depressed and were not screened. Men are more likely to die by suicide than women, but women are more likely to attempt suicide. Without looking at age, American Indians and Alaska Natives tend to have the highest rate of suicides, followed by non-Hispanic Whites. Hispanics have the lowest rate of suicide, and African Americans have the second lowest rate. Incorrect answers: (A) 17-year-old Hispanic male. Elderly people are at greater risk for suicide versus a 17-year-old. Hispanics have the lowest rate of suicide among ethnic groups. (C) 24-year-old African American female. African Americans have the second lowest suicide rate among ethnic groups. Men have a greater risk than women. Elderly people are at greater risk for suicide versus a 24-year-old. (D) 75-year-old White female. Men are more likely to die by suicide than women. References:

Answer 270

Correct Answer: C. Never accept a cash gift. A therapist should never accept money from a patient (except as previously agreed upon in a payment schedule). Incorrect Answers: A. If the gift is inexpensive or handmade, it is generally appropriate to accept it. B. Expensive gifts or inappropriate gifts should not be accepted. A small gift card may be acceptable. Fifty dollars is typically the limit, but it depends on the institution's policy. D. Gifts should always be discussed to explore the motivation of the patient and any significance with respect to transference. References:

Answer 271

Correct Answer: B. Tricuspid valve Ebstein’s anomaly is a malformation of the tricuspid valve. Incorrect Answers: A, C, and D. These structures aren't malformed in Ebstein's anomaly. References:

Answer 272

Correct Answer: D. Notify the emergency provider of the new findings The PMHNP should avoid highly personal or intrusive procedures that may make the formation of a therapeutic alliance more difficult. They should be able to recognize between normal and abnormal exams. The age of the patient is not discussed and therefore it is uncertain the legal implications of notifying the parents. Having her notify her sexual partners is not necessary yet as a diagnosis of an STD has not been established. Notifying the emergency provider of the new findings would be the next best step as they would be the one to complete the pelvic exam. Incorrect Answers: A. The emergency provider will complete the pelvic exam. B. It's not clear what the patient's age is, so not clear if parents need to be notified. C. Notifying sexual partners isn't needed unless an STD diagnosis is established, which it hasn't been yet. References:

Answer 273

Correct Answer: D. Putamen Methyl alcohol, an industrial solvent, is metabolized to formaldehyde and formate, leading to neurotoxicity. Symptoms begin 12-24 hours after exposure and include encephalopathy (often with disinhibition), ataxia, visual loss, seizures, headache, GI complaints, and tachypnea. The mechanism of visual loss is not known, although it may relate to formic acid accumulation within the optic nerve. Edema and hyperemia of the fundus and optic nerve may be evident, and patients may report blurring, scintillations, scotoma, diminished acuity, or frank blindness. The classic MRI finding is an infarction or hemorrhage of the putamen, as formic acid also tends to accumulate in this region. Lesions in the cortex and cerebellum are rare. Long-term survivors may experience Parkinsonism. Chronic exposure may result in an axonal polyneuropathy. Incorrect Answers: A. Lesions in the cerebellum due to chronic alcohol use disorder are rare. B, C. These are located in the cortex, where it's rare to see lesions. References:

Answer 274

Correct Answer: D. Diazepam The SSRI fluoxetine, mood stabilizers such as oxcarbazepine, propranolol, or a second-generation antipsychotic may benefit patients with intermittent explosive disorder. In particular, fluoxetine and oxcarbazepine have been superior to placebo in reducing impulsive aggression in these patients. Diazepam and other benzodiazepines may worsen the symptoms of intermittent explosive disorder long-term. Beta-blockers might help control explosive rage. Other new and unverified treatments also include decreasing testosterone levels in men or neurosurgery. Incorrect Answers: A. Will reduce impulse aggression B. Will reduce impulse aggression C. Treats high blood pressure, irregular heartbeats, and shaking (tremors) References:

Answer 275

Correct Answer: D. School-aged children with ADHD and comorbid tic disorder treated with guanfacine show reduced both tics and ADHD symptoms. The reduction in tics and ADHD is associated with a guanfacine at 0.5mg bid to 1mg tid. Guanfacine is FDA approved to treat ADHD in children ages 6 to 17-years-old. Not FDA approved for ADHD treatment in adults. It is also used off-label for conduct disorder, Tourette's and motor tics, migraine prophylaxis and opioid withdrawal. Is a centrally-acting selective alpha 2 adrenergic agonist. Guanfacine comes in IR tablets (Tenex) and ER tablets (Intuniv). Side effects include dry mouth, sedation, rare hypotension, and rare orthostatsis. Incorrect Answers: A. Guanfacine is a MORE selective alpha-adrenergic compound than clonidine. B. Guanfacine is associated with LESS sedation and a longer duration of action than clonidine. C. Guanfacine is associated with minor bradycardia and hypotension, not tachycardia/hypertension. Vital Concept: Guanfacine has been shown to reduce both tics and ADHD symptoms in children. Only FDA approved for ADHD for 6-17 year-olds. References:

Answer 276

Correct Answer: B. Restraints increase risk of rhabdomyolysis. The restrained patient may need to be sedated to avoid rhabdomyolysis associated with continued combativeness. Rhabdomyolysis occurs in approximately 2.5% of patients with phencyclidine (PCP) intoxication. Rhabdomyolysis can lead to kidney damage or failure. PCP overdose, in some cases, can cause muscle rigidity, which may evolve into rhabdomyolysis that mimics neuroleptic malignant syndrome. Incorrect Answers: A. This isn't a concern if medically appropriate. C. This isn't a reason for it to be medically inappropriate to keep a patient in handcuffs while on PCP. D. This is insufficient as reasoning either way. References:

Answer 277

Correct Answer: A. A The double-hump curve can be used to infer the negative and positive predictive value of a screening test. The sensitivity of the test is greatest at point A, where a low serum concentration of the marker is the cutoff for a positive test. Choosing point A will result in more false-positive tests. The negative predictive value of the test will be greater at point A. The specificity of the test will be greater if the cutoff for a positive test is at a higher concentration of the marker. The specificity of the test will be greatest at point E, but this will result in false-negative tests. The positive predictive value at point E is greatest, however, since people with a positive test are more likely to have the disease. The figure below illustrates this concept in terms of false positive and false negative results. If asked about where the cutoff point should be for a test, it usually depends on the consequences of missing a diagnosis or, in the case of research, the desire to avoid including subjects in a study who do not have the condition. In the first case, the vertical line for the cutoff for a test would be moved to the left. In the second case, to avoid including a false positive in a study, the cutoff point for a positive test would be higher, so the vertical line would be moved to the right. The World Health Organization has 2 sets of diagnostic criteria in acknowledgment of the utility of 2 different cutoff points, 1 for research and 1 for clinical care. Increased sensitivity leads to over-diagnosis and increased specificity leads to under-diagnosis. Incorrect Answers: B. Point B has increased sensitivity but point A has the highest sensitivity. C. Point C is considered the most accurate point. D. Point D has increased specificity but point E has the highest specificity. E. Specificity of the test is greatest at point E. Vital Concept: The double-hump curve can be used to infer the negative and positive predictive value of a screening test. References:

Answer 278

Correct Answer: B. Report this case immediately to Child Protective Services. Healthcare providers are mandatory reporters of suspected child abuse and have a legal and ethical duty to report any valid suspicion to child protective services. The duty to report a reasonable suspicion of child abuse supersedes any duty to maintain confidentiality. There is no breach of discretion in reporting either documented abuse or suspected abuse. Reporting should be immediate so intervention can be initiated to prevent further abuse. Healthcare providers are protected from liability when reporting suspected abuse in good faith. Incorrect Answers: A. Healthcare providers are mandatory reporters of suspected child abuse and have a legal and ethical duty to report any valid suspicion to child protective services. C. Healthcare providers are protected from liability when reporting suspected abuse in good faith. D. Suggesting the caregiver find another provider doesn't absolve the provider of the duty to report. Vital Concept: Signs of child maltreatment should be a part of the NP’s evaluation during clinic visits and knowing how to report and refer to the appropriate authority is a part of their scope of practice. References:

Answer 279

Correct Answer: D. Somatic symptom disorder (SSD) Correct Answer: D. Somatic symptom disorder (SSD). Formerly pain disorder, the DSM-5-TR describes SSD as a condition with somatic symptoms that must be significantly distressing or disruptive to daily life and must be accompanied by excessive thoughts, feelings, or behaviors. The diagnostic criteria include: At least one somatic symptom that substantially impacts the patient’s daily functioning or leads to anguish The patient then develops extraordinary actions, emotions, or ruminations regarding the symptom(s) or related medical condition(s), as evidenced by one or more of the following: · consistent worry or concern about their physical wellbeing · extraordinary devotion of resources (e.g., energy, time) to the symptom(s) or related medical condition(s) · ruminations that are consistent and unbalanced regarding the gravity and meaning underlying these symptoms These conditions persist for at least 6 months, although the specific symptom of focus may vary or shift during that time Specifiers include: · with prominent pain if the symptoms involve physical discomfort · persistent if the symptoms are severe, enduring (greater than 6 months), and cause substantial dysfunction · mild/moderate/severe based on the number of symptoms listed above that are present (1/2/2+ multiple symptoms) Incorrect Answers: A. Functional Neurological symptom disorder (FNSD) requires the presence of one or more voluntary motor or sensory symptoms that are incompatible with known neurological or medical conditions. B. There's no evidence that the patient is faking their condition to assume the role of the patient, which is the underlying motivation in factitious disorder. C. Illness anxiety disorder is characterized by a preoccupation with having or acquiring an illness and the presence of a high level of anxiety regarding one’s health despite no somatic symptoms present (or only mild in intensity). Vital Concept: Somatic symptom disorder (SSD) is a disease with somatic symptoms that must be significantly distressing or disruptive to daily life and must be accompanied by excessive thoughts, feelings, or behaviors. References:

Answer 280

Correct Answer: D. Mirtazapine In terms of structure, mirtazapine is classified as a tetracyclic antidepressant. It is a noradrenergic and specific serotonergic antidepressant. In addition, it is commonly used as an anxiolytic, hypnotic, antiemetic, and appetite stimulant. Atomoxetine is a norepinephrine reuptake inhibitor failed as an antidepressant but gets approved for the ADHD. Imipramine, doxepin, and clomipramine are tricyclic antidepressants. Incorrect Answers: A. This is a norepinephrine reuptake inhibitor (NRI, NERI) B, C. These are tricyclic antidepressants (TCAs) References:

Answer 281

Correct Answer: A. Grief is dominated by sensations of having lost something or feeling empty inside Distinguishing grief from a major depressive episode per DSM 5-TR Grief dominated by sensations of having lost something or feeling empty inside symptoms decrease within weeks and fluctuate with reminders of the deceased can occur with laughing and positive feelings associated with memories of the deceased but self-regard is largely intact Major depressive episode persistent feelings of sadness, and despair, without a visible end in sight emotional state is not related to specific thoughts/ruminations feeling self-critical and degrading is common, with poor sense of self-worth Incorrect Answers: B. Persistent feelings of sadness, and despair, without a visible end in sight are characteristic of a major depressive episode (MDE), not grief. C. Grief can occur with laughing and positive feelings as memories of the deceased are recalled. This is not seen in MDE D. Grief may be associated with memories of the deceased but self-regard is largely intact. In MDE, self-critical feelings thoughts are commonplace. Vital Concept: Grief and depression are dominated by sensations of having lost something or feeling empty inside, which typically resolve within weeks to months, and may co-occur with periods of levity and laughter when remembering good times with the deceased. References:

Answer 282

Correct Answer: C. Patients who have experienced major physical trauma (e.g. burns, serious accidents) rarely have ASD or PTSD. This patient population often experiences PTSD and ASD. Incorrect Answers: A. Patients with borderline personality disorder and psychotic disorders are particularly likely to have experienced victimization as a child and/or adult. B. These patients often have PTSD, which is usually overlooked in clinical assessment. D. Traumatic death of a family member (especially a spouse) may result in PTSD associated with bereavement. References:

Answer 283

Correct Answer: B. Delusions of reference and de Clerambault syndrome This patient is experiencing delusions of reference and de Clerambault syndrome, also known as erotomania. Incorrect Answers: A. Capgras syndrome is the belief that a family member or close friend is not actually the same person and has been replaced by a body double. C. The patient does not report delusions of control. D. A delusion of grandeur is an unrealistic belief in one's powers and abilities. References:

Answer 284

Correct Answer: D. The best treatment is a combination of psychotherapy and pharmacotherapy. The suggested treatment is both psychotherapy and pharmacotherapy as it has been shown to be more effective than either treatment alone. Incorrect Answers: Dialectical Behavior Therapy (DBT) is one of the most common therapy types used in clients with unipolar major depressive d/o is incorrect as CBT and interpersonal therapy are most common. A score of greater than 10 indicates Unipolar major depressive d/o on the PHQ-9 screening is incorrect as as score of greater than 10 suggests moderate depression. The most common side effect to SSRIs to treat depression is weight gain is incorrect as it more common to have GI upset and sexual related side effects than weight gain (paxil is the exception). References:

Answer 285

Correct Answer: B. Precontemplation People at Stage 1: Precontemplation (not ready) do not intend to start the healthy behavior in the near future (within 6 months) and may be unaware of their need to change. These patients need to learn more about healthy behavior and are encouraged to think about the pros of changing their behavior and to feel emotions about the effects of their negative behavior on others. In Stage 2: Contemplation (getting ready), participants intend to start the healthy behavior within the next 6 months. While they are usually more aware of the pros of changing, their cons are about equal. This ambivalence about changing can cause them to avoid taking action. In Stage 3: Preparation (ready), people are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell their friends and family that they want to change their behavior. In Stage 4: Action, people have changed their behavior within the last 6 months and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip. In Stage 5: Maintenance, people at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into the unhealthy behavior, particularly stressful situations. Incorrect Answers: A. Denial isn't a stage of DiClemente and Prochaska's stages of change. C. In this stage, the patient intends to start the healthy behavior in the near future (next six months) — this patient isn't there yet, although it's the next step. D. In this stage, the patient is ready to start the healthy behavior in the next 30 days — this patient isn't there yet, as there's still the Contemplation stage between his current stage (Precontemplation) and this. References:

Answer 286

Correct Answer: A. Weight gain Weight gain is typically the most problematic side effect of olanzapine. Incorrect Answers: B. Olanzapine may cause weight gain, not weight loss C. Olanzapine causes orthostatic hypotension. D. Sexual dysfunction does occur but is rarely problematic. References:

Answer 287

Correct Answer: C. Correlational study A correlational study describes and measures the relationships between two or more variables or interrelationships. Data are numerical and measurable, subject to statistical testing. Incorrect Answers: A. A randomized controlled study selects two or more groups in a population with a certain condition and randomly assigns patients to different treatment groups to measure the effects of treatment. B. A descriptive study describes and measures the characteristics of a group or phenomenon. D. A case study is a study of one person with a condition or illness. Vital Concepts: A correlational study describes and measures the relationships between two or more variables or interrelationships. Data are numerical and measurable, subject to statistical testing. References:

Answer 288

Correct Answer: C. Transference Transference is a phenomenon in which a patient projects feelings and identities on a therapist. Incorrect Answers: A. Adaptability is a combination of flexibility and stability. Healthy families balance the two. B. Connectedness is a key part of family functioning and defined as a balance between closeness and separateness. D. Interpersonal and generational boundaries are part of the family system. References:

Answer 289

Correct Answer: D. Spring birth Studies show that seasonal variation in the prevalence of births leading to schizophrenia has been identified, with an excess of births in winter and spring months. Other environmental factors that predispose to schizophrenia development are ambient temperature, exposure to infectious agents, nutritional deficiencies, infections, maternal rubella, late-winter/early-spring birth, urban birth, irradiation in the first trimester, prolonged labor, perinatal complications, and family and social stressors. Incorrect Answers: A. AMBIENT temperatures are associated with an increased incidence of schizophrenia in offspring, not cold temperature. B. There is an increased incidence of schizophrenia in the offspring of women who were subjected to radiation in their FIRST trimester, not third trimester. C. With URBAN birth there is an increased incidence of schizophrenia, not rural birth. Vital Concept: There is a seasonal variation in the prevalence of births leading to schizophrenia with an excess of births in winter and spring months. References:

Answer 290

Correct Answer: D. Descriptive studies do not prove causation A descriptive study's data are measurable, numerical, and are evaluated by standard statistical testing. It is not possible to prove causation with a descriptive study, although the correlation between variables may provide a direction for further research. Incorrect Answers: A. A descriptive study's data are evaluated by standard statistical testing. B. A descriptive study's data are measurable. C. A descriptive study's data are numerical. Vital Concepts: A descriptive study's data are measurable, numerical, and are evaluated by standard statistical testing. It is not possible to prove causation with a descriptive study, although the correlation between variables may provide a direction for further research. References:

Answer 291

Correct Answer: D. NP practice is not regulated by the Department of Health and Human Services Nurse practitioners are regulated by the Nurse Practice Act of the state where he or she plans to practice. The legal right to practice is derived from state law, which contains regulations that mandate educational requirements, responsibilities, and scope of practice for nurse practitioners (and other nurses in the state). NP practice is not regulated by the federal government, the Department of Health and Human Services, or the American Medical Association. Enforcement of each state’s Nurse Practice Act is the responsibility of the state board of nursing, a formal governmental agency with statutory authority to regulate nursing practice. The board of nursing in each state has legal authority to license, monitor, and discipline nurses. The board of nursing also has the authority to revoke a nurse’s license, after formal hearing. Incorrect Answers: A. The first NPs were pediatric NPs who practiced in rural areas with a shortage of physicians. B. Dr. Loretta Ford and Dr. Henry Silver developed the first Nurse Practitioner (NP) program at the University of Colorado in 1965. C. NP practice is not regulated by the federal government, the Department of Health and Human Services, or the American Medical Association. Vital Concepts: Nurse practitioners are regulated by the Nurse Practice Act of the state where he or she plans to practice. The legal right to practice is derived from state law, which contains regulations that mandate educational requirements, responsibilities, and scope of practice for nurse practitioners (and other nurses in the state). References:

Answer 292

Correct Answer: D. Paroxetine Paroxetine is known to cause cardiovascular malformations after first-trimester exposure, compared to exposure to other antidepressant medications. Infants exposed to paroxetine during the first trimester have a 1.5-2x increased risk of developing cardiovascular malformations compared to other SSRIs. Incorrect Answers: A, B, and C. While these are SSRIs, they haven't been shown to increase infants' risk of developing cardiovascular malformations to the same degree as Paroxetine. References:

Answer 293

Correct Answer: C. Two or more primary criteria for Schizophrenia in addition to criteria for mood disorder (mania or depression) A major mood episode must be present for the majority of the disorder’s total duration after Criterion A has been met. DSM-5-TR criteria for schizoaffective disorder include: The patient must have two sets of symptoms simultaneously: · Symptoms of a major depressive episode (MDE) or mania- the patient must meet the criteria, including poor or sad mood for the majority of the day most days · At least two primary symptoms of schizophrenia: o speaking incoherently without logical organization* o a misconception, belief, or thought that is firmly held despite not being grounded in reality* o illusions or perceived experiences that do not exist (e.g., sounds, voices, smells, visions, feelings, etc.)* o actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) o decreased display of emotion or a lack of motivation · The symptoms of schizophrenia must be present for at least two weeks alone, without the mood symptoms listed above · Mood symptoms are then present for the majority of the episode/illness · The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition · The disorder should be classified as Bipolar type if mania is present or Depressive type if ONLY depressive symptoms are present. Incorrect Answers: A. The patient must experience an uninterrupted period of illness during which there is a mood episode (major depressive episode or mania) concurrent with Criterion A of schizophrenia. B. Delusions, or hallucinations for 2 or more weeks in the absence of a mood episode (major depressive episode or mania) during the lifetime duration of the illness. D. Disturbance is not attributable to the effects of a substance or another medical condition. Vital Concept: The patient must have two sets of symptoms simultaneously, including a mood disorder (major depressive episode or mania) and at least two primary symptoms of schizophrenia. References:

Answer 294

Correct Answer: A. Theory of Cultural Care (Madeline Leininger) People from diverse cultural groups often experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions in differing manners. Incorrect Answers: B. The provider's self-care isn't in play in this situation; this theory isn't helpful in this case. C. This theory concerns the patient becoming a unitary being in continuous interaction with his environment; this theory isn't helpful in this case. D. This theory concerns healthy living; this theory isn't helpful in this case. Vital Concept: Commonly in Latino culture, the expression' ataque de nervios' is used to describe screaming uncontrollably, crying, or verbal/physical aggression. Madeline Leininger developed the Theory of Cultural Care, recommending using cultural-based knowledge to provide comprehensive care to patients. Nursing Interventions are not included in this theory as they are usually imposed practices that may offend certain cultures. References:

Answer 295

Correct Answer: B. In vivo exposure In vivo exposure, sometimes called flooding, is a method of psychotherapy in which patients are instructed to enter (in vivo) the situation causing them anxiety to decrease the anxiety associated with the exposure. Systemic desensitization may include flooding (in vivo exposure) or may utilize imagined exposure to increasing severity of feared scenarios as well as progressive muscle relaxation. Incorrect Answers: (A) Habit-reversal therapy. Habit-reversal therapy used to treat repetitive behavior disorders (e.g. Tourette's syndrome or tic disorders). Consists of awareness training, competing response training, contingency management, relaxation training and generalization training. (C) Guided discovery. Guided discovery is used in teaching to guide students to learn on their own. (D) Psychodynamic therapy. Psychodynamic therapy is long term talk therapy focusing on discovering unconscious processes that effect patient's current behaviors. References:

Answer 296

Correct Answer: C. It takes into consideration similar past situations Reflective thinking, according to the model developed by Taggart and Wilson (2005), is a process that includes identification of a problem and consideration of the problem or situation from the perspective of a third person in order to frame it, which involves observation, collection of data, reflection, and consideration of moral principles. This consideration should provide context or a way to frame the situation, taking into account similar past events and any solutions you may have used successfully in similar situations. After identifying possible approaches, reflective thinking includes observation and testing, with a final review of any action taken and the consequences of that action. Incorrect Answers: A. Reflective thinking is both an internal and an external process. B. When considering how to frame or reframe a problem or situation, an objective third-person viewpoint is useful. When defining the context of the situation, reflective thinkers will observe, gather data, reflect, and consider moral principles. D. Routine approaches within your experience may provide possible solutions to a problem. Vital Concepts: Reflective thinking is a process that includes identification of a problem and consideration of the problem or situation from the perspective of a third person in order to frame it, which involves observation, collection of data, reflection, and consideration of moral principles. References:

Answer 297

Correct Answer: A. Its proposed mechanism of action is that of a dopamine reuptake inhibitor. Modafinil is a schedule 4 controlled substance and has a proposed mechanism of action as a dopamine reuptake inhibitor. It is FDA-approved for use in narcolepsy, shift-work disorder, and excessive tiredness from obstructive sleep apnea. Used off-label in attention deficit and hyperactivity disorder (ADHD), fatigue, and treatment-resistant depression. Common side effects include increased blood pressure/heart rate, diarrhea, headache, and insomnia. Rare side effects include Stevens-Johnson syndrome, angioedema, multi-organ hypersensitivity reaction, and psychosis/mania/agitation. Incorrect Answers: B. Modafinil can rarely, not often, cause Stevens-Johnson syndrome. This is why although clinical efficacy in children was demonstrated, modafinil is not approved for use in children due to increased risk of Stevens-Johnson syndrome even a rare risk. C. Common side effects include tachycardia and hypertension, not bradycardia and hypotension. D. Modafinil is not FDA-approved for depression; it has been used off-label to in treatment-resistant depression as an adjunct to antidepressants. Vital Concept: Modafinil is a schedule 4 controlled substance, dopamine reuptake inhibitor and is FDA approved for narcolepsy, shift work disorder, and excessive tiredness from obstructive sleep apnea. References:

Answer 298

Correct Answer: C. Recall Recent memory operates on a scale of minutes to days. This bedside demonstration enhances the patient’s affective engagement with the task. Incorrect Answers: A. Procedural memory is not conscious, is automatically utilized, and includes complex motor activities like riding a bike and cognitive skills like reading. B. Remote memory operates on a scale of days to years. D. Episodic memory involves autobiographical events that can be consciously accessed and explicitly stated. Vital Concept: Problems of encoding, consolidation, and retrieval will cause errors of recall. Errors of recall might trigger other bedside tests, such as hiding objects around the patient’s room and asking the patient to locate them after several minutes. References:

Answer 299

Correct Answer: D. Patients often have elfin facies and starburst irises. Elfin facies and starburst irises are characteristic dysmorphic features of Williams syndrome. Incorrect Answers: A. Common comorbidities are anxiety disorders and depression. B. Patients typically have supravalvular aortic stenosis, renal artery stenosis, and hypertension. C. A genetic deletion occurs at chromosome 7. VitalConcept: Williams syndrome occurs due to a genetic deletion at chromosome 7. This typically leads to elfin facies, starburst irises, supravalvular aortic stenosis, renal artery stenosis, hypertension, anxiety, and depression. References:

Answer 300

Correct Answer: D. Hypnagogic hallucination Hypnagogic hallucinations are experienced when an individual is going to sleep. They also resolve quickly with full awakening and are known by the individual to have been non-existent. Incorrect Answers: A. Command hallucinations are a subtype of auditory hallucinations. The voices give commands to the person experiencing the hallucination. This patient is not reporting auditory hallucinations or command type hallucinations. B. Illusions are misinterpretations of actual stimuli. The individual will experience an actual sight or sound but will misinterpret the stimulus and manifest an inaccurate interpretation. For example, someone hears a dog barking but interprets it as a voice telling them to kill themselves. The real stimulus, a dog barking, is misinterpreted as a command to kill oneself. Hallucinations do not have a real stimulus that precipitates the hallucination. C. Hypnopompic hallucinations are hallucinations experienced when waking from sleep. These typically are brief and, once the individual is completely awake, resolve quickly and are known by the individual to have been non-existent. This patient has symptoms when going to sleep rather than when awakening. References:

Answer 301

Correct Answer: A. Clear and convincing evidence The standard of proof in a civil commitment, per the landmark US Supreme Court case Addington v. Texas (1979), is clear and convincing evidence. A preponderance of evidence is the standard of proof in a malpractice case. Guilt beyond a reasonable doubt is the standard of proof in a criminal case. Incorrect Answers: B, D. This is the isn't the standard of proof in any type of case C. This is the standard of proof in a malpractice case References:

Answer 302

Correct Answer: C. 1600/2000 Accuracy is the number of true positives and true negatives divided by the entire population tested. For clarity, it may be helpful to make a 2x2 table as shown below. Taking the number of true positives and true negatives divided by the total population gives 1600/2000. The accuracy of a binary classification test is the measure of how well the test correctly identifies or excludes a condition. It refers to the degree to which an estimate is immune from systematic error or bias. It also reflects the degree to which a measurement or test reflects a true value. Accuracy may be determined when the sensitivity, specificity, and prevalence are known. When the term is used to refer to a psychometric instrument of measurement, it is often used interchangeably with the term validity. In contrast, 600/750 Incorrect Answers: A. 600/750. Reflects the precision of the test or the proportion of true positives divided by all positive tests (true and false positives). Precision is the degree to which repeated measurements under unchanged conditions show the same results. A measurement or test is valid when it is both accurate and precise. B. 1000/1150. This is the specificity of the test. Specificity= (true negatives)/ (false positives+ true negatives). Specificity is the probability the test will be negative among those who do not have the disease. C. 600/850. This is the sensitivity of the test. Sensitivity= (true positives)/ (true positives + false negatives). Sensitivity is the probability that the test will be positive among those who have the disease. Vital Concepts: Accuracy is the number of true positives and true negatives divided by the entire population tested. References:

Answer 303

Correct Answer: C. Patients should not use alcohol or sedating antihistamines (e.g. diphenhydramine) while on benzodiazepines due to increased risk of accidents. Even without concomitant use of alcohol and sedating antihistamines, there is a higher risk for motor vehicle accidents and for accidental injuries in patients taking benzodiazepines. The greatest risk of accidental injuries is during the first 2-4 weeks of therapy. Incorrect Answers: A. Cognitive effects are greatest in the elderly. Patients with delirium and dementia are especially at risk. B. Initial side effects can persist and worsen in patients with liver disease and those taking longer-acting agents (e.g. diazepam). D. These psychological effects are uncommon. References:

Answer 304

Correct Answer: A. Diarrhea and cramps The gut is lined with 5-HT receptors. By blocking 5-HT reuptake, fluoxetine causes gastrointestinal problems like nausea, diarrhea, cramps, and heartburn. Incorrect Answers: B. Fluoxetine is not associated with hypertension. C. The anticholinergic activity of fluoxetine is low. Constipation is not a commonly reported side effect. D. Hyponatremia is a serious but uncommon side effect of fluoxetine, occurring more often in the elderly population. The mechanism of action is likely SSRI-induced SIADH. References:

Answer 305

Correct Answer: C. Stigma is a significant barrier for people who are seeking treatment for mental health. There are many barriers to treatment for individuals with diagnosed mental illness. These include health disparity, cost, lack of available services, and stigma. Stigma is a significant barrier that prevents many persons with mental illness from receiving treatment. Incorrect Answers: A. Mental illness can influence the onset, progression, and outcome of physical illness and overall health and well-being. It should be treated with the same urgency that physical illness is treated. Many individuals with mental illness have health risk behaviors that include substance abuse, tobacco use, and physical inactivity. B. Effective treatment of mental disorders is available. D. One in ten children in the United States are estimated to have a mental disorder. References:

Answer 306

Correct Answer: C. Therapeutic goal is to identify negative cognitions. Behavioral couples therapy is distinct from subsequent therapies. Cognitive-behavioral couples therapy does not emphasize cognition. Incorrect Answers: A. Behavioral couples therapy is based on operant conditioning in which the increase of social reinforcers decreases dyadic stress. This is accomplished through behavioral exchange. B. Behavioral couples therapy is based on operant conditioning, in which decreases in social punishers decrease dyadic stress. D. Couples behavioral therapy seeks to replace conflict with a problem-solving approach consisting of problem definition and problem solution. References:

Answer 307

Correct Answer: C. Do not perform a test for alcohol without the patient's permission. A healthcare provider cannot perform any procedure or test on a patient unless the patient has agreed, even when the treatment will be beneficial to the patient. A healthcare provider can only violate patient autonomy if there is a risk of harm to others. In most cases, questions about drug or alcohol use can be asked routinely during an office visit. If a competent adult does not acknowledge a problem or ask for assistance, the healthcare provider cannot act on the request of a family member, even if the healthcare provider feels it would be in the patient’s best interest. Incorrect Answers: A. This would be a violation of patient autonomy B. and D. If a competent adult doesn't acknowledge the problem or ask for assistance, the healthcare provider can't act on the request of a family member Vital Concepts: A healthcare provider cannot perform any procedure or test on a patient unless the patient has agreed, even when the treatment will be beneficial to the patient. A healthcare provider can only violate patient autonomy if there is a risk of harm to others. References:

Answer 308

Correct Answer: D. Barriers to healthcare that may be encountered by the target population should be considered When identifying a target population in the assessment of community health needs for implementation of a community health program, a narrow definition is used for planning purposes. Community health programs provide care for all who request it, but they are designed specifically to meet the needs of the target population. Incorrect Answers: (A) The target population is a group of people in the defined service area who are unserved or underserved and are experiencing health disparities as a result. (B) The target population is a group of people in the defined service area who are unserved or underserved and are experiencing health disparities as a result. (C) It is usually a subset of the total population and can be identified by obtaining demographic and health status information about the community, the amount of accessible health care available, and barriers faced by people in the target population. Vital Concept: When identifying a target population in the assessment of community health needs for implementation of a community health program, a narrow definition is used for planning purposes. Community health programs provide care for all who request it, but they are designed specifically to meet the needs of the target population. References:

Answer 309

Correct Answer: B. Methotrexate Taken orally, methotrexate helps psoriasis by decreasing the production of skin cells and suppressing inflammation. When methotrexate is used for long periods, it can cause a number of serious side effects, including severe liver damage and decreased production of red and white blood cells and platelets. Because Clozaril puts the patient at risk for leukopenia, adding methotrexate places the patient at increased risk for the reduction of white blood cells. An alternative treatment for psoriasis should be discussed with the patient and primary care manager and the methotrexate be discontinued. Incorrect Answers: A. Coal Tar is a thick, black byproduct of the manufacture of petroleum products and coal. It reduces scaling, itching and inflammation. Coal tar has few side effects, but it is messy and has a strong odor. C. Tazarotene (Tazorac) is a Vitamin derivative that normalizes DNA activity in skin cells and my decrease inflammation. The most common side effect is skin irritation. D. Calcipotriene (Dovonex) is a prescription cream or solution containing vitamin D analogue that may be used alone to treat mild to moderate psoriasis or in combination with other topical medications. The side effect of calcipotriene is skin irritation. References:

Answer 310

Correct Answer: D. He can throw a ball and try to scribble. This is within his 18-month milestones and would be considered a normal development, if the child could not yet throw a ball or attempt to scribble, this may be an indication there are more delays involved. It will be important on the exam to be aware of any information that may lead you to believe the patient is or is not meeting their milestones. Milestones help diagnose many normal or abnormal developments in children and is a basic assessment skill. Incorrect Answers: A. At 16 weeks a baby should be aware of a strange situation and if they are not other delayed milestones need to be evaluated. B. He should have been sitting up many months before. 4 months is the average age for this milestone. C. At 40 weeks a baby should understand peek-a-boo and other simple games. References:

Answer 311

Correct Answer: D. Auditory hallucinations may be due to overactivation in the temporal-parietal cortex. Auditory hallucinations appear to be the result of abnormal activation of the neural system serving auditory sensory processing. In a study of patients with schizophrenia with auditory hallucinations, onset and offset of hallucinations correlated with engagement and disengagement of the primary auditory cortex. There is activation of Heschl's gyrus during auditory hallucinations and in response to acoustical stimulation. Functional neuroimaging studies have shown overactivation in the temporal-parietal cortex during auditory hallucinations. Consequently, treatment of auditory hallucinations could be effected through the deactivation of this region. Incorrect Answers: A. There is activation of the Heschl's gyrus during auditory hallucinations. B. Hallucinations are related to the primary auditory cortex. C. Hallucinations are a positive symptom of schizophrenia and are related to sensory disturbances. Vital Concept: Functional neuroimaging studies have shown overactivation in the temporal-parietal cortex during auditory hallucinations. References:

Answer 312

Correct Answer: A. Illness anxiety disorder Due to the patient’s preoccupation with health concerns despite good overall health, they likely have illness anxiety disorder. They want exams done more frequently than recommended, as they fear developing a disease. The diagnostic criteria for IAD include: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months. The illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Incorrect Answers: B. Body dysmorphic disorder occurs when a person has an unrealistic belief that a body part is somehow malformed. C. While illness anxiety disorder may cause the patient anxiety, generalized anxiety disorder is not the best diagnosis. The patient's concerns and worries are not pervasive and present in multiple locations or in multiple situations. They are limited only to their physical health. D. Although this syndrome may at first appear to be malingering, somatization, or even conversion disorder, the best diagnosis is illness anxiety disorder as there is no evidence of underlying secondary gain or conscious intentionality to the patient's actions. Vital Concept: Illness anxiety disorder is characterized by consistent concern or worry about illness . References:

Answer 313

Correct Answer: C. A 20-year-old woman who continues to visit multiple dermatologists for treatment of her "severe acne," but physical evaluation reveals no blemishes This patient perceives that she has severe acne, although the objective views of her doctors reveal no problem. She has body dysmorphic disorder, which should be managed with psychological treatment. Incorrect Answers: A. Although plastic surgeons are likely to encounter patients with body dysmorphic disorder, due to their desire to fix their perceived physical flaws, there is nothing to suggest that this patient does not have uneven breasts. It is possible that this woman is completely warranted in her perception and would gain some benefit from surgery. If the patient had no physical asymmetry, then this could be diagnosed as body dysmorphic disorder. B. This describes a pain disorder and would more likely be a somatization disorder or PTSD syndrome. D. This describes agoraphobia. References:

Answer 314

Correct Answer: B. C-Reactive Protein CRP, an acute phase reactant, is a protein made by the liver and released into the blood within a few hours after tissue injury, the start of an infection, or other cause of inflammation. Because the patient was recently put on medication to decrease inflammation, the recently drawn CRP should be lower than it was with when the rheumatoid arthritis was initially diagnosed if the medication the patient was started on is effective. Incorrect Answers: A. Methotrexate is a medication to treat (decrease or suppress) inflammation, not a lab test to detect inflammation. C. Uric Acid is used to measure the level of uric acid in the blood and is indicative of gout. Uric acid lab value is not used to monitor rheumatoid arthritis. D. B-type Natriuretic Peptide (BNP). When the BNP level is elevated, that is suggestive of heart failure. BNP is not used to monitor rheumatoid arthritis. References:

Answer 315

Correct Answer: A. Fee for service system Incorrect Answers: B. Third party reimbursement includes private insurance and is the most common type of reimbursement. C. The NP signs a contract and agrees to provide health care for a certain population, such as the homeless. D. Second party reimbursement occurs when a legal guardian/guarantor makes a direct payment for services. Vital Concepts: Fee for service reimbursement occurs when the patient pays the nurse directly for specific services provided. References:

Answer 316

Correct Answers: B. Refractory epilepsy D. Treatment-resistant depression in adults E. Treatment-resistant depression in children in ages 12-17 Vagus nerve stimulation (VNS) is FDA indicated for treatment-resistant depression in adults and refractory epilepsy (ages 12 and up). In 2017 in the United States a noninvasive VNS "gammaCore" was FDA approved for cluster headaches in adults. Other areas of current study for the use of VNS are anxiety, obesity, and pain. VNS is a battery-powered device similar to a cardiac pacemaker. In most models, stimulating leads are surgically placed around the left vagus nerve in the carotid sheath and are connected to an infraclavicular subcutaneous programmable pacemaker. Pulses stimulate the vagus nerve at regular intervals, typically for 30 seconds every 5 minutes. Side effects include voice hoarseness, cough, neck pain, shortness of breath, infection, and nerve damage. Mechanism of action of VNS to treat depression is unclear but it is thought to be related to the vagus nerve stimulating the locus coeruleus and median raphe nucleus which could potentially stimulate serotonin and norepinephrine release. VNS is not typically covered by insurance. Because the right vagus nerve provides more innervation to the cardiac atria than the left vagus nerve, electrical stimulation of the left vagus nerve is generally used in clinical practice to avoid adverse cardiac effects. Incorrect Answers: A. The FDA has approved the antidepressants duloxetine (Cymbalta) and milnacipran (Savella) as well as the anti-seizure medicine pregabalin (Lyrica). C. A large, multisite clinical trial yielded the FDA approval of deep brain stimulation (DBS) in the subthalamic nucleus (STN) or globus pallidus internus (GPi) to treat motor symptoms in advanced Parkinson's disease (PD) in 2002. Istradefylline (Nourianz) is a new drug approved by the FDA for pharmacologic management of off episodes in adults with PD. Vital Concept: Vagus nerve stimulation (VNS) is only FDA indicated for treatment-resistant depression ages 12 and older and refractory epilepsy (ages 12 and up) at this time. References:

Answer 317

Correct Answer: B. Decreased formation of Purkinje cells in cerebellum Brains of individuals with autism spectrum disorders (ASD) have decreased formation of Purkinje cells in the cerebellum. ASD represents a diversity of conditions that vary in severity from Asperger’s disease (mild symptoms, less cognitive impairment) to Rett’s disease (severe symptoms, profound impairment), with considerable variation between types. Although a variety of brain anomalies occur in patients with ASD, a single unifying brain process has not yet been identified that is common to all patients with ASD. Also, 7% of patients with ASD have been identified with abnormalities at the mitochondrial level. Abnormal brain connections or organizational and biochemical changes may contribute to ASD. Incorrect Answers: A. Patients with ASD have increased overall brain size. C. Patients with ASD experience accelerated growth of the head during infancy. D. Although other portions of the brain are thought to demonstrate abnormal structure in patients with ASD, the brainstem is not affected. References:

Answer 318

Correct Answer: D. Individuals with OCD and intellectual disability have increased anxiety with response-blocking intervention. Patients with stereotypy (repetitive, simple movements that can be voluntarily suppressed) will have increased anxiety with response-blocking intervention. Incorrect Answers: A. Anxiety disorders are common in patients with intellectual disability, and anxiety around transitions (daily and developmental) is often seen. B. If there is an acute change from baseline behavior, trauma and posttraumatic stress needs to be considered. This population is particularly vulnerable to exploitation by others. C. Sensory-integration interventions are employed under the guidance of a qualified occupational therapist. Vital Concept: Patients with stereotypy will have increased anxiety with response-blocking intervention. References:

Answer 319

Correct Answer: A. Yes, augmentation is clinically indicated with a partial response. According to the Texas STAR-D algorithm, an agent with a partial response can be augmented or changed. Augmentation is indeed plausible. Can also consider maximizing the primary agent before adjunct. This question asked if augmentation was plausible and it is a reasonable option. In the STAR-D trial at level one patient's were trialed on citalopram, a selective serotonin reuptake inhibitor, and if did not reach remission advanced to level two. In level two patient's where either switched to sertraline or venlafaxine; or an adjunct (bupropion or buspirone) was added to citalopram. Incorrect Answers: B. No, the patient is unlikely to achieve remission with this agent. This is a false statement. It is common for a patient to be able to achieve remission with an agent that patient did have not have full therapeutic effect to once an adjunct is added. C. No, a change to another antidepressant class is needed. Changing to another antidepressant class is an option. However this answer also states that it is not reasonable to augment, of which it is. D. No, a full response is imminent, and the dose does not need to be changed. Patient’s last check up was 6 weeks ago when the patient was started on a selective serotonin reuptake inhibitor (SSRI). It is reasonable to considering increasing the dose or adding an adjunct after a 6-week trial on a SSRI without therapeutic effect. References:

Answer 320

Correct Answer: D. 22 Microdeletions in chromosomal region 22q11.2, including DiGeorge syndrome (DGS) and velocardiofacial syndrome, are associated with a 20-30x increased risk of schizophrenia. Studies provide various rates of 22q11.2 deletion syndrome in schizophrenia, ranging from 0.5-2.0% compared to the overall estimated 0.025% risk of the 22q11.2 deletion syndrome in the general population. About 30% of adults with DiGeorge syndrome have at least 1 incident of psychosis, and some studies suggest about 25% of these individuals develop schizophrenia. Incorrect Answers: A. 5. Microdeletion of 5p can lead to Cri-du-chat that consists of "cat like" cry, intellectually disabled, microcephaly, micrognathia and low set ears. B. 7. Microdeletion of 7q can lead to Williams with a loss of the elastin gene leading to elf like face, overly friendly and intellectually disabled. C. 15. Deletion of 15q11-q13 in mother (paternal imprinting) can lead to Angelman and deletion in father (maternal imprinting) can lead to Prader-Willi. Traits seen with Angelman include smiling, hyperactive, hypotonic, intellectually disabled, dysmorphic facial features and ataxic. Traits associated with Prader-Willi are short, obese, hyperphagia, intellectually disabled and dysmorphic facial features. Vital Concept: Microdeletions in chromosomal region 22q11 are associated with a 20-30x increased risk of schizophrenia. References:

Answer 321

Correct Answer: A. Functional somatic symptoms Medically not well-explained or functional somatic symptoms can be a symptom of sexual abuse in children. Children of sexual abuse can also have injuries, infections, pain, or bleeding in their genital area. Other possible symptoms include regression (bedwetting, thumb sucking, etc.), excessive talk about sexual acts or inappropriate knowledge of sexual acts, depression, anxiety, eating disorders and changes in school performance. Recognizing that “it’s normal to have a normal exam” is important in the evaluation of possible sexual abuse. Incorrect Answers: B. Children who have been sexually abused may have eating disorders and having normal eating patterns would not be an indication of sexual abuse. C. Children who have been sexually abused are more likely to talk excessively and inappropriately about sexual acts. D. Although sleep disturbances such as bedwetting and not wanting to sleep alone can be signs of sexual abuse, sleepwalking isn't known to be a symptom of sexual abuse in children. Vital Concept: Given that primary care providers assess pediatric patients on a regular basis they are at an advantage of being able to assess the family structure as well as interactions between child and caregiver routinely. Signs of child maltreatment should be a part of the primary care NPs evaluation during clinic visits and knowing how to report and refer to the appropriate authority is a part of the NPs scope of practice. References:

Answer 322

Correct Answer: A. Tardive dyskinesia can occur at lower rates with ziprasidone compared to other atypical antipsychotics. Although ziprasidone is associated with QTc prolongation, it is not clinically significant. There has been only 1 reported case of death secondary to cardiac arrhythmia. ECG monitoring is not advised, but the FDA warns that ziprasidone prolongs QTc and should not be used with other medications that prolong QTc. Tardive dyskinesia does occur, although rarely (see chart below). Incorrect Answers: B. Although ziprasidone is associated with QTc prolongation, the connection isn't clinically significant, and EGC monitoring isn't necessary C. This does not occur due to ziprasidone D. Very low weight gain is occasionally a rare side effect with ziprasidone use, but diabetes isn't a side effect References:

Answer 323

Correct Answer: A. Cocaine prevents dopamine reuptake, but amphetamine both slows reuptake of dopamine and induces dopamine release. Neurotransmitter activity is modulated by several mechanisms, including diffusion of the neurotransmitter out of the synaptic cleft, enzymatic degradation, and reuptake mechanisms. Monoamine neurotransmitter transporters mediate the reuptake process and are the sites of action of many drugs and neurotoxins. Cocaine prevents the reuptake of both dopamine and serotonin, while amphetamines not only slow the reuptake of dopamine and serotonin but also induce the efflux of dopamine by the presynaptic neuron. Incorrect Answers: B. These definitions are switched. Amphetamine slows reuptake of dopamine and induces dopamine release; it doesn't entirely prevent dopamine uptake. Cocaine prevents dopamine reuptake; it neither slows reuptake of dopamine nor induces dopamine release. C. It's true that amphetamine slows reuptake of dopamine and induces dopamine release; however, cocaine doesn't do this. It prevents dopamine reuptake. D. These statements are both true, but the statement of how amphetamine acts is incomplete. In addition to inducing dopamine release, amphetamine also slows reuptake of dopamine. References:

Answer 324

Correct Answer: C. Medicare Part D is a prescription drug benefit Medicare Part D is also known as the Medicare prescription drug benefit. Only individuals enrolled or eligible for Medicare Part A or Part B are eligible. The Medicare Advantage plan is one type of Part D coverage. All prescription drug plans have a formulary of preferred drugs. If a non-formulary drug is used, it may not be covered and the patient will have to pay for it out-of-pocket. Incorrect Answers: A. Medicare Part A and B patients are enrolled and eligible patients are eligible for Medicare Part D B. Not all prescription drugs are covered by Medicare Part D D. Some non-formulary drugs may be covered Vital Concepts: Medicare Part D is also known as the Medicare prescription drug benefit. Only individuals enrolled or eligible for Medicare Part A or Part B are eligible. The Medicare Advantage plan is one type of Part D coverage. All prescription drug plans have a formulary of preferred drugs. If a non-formulary drug is used, it may not be covered and the patient will have to pay for it out-of-pocket. References:

Answer 325

Correct Answer: A. FAB is based on operant conditioning. FAB is based on identifying antecedent stimuli, operant behaviors, and consequent stimuli. FAB may suggest treatment strategies such as stimulus control. Incorrect Answers: B. While FAB does identify stimuli that are possibly conditioned, the goal of FAB is modifying willful operant behaviors. C. FAB is concerned only with observable stimuli connected to operant behavior. D. Gestalt theory deals with perceptual psychology, not behavior. There is no theory of Gestalt conditioning. References:

Answer 326

Correct Answer: B. Preventing formation of free radicals and peroxynitrite in neurons Neurotoxicity is mediated by the formation of peroxynitrite, which can be reduced by antioxidants or L-carnitine. L-carnitine is needed to transport long-chain fatty acids into the mitochondria for fatty acid oxidation, preventing the generation of free radicals and peroxynitrite. Incorrect Answers: A. It decreases free radicals in the neuron. C. Vitamin E acts as antioxidant, but L-carnitine has no effect on it. D. L-carnitine is needed to transport long-chain fatty acids into the mitochondria for fatty acid oxidation. References:

Answer 327

Correct Answer: A. The care provided must comply with state restrictions and supervision requirements Nurse Practitioners may bill Medicare for services in accordance with state restrictions and supervision requirements. Incorrect Answers: B. Some states require direct supervision by a physician on the premises while others require indirect or periodical supervision. C and D. The Centers for Medicare and Medicaid Services (CMS) pay for NP services that are: Medically necessary; equivalent to physician services; accurately documented on medical records; and billed correctly. Medicare may directly reimburse the NP, if state law allows it. Vital Concepts: Nurse Practitioners may bill Medicare for services in accordance with state restrictions and supervision requirements. References:

Answer 328

Correct Answer: B. 5-HT1D and 5-HT1B agonist Sumatriptan is a 5-HT1D and 5-HT1B agonist. Incorrect Answers: A. Sumatriptan is a 5-HT1D, not 5-HT1A, agonist. It's also a 5-HT1B agonist. C. D. Aripiprazole is a 5-HT2C agonist and a weak partial agonist at 5-HT7.

Answer 329

Correct Answer: C. Special supervision of administration or storage may be necessary. Overdose is a significant adverse event associated with TCA use. Special supervision of administration and storage is important. TCAs have some evidence to be efficacious in adult ADHD but less effective than stimulants. TCAs have a wide range of side effects and are poorly tolerated compared to stimulants and other non-stimulant medications utilized for ADHD. Common side effects include dry mouth, constipation, weight gain, urinary hesitation, blurred vision and sexual dysfunction. Rare cardiac side effects (e.g. arrhythmias, AV block, QT prolongation, orthostasis) are the primary concern with TCAs especially in overdoses. Monitor EKG at baseline, at dosage increase, and every 3-4 months if on maintenance treatment. TCA plasma levels have not been shown to be related to efficacy but should be monitored at higher doses. Incorrect Answers: A. TCAs are metabolized primarily through the liver, not renally. B. TCA plasma levels have NOT been shown to be related to efficacy. D. TCAs have LESS robust evidence in treating ADHD than stimulants. Vital Concept: TCAs have some evidence to be efficacious in adult ADHD but less effective than stimulants. Due to poor tolerable and overdose toxicity risk, TCAs are rarely used for ADHD. If utilized special supervision of administration and storage is important due to overdose toxicity.

Answer 330

Correct Answer: B. Serotonin Serotonin is the most studied neurotransmitter in OCD and is the basis for the well-established efficacy of potent serotonin reuptake inhibitors in OCD treatment. Serotonin is thought to play a fundamental role in the pathogenesis of obsessions and compulsions. Patients with OCD have dopaminergic hyperfunction in the prefrontal cortex (mesocortical dopamine pathway) and serotonergic hypofunction in the basal ganglia. Recent evidence also implicates dysregulation in glutamate as well. Incorrect Answers: A. Norepinephrine works on the beta 1 adrenergic receptors as well as the alpha-adrenergic receptors that can increase heart rate and blood pressure. There are some drug classes such as SNRIs and NDRIs that are used to help treat depression related disorders. C. Dopamine is a neurotransmitter within the brain. Most often we see dopamine affected with ADHD. In schizophrenia medications are used to block dopamine (antipsychotics). Patients with OCD have dopaminergic hyperfunction in the prefrontal cortex but serotonin is the neurotransmitter that has the most evidence for its association with OCD. D. Glutamate is an excitatory CNS neurotransmitter. Decrease in function of both glutamate and NMDA have been associated with Schizophrenia. Other common neurotransmitters involved with Schizophrenia include GABA, Acetylcholine, and dopamine. There is supporting research that glutamate modulating drugs can be used with the treatment of OCD but serotonin is the neurotransmitter that has the most evidence for its association with OCD. Vital Concept: Serotonin is the most studied neurotransmitter in OCD and is the basis for the well-established efficacy of potent serotonin reuptake inhibitors in OCD treatment.

Answer 331

Correct Answer: A. Alcohol use disorder Alcohol use disorder, as defined in the DSM-5-TR, includes craving as a criterion for diagnosis. Incorrect Answers: B. Alcohol withdrawal does not involve craving as a criterion for diagnosis. C. Other alcohol-induced disorder does not involve craving as a criterion for diagnosis. D. Unspecified alcohol-related disorder does not involve craving as a criterion for diagnosis. Vital Concept: Alcohol use disorder includes the criterion of an intense need or impulse to drink alcohol.

Answer 332

Correct Answer: C. Eye blinking and throat clearing This child is presenting with symptoms of obsessive-compulsive disorder (OCD). Tourette’s syndrome is associated with OCD, showing substantial comorbidity (up to 30%) in family studies and suggesting a shared genetic diathesis. Eye blinking and throat clearing are the most common initial motor and vocal tics, respectively. OCD is also comorbid with anxiety disorders, depressive disorder, and bipolar disorders. In children there can be a triad seen between OCD, tic disorder and attention-deficient/hyperactivity disorder (ADHD). There are also associations between OCD and body dysmorphic disorder, trichotillomia, excoriation disorder, and oppositional defiant disorder. Patients with OCD are also commonly diagnosed with anxiety disorders (76%), mood disorders (63%), and substance use disorders (39%). Incorrect Answers: (A) There is no correlation between OCD and sleep/wake disorders. (B) There is no correlation between OCD and below-average intelligence. (D) There is no correlation between OCD and increased risk of fear of animals. Vital Concept: OCD and Tourette's syndrome

Answer 333

Correct Answer: B. Fluoxetine Fluoxetine (selective serotonin reuptake inhibitor) and bupropion (norepinephrine and dopamine reuptake inhibitor) are antidepressants that can increase insomnia and activation. When starting a patient on an SSRI and the patient could benefit from activation then consider fluoxetine (Prozac). Fluoxetine is FDA approved for major depressive disorder, obsessive-compulsive disorder, panic disorder, bulimia, and premenstrual dysphoric disorder. Also used off-label in anxiety disorders and posttraumatic stress disorder. Dose range is 20 to 80 mg daily and has a long half-life of 4-6 days. Incorrect Answers: A. Citalopram. Citalopram can be associated with dose dependent insomnia but also sedation. Fluoxetine is the SSRI that is most associated with activation and is the best answer choice. C. Paroxetine. Paroxetine is associated with sedation, not insomnia. D. Mirtazapine. Mirtazapine is an antidepressant with noradrenergic and serotonergic activity. It is sedating and is utilized to help patients with insomnia and appetite stimulation. Lower doses are more sedating because at higher doses there is increased noradrenergic effect compared to antihistaminergic effect. Vital Concept: Fluoxetine (selective serotonin reuptake inhibitor) and bupropion (norepinephrine and dopamine reuptake inhibitor) are antidepressants that can increase insomnia and activation.

Answer 334

Correct Answer: A. Narcissist and borderline patients share core features of borderline personality organization. Kernberg asserts that the narcissist and borderline patient both share a borderline personality organization. Incorrect Answers: B. Borderline personality organization consists of pathological internalized object relations. C. D. These accurately depict how Kohut conceptualized and treated people with narcissistic personality disorder. Overall, Kohut tended to be more supportive and introspective, while Kernberg gently confronted defenses more actively.

Answer 335

Correct Answer: D. Nurses can request an opportunity to testify in a committee The centers of policy making in a legislative body at the state or federal level are committees, which is where proposed legislation receives the greatest scrutiny. After legislation is proposed, the committee chairman sets an agenda for consideration of a policy or bill by negotiating with members of the committee. The procedures of a committee serve the function of gatekeeping, by determining which pieces of legislation will be considered, out of the many proposed actions that arrive from the members of a legislative body. Meetings of a committee are held to educate members of the committee and the public about the bill that is being considered. During a hearing, individuals can request the opportunity to testify, although representatives of large organized groups are more likely to get those opportunities. Individuals may still influence the committee by speaking privately to staffers or members. Individual nurses may request the opportunity to speak to a committee, but may be more successful as part of a large nursing organization with shared vision. Incorrect Answers: A. The most intense consideration of proposed legislation occurs within a committee. B. The committee has a gatekeeper function and determines which of the many pieces of proposed legislation will be considered and sent for a vote. C. The committee chair sets the agenda for the committee by negotiation with committee members. Vital Concepts: During a hearing, individuals can request the opportunity to testify, although representatives of large organized groups are more likely to get those opportunities. Individuals may still influence the committee by speaking privately to staffers or members. Individual nurses may request the opportunity to speak to a committee but may be more successful as part of a large nursing organization with a shared vision.

Answer 336

Correct Answer: A. Behavioral exchange, communication training, and problem-solving Behavioral couples therapy involves behavioral exchange, communication training, and problem-solving. Incorrect Answers: B. Cognitive restructuring is a component of cognitive-behavioral therapy. C. Imaginal exposure is a component of cognitive-behavioral therapy. D. Successive approximation is an operant conditioning technique used to develop complex behaviors, often in animals.

Answer 337

Correct Answer: A. Nursing associations may sponsor state legislative days Membership in a professional nursing association can help nurses become familiar with political advocacy. Professional associations have the resources to monitor and disseminate important policy information that affects healthcare. Many state nursing and specialty nursing societies sponsor annual state legislative days and may also conduct policy workshops to educate members about the current issues in health care and about the legislative process. Some organizations provide experienced mentors for members who would like to become involved in political advocacy for the first time. There are many opportunities for a nurse interested in influencing the formation of health policy. Incorrect Answers: B. Professional associations often support candidates who are supportive of nursing and healthcare issues. C. Complex issues usually require the concerted efforts of many individuals who work together to reach a common goal. D. Some professional associations have formed political action committees that determine where candidates stand on important issues and how their membership can help those candidates who support nursing and health care improvement. Vital Concepts: Professional associations have the resources to monitor and disseminate important policy information that affects healthcare. Many state nursing and specialty nursing societies sponsor annual state legislative days and may also conduct policy workshops to educate members about the current issues in health care and about the legislative process.

Answer 338

Correct Answer: C. ECT Electroconvulsive therapy (ECT) may continue to have a role in the rapid treatment of acute and subacute states that are refractory to pharmacological intervention, particularly catatonia. ECT is quite safely administered, with minimal short-term adverse events and no evidence for long-term morbidity. Short-term cognitive dysfunction is common. For this patient, ECT is recommended as an adjunctive therapy to control behavioral symptoms as well as agitation with the continual of antipsychotic medications. Use of lithium is a relative contraindication given its association with post-ECT delirium. Use of anti-epileptics and benzodiazepines may reduce seizure time and increase seizure threshold. Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics, such as haloperidol, bind the dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, a blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while a lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each second-generation drug has a different binding affinity (e.g. risperidone is high, and clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors as well, which may also contribute to their clinical effects. Second-generation drugs are more effective for treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis (at higher than maintenance dosage). Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used to treat their depression or anxiety disorders. ECT can also be used in schizophrenia for catatonia. Early studies also suggest that TMS might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT are important in the treatment success of schizophrenia. Incorrect Answers: A. Benzodiazepines can be used in conjunction with other antipsychotics for sedation. In this refractory case, ECT is an ideal recommendation. B. Beta-blockers are used for the treatment of akathisia, aggression, restlessness, and impulsivity in conjunction with the treatment of schizophrenia. D. Lithium is used for managing aggressive and impulsive behaviors in conjunction with other treatment modalities in schizophrenia. For catatonic symptoms, ECT is a better conjunction therapy for behavioral management.

Answer 339

Correct Answer: D. Ventricular arrhythmia can result from TCA overdose. Ventricular arrhythmia and seizures are seen with TCA overdose; cardiovascular effects are a frequent cause of death in overdoses. Incorrect Answers: A. TCAs are associated with an increased risk of MI when compared to SSRIs. It is unclear whether SSRIs reduce a depression-mediated decreased MI risk or whether TCAs increase the risk of MI associated with depression. B. Cardiac conduction defects are most severe with desipramine. C. TCAs are structurally similar to class I antiarrhythmics that are actually proarrhythmic in 20% of the population; approximately 20% of patients with preexisting conduction disturbances have cardiac complications while taking TCAs.

Answer 340

Correct Answer: D. Symptoms can be associated with another medical condition. SSD diagnosis does not require that somatic symptoms are medically unexplained. In other words, symptoms may or may not be associated with another medical condition or diagnosis. To meet the criteria for SSD, patients must have: At least one somatic symptom that substantially impacts the patient’s daily functioning or leads to anguish The patient then develops extraordinary actions, emotions, or ruminations regarding the symptom(s) or related medical condition(s), as evidenced by one or more of the following: · consistent worry or concern about their physical wellbeing · extraordinary devotion of resources (e.g., energy, time) to the symptom(s) or related medical condition(s) · ruminations that are consistent and unbalanced regarding the gravity and meaning underlying these symptoms These conditions persist for at least 6 months, although the specific symptom of focus may vary or shift during that time Specifiers include: · with prominent pain if the symptoms involve physical discomfort · persistent if the symptoms are severe, enduring (greater than 6 months), and cause substantial dysfunction · mild/moderate/severe based on the number of symptoms listed above that are present (1/2/2+ multiple symptoms) Incorrect Answers: A. SSD patients are rarely reassured by medical visits and may feel that their medical care is insufficient even with frequent visits. B. Symptoms need to persist for six or more months to be diagnosed. C. SSD diagnosis doesn't require that somatic symptoms be medically unexplained. Symptoms may or may not be associated with another medical condition or diagnosis. However, to meet the criteria for SSD, patients must have one or more chronic somatic symptoms and meet other criteria. Vital Concept: Somatic symptom disorder (SSD) is a disease with somatic symptoms that must be significantly distressing or disruptive to daily life and must be accompanied by excessive thoughts, feelings, or behaviors.

Answer 341

Correct Answer: B. Identity vs. Role confusion John is struggling with the developmental task of Identity vs. role confusion. This is evidenced by no plans for the future and no sense of identity or belonging. Industry vs. inferiority is more related to sense of accomplishment and the ability to work, which John is not struggling with. Intimacy vs. isolation could have been considered due to the lack of social relationships, however identify vs. role confusion was a better answer due to the lack of self-identity. Generativity vs. self-absorption or stagnation is experienced during middle adulthood. Incorrect Answers: A. This stage involves learning to read and create.. Presumably, John is beyond this stage (which should be ages 5-12). C. This stage is about seeking intimacy to avoid feeling isolated. John is too young for this stage (which should be ages 18-40). D. This stage involves establishing careers and families. John is too young for this stage (which should be ages 40-65).

Answer 342

Correct Answer: B. Requires the protection and confidential handling of protected health information HIPAA addresses the rights of the individual and family to continue insurance after a job loss or change and to maintain the privacy of their health information. HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following: - Protects the transfer of health information for continuity of care - Reduces health care fraud and abuse - Mandates industry-wide standards for health care information on electronic billing and other processes - Requires the protection and confidential handling of protected health information Incorrect Answers: A. HIPAA mandates industry-wide standards for health care information on electronic billing, not paper billing C. This is a mandate of the Affordable Care Act. D. This is a mandate of the Affordable Care Act. Vital Concept: HIPPA was created to “improve the portability and accountability of health insurance coverage” for employees between jobs. Once it was established, the Privacy Rule was enacted for Protected Health Information (PHI) giving patients permission the right to privacy of their health information and the ability to withhold it in certain circumstances. Under HIPPA, patients have a right to privacy of their PHI.

Answer 343

Correct Answer: C. All staff All staff members are responsible for identifying performance improvement projects. Incorrect Answers: A. Continuous Quality Improvement (CQI) is a management philosophy that emphasizes the organization structure, and system processes, rather than individuals. B and D. Total Quality Management (TQM) is a management philosophy to meet the needs of customers (patients and staff) at all levels. Vital Concept: All staff members are responsible for identifying performance improvement projects.

Answer 344

Correct Answer: C. Expect that a child testing negative would have a 99.9% chance of not having the condition. Positive predictive value (PPV) is the probability that patients with a positive screening test have the condition. In this question, for a patient who has a positive screening test, there is a 2.5% probability that he or she has autism (see figure below). This test has a poor PPV because only 2.5%, or 1 out of 40, of the patients with a positive screen, will ultimately be diagnosed with the condition. Negative predictive value (NPV) is the probability that patients with a negative screening test do not have the condition. If a child screens negative, there is a 99.9% probability that he or she does not have the condition. This test has a good NPV given the fact if the child's screen is negative there is a 99.9% probability that he or she does not have the condition (the test was correct). Positive Predictive Value = (Condition / Screen Positive) = a/(a+b). Negative Predictive Value = (Condition-Free / Screen Negative) = d/(c+d). Has the condition Does not have the condition Total Screen Positive a b a+b Screen Negative c d c+d a+c b+d N Incorrect Answers: A. A positive predictive value of 2.5% indicates that a child who tests positive would only have a 2.5% chance of having the condition. B. Since only 2.5% of patients who screen positive will ultimately have the condition, the remaining 97.5% of children testing positive will not have the condition. This means that a child testing positive would have a 97.5% chance of not having the condition. D. Since 99.9% of patients who have a negative screening do not have the condition, this means the remaining 0.1% of patients who screen positive do have the condition. Therefore, a negative predictive value of 99.9% indicates that the probability of still having the condition with a negative screening is only 0.1%. Vital Concept: Positive predictive value (PPV) is the probability that patients with a positive screening test have the condition. Negative predictive value (NPV) is the probability that patients with a negative screening test do not have the disease.

Answer 345

Correct Answer: B. The patient feels great pleasure/relief while committing the theft The DSM-5-TR defines kleptomania as: The repetitive urge to steal objects, even when they have no financial value or are not required or essential. The patient is unable to ignore these urges. The individual experiences increased strain and pressure directly before committing the crime. Once the crime is committed, the individual feels relaxed, satisfied, and fulfilled. The theft is not related to the presence of hallucinations or delusions and is not committed due to animosity or the need for retribution. Actions are not better explained by the presence of another mental health disorder, including conduct disorder, antisocial personality disorder, or a manic episode. Incorrect Answers: A. Items stolen are not of great value. C. Items stolen are not always the same thing D. Patients may or may not work in pairs Vital Concept: A defining characteristic of kleptomania is the elevated strain leading up to the act of stealing, followed by fulfillment and joy at the time of stealing.

Answer 346

Correct Answer: B. Severe poisoning that involves a coma is typically above a level of 850mg/L. Incorrect Answers: A. Valproic acid overdose can lead to CNS depression but is rarely fatal. C. Hemodialysis can also aid the removal of valproate. D. Thrombocytopenia and cerebral edema are associated with valproate poisoning but are rare Vital Concept: Key signs and symptoms of VPA toxicity include: CNS depression, lethargy and potential encephalopathy, respiratory depression, nausea/vomiting, and myoclonus. Lab abnormalities often include, in addition to elevated serum VPA levels, hypernatremia, elevated anion gap metabolic acidosis, hyperosmolality, hypocalcemia, and hyperammonemia with a transaminitis. A non-contrast head CT may demonstrate cerebral edema, the peak occurrence of which is between 12 hours and 4 days after ingestion. Activated charcoal can be given early if the timing of overdose is known. Serial head CT scans should be ordered to monitor the possible delayed side effect of cerebral edema.

Answer 347

Correct Answer: C. Clomipramine This patient is suffering from obsessive-compulsive disorder. Clomipramine (a tricyclic antidepressant) and the selective serotonin reuptake inhibitors (SSRIs) are effective in treating this disorder. Incorrect Answers: A. This is a non-benzodiazepine anxiolytic that does not have marked sedative or euphoric effects. Unlike the benzodiazepines, buspirone does not have hypnotic, anticonvulsant, or muscle relaxant properties. B. This is an antipsychotic, and is not indicated to manage OCD. D. This is a tricyclic antidepressant, but it is not used to manage OCD.

Answer 348

Correct Answer: B. Meaningful use The HITECH Act contains provisions for “meaningful use” of health information technology. Meaningful use is described in Section 4101 of the HITECH Act as e-prescribing, engaging in health information exchange, and submitting information regarding quality measures. The goal of the provision is to increase the use and reporting of outcome measures and to increase the exchange of electronic patient information in order to achieve changes in provider behaviors. The Centers for Medicare and Medicaid Services have defined objectives for meaningful use that are categorized under major policy initiatives, which include promoting patient and family engagement; reducing health care disparities and improving quality, safety, and efficiency; improving care coordination and population and public health; and maintaining privacy and security of patient health information. The objectives are to evolve over a 5-year period in 3 stages: * Stage 1: Data sharing and capture * Stage 2: Advance clinical process * Stage 3: Improve outcomes Incorrect Answers: A. The privacy rule — which ensures the confidentiality of patient health information — is set forth in HIPAA C. This term simply describes the system used to store digital versions of patients' health records D. This merely describes the pursuit of efficiency in healthcare Vital Concepts: The HITECH Act contains provisions for the “meaningful use” of health information technology. Meaningful use is described in Section 4101 of the HITECH Act as e-prescribing, engaging in health information exchange, and submitting information regarding quality measures.

Answer 349

Correct Answer: B. Quality improvement Quality improvement programs use patient outcome measures as surrogate markers of the quality and health of the program. Goals include improvement in quality of care, decreased complications, decreased hospitalizations, and improved patient satisfaction and outcomes. Risk management programs identify risky practices to identify and minimize adverse patient outcomes and corporate liability. These may include things like falls, iatrogenic infection, and medication errors. Accreditation refers to voluntary compliance in a program of evaluation and recognition that the providers have complete special additional training in a field, through education, experiment, and evaluation (examination) to indicate they are performing by meeting these requirements and have achieved advanced knowledge in the field. Incorrect Answers: A. Identifies risky practices to identify and minimize adverse outcomes and corporate liability C. Collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs D. Refers to voluntary compliance in an evaluation and recognition program Vital Concepts: Quality improvement programs use patient outcome measures as surrogate markers of the quality and health of the program. Goals include improvement in quality of care, decreased complications, decreased hospitalizations, and improved patient satisfaction and outcomes.

Answer 350

Correct Answer: A. MAOI - pyridoxine deficiency MAOIs can cause pyridoxine deficiency. Incorrect Answers: B. An MAOI in combination with meperidine can result in seizures and delirium. C. Bupropion can lower the seizure threshold and should be avoided in patients with a seizure disorder or an eating disorder. D. Nefazodone is not known to cause weight loss (however, it's known to increase appetite, which may lead to weight gain)

Answer 351

Correct Answer: A. Antidepressants combined with antipsychotics Patients with psychotic depression appear to recover more rapidly when antidepressants are combined with antipsychotics. Antipsychotics carry the risk of tardive dyskinesia and should be tapered after remission of the psychosis. Atypical antipsychotics are generally used as an alternative to typical antipsychotics but carry an increased risk of type 2 diabetes and dyslipidemia; they should also be tapered after remission of psychosis. Anecdotal reports and literature reviews suggest that ECT may be efficacious for psychotic, depressed adolescents. Currently there are a limited number of studies accessing combinations of antidepressants and antipsychotics for this population and more research need to be done. Incorrect Answers: B. Antidepressants combined with antipsychotics, not mood stabilizers, have shown to help adolescents diagnosed with psychotic depression recover more rapidly. C. Antidepressants combined with antipsychotics have shown to improve response verses antipsychotics alone in adolescents diagnosed with psychotic depression. D. Antidepressants combined with antipsychotics have shown to improve response verses mood stabilizers alone in adolescents diagnosed with psychotic depression. Vital Concept: Patients with psychotic depression appear to recover more rapidly when antidepressants are combined with antipsychotics. Antipsychotics should be tapered after remission of the psychosis.

Answer 352

Correct Answer: A. Valproate Valproate is commonly used for mood stabilization in bipolar disorder. Exposure during pregnancy has been associated with an increased risk of neural tube defects such as myelomeningocele, meningocele, or spina bifida. Carbamazepine and oxcarbazepine are other mood stabilizers commonly associated with an increased risk of neural tube defects. Incorrect Answers: B. Lithium is a mood stabilizer that has been associated with cardiac defects, such as Ebstein’s anomaly, in newborns exposed to this medication in utero. C. Lamotrigine is a mood stabilizer, and in utero exposure during the first trimester has been associated with a higher risk of a cleft lip or palate. D. Levetiracetam is not a preferred medication for bipolar disorder and is typically reserved for those who have failed other, more efficacious, medications. In utero exposure has not been studied significantly in humans, so there is no common anomaly associated with this medication at this time.

Answer 353

Correct Answer: A. Events and affective and behavioral responses Negative automatic thoughts mediate between experience and action, causing feelings and actions associated with depression. CBT is a data-based short-term therapy that focuses on relapse prevention. The underlying principle of CBT is cognitive interventions. Open-ended questions are used to evaluate the accuracy of a patient’s assumptions and perceptions. Patients are taught how to examine the evidence that they distort into automatic thoughts. Other topics that are addressed are catastrophic thinking, mind-reading, and personalization. Interventions used in CBT include imaginal exposure (exposure to feared thoughts or memories), interoceptive exposure (exposure to bodily sensations), gradual exposure (as opposed to flooding), response prevention, and systematic desensitization. Behavioral assignments and skill rehearsal are used to test beliefs and to ensure that patients can utilize certain skills. Incorrect Answers: B. Automatic thoughts mediate events, but not emotion. C. Automatic thoughts mediate response, but not emotion. D. Automatic thoughts mediate neither action nor subsequent emotional response. References:

Answer 354

Correct Answer: D. It's associated with overstimulation when associated with anxiety Incorrect Answers: A, B. These are both partially true. Rumination is associated with both gastrointestinal diseases and behavior problems C. Rumination may be part of self-stimulation behavior and anxiety. References:

Answer 355

Correct Answer: A. First-pass elimination: extensive drug extraction and metabolism in liver immediately after absorption from gut First-pass elimination is extensive drug extraction and metabolism in the liver immediately after absorption from the gut. Incorrect Answers: B. Bioavailability is the fraction of the drug that reaches the systemic circulation and is available to exert a biological effect on target tissues. C. Cmax is the maximum plasma concentration of the drug. D. Tmax is not a term typically used in pharmacokinetics. Key time related measure are the time to peak plasma or half-life. References:

Answer 356

Correct Answer: B. Patients have short stature with hypogonadism, hyperphagia, and obesity. In this disorder, patients have short stature with hypogonadism, hyperphagia, and obesity. Incorrect Answers: A. The genetic abnormality in 70% of patients is a deletion at chromosome 15. C. Obsessive-compulsive disorder is the most associated psychiatric disorder. D. Level of insight with regard to obsessions and compulsions may vary, but there is often an ego-dystonic aspect. Verbalizations for help may also occur in patients with higher cognitive function. References:

Answer 357

Correct Answer: D. Generosity and nurturance Generosity and nurturance are part of Christopher Peterson and Martin Seligman’s definition of mental health “positive psychology,” which also includes kindness, love, intimacy, social intelligence, forgiveness, modesty, curiosity, courage, humor, leadership, hope, spirituality, honesty, and open-mindedness. The other answer choice options are a part of Marie Jahoda’s definition of normal mental health (“mental health” or “normality”). In 1958, Marie Jahoda defined normal mental health as including the following six criteria: efficient self-perception, realistic self-esteem and acceptance, voluntary control of behavior, true perception of the world, sustaining relationships, and self-direction/productivity. Incorrect Answers: A. Efficient self-perception is a part of Marie Jahoda’s definition of normal mental health, not Christopher Peterson and Martin Seligman’s definition. B. Realistic self-esteem and acceptance are a part of Marie Jahoda’s definition of normal mental health, not Christopher Peterson and Martin Seligman’s definition. C. Voluntary control of behavior is a part of Marie Jahoda’s definition of normal mental health, not Christopher Peterson and Martin Seligman’s definition. Vital Concept: Christopher Peterson and Martin Seligman’s definition of mental health is referred to as “positive psychology” and includes kindness, generosity, nurturance, love, intimacy, social intelligence, forgiveness, modesty, curiosity, courage, humor, leadership, hope, spirituality, honesty, and open-mindedness. References:

Answer 358

Correct Answer: C. Nurses should avoid casual use of terms of phrases that could be offensive, such as “I’m so bored with this class that I am going to slit my wrists.” Policy and legislation impact the practice of health care providers. It’s important for practitioners to be knowledgeable about current policies and legislation that affects mental health and substance use care since these problems contribute significantly to the burden of illness and disability in the population. When advocating for mental health, it’s critical to be aware of the power of words and the way they can stigmatize people with mental illness. When referring to someone with a mental illness, it is better to use a phrase like “persons with mental illness” compared to “mentally ill persons.” Another sphere in which someone can inadvertently be offensive is the use of a casual phrase, such as “psycho” or “I’m going to slit my wrists.” You can never be certain what experience others may have had. Incorrect Answers: A. Sharing the personal experience with mental health issues with friends and colleagues may normalize these issues and empower others. B. To call someone “schizophrenic” is similar to calling patients with cancer “cancers.” An NP should refer to these patients as persons with schizophrenia. D. Advocacy is both a personal and professional call to action and all nurses should be responsible for advocacy for the health and quality of life of their patients. References:

Answer 359

Correct Answer: D. Some patients develop PTSD without prior having ASD. Some patients develop PTSD without prior ASD, although some patients with ASD do not develop PTSD. Incorrect Answers: A. Estimated lifetime prevalence of PTSD is 7.8%. The lifetime prevalence of ASD is unknown. B. About 50-90% of people experience traumatic events, but most do not develop ASD or PTSD. C. Lifetime prevalence of PTSD is higher in women than men. References:

Answer 360

Correct Answer: C. Phenothiazines are safe to treat psychosis. Most seizure medications exacerbate this condition. Medicines known to be safe include the phenothiazines, glucocorticoids, narcotic analgesics, and bromides. Gabapentin and levetiracetam (Keppra) are generally safe, but phenytoin, barbiturates, or valproic acid must be avoided. Olanzapine can be used for psychosis and nausea. Incorrect Answers: A. The onset is between ages 18-40 years of life. B. Acute intermittent porphyria may manifest as: (1) episodic, acute, abdominal pain; (2) motor polyneuropathy; and (3) psychosis. However, it may cause purely psychiatric symptoms, including insomnia, anxiety, mood lability, and psychosis. D. Eating a diet with high amounts of protein is recommended during the AIP attack is incorrect as it is recommended during an attack the diet should consist of high carbohydrates. References:

Answer 361

Correct Answer: D. Patient’s behavior modification and compliance rates Behavior modification and compliance rates are the best determinants of the effectiveness of patient education. Incorrect Answers: A, B, and C. The patient may be satisfied, may understand, and may be able to provide a demonstration. But, if the patient does not use what he learned, your education of the patient was ineffective. Vital Concept: Behavior modification and compliance rates are the best determinants of the effectiveness of patient education. References:

Answer 362

Correct Answer: D. Long-term potentiation Brief high-frequency stimulation of hippocampal pathways leads to long-term potentiation (LTP) of the synaptic connections and is the crucial process underlying memory formation. LTP is composed of an early phase that lasts for the first 3 hours after induction and does not require protein synthesis and a late phase that lasts for several hours and requires both gene transcription and protein translation. LTP can also stimulate the growth of new synapses and increase the rate of synaptic transmission via the release of additional synaptic vesicles. Short-term forms of learning generally involve the modification of existing proteins in response to sensitizing stimuli. Long-term memory, however, requires changes in gene transcription and the synthesis of new proteins to support the structural changes necessary to strengthen the synapse. Learning and memory require both short- and long-term changes that lead to dramatic increases in the range of responses that a neuron shows to synaptic input. Over time, activation of a single receptor may trigger a coordinated cellular response involving several systems. Incorrect Answers: A. Neurogenesis is the formation of neurons. B. Apoptosis is programmed cell death. C. Long-term depression involves similar mechanisms as long-term potentiation and eliminates irrelevant memories while fine-tuning lasting memories. References:

Answer 363

Correct Answer: C. Family history of mood disorders Maintenance therapy is generally recommended for patients with risk factors for recurrence such as the presence of residual symptoms, ongoing psychosocial stressors, early age at onset, and family history of mood disorders. Patients who have had ≥3 prior major depressive episodes should receive maintenance treatment. Incorrect Answers: A. Recommended that patients who have had ≥3 prior major depressive episodes should receive maintenance treatment. B. EARLIER age of onset is a factor for continuing maintenance therapy of an antidepressant in a patient with major depression. D. History of substance abuse is not considered a factor for continuing maintenance therapy of an antidepressant in a patient with major depression. Vital Concept: Maintenance therapy is recommended with risk factors for recurrence such previous depressive episodes, current residual symptoms, ongoing psychosocial stressors, early age at onset, and family history of mood disorders. References:

Answer 364

Correct Answer: D. CYP1A2, 2C9, 2C19, 2D6, 3A4, and 3A5 enzymes are responsible for metabolizing over 90% of drugs processed in the liver. Of the more than 50 Cytochrome p450 enzymes, CYP1A2, 2C9, 2C19, 2D6, 3A4, and 3A5 enzymes are responsible for metabolizing over 90% of drugs processed in the liver. Incorrect Answers: A. Cytochrome P-450 enzymes function both to metabolize foreign drugs and chemicals AND produce synthetic substances for the body such as cholesterol and steroids. B. Phase I metabolism involving the CYP 450 system is characterized by oxidation, reduction, and hydrolysis. C. The majority of cytochrome p-450 enzymes are found in the liver and small intestine. Smaller amounts of the enzymes can be found in the kidney, lung, brain, and placenta. References:

Answer 365

Correct Answer: C. Chlordiazepoxide All these drugs are used for the maintenance treatment of alcohol dependence except chlordiazepoxide, which is used in acute detoxification of alcohol It is not favored for relapse prevention in patients with chronic alcohol use disorder. Psychosocial support remains the cornerstone in achieving prevention of relapse. Incorrect Answers: A. Disulfiram serves as an alcohol deterrent drug by interrupting the metabolism of alcohol. The patient's fear of this disulfiram–alcohol reaction is meant to serve as reinforcement for abstinence. B. Acamprosate is an anti-craving drug and helps the maintenance of abstinence and decreases negative symptoms associated with the acute post-withdrawal period in recently detoxified alcohol-dependent individuals. D. Topiramate is an anti-craving drug used to prevent alcohol relapse. References:

Answer 366

Correct Answer: B. Retrograde amnesia Amnesia is the most commonly discussed side effect of ECT. Severe amnesia during the ECT course can be managed by increasing the interval between treatments (from 3 per week to 2 or even 1 per week), changing ECT type (e.g. bilateral to unilateral electrode placement), or, if necessary, ending treatment. Retrograde amnesia (i.e. difficulty remembering information learned before the ECT course) is more prominent with ECT use. This deficit is greatest for more recent memories, particularly those occurring several months before the ECT. Retrograde amnesia is more marked for information of an impersonal nature. The proportion of patients with persistent retrograde amnesia following ECT is unknown; patient surveys suggest that this may occur in a sizable minority. Pharmacological attempts to ameliorate ECT-induced amnesia (e.g. using nootropics, hormones, stimulants, and peptides) have not been reliably demonstrated. Amnesic effects with ECT are more prominent and may last longer in patients with preexisting cerebral disease, a greater number of treatments in a course, or bilateral stimulus electrode placement, particularly when treatment frequency is maintained at 3x weekly. Ironically, greater amnesia is generally associated with a greater antidepressant response. Incorrect Answers: A. and C. Retrograde, not anterograde or transient, amnesia is the most commonly discussed side effect of ECT D. No connection between ECT and expressive aphasia References:

Answer 367

Correct Answer: C. TCAs can be dangerous to patients with pre-existing glaucoma and lead to narrow-angle glaucoma. The anticholinergic side effects of TCAs include dry mouth, blurry vision, constipation, tachycardia, and delirium. In those with a history of benign prostatic hypertrophy this may result in acute urinary retention. Incorrect Answers: A. Anticholinergic effects result from the blockade of muscarinic cholinergic receptors. B. Hypotension is due to alpha-1 receptor blockade, while sedation is most likely related to histamine receptor blocking. D. Patients with dementia can develop acute confusional states due to the anticholinergic side effects of TCAs. Vital Concept: The side effects associated with TCAs, including anticholinergic effects, are largely responsible for their infrequent use since the introduction of newer antidepressants such as SSRIs and SNRIs. References:

Answer 368

Correct Answer: B. Experiential The experiential approach focuses on the present and encourages change through growth experiences. Incorrect Answers: A, The psychodynamic approach focuses on the past that is causing present problems. It also addresses multigenerational transmission and encourages change through insight. C. The structural approach focuses on the blueprint of a healthy family with well-defined subsystems, clear boundaries, and parents in charge. D. The strategic approach requires a change that interrupts maladaptive behavior sequences. References:

Answer 369

Correct Answer: D. Naloxone Naloxone is a drug of choice for opioid intoxication. This patient is suffering from opioid overdose. Nausea, vomiting, and severe itching can also occur as part of opioid intoxication. Fatal respiratory depression can occur due to direct suppression of respiratory centers in the midbrain and medulla. Opioid intoxication is a medical emergency that is treated by adequate hydration, mechanical ventilation, and naloxone. Incorrect Answers: A. Acamprosate is an anti-craving drug used for maintenance therapy of alcohol abstinence. B. Bupropion is used for nicotine withdrawal and acts on dopamine and noradrenaline receptors. C. Buprenorphine is used for detoxification and as a part of maintenance therapy in opioid withdrawal. References:

Answer 370

Correct Answer: D. 66-75% About 66-75% of patients with specific learning disorder are male. The ratio of males to females is 2-3:1. Specific learning disorder is a DSM-5-TR diagnosis that combines the prior diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Specific learning disorder is defined as Challenges acquiring or utilizing new mental skills or capabilities, as evidenced by one or more of the following for a period lasting 6 months or more despite attempts to address those challenges: · challenges with reading comprehension (reading to understand) · challenges writing with proper punctuation, grammar, organization, and intelligibility · challenges with numerical facts/calculation (math skills) OR reasoning (concepts) · challenges reading individual words (may guess, read words incorrectly, unable to sound them out, or read extremely slow) · challenges with spelling words correctly These challenges are not as expected given the patient’s age and substantially hinder educational, professional, or daily functioning as evidenced by standardized tests or clinical evaluation. In patients over 17, historical evidence of challenges may replace standardized testing. While these challenges emerge while in primary school, the patient may be capable of compensating, and thus delay their observation until the requirements exceed the patient’s abilities (e.g., a significant deadline, increased education responsibilities, time-based testing) These challenges are not more accurately attributed to a poor teaching/access to education, pervasive intellectual disability, decreased language proficiency, vision or hearing deficit, or another mental or medical condition. Specifiers: · r/t reading: word reading accuracy; reading rate/fluency; reading comprehension · r/t writing: spelling accuracy; grammar and punctuation accuracy; clarity or organization of written expression · r/t mathematics: number sense; memorization of arithmetic facts; accurate or fluent calculation; accurate math reasoning · mild: one or two domains affected but able to complete tasks with accommodations · moderate: substantial challenges in at least one domain requiring intense support/assistance · severe: several domains affected requiring intense support/assistance continuously and accommodations. Despite this, patient may still not complete all work. Incorrect Answers: A. B. and C. These percentages are all lower than the correct response of 66-75%. Vital Concept: Specific learning disorder is more common in males than females, with ratios that range from 2:1 to 3:1. References:

Answer 371

Correct Answer: D. Poor neonatal adaptation Correct Answer: D. Poor neonatal adaptation Adverse effects in the newborn following SSRI/SNRI exposure in the third trimester include agitation/restlessness, respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypo- or hypertonia, hyperreflexia, jitteriness, irritability, constant crying, and tremor. Symptoms may be due to SSRIs/SNRIs toxicity or the result of poor neonatal adaptation (or neonatal behavioral syndrome). The symptoms may be similar to those seen in serotonin syndrome associated with SSRI treatment. Discontinuation syndrome is seen at higher rates with paroxetine, compared to other SSRI/SNRI antidepressants. Incidence varies in studies from 5-85%. Symptoms are typically mild and self-limiting, beginning within 72 hours of birth and largely resolving within 2 weeks. Discontinuation syndrome is more likely to occur when paroxetine is used during the late third trimester. At this time SSRIs have been found to pose minimal risk of teratogenicity. They do not appear to increase the risk of spontaneous abortion, gestational diabetes, or perinatal death. They may increase the risk of cardiac malformation (especially paroxetine), hypertension during pregnancy, postpartum hemorrhage, preterm birth (before 37 weeks), and persistent pulmonary hypertension in the newborn. The data regarding the effect of SSRIs on birth weight and Apgar scores are conflicting. Incorrect Answers: A. Pregnancy loss or miscarriage is not a potential neonatal risk associated with continuing antidepressants during the third trimester of pregnancy. B. Organ malformation or teratogenesis is not a potential neonatal risk associated with continuing antidepressants during the third trimester of pregnancy. C. Gestational diabetes is not a potential neonatal risk associated with continuing antidepressants during the third trimester of pregnancy. Vital Concept: The decision to continue antidepressants through the third trimester should be made with extensive patient education via shared decision-making between the patient and the prescriber. There is a risk of transient mild symptoms of poor neonatal adaptation following delivery. References:

Answer 372

Correct Answer: D. Child and adolescent resistance can be managed with less resistance and hostility. MI is well-suited to treatment with children and adolescents. Of note, it is often used in substance abuse disorders to assess readiness to change and to help patients progress in their commitment when ready. Incorrect Answers: A. Children and adolescents are likely to be resistant to change. B. Children and adolescents dislike diagnostic labels. C. Children and adolescents most likely to resist the advice of parental figures. References:

Answer 373

Correct Answer: C. Hiring a patient to do lawn maintenance Having any type of financial or business relationship with a patient is considered an exploitation of the physician's authority and the therapeutic relationship. This would include buying or selling anything to/from a patient, investing in or accepting an investment from a patient, or hiring a patient. This involves the beneficence principal as providers need to do the best treatment that is best for the patient, not the provider. Incorrect Answers: A. Having separate therapy notes and denying patient access to those notes is not considered unethical. B. Charging fees for missed appointments or late arrivals are not considered unethical. D. Declining gifts is not unethical; in fact, accepting a gift is generally unethical except in certain situations where the gift’s value is negligible (e.g. homemade goods or a bottle of water). Vital Concepts: Having any type of financial or business relationship with a patient is considered an exploitation of the physician's authority and the therapeutic relationship. This would include buying or selling anything to/from a patient, investing in or accepting an investment from a patient, or hiring a patient. This involves the beneficence principal as providers need to do the best treatment that is best for the patient, not the provider. References:

Answer 374

Correct Answer: B. Anticholinergic delirium secondary to benztropine overdose Anticholinergic delirium is distinguished from neuroleptic malignant syndrome (NMS) by a lack of diaphoresis and a reduction in symptoms after a trial of physostigmine. NMS, serotonin syndrome, and malignant hyperthermia all present with elevated temperature and clouded sensorium. Incorrect Answers: A. NMS is diagnosed by severe muscle rigidity and fever as well as two or more of the following: hypertension or labile blood pressure, change in the level of consciousness, leukocytosis, elevated CPK, elevated liver enzymes, tremor, incontinence, mutism, dysphasia, or tachycardia. Treatment includes immediate discontinuation of antipsychotics, IV hydration, temperature control, and in some cases, ventilator support or dialysis. In severe cases, admission to the ICU is warranted. NMS is fatal in about 10% of cases. Treatment is with dopaminergic agonists, including levodopa/carbidopa, dantrolene, amantadine, and bromocriptine, as well as benzodiazepines and ECT. C. In serotonin syndrome, the tremor is peripheral and is less likely to have fever or lab abnormalities common to NMS. Serotonin syndrome presents with tremors, confusion, restlessness, myoclonus, autonomic changes, and hyperreflexia. The most common interaction between drugs causing the reaction involves SSRIs and MAOIs. Treatment is the discontinuation of the offending agent and supportive treatment. Symptoms usually resolve within 24 hours. Labs are drawn to rule out NMS (chemistry, blood count, and CPK). D. Malignant hyperthermia is caused by a genetic predisposition to hyperthermia, rhabdomyolysis, and possible kidney failure secondary to exposure to general anesthesia. This patient has had no exposure to general anesthetics. Vital Concept: Fever and clouded sensorium may represent benztropine overdose (anticholinergic delirium), neuroleptic malignant syndrome, or serotonin syndrome. Benztropine overdose will respond to physostigmine administration. References:

Answer 375

Correct Answer: C. Substance use disorders contribute to homelessness in patients with schizophrenia. Substance use disorders, including alcohol, contribute to homelessness in patients with schizophrenia. Incorrect Answers: A. Other risk factors for homelessness include social isolation, infectious disease. and substance use. B. Other factors include lack of affordable housing, fragmented services, and limited public funding. D. Slightly less than 50% of homeless people with schizophrenia receive psychiatric services. References:

Answer 376

Correct Answer: B. A rash with facial involvement, mucus membrane involvement, or fever and lymphadenopathy requires immediate emergency evaluation. Mucus membrane involvement includes dysuria and tongue/mouth/eye lesions. This can be life-threatening. Incorrect Answers: A. Both Stevens-Johnson syndrome and toxic epidermal necrolysis are associated with lamotrigine use. C. Initial side effects (dizziness, ataxia, diplopia, blurred vision, sedation, headache, nausea, vomiting, and simple rash) are rare due to the slow dose escalation required to reduce dangerous dermatologic effects. D. Lamotrigine overdose can be fatal. Common symptoms include stupor, convulsions, and intraventricular delay. Treatment is largely supportive. References:

Answer 377

Correct Answer: C. High Reliability Organizations Organizations with a culture of safety, that foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improvements in safety and quality care are considered to be high reliability organizations (HROs). In their culture centered on safety and quality, there is direct involvement of top and middle leadership, and safety and quality efforts are aligned with the strategic plan. There is an established infrastructure for safety with active engagement of staff and continuous improvement. Incorrect Answers: A. Preferred provider organizations (PPOs) are managed care organizations composed of doctors, hospitals, and other healthcare providers who have agreed with a third party or insurance company to provide care at reduced rates to participants in the plan. B. Health maintenance organizations are organizations that provide or arrange managed care for insurance or benefit plans, individuals, and other entities. D. An accredited health care organization has been reviewed and has met predetermined standards set by an accrediting body, such as the Joint Commission. Vital Concepts: Organizations with a culture of safety, that foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improvements in safety and quality care are considered to be high reliability organizations (HROs.) References:

Answer 378

Correct Answer: D. Tramadol and venlafaxine are functionally similar. Tramadol is an opiate agonist with weak mu properties, though it should be noted that Tramadol does have some SSRI properties, and therefore its combination with an SSRI could increase the risk for serotonin syndrome. Venlafaxine and duloxetine are SNRIs, and duloxetine has recently been FDA-approved for treating chronic pain (especially neuropathic pain). Incorrect Answers: A. NSAIDs are useful for acute and chronic pain, but alternatives are necessary for patients on lithium due to the risk of potentiating lithium toxicity. B. TCAs are analgesia at lower doses than those used for depression, although some patients may require higher doses for effective analgesia. They are often used in conjunction with other agents such as anticonvulsants. C. Serum TCA levels can help establish the appropriate dose, particularly in patients who are rapid or slow metabolizers. Following TCA serum levels are very important when multiple pharmacologic agents are used, as many medications will increase TCA serum levels. The only TCA levels that can be reliably followed are desipramine, imipramine, and nortriptyline. References:

Answer 379

Correct Answer: C. Risk for aggressive behavior decreases with neurological impairment. Risk for aggressive behavior increases with neurological impairment. Incorrect Answers: A. This is true, although only a minority of patients with schizophrenia are violent. B. Risk for aggressive behavior also increases with comorbid alcohol abuse and substance abuse. D. Patients with schizophrenia are also more likely to act on their delusions if they can find evidence to support them. Patients who experience command hallucinations to harm others are also more likely to be violent. References:

Answer 380

Correct Answer: D. Factitious disorder involves deceptively reporting false symptoms, whereas symptoms in somatic symptom disorder are produced unconsciously. Patients are diagnosed with a factitious disorder or malingering because they are “faking” or even creating symptoms that have no real pathological basis. Somatic symptom disorder is difficult to differentiate from other psychiatric disorders, but it is characterized by physical symptoms - one or more current somatic symptoms that are long-standing and cause distress or psychosocial impairment. The patient experiences excessive thoughts, feelings, or behaviors related to the symptom or symptoms. In some cases, these symptoms are related to a patient's known medical history or illness. Differentiation between factitious disorder and malingering involves determining the patient’s motivation. In malingering, there is some secondary gain (e.g., getting out of a crime by "pleading insanity," making money). In factitious disorder imposed on self or another, the patient wants to assume the “sick role” (such as in Munchausen syndrome). The two disorders require different treatments. Both are diagnoses of exclusion, and clinicians should take care to rule out any other causes for these symptoms before coming to a diagnosis of factitious or somatic symptom disorder. Factitious disorder imposed on another is considered child maltreatment and must be reported to the appropriate authorities. The DSM-5-TR diagnostic criteria for factitious disorder include: Exaggerating or fabricating physical or phycological manifestations of an injury or medical condition or the intentional self-infliction of an injury. The individual manipulates themselves to appear to others as unwell, disabled, or wounded. The false and misleading behavior persists despite the lack of an apparent benefit to the individual. The behavior cannot be attributed to another mental health disorder. Incorrect Answers: A. Somatic symptom disorder does NOT involve faking symptoms, and factitious disorder DOES involve faking symptoms. B. Symptoms are unconsciously produced in SOMATIC SYMPTOM disorder but are intentionally produced or feigned in FACTITIOUS disorder. C. Malingering, not somatic symptom disorder, involves the patient wanting to assume the "sick role" for secondary gain. Factitious disorder does not involve secondary gain. Vital Concept: Factitious disorder involves deceptively reporting false symptoms to play the "sick role" without motivation related to secondary gain, whereas symptoms in somatic symptom disorder is produced unconsciously. References:

Answer 381

Correct Answer: D. The standard of practice for psychiatric mental health registered nurse practitioners includes identification of consumer resources to assist consumers in appropriate use of mental health services Standards of practice in nursing refer to authoritative statements of the duties that all nurses are expected to perform competently, regardless of role, specialty, or patient population. Among the standards of psychiatric mental health nursing standards is the development of expected outcomes of treatment, as measurable goals and to provide direction for continuity of care. Coordination of care delivery is another standard of care for advanced practice psychiatric mental health nurse practitioners. Incorrect Answers: A. Quality standards of care are determined by governmental agencies, professional societies, and licensing boards. They may be general in scope or specific. B. Identification of expected outcomes is a standard of care for psychiatric mental health registered nurse practitioners in general; there's no experience component to this expectation. C. Time estimates for the attainment of expected outcomes in psychiatric care are a standard of care for psychiatric mental health registered nurse practitioners. Vital Concepts: Standards of practice in nursing refer to authoritative statements of the duties that all nurses are expected to perform competently, regardless of role, specialty, or patient population. Among the standards of psychiatric mental health nursing standards is the development of expected outcomes of treatment, as measurable goals and to provide direction for continuity of care. References:

Answer 382

Correct Answer: C. Teamwork training for interprofessional collaborative practice in health professions has lagged behind practice changes Teamwork training for interprofessional collaborative practice in the education of health professions has lagged behind the realities of current practice, which has resulted in a gap between current training and actual practice. Incorrect Answers: A. Although accrediting standards often contain content about interdisciplinary teams, few are outcomes-based competency expectations. B. Teamwork training for interprofessional collaborative practice includes all healthcare professions that form part of a healthcare team. D. The primary responsibility for developing core competencies is with health professions schools. Vital Concepts: Teamwork training for interprofessional collaborative practice in the education of health professions has lagged behind the realities of current practice, which has resulted in a gap between current training and actual practice. References:

Answer 383

Correct Answer: B. Relative risk reduction The relative risk reduction is calculated on the basis of event rates and is a percentage of the benefit conferred by a specific therapy. Incorrect Answers: A. Risk ratio is the ratio of risk in the treated group to the risk in the control group, and can be helpful to determine if an intervention prevents or increases an outcome or disease. C. The numbers needed to treat (NNT) defines the number of people who must receive a therapy for one person to benefit from it. D. A confidence interval is certainty, given in percentage, that the true value lies within the range of values. If a 95% Confidence Interval is given, it means there is a 95% chance that the true value is within the range and a 5% chance that the true value is not within the range. Vital Concepts: The relative risk reduction is calculated on the basis of event rates and is a percentage of the benefit conferred by a specific therapy. References:

Answer 384

Correct Answer: C. Persistent depressive disorder In the DSM-5-TR, persistent depressive disorder is characterized by at least two symptoms of depressed mood with a duration of 24 months or more. Incorrect Answers: A. Major depressive d/o has a list of nine diagnostic criteria, five of which need to be met within a 2-week period. B. Major depressive d/o in partial remission is diagnosed when MDD was previously diagnosed, and now some of the s/s of depression remain but the patient no longer meets the full criteria of the dx. D. Hypomanic episode displays symptoms of a mood disorder involving elevated mood and these symptoms are not within the question. Vital Concept: A patient must be symptomatic on most days for at least 2 years for a diagnosis of persistent depressive disorder in adults. References:

Answer 385

Correct Answer: C. Persistent depressive disorder In the DSM-5-TR, persistent depressive disorder is characterized by at least two symptoms of depressed mood with a duration of 24 months or more. Incorrect Answers: A. Major depressive d/o has a list of nine diagnostic criteria, five of which need to be met within a 2-week period. B. Major depressive d/o in partial remission is diagnosed when MDD was previously diagnosed, and now some of the s/s of depression remain but the patient no longer meets the full criteria of the dx. D. Hypomanic episode displays symptoms of a mood disorder involving elevated mood and these symptoms are not within the question. Vital Concept: A patient must be symptomatic on most days for at least 2 years for a diagnosis of persistent depressive disorder in adults. References:

Answer 386

Correct Answer: B. Delirium tremens The patient has developed delirium tremens. This is the most common cause of new-onset hallucinations. Delirium tremens (DT), or alcohol withdrawal delirium, is characterized by agitation and tremulousness, autonomic instability, fevers, auditory and visual hallucinations, and disorientation. DT usually develops 2-4 days from the person's last drink, and the average duration is <1 week. Incorrect Answers: A. Alcoholic psychosis is a complicated form of alcohol withdrawal with auditory, visual, or tactile hallucinations in the presence of a clear sensorium. C. The sudden onset of schizophrenia in a 45-year-old male with no previous psychosis is unlikely. D. A subdural bleed usually does not cause diaphoresis and hallucinations. It mostly presents with headaches and confusion. References:

Answer 387

Correct Answer: B. The State Board of Nursing The mission of the State Board of Nursing in each state and the District of Columbia is to protect the public from harm. The nursing board of each state is responsible for establishing initial licensure requirements and retention of licensure requirements; interpretation of scope of practice parameters; investigation of complaints against licensees; and taking appropriate action when complaints are found to be valid. Incorrect Answers: A. The State Board of Nursing in each state regulates the practice of nursing. C. The state legislature may pass laws concerning scope of practice, but interpretation rests with the State Board of Nursing. D. The individual NP must become aware of the scope of practice that is acceptable in the state. Vital Concepts: The nursing board of each state is responsible for establishing initial licensure requirements and retention of licensure requirements; interpretation of the scope of practice parameters; investigation of complaints against licensees; and taking appropriate action when complaints are found to be valid. References:

Answer 388

Correct Answer: D. Decline, as this is considered unethical. Dating a patient or any key third party (parent, spouse, ex-spouse, guardian, or surrogate) even months later is considered unethical. Although it may seem benign, the psychiatrist has treated this patient in the past, and the family members have disclosed personal information. The father may have developed a positive transference toward her that would be considered "exploiting the therapeutic relationship." Incorrect Answers: A. This is unethical, and the therapist shouldn't proceed with the date B. It doesn't matter if the therapist severs all therapeutic ties with the family — it's still unethical to date a former patient's father C. It doesn't matter if the therapist assigns the child a new therapist — it's still unethical to date a former patient's father References:

Answer 389

Correct Answer: C. Phencyclidine (PCP) Phencyclidine (PCP, “angel dust”) causes violent behavior, nystagmus, tachycardia, hypertension, anesthesia, and analgesia. It is the only illicit drug that causes vertical nystagmus, but horizontal and rotatory nystagmus can also occur with PCP. Other substances that cause nystagmus include alcohol, amphetamines, barbiturates, benzos, ketamine, lithium, SSRIs, and salicylates. Benzodiazepines, marijuana, and heroin are unlikely to cause combativeness and agitation. Incorrect Answers: A. B. D. These medications are unlikely to cause combativeness and agitation. They also don't cause vertical nystagmus. References:

Answer 390

Correct Answer: B. Correcting the calcium level will prevent delirium. Hyperparathyroidism and elevated calcium level can also cause delirium or personality change. Remember, "stones (kidney stones), groans (bone pain), and psychiatric overtones" for hypercalcemia. Incorrect Answers: A. As many as 50% of patients may have no recognizable symptoms. C. Early hyperparathyroidism, associated with hypercalcemia, may manifest as nonspecific mental slowing with attention and memory problems. D. Despite the lack of conclusive correlation with absolute serum calcium levels, symptoms of parathyroid dysfunction are likely associated with disturbances in calcium, phosphate, and bone metabolism. References:

Answer 391

Correct Answer: B. The Nurse Practice Act of the state where he or she practices. The Nurse Practice Act of the state gives every nurse the legal right to practice nursing. Incorrect Answers: A. The laws of the state give the Board of Nursing the authority to enforce the Nurse Practice Act. C. The federal Medicare laws provide funding for health care for older adults aged 65 years and older. D. The Board of Nursing is the agency that is tasked with enforcing the Nurse Practice Act in the state. Vital Concepts: The Nurse Practice Act of the state gives every nurse the legal right to practice nursing. References:

Answer 392

Correct Answer: C. Samples may allow estimations of error in resulting statistics. Research is typically conducted on a sample of subjects who represent a larger population. When selected using random sampling, the study sample is most representative of the overall population. The use of samples rather than populations provides many advantages. Samples are, by definition, smaller and can be studied more quickly and at a lower cost. The use of samples may be the only feasible approach when the study of populations is impossible or impractical. It would not be possible, for example, to obtain blood samples from every US resident. Often, results from samples are more accurate than those of a population, and more time and costly resources can be invested in each research staff member or subject. An MRI is more accurate than an X-ray in detecting certain abnormalities, for example, but this would only be financially feasible to perform in a smaller sample. When samples are appropriately selected, methods can be used to estimate the error of the resulting statistics, which allows the calculation of probabilities regarding study observations. Samples may be selected in ways that reduce heterogeneity. If studying a certain aspect of migraines, for instance, an investigator may not want to study the entire population with migraines, as there is great variability in presentation. Instead, he or she may wish to select subjects with certain features that are appropriate for the study. Incorrect Answers: A. Sampling may produce more accurate results than a population survey. B. Samples may be selected to reduce heterogeneity. D. Nonprobability sampling techniques base sample selection on the subjective judgment of the researcher, which can result in samples that are not representative of the entire population. References:

Answer 393

Correct Answer: C. Do the lumbar puncture and treat the patient since they requires emergency care for a condition that could endanger life and limb. Consent for emergency care is implied in the ER. If the patient was not able to give informed consent due to her illness, then the NP should proceed with the procedure and treatment. The diagnosis will be made by a lumbar puncture, so it would be inappropriate to guess and subsequently make decisions about whether suspected meningitis is bacterial or viral. Bacterial meningitis is one type of life-threatening emergency that may be treated even if the patient is not able to understand the procedure unless there is a prior instruction or proxy appointed to make decisions when the patient is incapacitated. In those cases, the proxy is expected to make decisions based on the best knowledge of the patient’s healthcare preferences. Incorrect Answers: A. The patient is not able to give informed consent due to her disorientation and delirium, therefore should not have the patient sign a consent form. B. Attempts have already been made to contact her parents and continuing to call them could delay diagnosis and treatment. D. Close relatives that are not her parents/legal guardians cannot give consent for the patient's procedure. Vital Concept: Consent for emergency care is implied in the emergency room. References:

Answer 394

Correct Answer: D. Oral Paranoia, schizophrenia, and substance abuse are all linked to the oral stage that occurs during 0-18 months of life. Failure of the latency stage is the inability to form social relationships, phallic stage is sexual identity disorders, and anal is depressive disorders. Incorrect Answers: A. This is linked to failure to form social relationships. B. This is linked to sexual identity disorders. C. This is linked to depressive disorders.

Answer 395

Correct Answer: C. The effects seen in the study are not due to chance The null hypothesis states that there is no significant relationship between the variables in a study. In this case, the null hypothesis would be that any differences between the control group and the treatment group were due to chance. Since the researcher has rejected the null hypothesis, he or she has determined that the differences between the two groups were not the result of chance. This does not mean that the drug or treatment is effective – that determination depends upon the treatment goals. In general, if the null hypothesis is rejected, the significance level or p-value will be less than 0.05. This means there is a 5% chance the differences seen between the two groups are due to chance alone. Incorrect Answers: A. Rejection of the null hypothesis means the differences between the two groups weren't due to chance B. It's not determined yet if the effects were due to chance D. It's still not determined if the drug is effective at meeting treatment goals Vital Concepts: The null hypothesis states that there is no significant relationship between the variables in a study. In this case, the null hypothesis would be that any differences between the control group and the treatment group were due to chance. Since the researcher has rejected the null hypothesis, he or she has determined that the differences between the two groups were not the result of chance. This does not mean that the drug or treatment is effective – that determination depends upon the treatment goals. References:

Answer 396

Correct Answer: C. Mirtazapine Mirtazapine has a tetracyclic structure but is not considered a tricyclic because it works by alpha 2 antagonism at the presynaptic receptors and antagonism of postsynaptic serotonin 5-HT3 and 5-HT2 receptors, which may block some of the body's mechanisms of reward for alcohol abuse. The other drugs listed are all tricyclic antidepressants except chlorpromazine, which is an antipsychotic. Incorrect Answers: A. D. These are tricyclic, not tetracyclic. B. This is an antipsychotic, not an antidepressant. References:

Answer 397

Correct Answer: D. Repression Repression is the defense mechanism the man is using to deal with the tragedy of losing his roommates in a fire. Repression is withholding from consciousness an idea or feeling, hence while the patient is unable to recall details about the fire. Humor, regression, or projection does not pertain to this patient. Incorrect Answers: A. The man isn't blaming the fire or its consequences on others, which would be projection. B. The man isn't trying to make a joke of the situation, which would be humor. C. The man hasn't returned to a childlike state, which would be regression. References:

Answer 398

Correct Answer: A. Structural-strategic approach This is an example of the structural-strategic approach. A strategic approach focuses on methods to solve unwanted behaviors in the family and has been described as strategies used by the therapist to uncover varied motives of family members and elicit change. Structural therapy uses various strategies to change the structure of the family over time. Incorrect Answers: B. In the experiential humanistic approach, the therapist tries to help the patient to get out of a persistent narrow role by encouraging connective emotional experiences in the here-and-now. C. In the transgenerational approach, the therapist focuses on the relationship between one’s role in the family of origin and the current couple's difficulty. D. In the behavioral approach, the therapist encourages cognitive restructuring to relieve marital tension. References:

Answer 399

Correct Answer: B. Cluster analysis Cluster analysis breaks a large group into smaller groups (clusters) so that each individual cluster is more homogenous by some measure. Incorrect Answers: A. Factor analysis is a statistical technique that seeks to explain the variance of multiple variables by utilizing a smaller number of unobserved factors. C. Dimension reduction is the process of reducing the number of variables studied to focus on a smaller number. D. Discriminant analysis is used to determine independent variables (X) that appear to affect a quantity of interest (Y). References:

Answer 400

Correct Answer: C. Gastrointestinal lithium-toxicity symptoms and side effects may overlap. Nausea and vomiting can occur as a side effect or as a sign of toxicity. Incorrect Answers: A. Lithium affects the sinoatrial node and atrial node transmission. Sick sinus syndrome is the only contraindication for lithium use. B. Lithium has a low therapeutic index; lithium toxicity has many symptoms. D. Lithium does not have a characteristic discontinuation syndrome, but rapid discontinuation of lithium is associated with higher rates of relapse than when lithium is tapered. References:

Answer 401

Correct Answer: D. Bupropion is an NDRI that should be avoided in patients with anorexia nervosa. Bupropion is an NDRI that has been demonstrated to lower the seizure threshold. It should be avoided in patients with comorbid conditions that increase seizure risk such as anorexia nervosa or heavy alcohol use. Incorrect Answers: A. Phenelzine is an MAOI; however, MAOIs should not be combined with SSRIs because of an increased risk of serotonin syndrome. B. Duloxetine is an SNRI and exerts its action via serotonin and norepinephrine. Also, SSRIs do not have an effect on norepinephrine. C. Clomipramine is a TCA; however, it lowers the seizure threshold and should be avoided in patients with epilepsy. References:

Answer 402

Correct Answer: B. Early onset bipolar disorder is less responsive to lithium. Early onset bipolar disorder is less responsive to lithium, therefore, is used often in conjunction with other medications. FDA approved medications for bipolar mania in adolescents are lithium and the following second generation antipsychotics: aripiprazole, risperidone, quetiapine, olanzapine, and asenapine. FDA approved medications for bipolar depression for adolescents are lurasidone and olanzapine/fluoxetine. None of the FDA approved medications for bipolar disorder are approved for children <10 years old. Incorrect Answers: A. Anticonvulsants are used to treat and prevent MANIA, not the depressive phase. C. Therapeutic lithium levels are the SAME in pediatric patients as compared to adult patients. Renal, thyroid, and cardiac function should also be monitored. D. Stevens-Johnson syndrome occurs in 1% of children on lamotrigine. Vital Concept: Early onset bipolar disorder is less responsive to lithium, therefore, is used often in conjunction with other medications. References:

Answer 403

Correct Answer: C. Functional neurological symptom disorder (conversion disorder) All these diagnoses are listed in the DSM-5-TR Chapter on Somatic Symptoms and Related Disorders. This patient's presentation is consistent with functional neurological symptom disorder, which is also called conversion disorder. Incorrect Answers: A. Somatic symptom disorder occurs when a patient has a strong focus on physical symptoms that can impact their day-to-day functioning and cause distress. B. Factitious disorder describes when a patient purposefully deceives others by creating illness, typically by intentionally getting sick or injuring themselves. D. Illness anxiety disorder, previously called hypochondriasis, describes when a patient is overly concerned that they have a serious medical condition, despite having mild or no symptoms. Vital Concept: Functional neurological symptom disorder (FNSD), also called conversion disorder, describes nervous system symptoms affecting movement or senses that cannot be explained by a neurological disease or other medical condition. References:

Answer 404

Correct Answer: A. They are quite composed and vigilant in avoiding emotional extremes when they are inappropriate, in an effort to avoid impaired judgment. These individuals are are quite composed and vigilant in avoiding emotional extremes that could impair judgment. Incorrect Answers: B. Good copers tend to be practical and emphasize immediate problems, issues, and obstacles that must be conquered before visualizing a remote or ideal resolution. C. Good copers select from a wide range of potential strategies. D. Good copers improve their coping by being aware of consequences. References:

Answer 405

Correct Answer: B. Filtering Filtering is defined as the need to focus on the negative details while all of the positive aspects of the situation are ignored. Christopher appears to have only heard the negative feedback regarding his speech. Overgeneralization is more associated with playing the victim, everything always goes wrong for me. Emotional reasoning is always feeling inadequate which may apply to this situation, but this is regardless of feedback. There is no evidence of comparing occurring in the situation. Incorrect Answers: A. This is associated with playing the victim, such as thinking, "everything goes wrong for me." C. This is associated with always feeling inadequate regardless of feedback. It could apply here, but doesn't account for the fact that Christopher is reacting to feedback. D. There's no evidence of comparing, which is basing social and personal worth on how oneself stacks up to others References:

Answer 406

Correct Answer: C. Plain film of abdomen The primary objective at this time is to rule out a bezoar as the cause of her symptoms. The alopecia, hair chewing, and abdominal pain are concerning for this diagnosis. Incorrect Answers: A. A CBC would be appropriate if this were a purely infectious process, however it would not confirm nor rule out a bezoar. B. D. These may be appropriate later in the investigation. These would not confirm or rule out a bezoar, but would be helpful to evaluate for other pathology. References:

Answer 407

Correct Answer: B. Reaction formation Reaction-formation involves the conversion of unconscious wishes into their opposites. The behavior is the opposite of what one really desires or feels. Incorrect Answers: A. Identification is the unconscious modeling of one’s self on another person’s character and behavior. C. Repression involves avoiding pleasurable instincts or drives due to the threat of suffering if the drive is satisfied. D. Displacement is the shift of a sexual or aggressive drive to a more acceptable target. References:

Answer 408

Correct Answer: A. Doxepin Infant plasma concentrations are considerably higher for doxepin than for other TCAs. Incorrect Answers: B, C, and D. Infant plasma concentrations for these TCAs aren't significantly higher. References:

Answer 409

Correct Answer: C. Schizophreniform disorder with good prognostic features, provisional This patient has had a duration of symptoms of hallucinations and paranoia for >1 month but <6 months. Even though some change in functioning started 4 months ago, symptoms consistent with a psychotic disorder did not appear until the past 3 months. This symptom pattern and the duration of symptoms are consistent with schizophreniform disorder. The diagnosis is provisional since it is made before recovery. Since the symptoms did not develop rapidly within 1 month of the first sign of disturbance, the full range of affect and presence of confusion or perplexity constitute two positive prognostic factors to meet the “with good prognostic features” specifier. To confirm the diagnosis, at least two of the following symptoms must be present for a substantial period during a month or more timeframe: · speaking incoherently without logical organization* · a misconception, belief, or thought that is firmly held despite not being grounded in reality* · illusions or perceived experiences that do not actually exist (e.g., sounds, voices, smells, visions, feelings, etc.)* · actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) · decreased display of emotion or a lack of motivation *at least one of the two symptoms displayed must be among the first three symptoms described above · An incidence of this disorder should persist for 1-6 months · There have been no (or minimal) concurrent periods of depressive or manic symptoms that would satisfy the requirements for schizoaffective DO, major depressive disorder, or bipolar disorder with psychotic features · The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition · The prognosis is considered good if two or more of the following are true: o A healthy or strong ability to function in professional or social environments prior to the incident o A sense of bewilderment or puzzlement o A consistent, observable, and appropriate emotional reaction or response to external stimuli o Significant symptoms of psychosis within a month of the initial alteration in function or behavior Incorrect Answers: A. This presentation meets all the required criteria for schizophreniform disorder. B. The duration of psychotic symptoms is <6 months which is required for a diagnosis of schizophrenia. D. The duration of psychotic symptoms is >1 month which is the limit for a diagnosis of brief psychotic disorder. Vital Concept: The diagnosis of schizophreniform disorder mirrors the symptomatology of schizophrenia, but with a duration of just 1-6 months. References:

Answer 410

Correct Answer: D. Oedipal complex describe feelings that start during the phallic phase. Freud used "oedipal complex" to describe a boy’s unconscious desire to possess his mother sexually and to kill his father. Incorrect Answers: A. Penis envy refers to girls realizing that they do not have a penis known as the electra complex. This occurs during the phallic phase of development (age 3-6). B. Castration anxiety refers to boys aged 3-6 years who have feelings of guilt regarding the oedipal complex. C. The oral phase occurs from birth to 12 months. The anal phase occurs from ages 12 months to 3 years. References:

Answer 411

Correct Answer: B. 1-5% Illness anxiety disorder (formerly hypochondriasis) is a preoccupation with having or getting a serious disease causing anxiety and performing frequent health-related behaviors or avoiding medical care. Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Findings with respect to age and gender prevalence are inconsistent, but the prevalence in the general population is approximately 1-5%. Onset is commonly in early adulthood and displays a chronic, waxing/waning course. Illness Anxiety Disorder Diagnostic Criteria according to DSM-5-TR: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months, but the illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Incorrect Answers: A. Prevalence of illness anxiety disorder is about 1-5%, not <1%. C. Prevalence of illness anxiety disorder is about 1-5%, not 6-10%. D. Prevalence of illness anxiety disorder is about 1-5%, not 11-15%. E. Prevalence of illness anxiety disorder is about 1-5%, not 16-20%. Vital Concept: The prevalence of illness anxiety disorder is about 1-5%. References:

Answer 412

Correct Answer: D. Adolescent moral decision-making is impacted by limited impulse control, self-absorption, and vulnerability to peer pressure. Adolescents may have the capacity for sound moral decision-making, but they are often impacted by limited impulse control, self-absorption, and vulnerability to peer pressure. Incorrect Answers: A. This process occurs by mid-adolescence. B. Not all adolescents and adults develop a high level of reasoning in moral development. C. Adolescents make moral decisions based on their beliefs in the context of the rules. References:

Answer 413

Correct Answer: D. Extensive history of extreme isolation and social withdrawal A premorbid history of social withdrawal and extreme independence is predictive of more long-lasting psychopathology that is often more severe as well. Factors like male gender, family history of schizophrenia, structural brain abnormalities, and tardive dyskinesia are also associated with poor outcome. Incorrect Answers: A. With schizophrenia, a sudden onset of illness has a more favorable prognosis than when the onset is insidious, especially if symptoms of agitation and psychosis are present. B. MRI changes in brain morphology are associated with a severe clinical course of schizophrenia. C. The presence of catatonic symptomatology is not associated with any particular clinical course. References:

Answer 414

Correct Answer: D. Quality improvement is a team process Quality improvement is a team process in almost every case, whether it is targeted at improvement in disease care or telephone service. Significant and lasting improvements can result from the work of a team. Incorrect Answers: A. Although studies demonstrate that specific steps tied to pertinent clinical guidelines are required to deliver optimal health care services, guidelines can be created by a consensus among any group of knowledgeable experts. B. Optimal outcomes are achieved when specific steps tied to pertinent clinical guidelines are taken. C. Patient satisfaction is an important measure of health care quality. Some services designed to meet patient needs and expectations include patient safety, support for patient engagement, and cultural competence. References:

Answer 415

Correct Answer: C. Madeleine Leininger Madeleine Leininger is the founder of the transcultural nursing movement in education research and practice. She defined transcultural nursing as nursing practice that is focused on comparative cultural care values, beliefs, and on the practices of individuals or groups with similar or different cultural perspectives. This type of practice is aimed at providing culture-specific and universal nursing care practices when promoting health or well-being. It is also aimed at helping people face unfavorable human conditions, including illness, or death, in ways that are culturally meaningful to them. Leininger developed the Theory of Culture Care: Diversity and Universality to provide “culturally congruent care.” Incorrect Answers: A. Abraham Maslow developed the psychological theory based on a hierarchy of needs. B. Kubler-Ross identified the stages of grieving. D. Rosentock, Stretcher, and Becker developed the Health Belief Model. Vital Concepts: Madeleine Leininger is the founder of the transcultural nursing movement in education research and practice. She defined transcultural nursing as nursing practice that is focused on comparative cultural care values, beliefs, and on the practices of individuals or groups with similar or different cultural perspectives. References:

Answer 416

Correct Answer: D. Pick's disease Although depression can occur in patients with FTD, it is uncommon compared to the other options. Apathy, which is commonly seen in FTD, is often mistaken for depression by caregivers. Other common early symptoms include disinhibition, hyperorality, and compulsive behaviors it can often be mistaken as depression but it is less common. Incorrect Answers: A. Depression is a common finding with Alzheimers and can often be displayed with aggression due to the confuision. It is often treated with SSRI's. B. Depressive disorders are common in patients with Parkinson’s disease as it decreases quality of life. It can also be associated with apathy and anxiety, C. Patients with Huntington's disease often present with neuropsychiatric symptoms like depression and can occur at any point during the illness. References:

Answer 417

Correct Answer: D. Corpus callosum Corpus callosum is the nerve fibers that run across the brain's midline connecting the right and left hemispheres. Incorrect Answers: The brainstem has 3 divisions: Pons Midbrain Medulla References:

Answer 418

Correct Answer: C. 4 weeks It takes 4 weeks of good compliance with buspirone to achieve the same anxiolytic effects as benzodiazepines. The drawback, obviously, is that it takes 4 weeks to become as effective. However, patients can avoid dependence, tolerance, and sedation, which are problems with benzodiazepines. Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry that causes impairment of at least 1 realm of the patient’s life without panic disorder lasting at least 6 months. Patients with GAD often worry about small things and have significant fear while expecting the worst in most situations. They also may present with muscle tension, sleep problems, fatigue, or irritability. The prevalence of GAD is highest among women, the elderly, and patients with low socioeconomic status. Treatment of GAD includes the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) as well as buspirone. Benzodiazepines may be effective in reducing physical symptoms of anxiety, and beta-blockers like propranolol may help with palpitations and tremors. Pregabalin has shown efficacy for GAD compared to placebo in several randomized trials. A meta-analysis of 5 trials with 884 patients showed that hydroxyzine was efficacious for GAD as well, but it was also more sedating than benzodiazepines and buspirone. Incorrect Answers: A. 1 week. It takes 4 weeks on buspirone to see the same anxiolytic effects as benzodiazepines, not 1 week. B. 2 weeks. It takes 4 weeks on buspirone to see the same anxiolytic effects as benzodiazepines, not 2 weeks. D. 8 weeks. It takes 4 weeks on buspirone to see the same anxiolytic effects as benzodiazepines, not 8 weeks. References:

Answer 419

Correct Answer: D. It is a potent inhibitor of cytochrome P450. Nefazodone is a potent inhibitor of cytochrome P450. Incorrect Answers: A. Nefazodone is a potent enzyme inhibitor of cytochrome P450 enzyme 3A4. Blood levels of drugs metabolized by this enzyme increase with coadministration of nefazodone. B. This medication is associated with a low incidence of sexual dysfunction. It may be used as an antidote to SSRI-induced impotence. C. Unlike other antidepressants, it enhances rapid eye movement (REM) and may increase restful sleep in some patients. References:

Answer 420

Correct Answer: C. Shorter duration of untreated psychosis Shorter duration of untreated psychosis and good premorbid function are associated with a better response. Predictors of poor treatment response include a high level of expressed emotion in the patient’s family, male gender, more severe hallucinations/delusions, and low premorbid function among patients with their first psychotic episode in adulthood. Incorrect Answers: A. B. D. These are predictors of poor, not good, treatment response. References:

Answer 421

Correct Answer: B. Clomipramine Clomipramine is a tricyclic antidepressant (TCA) that is FDA approved to treat obsessive-compulsive disorder. When treating OCD the onset of therapeutic action can be up to 6-12 weeks. When using Clomipramine to treat OCD patients usually need higher doses, 200-250mg/day. TCAs have a prominent side effect profile. Most common side effects include sedation, weight gain, sexual dysfunction, constipation, blurred vision, urinary retention, nausea, diarrhea, anxiety, fatigue and sweating. Dangerous rare side effects include lowering seizure threshold, QTc prolongation, hyperthermia, arrhythmias, and hepatic failure. Remember the 3 Cs of TCA overdose: Convulsions, Coma, Cardiac conduction. The only other medications FDA approved to treat OCD are the following selective serotonin reuptake inhibitors (SSRIs): fluoxetine, paroxetine, fluvoxamine, and sertraline. Incorrect Answers: (A) Mirtazapine. Mirtazapine, a serotonin/norepinephrine receptor antagonist and alpha 2 antagonist, has not been shown to be efficacious to treat OCD. (C) Haloperidol. Haloperidol, a first generation (typical) antipsychotic, has not been shown to be efficacious to treat OCD. (D) Lorazepam. Lorazepam, a benzodiazepine, and has not been shown to be efficacious to treat OCD. References:

Answer 422

Correct Answer: D. TD is commonly associated with clozapine. TD is not commonly associated with clozapine. Clozapine is associated with some tardive dyskinesia, although less than other antipsychotics. There are also reports of TD improving with a switch to clozapine. Incorrect Answers: A. Agranulocytosis is the most significant adverse effect of clozapine. It occurs mostly in the first 6 months of treatment; it is more likely in women, those of Ashkenazi Jewish descent, and those of advanced age. There are special guidelines to follow white cell count and manage dosage. B. Seizures are a risk with clozapine treatment and increase with increasing dose; about 4-6% of patients on dosages >600mg/day will have seizures. C. Weight gain and metabolic changes are significant and similar to olanzapine. Weight gain, development of diabetes, and hyperlipidemia are very prevalent; teens especially have weight gain. References:

Answer 423

Correct Answer: A. Normalizing The therapist has offered a kind of reassurance (normalizing) to help the patient feel more normal. Incorrect Answers: B. Exhortation is a form of encouragement that is used to convey the therapist’s high level of confidence in a patient. C. Inspiration is a form of encouragement in which a patient is encouraged to have a self-transcendent experience and to achieve a higher level of self-actualization. D. Encouragement, such as exhortation and inspiration, is done to promote the patient’s sense of hope and capability. References:

Answer 424

Correct Answer: A. Miconazole (Monistat) The patient has described Candida albicans (most likely) but could be Candida glabrata which is a fungal or yeast infection. Clinical manifestations of yeast include pruritus (itching) and subsequent irritation. The discharge may be watery or thick, but usually has a white, cottage cheese-like appearance. Treatment for yeast or fungus is an anti-fungal, such as miconazole, nystatin (Mycostatin), clotrimazol (Gyne-Lotrimin) and terconazol (Terazol) cream. Incorrect Answers: B. Metronidazole (Flagyl) is used to treat bacterial vaginosis (BV) most commonly caused by Gardnerella vaginalis. BV may present as a heavier than normal and gray to yellowish discharge. More than half of all women with BV do not notice any symptoms. Flagyl may also be used to treat Trichomoniasis vaginalis, which is a flagellated protozoan that presents with clinical manifestations of a vaginal discharge that is thin (sometimes frothy), yellow to yellow-green, malodorous, and very irritating. C. Doxycycline (Vibramycin) is used to chlamydia. Chlamydia infections of the cervix often produce no symptoms, but cervical discharge, dyspareunia (painful intercourse), dysuria (painful urination) and bleeding may occur. D. Azithromycin (Zithromax) is an alternative treatment for chlamydia to use for a one time dose. This is a good choice for patients who may not be able to remember to take medication for 7-10 days. References:

Answer 425

Correct Answer: B. Compulsive behaviors Response prevention means refraining from compulsions, avoidance, or escape behaviors. The response most commonly prevented is a compulsion that acutely reduces anxiety but perpetuates the disorder by making the sufferer believe that the compulsion is needed to reduce anxiety or some feared consequence of not performing the compulsion. Incorrect Answers: A. By preventing avoidant behaviors, anxiety will actually increase. C. By preventing avoidant behaviors, anxious thoughts will actually increase. D. Coping behaviors such as relaxation are not prevented. References:

Answer 426

Correct Answer: B. Pilot study A pilot study is a small-scale experiment or a set of observations that are undertaken to decide how and whether to launch a full-scale project. Incorrect Answers: A. A systematic review is a critical assessment and evaluation of all research studies about a particular topic, using an organized method to locate, assemble, and evaluate a body of literature on the topic, using a specific set of criteria. It may or may not include a meta-analysis, which is a quantitative pooling of data. C. An experimental study is an evaluation of whether a program or intervention had the intended effect on participants or subjects. D. A cohort study is a clinical research study in which one group of people with a certain condition or exposure are followed over time and compared to another similar group not affected by the condition or exposure of interest. Vital Concept: A pilot study is a small-scale experiment or a set of observations that are undertaken to decide how and whether to launch a full-scale project. References:

Answer 427

Correct Answer: D. Sleep deprivation associated with PTSD may amplify aggressive behavior beyond level of provocation. After sleep deprivation in PTSD, the resulting aggression is due to a reduced ability to tolerate mild or moderate slights. Incorrect Answers: A. Increased aggressive behavior can occur in a patient with comorbid PTSD and SUD during intoxication and withdrawal. B. Concurrent treatment of PTSD and Substance Use Disorder should decrease aggressive behavior. C. Rates of delinquency increase after disasters. References:

Answer 428

Correct Answer: D. Conversion disorder Conversion disorder presents as a pseudo-neurological syndrome. This patient most likely did not experience a true seizure, nor were her other symptoms (dizziness, unsteady gait) likely caused by a physiologic disorder. Normal labs and imaging rule out a neurological cause. Additionally, she recovers completely within 24 hours, which is characteristic of conversion disorder. Incorrect Answers: A. While those with personality disorders may also be more likely to show conversion disorder symptoms, this patient does not meet the criteria for borderline personality disorder. B. To be diagnosed with somatic symptom disorder (SSD), the individual must be persistently symptomatic (typically at least for 6 months). C. This patient may also be depressed, but there is not enough information to make this diagnosis. References:

Answer 429

Correct Answer: A. An expert witnesses and peers in the field Expert witnesses and peers in the field are most commonly used in malpractice trials to determine if standards of care were met. This could also be determined by journal articles, textbooks, practice guidelines, and professional organizations. It is also common to poll peers in the same field to review their common practices, if there are no concrete guidelines for the subject area. Incorrect Answers: B. Professional organizations do not develop standards of care or treatment guidelines for clinical practice. They may review common standards and their qualifications to be part of the organization. C. By laws are written facility specific. These are not the legal general guidelines for clinical practices. A facility may initiate a tort of action if the provider went against the by laws and was on staff. D. While it is true that some cases may go to jury, this has nothing to do with establishing a standard of care. The jury should be aware of standards of care by each parties attorney’s plans. References:

Answer 430

Correct Answer: D. Ketamine - cat valium Ketamine is commonly referred to on the street as "cat valium,” "special K," "vitamin K," "kit kat," and “honey oil.” Ketamine is a derivative of PCP that was first developed in 1965. It is less potent and shorter-acting and is used as a dissociative anesthetic in humans. Incorrect Answers: A. MDMA (methylenedioxymethamphetamine) is referred as “ecstasy,” “Adam,” “club drug,” “disco biscuits,” and “love drug.” B. Cocaine is referred as “crack,” “coca,” “freeze girl” and “happy dust” on the streets. Crack is the hardened form of cocaine. C. Methamphetamine is referred as “crank,” “crystal,” “ice,” “speed”, and “crystal meth” on the streets. References:

Answer 431

Correct Answer: D. Shared goals Key elements of an organization culture of safety include an organizational priority for safety, patient involvement, openness, and accountability. Shared core values and goals, non-punitive responses to errors or adverse events, and promotion of safety through education and training are also required to establish a culture of safety. Incorrect Answers: A. Non-punitive responses to error or adverse events are a key element of a strong culture of safety. B. Goals and vision within an organization should be shared and the organization with a strong safety culture will promote safety through education and training. C. Although strong leadership is important, all employees should be engaged and empowered. Vital Concepts: Shared core values and goals, non-punitive responses to errors or adverse events, and promotion of safety through education and training are also required to establish a culture of safety. References:

Answer 432

Correct Answer: A. Acute alcohol ingestion lowers the rate of drug metabolism. Acute or binge use of alcohol lowers the rate of drug metabolism and alcohol serves as an enzyme inhibitor. When any enzyme works as an inhibitor of the CYP-450 system, it reduces the activity of the CYP-450 system. For example, say a patient is taking Drug-X. Without the ingestion of alcohol, CYP-450 activity is low. The CYP-450 system easily breaks down Drug-X and the metabolites are excreted. But after binge amounts of alcohol, the CYP-450 must work to break down Drug-X and the large amounts of alcohol. This competition reduces the metabolism of Drug-X. Drug-X is not broken down as quickly (and subsequently less is excreted) leaving large amounts of Drug-X in the body (potentially toxic). Incorrect Answers: B. Acute alcohol ingestion will result in higher levels of most benzodiazepines such as diazepam. Remember, when consumed acutely (or in binge form) alcohol is an inhibitor and will subsequently decrease the metabolism of drugs – in this case, benzodiazepines. Therefore, there will be HIGHER levels of benzodiazepines. For further explanation, see the full response to answer (A). C. Chronic alcohol ingestion is associated with an increased binding of ethanol to cytochrome P-450. For chronic, heavy drinkers CYP-450 activity is enhanced/higher. This heighted activity of CYP-450 results in an increased metabolism of medications, subsequently leaving lower levels of medications in the body because they are metabolized and excreted so quickly. D. Chronic alcohol ingestion enhances/increases the rate of drug metabolism in humans, serving as an inducer. References:

Answer 433

Correct Answer: D. Self-help groups Self-help groups like AA comprise the largest number to affect substance abusers. These types of groups provide mutual support, offer relationships, and are usually free of charge. Incorrect Answers: A. B. C. These groups aren't used by as many substance abusers as self-help groups like AA. References:

Answer 434

Correct Answer: C. Discuss possible alternatives to stimulants. Nonmaleficence, or the principle of doing no harm, applies in this case. Physicians have no ethical obligation to fulfill a patient’s request for medication, especially when the requested medication is contraindicated and could adversely affect the patient. The correct course of action is to discuss alternatives to stimulants. A referral to psychiatry could be warranted in this case, but not as a means of deferring the patient’s request for stimulants. Dismissing the patient from the practice would be premature. The ethical issues of prescribing “cognitive enhancers” or using medications for reasons other than treatment are debated at this time. A diagnosis of ADHD in adults is based on meeting 5 symptoms of inattention and/or hyperactivity and impulsivity for at least 6 months. This patient meets 3 criteria for inattention and has only had symptoms for 3 months. It would be atypical to develop ADHD so late in life. Most likely symptoms would have interfered during his school years. Incorrect Answers: A. Prescribe stimulants for inattention as requested by the patient. Physicians have no ethical obligation to fulfill a patient’s request for medication, especially when the requested medication is contraindicated and could adversely affect the patient. B. Prescribe a short course of stimulants to help the patient with his work deadline. Should NOT prescribe stimulants, even a short course, given the patient’s cocaine use and cardiovascular history. D. Dismiss the patient from the practice. Dismissing the patient from the practice would be premature. Vital Concept: Nonmaleficence, or the principle of doing no harm, is an essential tenet of the practice of medicine. When patients request medications that are contraindicated for them, a physician should not fulfill the request. References:

Answer 435

Correct Answer: D. Reduce suicide rate and suicide attempts by adolescents. Healthy People 2020 is a milestone report issued by the United States Department of Health and Human Services in 2010 that identified a list of leading health indicators reflecting major public health concerns in the United States. Issues related to mental health included tobacco use, substance abuse, mental health, responsible sexual behavior, injury and violence, and access to healthcare. Objectives were derived from this report for each leading health indicator. For mental health, objectives were the reduction of the suicide rate and suicide attempts by adolescents, reduction of the proportion of adolescents engaging in disordered eating behaviors in an attempt to control their weight, and reduction of the proportion of persons who experience major depressive episodes. Incorrect Answers: A. Healthy People 2020 objectives for mental health outline a goal of increased primary care facilities that provide mental health treatment on-site or by paid referral. B. The goals of treatment expansion in mental health include increasing depression screening by primary care providers. C. Treatment expansion recommendations include increasing the proportion of children with mental health problems who receive treatment and increasing the proportion of juvenile residential facilities that screen admissions for mental health problems. References:

Answer 436

Correct Answer: D. Benzodiazepine Benzodiazepines, as well as other sedative-hypnotics, are commonly used in polysubstance abuse. They may enhance the "high" of other substances or may be used to help a person "come down" from the effects of stimulant drugs. Signs of intoxication are similar to those of alcohol intoxication and can include slurred speech, ataxia, and incoordination (see image below). At more severe levels of intoxication, stupor and coma may develop. An overdose on benzodiazepines alone virtually never leads to death. When they are ingested along with alcohol, major tranquilizers, or opioids, however, the polysubstance overdose can be fatal. Because of synergistic effects, a mixture of benzodiazepine and alcohol is about 4x as powerful as either drug used by itself. Benzodiazepines are frequently abused with opioids, and when detected, the benzodiazepine component of the overdose can be reversed with flumazenil. Treatment of an opioid overdose includes general supportive management in addition to naloxone, a pure opioid antagonist that can reverse the CNS effects of opioid intoxication and overdose. Incorrect Answers: A. Cocaine overdoses can produce high blood pressure with restlessness, insomnia, headaches, nausea, convulsions, tremors, hallucinations, delusions, and even sudden death due to respiratory or cardiovascular collapse. B. Heavy alcohol consumption results in serious health sequelae over time, and many cases ultimately result in death. It elevates blood pressure and increases the risk of myocardial infarction. C. Maladaptive behavior, pupillary constriction, hypotension, memory impairment, and dizziness are commonly associated with heroin intoxication. References:

Answer 437

Correct Answer: D. Preparation In preparation, the patient is willing to quit and is making a plan to quit but is not yet actively trying to quit. Incorrect Answers: A. Maintenance stage is characterized by completed goals being maintained. B. Precontemplation stage is characterized by not being cognizant of a need for change or resistance to change. C. Contemplation stage is characterized by ambivalence with a willingness to consider but not to commit to change. References:

Answer 438

Correct Answer: B. What went wrong? In a culture of safety, when an error or adverse event occurs, the focus is on what went wrong, not on who should be blamed. Incorrect Answers: A. The focus in a culture of safety after an adverse event is on “what” went wrong, not on “who” caused the problem. C. A culture of safety emphasizes determination of what went wrong, not the financial consequences of the event or error. D. In a culture of safety, the focus is not on who is at fault, but instead it is a non-punitive culture that emphasizes excellence, accountability, integrity, honesty, and mutual respect. Vital Concepts: In a culture of safety, when an error or adverse event occurs, the focus is on what went wrong, not on who should be blamed. References:

Answer 439

Correct Answer: D. Counterphobia Counterphobia is seeking out experiences that are consciously or unconsciously feared. For example, the attraction to horror movies may stem from a counterphobic impulse. Incorrect Answers: A. Denial is the unconscious process through which unpleasant feelings, thoughts, or impulses are avoided. B. Splitting is a defense that is created by the failure of an individual to unite the positive and negative attributes of self and others into a realistic whole (also known as all-or-none thinking). C. Acting out is the expression of unconscious conflicts in a setting other than the one in which they initially arose. References:

Answer 440

Correct Answer: D. Olanzapine Olanzapine is the drug of choice in patients with a history of severe extrapyramidal symptoms (EPS). These medications are as effective in acute psychosis as first-generation antipsychotics and cause fewer EPS but more metabolic symptoms. Anticholinergic medications are a mainstay of treatment, serving as effective prophylaxis for EPS found in response to first-generation antipsychotics and occasionally second-generation antipsychotics (especially risperidone). Anticholinergic medications contribute to increased side effects (e.g. cognitive dulling) when used with a first-generation antipsychotic like haloperidol. Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics like haloperidol bind the dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, a blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while a lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each drug has a different binding affinity (e.g. risperidone is high, while clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors as well, which may also contribute to their clinical effects. Second-generation drugs are more effective in treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis at higher than maintenance doses. Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used to treat comorbid depression or anxiety disorders. ECT can also be used in schizophrenia, most often for catatonia. Early studies also suggest that transcranial magnetic stimulation (TMS) might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT are important in the treatment success of schizophrenia. Incorrect Answers: A. Benzodiazepines can be used as an adjunctive medication for schizophrenia to sedate the patient and to permit the use of relatively lower doses of antipsychotics. B. Risperidone is an atypical antipsychotic that causes fewer EPS symptoms compared to typical antipsychotics. However, it is associated with greater EPS than other atypical antipsychotics. C. High-potency haloperidol is a drug of choice in the management of acute psychosis, but it is also linked to severe EPS, especially in younger patients. References:

Answer 441

Correct Answer: A. Clozapine (Clozaril) Clozapine is the only antipsychotic currently carrying a black box warning from the FDA regarding seizure risk, although almost all antipsychotics may increase seizure risk. Amongst first-generation antipsychotics, chlorpromazine, haloperidol, and loxapine are more likely to cause seizures. Among the atypical or second-generation options, seizure risk may be increased most with clozapine but has also been reported in patients taking quetiapine and olanzapine. Incorrect Answers: B. The FDA does not have a black box warning regarding seizures with olanzapine (Zyprexa). C. The FDA does not have a black box warning regarding seizures with lurasidone (Latuda). D. The FDA does not have a black box warning regarding seizures with aripiprazole (Abilify). Vital Concept: While all antipsychotics may lower the seizure threshold, primarily when used in larger doses or titrated too quickly, clozapine currently carries a black box warning from the FDA regarding this potential complication. References:

Answer 442

Correct Answer: A. Intermittent explosive disorder DSM-5-TR criteria for intermittent explosive disorder in individuals over the age of 5 include repeated eruptions of rage or aggression as indicated by either: three or more instances within a year that involve physical attacks (of people or animals) or property damage instances of physical or verbal outbursts of rage that happen at least twice per week over a 12-week period (these do not result in physical damage or assault) These outbursts are not designed for some intention or purpose or planned in advance These outbursts incur legal or financial repercussions, cause personal anguish for the patient, or lead to significant dysfunction (socially or professionally) These outbursts are disproportionate in relation to the inciting or preceding event These outbursts should not be better attributed to a substance, another medical condition, or another mental health condition These outbursts should not occur in children between 6-18 as a component of an adjustment disorder. This disorder can occur comorbid with ADHD, conduct disorder, oppositional defiant disorder, or autism spectrum disorder. Incorrect Answers: B. Manic episodes are characterized by increased activity, euphoria, excess spending, risk-taking, and a decreased need for sleep. C. Antisocial personality disorder is characterized by a general lack of concern for others, accountability, or honesty. D. Temporal lobe seizures would present with a lack of awareness, confusion, or abnormal movements. Vital Concept: The diagnosis of intermittent explosive disorder is based on repeated incidents of aggression and rage directed towards people, animal,s or property that lead to significant anguish or consequences. References:

Answer 443

Correct Answer: A. Discrete trial training (DTT) is used with applied behavioral analysis (ABA) in school programs for children with pervasive developmental disorders. Discrete trial training (DTT) is used in conjunction with applied behavioral analysis (ABA) in school programs for children with pervasive developmental disorders. Incorrect Answers: B. ABA is a systematic approach to developing a program for each child. Steps include evaluating a child's strengths and weaknesses, identifying educational and treatment goals, and applying techniques for skill development. C. DTT is among many techniques used to teach new skills. D. Positive reinforcement is used in DTT. References:

Answer 444

Correct Answer: B. To evaluate patients in community who may have mental health conditions Psychiatric Emergency Services (PES) may have a mobile crisis team whose role is to evaluate patients in the community, to diffuse a crisis before a patient is treated at the ED, and to decrease rates of hospitalization. Case workers generally can arrange for transportation on a case-by-case basis, but this is not the explicit role of PES. Incorrect Answers: A. To provide medication for faster relief is incorrect as the service does not provide medications in crisis but can help get clients to a safe place where medication is available. C. To increase rates of hospitalizations for patients with psychiatric conditions is incorrect as the goal is to decrease rates of hospitalizations. D. To drive patients with psychiatric conditions to doctor appointments is incorrect as they do not drive clients to appointments. Vital Concept: Psychiatric Emergency Services (PES) may have a mobile crisis team whose role is to evaluate patients in the community, to diffuse a crisis before a patient is treated at the ED, and to decrease rates of hospitalization. References:

Answer 445

Correct Answer: B. This program type is appropriate for patients with frequent relapses and hospitalizations. This type of program is most appropriate for patients with schizophrenia who have frequent nonadherence to care and subsequent frequent relapse and hospitalization. These programs utilize comprehensive individualized services for a prolonged length of time. Key to the success of these programs is documented improvement in quality of life and other positive outcomes. Incorrect Answers: A. Mandatory outpatient treatment is most appropriate for schizophrenia patients with frequent nonadherence to care and subsequent frequently relapse and hospitalization; this doesn't describe most schizophrenia patients C. Mandatory outpatient treatment patients have been documented to show changes in quality of life and other positive outcomes, including substance use. D. Mandatory outpatient treatment patients have been documented to show changes in quality of life and other positive outcomes, including violent behavior. References:

Answer 446

Correct Answer: C. Secondary prevention Rhesus (Rh)-D negative women who deliver an Rh(D) positive baby or who are otherwise exposed to Rh(D) positive red cells are at risk of developing anti-D antibodies. Rh(D) fetuses of these mothers are at risk of developing hemolytic disease of the fetus and newborn, which is associated with serious morbidity or mortality. Administration of a full dose of Rh(D) immunoglobulin is recommended for all unsensitized Rh(D)-negative women after repeated antibody testing at 24-28 weeks gestation. Rh(D) blood typing and antibody testing prevents maternal sensitization and improves outcomes for newborns and is a secondary prevention measure. Primary prevention strategies are designed to prevent onset of a targeted condition. Secondary prevention measures identify and treat asymptomatic persons with certain risk factors or in whom the condition is not yet clinically apparent. Screening tests are secondary preventive measures. With early diagnosis, the natural course of a disease can be altered to maximize the well-being of a patient. Tertiary prevention manages an existing disease to restore the patient to highest function, minimize negative consequences, and prevent complications of a disease. Incorrect Answers: A. Observational study that analyzes data from a population, or a representative subset, at a specific point in time; doesn't fit this. B. Designed to prevent onset of a targeted condition; there's no condition to prevent. D. Manages an existing disease; but there's no existing disease to manage. Vital Concepts: Rhesus (Rh)-D negative women who deliver an Rh(D) positive baby or who are otherwise exposed to Rh(D) positive red cells are at risk of developing anti-D antibodies. Rh(D) fetuses of these mothers are at risk of developing hemolytic disease of the fetus and newborn, which is associated with serious morbidity or mortality. Administration of a full dose of Rh(D) immunoglobulin is recommended for all unsensitized Rh(D)-negative women after repeated antibody testing at 24-28 weeks gestation. References:

Answer 447

Correct Answer: B. Disqualifying the positive Disqualifying the positive is the correct answer for this question. This patient is chalking her success up to flukes and luck not to her hard work. There is not enough information in this scenario to determine if this patient is experiencing perfectionism and unrealistic expectations. Selective abstraction does not apply in this situation. Incorrect Answers: A. D. There isn't enough information to determine if the patient is experiencing these. C. This doesn’t apply — the patient isn't taking details out of context. References:

Answer 448

Correct Answer: B. Some side effects may have presented as problems prior to starting medication; document baseline symptoms prior to starting stimulants. Documentation of baseline problems is important prior to the start of medication therapy. Incorrect Answers: A. ADHD patients may have side effects from stimulants that represent a manifestation or exacerbation of a comorbid disorder or a side effect of treatment. C. Appetite suppression does occur with stimulant use, but the antihistamine cyproheptadine is used to increase appetite. Diphenhydramine is used to treat sleep problems. D. Melatonin is used to treat sleep problems. Other medications used include clonidine, diphenhydramine, trazodone, and mirtazapine. References:

Answer 449

Correct Answer: D. They provide for spending authority for a single fiscal year There are two general categories of legislation: authorization and appropriations. Authorization bills establish laws or programs and although they recommend dollar amounts in some cases, they do not allocate the funds or guarantee funding for a program. Appropriations bills usually originate in the House of Representatives and provide spending authority for a single fiscal year, from the first of October through September 30. Incorrect Answers: A. Appropriations bills usually originate in the House of Representatives. B. Appropriations bills provide for spending for a fiscal year. General appropriations bills provide budgeting authority for most federal agencies. Supplemental appropriations provide additional funding for projects as needed through the current fiscal year. Continuing appropriations extend appropriations from one fiscal year to the next. C. Authorization bills establish laws or programs and they may contain recommended dollar amounts, which must be funded by appropriations bills. Vital Concepts: Appropriations bills usually originate in the House of Representatives and provide spending authority for a single fiscal year, from the first of October through September 30. References:

Answer 450

Correct Answer: B. n-Hexane n-Hexane exposure is most commonly due to recreational inhalation of household glues. n-Hexane is metabolized to 2, 5-hexanedione, which has neurotoxic effects. These effects are potentiated by methyl ethyl ketone, which may also be contained in adhesives. Acute exposure leads to CNS depression. Repeated glue inhalation may cause “glue-sniffer neuropathy,” a progressive, symmetric, ascending, sensorimotor, peripheral axonopathy. Motor symptoms may be predominant and similar in presentation to Guillain-Barré syndrome. The neuropathy may be associated with autonomic dysfunction, including bluish discoloration and decreased temperature of the involved extremities. This neuropathy has been referred to as a “central-peripheral-distal axonopathy,” as it may also have central effects and lead to spasticity. Other symptoms may include facial numbness, maculopathy, and optic neuropathy. Coasting may occur when symptoms continue to worsen for some period of time following the cessation of exposure. Incorrect Answers: A. Elemental mercury contained in dental fillings and thermometers, for example, may be inhaled. The liquid form may be ingested. Inhalation may result in “erethism,” consisting of gingivitis, tremor, and behavioral changes. This patient’s presentation is not consistent with mercury poisoning. C. Acute toxicity due to acrylamide (a chemical used in ore processing, wastewater management, gel chromatography, and certain foods) leads to encephalopathy and ataxia. Acute exposures may also lead to a delayed neuropathy. Chronic toxicity is marked by progressive, symmetric, large-fiber, axonal, sensory or sensorimotor peripheral neuropathy with minimal associated weakness. This neuropathy may also be associated with autonomic dysfunction. In contrast to n-Hexane exposure, the skin findings in acrylamide toxicity include dermatitis with erythema and exfoliation of the skin, including palmar erythema. Acrylamide toxicity may also be distinguished from n-Hexane exposure based on this patient’s facial numbness and visual symptoms, which would be unusual in acrylamide poisoning. D. Carbon disulfide (found in perfumes, varnishes, insecticides, and other manufacturing processes) may be inhaled. Acute exposure results in mucosal irritation and burns, encephalopathy, seizures, coma, and respiratory failure. Chronic exposure may lead to behavioral changes, extrapyramidal signs, cerebellar dysfunction, and peripheral neuropathy (sensory or sensorimotor with minimal weakness). Cranial nerve dysfunction may also occur. References:

Answer 451

Correct Answer: D. Low CD4 count increases likelihood that psychiatric symptoms may be determined by HIV infection. New onset of symptoms and a low CD4 count of the likelihood that psychiatric symptoms may be due to HIV infection or another HIV-related cause rather than a new psychiatric diagnosis. Incorrect Answers: A. Early cognitive and motor deficits involve attention, concentration, visuospatial performance, fine motor control, coordination, and speed. B. New-onset psychosis is uncommon and generally seen only in advanced disease stages. C. Problems with sleep and anxiety are prevalent in the HIV-infected population. References:

Answer 452

Correct Answer: C. Do not rechallenge with clozapine in future. Clozapine-induced myocarditis most frequently occurs within 1 month of treatment initiation; based on case reports, the median time of treatment before diagnosis is <3 weeks. Usual symptoms include fever and flu-like symptoms, and common objective findings include peripheral eosinophilia, EKG changes, and elevated troponin and CK levels. If myocarditis is suspected, clozapine should be immediately discontinued. With a history of clozapine-induced myocarditis, rechallenge should not be attempted due to reported incidents of symptom recurrence upon restarting the medication. Incorrect Answers: A. B. D. Clozapine shouldn't be challenged in cases where myocarditis is suspected, as there have been reported incidents of symptom recurrence upon restarting medication. References:

Answer 453

Correct Answer: D. 25-35% The most common category of psychiatric problems in the United States is anxiety disorders. The annual prevalence is 19.1%, and the lifelong prevalence is 31.1%, according to the National Comorbidity Study Replication. In the US, anxiety disorders comprise almost 33% of mental health costs. Anxiety can present symptomatically in physical, cognitive, and behavioral ways. In the DSM-5-TR, OCD is now included in obsessive-compulsive and related disorders, and PTSD and acute stress disorder are included with trauma- and stressor-related disorders. Incorrect Answers: A. Anxiety disorders' lifetime prevalence in the U.S. is 31.1%, not <5%. B. Anxiety disorders' lifetime prevalence in the U.S. is 31.1%, not 5-10%. C. The annual prevalence of anxiety disorders falls in this range (it's 19%). However, this question asked for anxiety disorders' lifetime prevalence in the U.S. which is 31.1%. Vital Concept: The National Comorbidity Study Replication indicates a lifetime prevalence of anxiety in the US at 31.1%. References:

Answer 454

Correct Answer: A. Social anxiety disorder Social phobia (social anxiety disorder within the DSM-5-TR) is often seen as a comorbid state with body dysmorphic disorder. Social anxiety disorder criteria include: Terror or significant concern about a certain environment exposes the patient to potential judgment by the public or individuals. This may be when being watched (e.g., during observations, dining in public spaces), presenting (e.g., public speaking), or socializing (e.g., talking or interacting with new people). The patient is concerned that they will behave poorly and be judged by others (i.e., they will be rejected, mortified) The patient reports sudden terror or significant concern every time they are exposed to the certain environment The patient evades the certain environment The actual risk or threat posed by the environment is insignificant in comparison to the patient’s emotional response and concern The terror or concern is consistent for at least 6 months The terror/concern or active evasion of the environment leads to dysfunction (academic, professional, social, or otherwise) or substantial anguish The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern. The concern is not due to a more appropriate psychiatric condition such as autism spectrum disorder, panic attacks (i.e., panic disorder), past trauma (i.e., post-traumatic stress disorder), separation from a loved one (i.e., separation anxiety disorder), a specific trigger (i.e., specific phobia), physical judgment (i.e., body dysmorphic disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). In pediatric patients, the terror/concern must be present when interacting with peers (not only grown-ups) and may present as dependence, immobility, mutism, outbursts, or fits The terror/concern is disproportionate or unconnected in those with a physical attribute that causes them discomfort (e.g., significant scars, facial or other obvious physical difference Incorrect Answers: B. GAD is not often found to be comorbid with body dysmorphic disorder. C. Bipolar disorder is not often found to be comorbid with body dysmorphic disorder. D. Specific phobias are not often found to be comorbid with body dysmorphic disorder. Vital Concept: Body dysmorphic disorder is often comorbid with unipolar depression, social anxiety disorder, personality disorders, substance use disorder, or obsessive-compulsive disorder. References:

Answer 455

Correct Answer: C. The NP should leave a message with a contact number for the patient to call back HIPAA rules are designed to protect the privacy of patients and their confidential medical information. Patient consent is required before releasing patient information to third parties, except in specific circumstances (having to do with third-party payers, reportable diseases, minors). If a healthcare provider is delivering the results of a laboratory test or diagnostic study to a patient, even if the study result is normal, that information cannot be released to anyone for whom the patient has not signed a written consent for release of information. The NP or provider who is calling a patient with test results should leave only a message with name and contact number for the patient to return the call. Information cannot be given to spouse or family members without express consent by the patient. Laboratory or test results should never be left on an answering machine. With respect to psychiatric records, a psychiatric diagnosis and/or mental health records may not be released without a specific signed authorization by the patient. However, patients can be denied access to their psychotherapy records. Incorrect Answers: A. Message should only have name and contact number for the patient to return the call B. Information can't be given to a spouse or family member without the patient's express consent D. Patients can be denied access to the psychotherapy records Vital Concepts: HIPAA rules are designed to protect the privacy of patients and their confidential medical information. Patient consent is required before releasing patient information to third parties, except in specific circumstances (having to do with third-party payers, reportable diseases, minors). If a healthcare provider is delivering the results of a laboratory test or diagnostic study to a patient, even if the study result is normal, that information cannot be released to anyone for whom the patient has not signed a written consent for release of information. References:

Answer 456

Correct Answer: B. Somnolence and dizziness are the most common side effects and may lead to discontinuation. It shows no inhibition of cytochrome P450 enzymes to any degree. Somnolence and dizziness may prompt discontinuation of the drug. The extent of these symptoms can be mitigated by administering a larger percentage of the drug at night. It is not metabolized by the liver but is excreted largely unchanged. Incorrect Answers: A. Gabapentin doesn't interact with anticonvulsants C. Gabapentin isn't metabolized by the liver; it's excreted largely unchanged D. Gabapentin doesn't show any inhibition of cytochrome P450 enzymes References:

Answer 457

Correct Answer: B. Projection Kelly’s defense mechanism is projection, instead of recognizing her role in losing her job she blames her boss. Denial could be considered but does not explain Kelly blaming her boss. Undoing and regression do not apply in this situation. Incorrect Answers: A. This could be considered, but doesn't explain why Kelly blames her boss for being incompetent and lazy. C. This is engaging in contrary behavior to remove an unhealthy or otherwise threatening thought or behavior; it doesn't apply here. D. Kelly hasn't shown signs of reverting to a childlike or similarly regressed state; so regression doesn't apply here. References:

Answer 458

Correct Answer: B. Barbituates lower plasma TCA. In depressed patients, the administration of barbiturates often reduces TCA plasma levels and diminishes antidepressant effects because of their induction of liver microsomal enzymes and accelerated degradation of the TCA. Clinicians should keep this in mind when considering the adjunctive use of hypnotics in depressed patients. Incorrect Answers: A. Barbiturates act on GABA receptors, while the TCA acts as an SNRI. C. The plasma concentration of the TCA decreases. References:

Answer 459

Correct Answer: C. Childhood-onset fluency disorder Childhood-onset fluency disorder (stuttering) is the most appropriate diagnosis for this patient. It is a disorder where a disturbance in the normal fluency and time patterning of speech is not appropriate for the patient's age, with frequent repetitions or prolonging of sounds. Typically develops before age 6. Speech therapy can assist patients in speaking slowly and effectively. CBT can be helpful in identifying situations that worsen stuttering and strategies to decrease stress with stuttering. Incorrect Answers: A. Specific phobia is diagnosed when there is fear about a specific situation/object, and that stimulus always provokes an immediate response. B. With social (pragmatic) communication disorder, patients have problems with verbal and nonverbal communication in social situations. D. Speech sound disorders refer to functional (e.g., articulation, phonology) or organic (e.g., dysarthria, apraxia, cleft palate, hearing impairment) speech sound disorders. Vital Concept: Childhood-onset fluency disorder (stuttering) is a disorder where a disturbance in the normal fluency and time patterning of speech is not appropriate for the patient's age, with frequent repetitions or prolonging of sounds. References:

Answer 460

Correct Answer: B. Inductive Inductive reasoning refers to developing generalizations from specific observations. Deductive reasoning is the opposite process and refers to developing specific predictions from a set of general principles. Incorrect Answers: A. Correlation can be determined through statistical analysis of variables, but it is not a type of reasoning. C. In this case, a nurse practitioner who knew that children of smoking mothers have a higher rate of respiratory infections may have used deductive reasoning to predict that this child would develop a respiratory infection. D. Experimental design is a formal process through which the outcome of an intervention can be measured. Vital Concept: Inductive reasoning refers to developing generalizations from specific observations. Deductive reasoning is the opposite process and refers to developing specific predictions from a set of general principles. References:

Answer 461

Correct Answer: B. Diphenhydramine (Benadryl) The patient has developed akathisia, which is a side effect of high-potency typical antipsychotics. It is an acute extrapyramidal syndrome (EPS). It is likely related to an imbalance between dopamine receptor antagonism and muscarinic receptor antagonism. It is associated with a subjective or objective feeling of restlessness, walking, inattention, and sweating. Akathisia is also seen with antidepressants and sympathomimetics. The treatment of choice is diphenhydramine (Benadryl). A beta-blocker like propranolol may be used to reduce involuntary movements but does not affect anxiety. Other treatments include benztropine, benzodiazepines, and amantadine. Incorrect Answers: A. An increased dose would be warranted to manage residual agitation or psychosis. Acute psychosis is unlikely due to the absence of any psychotic symptoms. C. Flumazenil (Romazicon) is administered to reverse an acute overdose of benzodiazepines, and would not be effective in managing an acute side effect of an antipsychotic. D. A normal saline bolus and phenylephrine would be appropriate to manage a patient presenting with refractory hypotension related to antipsychotic overdose, but this does not correlate with the clinical scenario described. Vital Concept: The presentation of akathisia related to typical antipsychotics is described here. The initial treatment typically consists of an antihistamine (diphenhydramine). Alternatives include the use of benztropine, benzodiazepines, propranolol, or amantadine. References:

Answer 462

Correct Answer: B. Substance abuse Risk factors for child/adolescent suicide include substance use, exposure to violence, previous suicide attempts, immediate family member who completed suicide, previous psychiatric hospitalizations, recent losses, social isolation, bullying, access to guns, lower socioeconomic status, current psychiatric disorder, prior suicide attempts, age >16, male gender, and gay/lesbian/bisexual individuals. Incorrect Answers: A. Gay/lesbian/bisexual individuals have an increased risk for suicide compared to heterosexual individuals. C. Living alone is a risk factor for suicide, not living with multiple family members. D. There is no correlation with low IQ and suicidality in children/adolescents. Vital Concept: Children and adolescents that identify as gay/lesbian/bisexual, use substances and/or live alone are at increased risk for suicide. References:

Answer 463

Correct Answer: D. “It is important to understand that this paralysis is involuntary.” When treating conversion disorder, confrontation about the symptoms is contraindicated. Treatment recommendations include reassurance (in this case, emphasizing to the family that the symptoms are involuntary) and reasonable rehabilitation. Incorrect Answers: A. To be diagnosed with conversion disorder, symptoms cannot be intentionally produced or feigned. B. Conversion disorder is typically of short duration, usually remitting spontaneously within 2 weeks in hospitalized patients. It is unlikely that her symptoms will persist for a year. C. Psychotherapy may be useful but may also be contraindicated, particularly if the patient is resistant to psychotherapy or the symptoms worsen when treatment is initiated. References:

Answer 464

Correct Answer: B. Semiformal Semiformal support systems provide physical and emotional assistance. They include organizations and agencies in the community that provide goods and services. Incorrect Answers: A. Formal support is regulated by laws or statutes. Formal social support is provided by social workers, financial support by Social Security, and medical support provided by Medicare. C and D. Informal support derive from the social network, includes family, and friends, but only those who actually provide assistance in some way. Vital Concept: Semiformal support systems provide physical and emotional assistance. They include organizations and agencies in the community that provide goods and services. References:

Answer 465

Correct Answer: C. Jean Baker Miller Jean Baker Miller is associated with relational theory. Incorrect Answers: A. Sigmund Freud is associated with classical or structural theory. B. Anna Freud is associated with ego psychology. D. Carl Jung is associated with transpersonal psychology. References:

Answer 466

Correct Answer: C. Impaired development of social interaction Impaired development of social interaction is an essential feature of autism spectrum disorder. The diagnostic criteria for ASD include: 1) Current or historical struggles engaging with others across several domains: building, sustaining, and comprehending relationships challenges with the back-and-forth in a group setting, talking and interacting body language, reading facial expressions 2) Actions, thoughts, and attention that are limited and very consistent, sometimes referred to as restricted repetitive behaviors (RRBs). At least two of the following (previously or currently): curiosity and attention to a limited number of topics patterns of speech and movement that are unchanging significantly increased or decreased response or attention to sights/sounds/smells/touches/feelings from their environment very consistent patterns in daily routines Both components 1 and 2 are required for the diagnosis of ASD, although social communication disorder may be diagnosed if no RRBs are present. 3) Signs may increase with age and elevated communication and interaction requirements but are initially evident at a very young age 4) The ability to perform successfully in crucial environments (home, school, work, friends) is significantly hindered by the condition 5) Another condition, such as developmental delay or intellectual limitation, does not provide an enhanced reason for the symptoms. Incorrect Answers: A. Impairment in communication is an essential feature of autism spectrum disorder; accelerated development of communication wouldn't be an essential feature of autism spectrum disorder. B. Aversion to stimuli isn't an essential feature of autism spectrum disorder. D. Repetitive patterns of activities and interests are an essential feature of autism spectrum disorder; a broad repertoire of activities and interests wouldn't be an essential feature of autism spectrum disorder. Vital Concept: Autism spectrum disorder is defined by current or historical struggles engaging with others across several domains. References:

Answer 467

Correct Answer: D. Suicidality in schizophrenia While clozapine may have some potential benefit in other situations, it is FDA-indicated for only suicidality in schizophrenia among the choices listed. Clozapine has a risk of causing leukopenia (specifically agranulocytosis). Clozapine would not be used to treat leukocytosis. Incorrect Answers: A, B. Clozapine isn't FDA-indicated for these conditions. C. Clozapine has a risk of causing leukopenia, so it wouldn't be used to treat leukocytosis. References:

Answer 468

Correct Answer: D. Valproate competes with lamotrigine for some glucuronidation sites. UDP-glucuronosyltransferase (UGT) enzymes comprise a superfamily of key proteins that catalyze the glucuronidation reactions that are needed to metabolize some drugs. Valproate inhibits UGT2B7 but does not effect UGT1A4. Lamotrigine depends on glucuronidation to be eliminated and inactivated, so anything that blocks either UGT1A4 or UGT2B7 will increase lamotrigine levels. Depakote also inhibits only UGT2B7. Drugs that inhibit UGT1A4 include: 4-OH-tamoxifen, amitriptyline, androsterone, asenapine, chlorpromazine, clozapine, cyclobenzaprine, cyproheptadine, diphenhydramine, doxepin, imipramine, irinotecan, lamotrigine, loxapine, meperidine, nicotine, olanzapine, progestins, promethazine, and retigabine. Drugs that inhibit UGT2B7 include: almokalant, atorvastatin, buprenorphine, carvediolol, chloramphenicol, clofibric acid, codeine, cyclosporine, diclofenac, entacapone, epirubicin, febuxostat, fenofibrate, fenoprofen, fluvastatin, gemfibrozil, hydromorphone, ibuprofen, ketoprofen, lamotrigine, lorazepam, methadone, morphine, mucophenolate, nalorphine, naloxone, naltrexone, naproxen, nicotine, oxazepam (r), oxycodone, naloxone, simvastatin, tacrolimus, temazepam, valproic acid, and zidovudine. Incorrect Answers: A. Valproate inhibits microsomal enzymes. The correct mechanism of action is Valproate inhibits UGT2B7 that assists in lamotrigine elimination; blocking it increase lamotrigine levels. B. Valproate inhibits excretion of lamotrigine in kidneys. The correct mechanism of action is Valproate inhibits UGT2B7 that assists in lamotrigine elimination; blocking it increase lamotrigine levels. C. Valproate displaces lamotrigine from protein-binding sites. The correct mechanism of action is Valproate inhibits UGT2B7 that assists in lamotrigine elimination; blocking it increase lamotrigine levels. References:

Answer 469

Correct Answer: A. 0.3-1% Schizophrenia affects less than 1% of people worldwide. It is characterized by positive symptoms (hallucinations, delusions, and disorganized speech and behavior), negative symptoms (flattened affect and alogia), and other symptoms like inattentiveness. Many patients also have a lack of insight regarding their condition. There is usually significant impairment in their social, occupational, and interpersonal lives. In order to diagnose schizophrenia, symptoms must be present for at least 6 months, including at least 1 month of positive or negative symptoms. Incorrect Answers: B. The estimated lifetime prevalence of schizophrenia is 0.3-1%, not 1-2%. C. The estimated lifetime prevalence of schizophrenia is 0.3-1%, not 2-4%. D. The estimated lifetime prevalence of schizophrenia is 0.3-1%, not 4-5%. Vital Concept: The DSM estimates that the lifetime prevalence of schizophrenia is 0.3-0.7%. References:

Answer 470

Correct Answer: B. Mindfulness Mindfulness involves learning direct attention, increasing awareness, and promoting immersion in the present moment. Unified detachment involves examining a problem from an emotional distance with a greater objective focus. Incorrect Answers: A. Empathic joining is another technique used in integrative behavioral couples therapy that involves evocation of strong emotions in the dyad. C. Emotional acceptance is promoted in integrative couples behavioral therapy through empathic joining, unified detachment, and tolerance building. D. Tolerance building is another technique used in integrative behavioral couples therapy that involves helping dyad members to be more tolerant of upsetting behaviors. References:

Answer 471

Correct Answer: A. Folate (B-9) All women of childbearing potential who are treated with valproate should receive concomitant folate (B-9) supplementation, regardless of whether they plan to conceive. Incorrect Answers: A, C, and D. These are not the vitamin supplement that women of childbearing age should receive. They should receive folate, which is vitamin B-9. References:

Answer 472

Correct Answer: D. St. John's wort St. John’s wort is used as an herbal treatment for depression. It causes marked CYP induction and lowers the level of many common drugs, including warfarin and digoxin. It also acts as a serotonin reuptake inhibitor and should be avoided in patients taking serotonin-raising medications like MAOIs and SSRIs due to the risk of serotonin syndrome. Incorrect Answers: A. Ginkgo biloba has several perceived effects on blood flow and cognitive enhancement, although studies in humans have been equivocal. It should be avoided with antiplatelet and anticoagulant medications. B. Echinacea purpurea may have anti-inflammatory and immune-enhancing properties. It may cause a flu-like syndrome but has no known drug interactions. It is generally recommended to avoid echinacea in immune-related conditions such as post-transplant immune suppression as well as autoimmune and immune-deficiency conditions (e.g. AIDS, cancer). C. Allium sativum is garlic, which has mild cholesterol-lowering characteristics. Garlic has reported antiplatelet effects and should be used cautiously with antiplatelet and anticlotting medications. References:

Answer 473

Correct Answer: C. Start electroconvulsive therapy (ECT) The diagnostic criteria for catatonia in the DSM-5-TR includes at least three of the symptoms below: catalepsy (i.e., a posture maintained due to muscular contractions, often against gravity and without intention, after being placed in that position by the examiner) mutism (i.e., minimal or absent speech, not applicable if the patient has a history of aphasia) posturing (i.e., a posture maintained due to muscular contractions, often against gravity and without intention, after spontaneously assuming that position) stereotypy (i.e., recurring actions or movements that are quickly performed without purpose) facial expressions that communicate pain or anguish echopraxia (i.e., copying someone else’s actions) echolalia (i.e., to copy someone else’s sounds when talking) stupor (i.e., a lack of responsiveness) waxy flexibility (i.e., a consistent yet minimal muscular opposition to being placed in a position by the examiner) negativism (i.e., doing the opposite or not reacting to external directions or requests) mannerism (i.e., strange or affected display of normal motions) irritability not affected by the surrounding environment There is strong evidence for treatment with a benzodiazepine and ECT. Patients generally respond well to benzodiazepines, and lorazepam has the most evidence. If a good response does not occur, ECT should be strongly considered as an effective treatment for catatonia. When the diagnosis of catatonia has been made, the use of antipsychotic and/or antidepressant medications should generally be avoided. Incorrect Answers: A. Antipsychotics can worsen catatonia due to parkinsonian side effects and can increase the risk of neuroleptic malignant syndrome. B. Increasing the dose of the mood stabilizer is not as effective as ECT when there is a critical manifestation such as catatonia. D. A change in mood-stabilizer dose or a change to another mood stabilizer is not an effective treatment for catatonia. Vital Concept: In patients that exhibit catatonia, first-line treatments include the use of benzodiazepines and electroconvulsive therapy (ECT). References:

Answer 474

Correct Answer: D. Schizophreniform disorder Schizophreniform disorder is differentiated from schizophrenia by the duration of symptoms. In schizophreniform disorder, the total duration of illness (including prodromal and residual phases) is at least 1 month and under 6 months. At follow up, 33% of patients will show full recovery, while the rest will be diagnosed with identified mood disorders or schizophrenia. Incorrect Answers: A. Schizoaffective disorder is diagnosed with prominent features of both schizophrenia and major mood disorders. Psychotic features occur intermittently in the absence of mood disorder. B. Delusional disorder is characterized by the presence of 1 or more delusions in the relative absence of other symptoms of psychosis and stressors. C. Brief psychotic disorder is mostly diagnosed with acute psychotic symptoms after any social or family stressor. Symptoms last for <1 month with full spontaneous remission. Vital Concept: Duration of psychotic symptoms (e.g. delusions, hallucinations, disorganized speech/behavior) is important for diagnostic clarification. In brief psychotic disorder symptoms are present for 1 day to 1 month. In schizophreniform disorder symptoms are present for 1 to 6 months. In schizophrenia symptoms are present for at least 6 months. References:

Answer 475

Correct Answer: D. The 17-year-old is repeatedly caught sneaking out, drinking alcohol, and she is failing two classes. There are five stages of grief in the model created by Kubler-Ross: denial, anger, bargaining, depression, and acceptance. The stages of grief can occur in any order, and the duration usually varies from 6-12 months. Children may have separation anxiety, regressive behavior, somatic complaints, thoughts of death, or hallucinations of the lost loved one. Complicated grief is persistent and causes functional impairment. Reactions to grief are influenced by developmental stages, family coping style, cultural background, and the circumstances surrounding the death. Common expressions of grief include repeated questioning, regressive behaviors, and extreme emotions like anger or fear. This adolescent is demonstrating an increase in high-risk behaviors by experimenting with alcohol. Other high-risk behaviors are drug use, delinquency, and precocious sexual activity. This alcohol use concerns complicated grief, and the family should be referred to a grief counselor. Incorrect Answers: A. The 3-year-old child is experiencing separation anxiety. Separation anxiety is only concerning for complicated grief if it persists for more than six months after a predictable home routine has been established following a traumatic event such as a death. B. Daytime urinary accidents are an example of regressive behavior. This can be normal after a traumatic event if it resolves within six months. C. School-aged children may respond to a death by reporting physical symptoms such as abdominal pain and headaches that have no organic cause. If these symptoms persist for more than 3 months, they would indicate the presence of pathological grief. Since the pain only occurs on school mornings, it is likely due to school phobia. School phobia that persists for 3 months after the sibling’s death would be considered complicated grief. Vital Concept: The five stages of grief include denial, anger, bargaining, depression, and acceptance. These stages may occur in any order. Sadness, shock, anxiety, and somatic complaints are also symptoms of grief and can occur in waves. If grief does not resolve within 6-12 months or causes functional impairment, it is considered complicated grief. References:

Answer 476

Correct Answer: D. Self-pity Self-pity is not a central aspect of Lazarus’ conceptualization of coping. Self-exploration, self-instruction, self-correction, and self-rehearsal are part of the extensive and recursive process Lazarus notes in his “Transactional Model for Stress Management.” Incorrect Answers: A, B, and C. These are all part of the process Lazarus notes in his "Transactional Model for Stress Management." References:

Answer 477

Correct Answer: B. It is more effective than lithium in patients with prominent depressive symptoms during mania and with multiple prior mood episodes. Valproic acid is more effective than lithium in patients with prominent depressive symptoms during mania, with mixed symptoms, or with multiple prior mood episodes. Incorrect Answers: A. Valproic acid is much more effective than lithium in patients with mixed symptoms. C. Valproic acid and haloperidol are equally effective in acute mania D. Olanzapine is superior to valproic acid in reducing acute manic symptoms and facilitating remission References:

Answer 478

Correct Answer: C. Toxicology analysis for cocaine overdose Cocaine use is a dangerous etiology of an apparent anxiety attack, which could possibly have serious repercussions for her health. The other conditions, although scary for the patient, would not be as potentially dangerous from a medical standpoint or are much less likely in this situation. Incorrect Answers: A. It seems unlikely that she would be having delirium tremens, and her symptoms don't exactly match (no “tremens” or shakes, dilated pupils). B. A beta-blocker would be premature at this point, without determining the etiology of her anxiety. In addition there is the possibility of unopposed alpha stimulation with a combination of cocaine and beta-blockers. References:

Answer 479

Correct Answer: D. Smoking appears to relieve symptoms associated with schizophrenia. Smoking cessation is important to the health of schizophrenic patients. It is unclear whether increased risk is attributable to an innate aspect of the schizophrenia or to lifestyle, poor health care in this particular population, or antipsychotic usage or other drug therapy. As many as 70-80% of all schizophrenic patients smoke. Research shows no association between smoking and antipsychotic use after controlling for schizophrenia. It is theorized that nicotine increases the release of dopamine and corrects dopamine deficiency in the prefrontal cortex, relieving negative symptoms. Incorrect Answers: A. 70-80%, not 95%, of schizophrenia patients smoke B. Most people gain weight after quitting smoking; smoking doesn’t cause weight gain C. Smoking is a modifiable cardiac risk factor; it's a major risk factor for heart disease Vital Concept: It is theorized that nicotine increases the release of dopamine and corrects dopamine deficiency in the prefrontal cortex, relieving negative symptoms. In other words, smoking appears to relieve negative symptoms associated with schizophrenia. References:

Answer 480

Correct Answer: B. Self-actualization The hierarchy of needs proposed by Abraham Maslow posits five levels, each of which must be substantially met before a person can address “higher” levels of need. The first, or basic, level of Maslow’s hierarchy of needs includes the basic elements of survival, like air, food, and water. The second level includes safety; the third level includes love and belonging. The fourth level includes esteem, including self-esteem, confidence, achievement, respect of others, and respect by others. The fifth and final level is self-actualization, which refers to the acceptance of facts, lack of prejudice, spontaneity, morality, creativity, and problem-solving. Incorrect Answers: A. This is level 4. C. This is level 3. D. This is level 1. Vital Concepts: The hierarchy of needs proposed by Abraham Maslow posits five levels, each of which must be substantially met before a person can address “higher” levels of need. The fifth and final level is self-actualization, which refers to the acceptance of facts, lack of prejudice, spontaneity, morality, creativity, and problem-solving. References:

Answer 481

Correct Answer: C. Overgeneralization Overgeneralization involves coming to generalized conclusions based on a single experience. Incorrect Answers: A. Selective abstraction involves taking a small detail out of context and using it to make an entire experience negative. B. Arbitrary inference involves coming to an incorrect conclusion based on a previous experience. D. Magnification and minimization involve making certain events more or less significant based on a negative interpretation. Vital Concept: Overgeneralization can frequently affect individuals with depression or anxiety disorders. Patient will apply past experience to all future ones. For example, once a patient gives a poor speech, they think "I always mess up speeches." References:

Answer 482

Correct Answer: B. Unethical Dating or any romantic relationship between a psychiatrist and any "key third party" (which includes a parent, guardian, spouse, significant other, or surrogate) is considered unethical by the APA. Relationships of this nature between a practitioner and a person in a decision-making capacity for the patient is a clear conflict and puts the therapeutic relationship between the patient and physician at risk. Incorrect Answers: A, C, and D. There's no way to make this ethical References:

Answer 483

Correct Answer: C. Report the situation to Child Protective Services Physicians are mandatory reporters of child abuse. They are legally and ethically bound to report suspected abuse to Child Protective Services. Risk factors for abuse include young or single parents, parents with lower levels of education and unrealistic expectations for the child, or poor knowledge of child development. Red flags include no history or denial of trauma despite severe injury, implausible history for degree or type of injury, unexplained or excessive delay in seeking care, and caregiver histories that change with retelling or conflict with versions from other observers. Any injury which is inconsistent with the history given by a caregiver should prompt suspicion of child abuse. The child should be examined thoroughly for evidence of other injuries, and a complete skeletal X-ray survey should be obtained. Other findings that should raise concern for child abuse include bruises on the buttocks, genitalia, or elsewhere on the body, lash marks, and burns from cigarettes or immersion in hot water. A retinal examination may reveal hemorrhages. X-ray studies may show spiral fractures of the long bones, subdural hematomas, and multiple bony injuries at different stages of healing. Medical providers are required by law to report cases of suspected child abuse to state authorities. If suspicion is high enough, a child may be admitted to the hospital for protection until an investigation is complete. Incorrect Answers: A. While discussing the concerns with the child's mother is appropriate, calling CPS is required if there is a reasonable suspicion of abuse. B. If there is any suspicion of child abuse, reporting to CPS is required regardless of the history provided by the caregiver or anyone involved in the child’s care. D. This patient may be unsafe at home. Delaying evaluation by Child Protective Services increases the risk of further abuse at home and would be inappropriate. Vital Concept: Physicians are mandatory reporters of child abuse and are legally and ethically bound to report suspicion of abuse to Child Protective Services. References:

Answer 484

Correct Answer: C. Excessive increases in excitatory neurotransmitters Excitatory neurotransmitters such as glutamate control the growth of neurons and their connections via their effects on calcium flow through NMDA receptor channels. Too much calcium can arrest growth and eventually lead to the destruction of neuronal processes. High levels of glutamate produce excitotoxicity. Incorrect Answers: A. Programmed cell death is incorrect. In the event neuron loss in an ischemic stroke there is no programmed cell death. It involves sustained calcium entry through NMDA receptor channels activates intracellular proteases and possibly generates free radicals, ultimately leading to neuron death. B. Interstitial fluid accumulation is incorrect. Excitotoxicity appears to play a prominent role in strokes, status epilepticus, hypoglycemia, and head trauma; these brain injuries cause neuronal depolarization, which leads to excessive electrical activity and excessive increases in glutamate release. Excitotoxicity also appears to play a role in neurodegenerative disorders like Huntington’s disease. D. Interrupted blood flow is incorrect as it is due to the calcium flow through the NMDA receptor channels and can be desctructive on the neuronal process. References:

Answer 485

Correct Answer: D. Alcohol withdrawal Alcohol withdrawal typically begins 6–8 hours after the last drink, peaks 24–28 hours after the last drink, and generally resolves within 7 days. Alcohol hallucinosis occurs in 3–10% of patients with severe alcohol withdrawal. It can present as auditory, visual, or tactile hallucinations in the presence of a clear sensorium. Delirium tremens (DT) is characterized by agitation and tremulousness, autonomic instability, fevers, auditory and visual hallucinations, and disorientation. DT usually develops 2–4 days from the person's last drink, and the average duration is <1 week. Seizures (grand mal), another complication of alcohol withdrawal, are estimated to occur in 5–15% of patients. They usually occur in the first 24 hours from the last drink, but they can occur at any time in the first 5 days. Incorrect Answers: A. Alcohol intoxication is dependent on the individual's tolerance, the amount and type of alcoholic beverage ingested, and the amount absorbed. Alcohol intoxication presents with impaired recent memory, passivity, lack of concern, and disinhibition. B. Cocaine intoxication can resemble a manic episode with euphoria, impulsive behavior, aggression, dystonias, heightened self-esteem, mydriasis, increased vitals, hyperthermia, or cardiac conduction abnormalities. C. Cannabis intoxication involves behavioral changes like euphoria, anxiety, isolation, impaired cognition, and somatic symptoms of dry mouth, tachycardia, and red eyes. References:

Answer 486

Correct Answer: D. May no longer be applicable to the delivery of client care. Such a drastic change in health care delivery may make previous studies no longer applicable. Incorrect Answers: A, B, and C. Health care restructuring has changed the way client care is provided. These options are not applicable. Vital Concepts: Such a drastic change in health care delivery may make previous studies no longer applicable. References:

Answer 487

Correct Answer: A. Medical conditions that cause ASD can be identified in <5% of cases. Medical conditions that cause ASD can be identified in <5% of cases. Medical conditions that are best established as probable causes of ASD include Rett syndrome, fragile X syndrome, tuberous sclerosis, and abnormalities of chromosome 15 involving the 15q11-13 region. Incorrect Answers: B. ASD is a heterogenous disorder and may be due to multiple gene changes. C. Up to 5% (or possibly more) of ASD may be due to mitochondrial dysfunction. This is 500x higher than the general population (0.01%). A growing body of clinical, genetic, and biochemical evidence now suggests that ASD, or at least a subset of ASDs, may also be linked to impaired mitochondrial function. D. Fragile X syndrome and tuberous sclerosis are genetic syndromes that have a high rate of comorbidity with autism spectrum disorder (ASD). The FMR1 gene associated with fragile X syndrome is associated with ASD. References:

Answer 488

Correct Answer: D. Concordance Concordance, as used in genetics, usually means the presence of the same trait in both members of a pair of twins. Twin studies can be performed with monozygotic and dizygotic twins to look for the heritability of a certain condition. They are often used in behavior genetics and include genetically informative data (e.g., pedigree, adoption, and sibling data). The studies evaluate the relative contributions of the environment and genetics on an outcome or attribute. Twin studies are frequently performed by comparing the characteristics of identical (monozygotic) twins who were raised in different households since they share a genotype but not an environment. Comparison studies of identical twins raised together and fraternal twins raised together can also provide important information since each twin set shares the same environment, but only the identical twins have the same genotype. Fraternal twins share only half of the same genetic makeup. Incorrect Answers: A. Genetic variance describes the difference in an individual’s phenotype compared to a norm due to the inheritance of a specific allele. B. Cohort study design compares groups with exposure or risk factor to groups without that exposure or risk factor. Cohorts utilize relative risk measures. C. Case-control. Case-control study design compares people with and without disease. Case-controls utilize odds ratio measures. Vital Concept: Concordance, as used in genetics, usually means the presence of the same trait in both members of a pair of twins. References:

Answer 489

Correct Answer: D. It is associated with higher rates of depression and rapid cycling After lithium-induced hypothyroidism develops, it's associated with rapid cycling and an increased risk of developing depression Incorrect Answers: A. Lithium-induced hypothyroidism occurs in 5-35% of patients treated with lithium B. Lithium-induced hypothyroidism occurs in women more often than in men C. Lithium-induced hypothyroidism isn't a contraindication to lithium treatment, and it can be treated with levothyroxine References:

Answer 490

Correct Answer: D. Symptoms present for at least 30 days are consistent with PTSD rather than ASD. The symptoms of ASD must persist for 3 or more days but not more than 30. By contrast, the diagnostic criteria for PTSD specify that symptoms must last a minimum of 30 days. Incorrect Answers: A. Dissociative symptoms may be associated with either PTSD or ASD. B. Screening for an exposure event is a necessary first step in both ASD and PTSD. C. The three major symptom clusters in the DSM-4 were avoidance/numbing, hyperarousal, and re-experiencing. The DSM-5 included four clusters: re-experiencing, avoidance, negative cognitions and mood, and arousal. The DSM-5-TR lists: affective/mood, intrusive, dissociative, arousal, and avoidance. Vital Concept: In ASD, symptoms are present for 3 or more days and may last up to a month. In PTSD, symptoms are present for at least 30 days after a traumatic experience. References:

Answer 491

Correct Answer: D. CN VIII The Rinne test evaluates conductive hearing loss. The test is performed by striking a tuning fork of 256 or 512 Hz and placing it on the mastoid process. A normal test will show air conduction time that is twice as long as bone conduction time. if there is hearing loss bone conduction is longer than air conduction. CN VIII is the auditory nerve. Incorrect Answers: A. CN V. The trigeminal nerve (CN V) is responsible for facial movement and sensation. To test CN V check pinprick sensation of bilateral face and have patient open jaw against resistant. B. CN VI. The abducens nerve (CN VI) is responsible for movement of the lateral rectus eye muscle. To test CN VI test extraocular eye movements. C. CN VII. The facial nerve (CN VII) is responsible for muscles of facial expression and taste. To test CN VII ask the patient to smile and look for any hemifacial weakness. Vital Concepts: CN VIII is the auditory nerve. References:

Answer 492

Correct Answer: B. Secondary The CRAFFT test is a short, self-administered behavioral-health tool developed to screen adolescents for high-risk alcohol and other drug-use disorders simultaneously. Secondary prevention detects diseases early when patients are asymptomatic and address treatment to halt its progression. Examples include HIV testing, screening for nutrition and exercise, depression screening for at-risk teens, urine drug testing, or identifying prodromal schizophrenia. Incorrect Answers: A. Primary prevention keeps a disease from occurring by removing its causes. Primary prevention includes counseling about lifestyle changes like drinking and smoking, immunizations, and suicide prevention programs. C. Tertiary prevention is defined as activities that prevent deterioration or reduce complications after a disease is already present. Examples include metabolic monitoring of patients on antipsychotics, assertive community treatment for people with schizophrenia, and intensive case management. D. CRAFFT screening is a form of secondary prevention. References:

Answer 493

Correct Answer: A. The rate of alcohol use disorder is significantly higher amongst patients with bipolar disorder The prevalence of alcohol use disorder (AUD) in American bipolar patients is 40-60% compared to the 15% incidence in the US general population. Recommendations about treatment should be advised by an addiction specialist. Liver function tests should be monitored, as they are commonly elevated in patients with AUD. In patients with increased liver enzymes, valproate should be used cautiously. Lithium levels can reach toxic levels in patients who become dehydrated due to alcohol use. Incorrect Answers: B. The rate of AUD in patients with bipolar disorder is more than twice the general population. C. The rate of AUD in patients with bipolar disorder is more than twice the general population. D. Alcohol use has been shown to increase the number of mood episodes, mood symptoms, suicide attempts, hospitalizations, and otherwise worsen the prognosis of bipolar disorder in general. Vital Concept: The relationship between AUD and bipolar disorder is mutually destructive. The rate of AUD amongst bipolar patients is 40-60%, more than twice the general population. References:

Answer 494

Correct Answer: B. The healthcare provider must decline this valuable gift. A healthcare provider should consider the potential implications of accepting a gift in light of the provider-patient relationship, including any patient expectations of the healthcare provider as a result of the gift. To demonstrate favorable treatment to a patient due to a patient gift may impair the healthcare provider’s objectivity when caring for the patient and can undermine the professionalism expected of the provider. In general, a healthcare provider ethically can accept a small gift as a token of appreciation, but acceptance of a valuable gift is problematic. The promise of a bequest may cause the healthcare provider consciously or unconsciously to alter treatment decisions in the care of a patient and may tarnish the healthcare provider’s reputation by the suggestion of impropriety. Incorrect Answers: A. The proposed gift has a large monetary value, so the provider can't accept it C. This would be unethical D. Tax law doesn't carry risk in this case Vital Concepts: A healthcare provider should consider the potential implications of accepting a gift in light of the provider-patient relationship, including any patient expectations of the healthcare provider as a result of the gift. References:

Answer 495

Correct Answer: D. Development of spiritual beliefs Alcoholics Anonymous emphasizes the development of spirituality. Incorrect Answers: A. A function of dialectical behavioral therapy (DBT) is to enhance patient motivation for change. B. A function of DBT is to develop new patient capabilities. C. A function of DBT is to promote the generation of patient capabilities. References:

Answer 496

Correct Answer: D. Discharge with enough Ativan to control symptoms until follow-up The physician’s response during the withdrawal phase is critical to achieving a satisfactory resolution of the physical dependency. Increasing the benzodiazepine dosage will reduce symptoms because benzodiazepines have not completely lost effectiveness and because the withdrawal syndrome is reversed; however, symptom reduction will not be as complete as during the initial therapeutic phase. The duration of the resolution phase is highly variable. Most patients will have symptom rebound lasting only a few weeks; others will have a severe, protracted abstinence syndrome lasting months to >1 year. When withdrawing patients from benzodiazepines, use decreasing dosages of the agent of dependence or substitute a longer-acting agent, then gradually withdraw the substitute medication. Although withdrawal from high dosages of sedative-hypnotics should generally be done in a hospital, the realities of managed care often mean that many patients must be treated in part, if not exclusively, as outpatients. For patients who are withdrawing from therapeutic doses of benzodiazepines, a slow outpatient taper is a reasonable strategy and should be continued on an outpatient basis as long as the patient can tolerate withdrawal symptoms. The decision to initiate a taper or to continue treatment with benzodiazepines should be agreed upon by the patient and the primary treatment provider. In this situation, the patient’s symptoms of withdrawal are well controlled with relatively little agonist therapy; he is also actively in treatment and has close follow-up. Discharging the patient with enough benzodiazepines to manage any re-emerging symptoms before his next appointment would be a reasonable treatment plan. Incorrect Answers: A. Admit to detoxification unit. A common response is to declare the patient “addicted to benzos” and to refer him or her for chemical-dependency treatment; however, chemical dependency treatment is not appropriate unless the patient has a substance use disorder. Some physicians interpret escalating symptoms as evidence of the patient’s “need” for benzodiazepine treatment and reinstitute higher dosages or switch to another benzodiazepine. Discharging the patient without any benzodiazepines could be dangerous if withdrawal progresses without intervention over the next few days. B. Admit to inpatient psychiatry unit. The patient is not a danger to themselves or others. Nor is hospitalization expected to prevent decompensation. Therefore, an admission to an inpatient unit is not appropriate. C. Discharge with Xanax refill. The patient has follow up with their primary provider within one week and therefore a month supply of Xanax is unnecessary. He only needs a bridge of benzodiazepines until next appointment. References:

Answer 497

Correct Answer: A. Motor delay Infants deprived of affection, particularly in the first 6 months of life, are vulnerable to short-term and long-term complications, including language delay, delayed gross and fine motor development, learning disabilities, attachment disorders, and other psychiatric disorders. The length of time spent in a psychosocially deprived environment also directly affects outcomes, with worsening outcomes in children exposed to these environments for longer periods. The remaining answer choices are not as relevant as motor delay in formerly institutionalized infants. Incorrect Answers: B. Risk factors for night terrors include sleep deprivation, medication, stress, and intrinsic sleep disorders. C. Hyperorality is associated with frontotemporal dementia. D. Limb contractures are associated with cerebral palsy and muscular dystrophy in children. Vital Concept: Psychosocial deprivation in infants, especially in the first 6 months of life, can lead to delayed milestones in many areas of development, as well as long-term psychiatric morbidity. References:

Answer 498

Correct Answer: D. Parental psychiatric disorder History of psychiatric disorder in a parent is a risk factor for suicide attempt. The other responses are not risk factors for suicide. Incorrect Answers: A. Low IQ isn't a risk factor for suicide B. Male, rather than female, gender is a risk factor for suicide C. Non-heterosexual sexual orientation, not heterosexual sexual orientation, is a risk factor for suicide Vital Concept: Risk factors include prior suicide attempts, age >16, male gender, and gay/lesbian/bisexual individuals. References:

Answer 499

Correct Answer: D. Ginseng Ginseng is thought to have a large number of positive effects as well as the general ability to improve mental and physical performance. Clinical trials, however, have shown few significant and no conclusive benefits in humans. Although the mechanism has not been fully described, ginseng has been reported to interact with certain psychiatric medications (including phenelzine, lithium, and neuroleptics), causing irritability, insomnia, and mania. Incorrect Answers: A. Ginkgo biloba has several perceived effects on blood flow and cognitive enhancement, although studies in humans have been equivocal. It should be avoided with antiplatelet and anticoagulant medications. This patient is taking warfarin for atrial fibrillation and should avoid using ginkgo. B. Echinacea purpurea is thought to have anti-inflammatory and immune-enhancing properties. Echinacea may cause a flu-like syndrome but has no known drug interactions. It is generally recommended to avoid echinacea in immune-related conditions such as post-transplant immune suppression and autoimmune and immune deficiency conditions (e.g. AIDS, cancer). C. Allium sativum is garlic, which has mild cholesterol-lowering characteristics. Garlic has reported antiplatelet effects and should be used cautiously with antiplatelet and anti-clotting medications. While garlic should be avoided in patients on warfarin, it is not used as a cognitive enhancer. References:

Answer 500

Correct Answer: B. Relatives of suicide completers and suicide attempters have a heritable risk of suicide attempts and completions. Considerable evidence suggests that genetic factors play a role in suicide and impulsive behavior. Many family studies have established familial clustering of both suicide attempts and completions. The relatives of both suicide completers and suicide attempters have an increased risk of suicide attempts and completions. Some studies have marked this risk as high as 4x in the relatives of suicide probands as compared to the relatives of control subjects in the community. Twin studies have estimated the heritability of reporting any suicidal ideation, suicide plans, or attempts to be about 44% and that of reporting serious suicide attempts to be 55%. Adoption studies further support the hypothesis that genetic factors contribute to suicide. Incorrect Answers: (A) Relatives of suicide completers, not suicide attempters, have a heritable risk of both suicide attempts and completions. Relatives of suicide completers AND suicide attempters have a heritable risk of suicide attempts and completions. (C) Relatives of suicide completers and suicide attempters have a heritable risk of suicide attempts, not completions. Relatives of suicide completers and suicide attempters have a heritable risk of suicide attempts AND completions. (D) Relatives of suicide completers or suicide attempters do not have an increased risk of suicidal behavior compared to relatives of control subjects. Relatives of suicide completers and suicide attempters have a heritable risk of suicide attempts and completions. References:

Answer 501

Correct Answer: A. Reducing frown lines when injected into glabellar region Botulinum toxin injected into the glabellar region of frowning patients improved depressive symptoms, according to the Hamilton Depression Rating Scale 21, the Beck Depression Inventory, and the Patient Health Questionnaire-9. When the face cannot frown or is not able to frown as deeply, there is less activation in the left amygdala when the patient tries to mimic angry facial expressions. According to the facial-feedback hypothesis, frowning can actually make patients unhappy, and smiling can make them happy. Reducing the ability to frown creates changes in neural circuitry beyond the cosmetic and esthetic effects of botulinum toxin. Incorrect Answers: B. No correlation between enhancing lips and depression symptoms. C. Botulinum toxin is not injected into the facial nerve. D. When the face cannot frown or is not able to frown as deeply, there is LESS activation in the left amygdala when the patient tries to mimic angry facial expressions. Vital Concept: Botulinum toxin injected into the glabellar region of frowning patients improved depressive symptoms. References:

Answer 502

Correct Answer: D. Durable medical equipment and home health care Medicare Part B provides coverage for durable medical equipment. In general, Medicare Part B provides both medically necessary services/supplies (including DME) and preventative services for outpatient needs. This includes primary care appointments, preventative care, outpatient therapy, and outpatient mental health services. It does not cover inpatient services (hospital charges), medications, eye care, or dental care. Incorrect Answers: A. Medicare part B does not provide coverage for eye exams or eyeglasses B. Medicare part B does not provide coverage for routine dental care C. Medicare part D (not part B) covers prescription medications Vital Concept: Medicare Part B provides coverage for durable medical equipment and home health care, as both are medically necessary or preventative outpatient services/supplies. References:

Answer 503

Correct Answer: D. You are obligated to provide access to confidential patient information requested by law enforcement on presentation of a search warrant. A healthcare provider is obligated to protect confidential patient information unless furnished with a search warrant, subpoena, or court order or if sharing the information is necessary to prevent harm to others. If a law-enforcement agent, government agent, or employer requests confidential patient information, you must refuse access under other conditions. All patient information (including genetic information, immigration status, and patient history) should be protected from third parties unless the patient authorizes their release. Incorrect Answers: A. B. and C. Law enforcement needs a warrant to compel release of patient records. Vital Concepts: If a law-enforcement agent, government agent, or employer requests confidential patient information, you must refuse access under other conditions. All patient information (including genetic information, immigration status, and patient history) should be protected from third parties unless the patient authorizes their release. References:

Answer 504

Correct Answer: D. For patients with pheochromocytoma Absolute contraindications for selegiline use include a pheochromocytoma (due to excess norepinephrine leading to a hypertensive crisis) and surgery (planned discontinuation of the patch 10 days prior to elective surgery due to the risk of severe hypotension after general anesthesia is recommended). Monoamine oxidase (MAO) is responsible for the catabolism of serotonin, norepinephrine, and dopamine. Selegiline is an irreversible MAO inhibitor and works by selectively inhibiting MAO-A and MAO-B in the CNS with preservation of the MAO-A in the gut. Its use presents little need for dietary tyramine restriction. However, the lack of clinical, peripheral tyramine effects has only been shown at doses of 6mg/24hr. Higher doses must follow a tyramine-restricted diet. The other situations are good indications for using selegiline to provide additional benefit. Incorrect Answers: A, B, and C. These are all good indications for using selegiline to provide additional benefit References:

Answer 505

Correct Answer: D. A first-degree relative with bipolar disorder There is an average 10% risk of bipolar disorder in adults who have a relative with bipolar disorder. This risk increases with the degree of kinship. Bipolar disorder is also more common in high-income countries compared to low-income. There are higher rates of bipolar I disorder in those who are widowed/separated/divorced compared to those who have never been married or are currently married. Females with bipolar disorder have an increased risk of rapid cycling and mixed states than males. Incorrect Answers: (A) Pregnancy and obstetrical complications are putative environmental risks that have been described for bipolar disorder. (B) Season of birth is a putative environmental risk that has been described for bipolar disorder. (C) Stressful life events are putative environmental risks that have been described for bipolar disorder. Vital Concept: The genetic link for bipolar disorder is significant, so the most established risk factor for the condition is the presence of a first-degree relative with bipolar disorder. References:

Answer 506

Correct Answer: B. Legitimate power Power refers to the potential to exert influence and it is important of human interaction. French and Raven described five categories of interpersonal power. Legitimate power is the power bestowed by the particular status or role of an individual. Licensed nurses and nurse practitioners have legitimate power through their license to practice nursing, granted by the State Board of Nursing. Incorrect Answers: A. Expert power refers to power derived from skill or knowledge that others lack. C. The power of numbers refers to power derived from being part of a group with similar goals. D. Reward power refers to the ability to give others what they want and to ask them to do things in exchange. Rewards can also be withheld as punishment. Vital Concepts: Power refers to the potential to exert influence and it is important of human interaction. French and Raven described five categories of interpersonal power. Legitimate power is the power bestowed by the particular status or role of an individual. Licensed nurses and nurse practitioners have legitimate power through their license to practice nursing, granted by the State Board of Nursing. References:

Answer 507

Correct Answer: D. Propranolol Beta-blockers are effective for acute treatment of performance anxiety. Several small trials have found that beta-blockers reduce performance anxiety. This patient should also administer a test dose prior to the speaking event to assess the drug's effects. Incorrect Answers: A. Fluoxetine. Selective serotonin reuptake inhibitors (SSRIs) are utilized for long-term management of anxiety and require several weeks to take full effect. This patient is looking for immediate relief from performance anxiety. B. Buspirone. Buspirone is FDA approved to treat anxiety disorders. It is utilized for long-term management of anxiety and requires several weeks to take full effect. This patient is looking for immediate relief from performance anxiety. C. Lorazepam. Benzodiazepines (e.g. lorazepam) can be used for the acute management of anxiety. However the potential for benzodiazepine abuse is highest in persons with a history of alcohol or other substance use and is a less desirable option in this patient. References:

Answer 508

Correct Answer: D. Political activism Political activism is important, but it is not specific to collaborative practice. Incorrect Answers: A, B, and C. These are the three major issues that are central to the expansion of the nurse practitioner role. Vital Concepts: Political activism is important, but it is not specific to collaborative practice. References:

Answer 509

Correct Answer: D. Non-prolactin-elevating antipsychotics should be used in women with menstrual and fertility problems diagnosed with schizophrenia. Clinicians should be certain about the severity of symptoms and whether they contributed to hyperprolactinaemia. Typical antipsychotic agents can cause an increase in prolactin, which can cause bone metabolism issues, menstrual issues, infertility issues, and breast cancer. It is important to obtain a thorough medical history before placing someone with schizophrenia on a typical antipsychotic that can potentially raise prolactin levels. Current antipsychotic therapy can be switched to prolactin-sparing agents like olanzapine, quetiapine, aripiprazole, or clozapine. Incorrect Answers: A. Elevated prolactin levels are associated with increased bone demineralization, osteopenia, and osteoporosis. Patients with schizophrenia with concurrent osteopenia and osteoporosis should be prescribed antipsychotics with minimal to no effects on prolactin levels. B. Women with schizophrenia and breast cancer should avoid antipsychotics with prolactin-elevating effects. Aripiprazole may be a more appropriate antipsychotic. C. Women with menstrual and fertility problems who are diagnosed with schizophrenia should be evaluated for prolactin secretion abnormalities such as prolactinomas, and antipsychotics that do not elevate prolactin should be used. References:

Answer 510

Correct Answer: A. Tetracyclic antidepressants Mirtazapine is a tetracyclic compound used in the treatment of depression. It is a noradrenergic and specific serotonergic antidepressant (NaSSA). Mirtazapine is unrelated to the tricyclic antidepressants (TCAs). It blocks the presynaptic alpha-2-adrenergic receptor, which results in 5-HT-1A activation and causes an increased release of dopamine. Incorrect Answers: B. These drugs increase norepinephrine and serotonin levels. Mirtazapine doesn’t fall into this category as it has a different MOA. C. These drugs inhibit monoamine oxidase A and monoamine oxidase B activity. Mirtazapine doesn’t fall into this category as it has a different MOA. D. These drugs' core chemical structure fuses a benzene ring and a diazepine ring. Mirtazapine doesn’t fall into this category as it has a different structure. References:

Answer 511

Correct Answers: A. Age of the population of interest B. Identification of risk factors for diabetes C. Previous interventions Using the PICO process to frame a focused research question for consideration of evidence-based change in practice, a nurse practitioner should define the characteristics of the population of interest, determining, for example, whether the population is all adults or all persons with risk factors for diabetes. Risk factors (or of a disease of interest) should also be defined. The NP should determine if the area of interest is patients with one specific risk factor or patients with all risk factors. There may be only certain risk factors applicable to the population of patients whose needs are being addressed. The NP will further need to consider the interests of the organization and patient population. Any previous interventions and/or control groups for comparison to a proposed intervention must be identified. Finally, the NP must determine the type of outcome desired. This can vary, and may refer to short-term or long-term outcomes, or to patient outcomes or provider outcomes. Incorrect Answer: D. Cost is not a consideration in framing a research question related to a change in evidence-based practice. Although organization priorities may be influenced by cost, this is not considered when framing a question for research into evidence on clinical practice. Vital Concept: Use PICO process to frame an evidence-based change in practice by identifying the population/patient/problem, intervention, comparison/control, and the outcome desired. References:

Answer 512

Correct Answer: C. It may be the early phase of a more serious disorder. This diagnosis may indicate a major mental disorder is brewing. It is important to keep this patient under a watchful eye. Incorrect Answers: A. A less experienced practitioner may diagnose an adjustment disorder. There are no studies showing that senior physicians predominantly make adjustment disorder diagnoses B. There are no studies showing that adjustment diagnoses are less likely to be noticed by a non-specialist. D. This is not the correct interpretation of a subthreshold diagnosis. References:

Answer 513

Correct Answer: C. Generalized anxiety disorder Generalized anxiety disorder is characterized by extraordinary concern on most days for 6 months or more regarding various things (school, work, family). This is accompanied by at least three of the following: feeling tired, agitated, uneasy/fidgety, tense/clenched with poor sleep, and an inability to sustain focus. The individual must find it difficult to control the worry. The lifetime prevalence rate of GAD is 5%, and the course is fluctuating but is worse during stressful periods. Incorrect Answers: A. Social anxiety disorder (social phobia) includes discomfort with social events/interactions out of concern for judgment. This patient does not describe concern regarding interacting with others or being externally judged. B. Posttraumatic stress disorder (PTSD) criteria include symptoms of intrusive and unsettling thoughts, memories, and flashbacks/nightmares related to an index traumatic experience. Symptoms must continue to cause anguish and dysfunction for 30 days or more to qualify. This clinical scenario does not include an index traumatic experience. D. Panic disorder is characterized by repeated panic attacks, with associated concern for additional attacks in the future. This patient is not describing episodic intense panic but a generalized, consistent concern. Vital Concept: This patient is describing pervasive (generalized) anxiety over the past 6 or more months. The most appropriate diagnosis based on this description is generalized anxiety disorder. References:

Answer 514

Correct Answer: B. The adolescent prefrontal cortex may not be fully formed, causing errors in tasks involving executive functions. An adolescent’s prefrontal cortex may not be fully formed. Errors in tasks involving executive functions may occur. Executive functioning tasks include controlling impulses, prioritizing, and planning. The prefrontal cortex is fully developed by the mid-20s. Incorrect Answers: A. Early adolescents need more sleep than average adults (average 9.5 hours a night) and also tend to wake later in the morning and go to bed later at night. Increased sleep is needed for teenagers, although many do not get it due to school and activity demands. Sleep-phase shifting also is common, creating a challenge if the teen attends a school with an early start time (e.g., before 8:00). C. Although adolescents have the capacity for abstract thinking (formal operations), their decision-making may be faulty. They are also readily influenced by their emotions, peers, and a sense of omnipotence. D. Limit-testing and risk-taking are a part of the adolescent process of developing one’s own boundaries and limitations. External controls such as clear parental and school rules are important supports during this phase. E. Adolescents have not yet developed the capacity to always understand the consequences of their actions. Vital Concept: The adolescent prefrontal cortex may not be fully formed, possibly causing errors in tasks involving executive functions. References:

Answer 515

Correct Answer: D. Altruism Altruism is the redirection of internal conflict through meeting the needs of others. Incorrect Answers: A. Rationalization is the use of false logic to convince oneself that no wrong has been done. B. Intellectualization is the excessive use of thinking to avoid expressing underlying emotion. C. Denial is the rejection of a truth. References:

Answer 516

Correct Answer: A. When used for ADHD, atomoxetine does not worsen preexisting anxiety disorders. In randomized controlled trials, atomoxetine does not worsen anxiety in patients with existing anxiety disorders or worsen tics related to Tourette’s disorder. Another option is to treat ADHD first, then add an SSRI if needed. Incorrect Answers: B. Stimulants are used often in children with ADHD and OCD. Stimulants are often used in conjunction with SSRIs. C. There is a black box warning regarding the use of antidepressants and increased suicide risk in children. D. Stabilization of substance use disorder first is preferred. In addition, the use of ADHD medications with less addiction and diversion potential such as atomoxetine and bupropion is suggested. References:

Answer 517

Correct Answer: A. Interpersonal boundaries Enmeshment involves a failure to achieve appropriate interpersonal boundaries. Individuals in a family must properly differentiate from each other and achieve sufficient autonomy. Incorrect Answers: B. Minuchin refers to interpersonal boundaries, not individual boundaries. C. Generational boundaries refer to the maintenance of hierarchical structure in the family through generations. D. Boundary violations refer to the actions of psychotherapists toward a patient. References:

Answer 518

Correct Answer: C. Pender’s Health Promotion Model Pender’s Health Promotion Model is an excellent Nursing model that fits into a nurse practitioner’s scope of care. Incorrect Answers: A, B, and D. These models are useful because they are models for professional nursing practice. According to Watson's theory, “Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health.” The Neuman Systems Model views the client as an open system that responds to stressors in the environment. The Roy’s Adaptation Model sees the individual as a set of interrelated systems who strives to maintain balance between various stimuli. Vital Concepts: Pender’s Health Promotion Model is an excellent Nursing model that fits into a nurse practitioner’s scope of care. References:

Answer 519

Correct Answer: D. Process measures can be based on scientific evidence When evaluating quality in a healthcare organization, structure, process, and outcomes can be measured. Most publicly-reported quality indicators are process measures. Outcome is used less frequently to report quality since it is more difficult to measure methodologically. Process measures can be based on scientific evidence and can also be measured and compared with relative ease. Incorrect Answers: A. Outcome measures are heavily confounded by patient mix. If sample sizes are small, even poor practitioners may have mortality rates that are not statistically worse than those of excellent practitioners. B. Studies show that hospitals that perform well on process measures also have better outcomes, although the strength of the association is unclear. C. Process measures can be easily measured or compared. Vital Concepts: When evaluating quality in a healthcare organization, structure, process, and outcomes can be measured. Outcome is used less frequently to report quality since it is more difficult to measure methodologically. Process measures can be based on scientific evidence and can also be measured and compared with relative ease. References:

Answer 520

Correct Answer: D. Systemic lupus erythematosus Most common neuropsychiatric manifestations in systemic lupus erythematosus (SLE) are cognitive dysfunction, lupus headache, psychosis, seizures, and cerebrovascular events. The following can cause psychiatric syndromes in SLE: direct CNS effects, drug induced side effects, physiological reaction to chronic illness or primary psychiatric illness. Many medical conditions can cause psychosis, including multiple sclerosis, myxedema, pancreatitis, pellagra, pernicious anemia, porphyria, lupus, temporal epilepsy, thyrotoxicosis, Huntington's disease, Lewy body dementia, dementia, delirium, Cushing's disease, trauma, brain tumors, meningitis, encephalitis, encephalopathy, and Addison's disease. Medications/drugs can also cause psychosis, including amphetamines, cocaine, steroids, anticholinergics, LSD in schizophrenic patients, and L-dopa. A. Fibromyalgia. There is an association between fibromyalgia with depression and anxiety disorders, not psychosis. B. Asthma exacerbation. Asthma itself cannot cause psychosis, but the steroids often used to treat it can. C. Heart disease. People with heart disease are at increased risk of developing depression, not psychosis. Patients with psychotic disorders have an increased risk of heart disease due to poor self-care and medication side effects, but the heart disease does not cause the psychosis. Vital Concept: Neuropsychiatric manifestations in systemic lupus erythematosus (SLE) are cognitive dysfunction, lupus headache, psychosis, seizures, and cerebrovascular events. References:

Answer 521

Correct Answer: B. Globus pallidus The patient has likely suffered carbon monoxide poisoning. Carbon monoxide is found in motor vehicle exhaust, as well as in smoke and combustion appliances (i.e. furnaces). When this gas is inhaled, it diffuses to the bloodstream and binds to hemoglobin, forming carboxyhemoglobin. Carbon monoxide binds to hemoglobin with greater affinity than oxygen. As a result, oxygen is displaced, and the patient becomes hypoxic. Signs of acute toxicity include headache, neuropsychological changes (e.g. confusion, memory loss), seizures, impaired consciousness or coma, and death. Additional signs include cherry-red skin discoloration, cyanosis, dyspnea, and chest pain. Treatment is with hyperbaric oxygen. MRI findings include diffusion-weighted imaging lesions of the globus pallidus and deep cerebral white matter. Less commonly, lesions may be seen in the putamen, caudate, thalamus, hippocampus, substantia nigra, neocortex, and cerebellum. Incorrect Answers: A. Caudate is incorrect. Both putamen and caudate deal with structure in the basal ganglia and involves motor and non-motor function. It is involved in Parkinson based disorders. C. Putamen is incorrect. Both putamen and caudate deal with structure in the basal ganglia and involves motor and non-motor function. It is involved in Parkinson based disorders. D. Thalamus is incorrect. It depends on the location pf the lesion but lesions are commonly visible in vascular disease, inflammatory diseases, and trauma. References:

Answer 522

Correct Answer: E. None of the Above Methylphenidate does not have any significant metabolism in humans via the CYP2D6 enzyme. This is likely because the majority of methylphenidate metabolism occurs at first pass and outside of the liver. Incorrect Answers: A. B. C. and D. Because methylphenidate doesn't have any significant metabolism in humans via the CYP2D6 enzyme, administration of a drug that causes CYP2D6 enzyme inhibition won't affect its side effects. References:

Answer 523

Correct Answer: D. If a patient refuses oral medication, most states allow the administration of parenteral medication despite patient's objection if there is a risk to themself or others Many states permit parental medication over the patient's objection if there are risks to self or others. Incorrect Answers: A. Droperidol has the potential for QTc prolongation and arrhythmia. It has a black box warning regarding this adverse effect. It should be avoided in patients with known prolonged QTc intervals or who are already taking other agents that prolong the interval. B. Rapidly dissolving antipsychotics include olanzapine and risperidone; antipsychotics in oral concentrate form include haloperidol and risperidone. C. The prone restraint position has resulted in sudden, unexpected deaths (possibly due to asphyxia) and is not recommended. Vital Concept: A patient who is in an acute psychotic episode lacks capacity in their current mental state. They should be treated in their medical best interest. References:

Answer 524

Correct Answer: B. Incidence of rhabdomyolysis in patients with PCP intoxication and physical restraints is much higher than baseline but can occur with PCP alone. PCP intoxication is usually a clinical diagnosis heralded by fluctuating behavior, motor disturbance, nystagmus, and autonomic stimulation. Autonomic stimulation results in hypertension, tachypnea, tachycardia, flushing, diaphoresis, salivation, and hyperthermia. Severely intoxicated patients may develop metabolic acidosis and rhabdomyolysis. Incorrect Answers: A. Use of restraints in the short-term may be justified if for the patient's safety. C. While a patient is in a psychiatric facility, most states require a physician to order restraints. D. The primary concern in this patient is in an acute episode of PCP intoxication. Vital Concept: Patients intoxicated with PCP are at higher risk of rhabdomyolysis when in restraints. References:

Answer 525

Correct Answer: C. Cohort study A cohort study examines a group of individuals with one or more common characteristics, such as people who work in shifts. Another example of a cohort is the group of nurses studied in the Framingham study, whose health habits have been studied for many years. Incorrect Answers: A. A case study is a study of one person that is intensive and in-depth. B. A retrospective study is one that examines a population by looking backwards at different parameters, which may be done by chart review or recall. D. Deductive reasoning refers to the use of broad generalizations to figure out the solution to a problem. Vital Concepts: A cohort study examines a group of individuals with one or more common characteristics, such as people who work in shifts. References:

Answer 526

Correct Answer: B. Xerostomia Xerostomia is dry mouth caused by reduction or absent flow of saliva. Methamphetamine use has resulted in an increased incidence of "meth mouth" which is severe tooth decay caused by methamphetamine-induced xerostomia. Incorrect Answers: A. Xerosis is dry skin most common in the winter and exacerbated by dry heat. Xerosis is not a side effect of methamphetamine use. C. Icterus is also known as jaundice, a yellowish pigmentation of the skin and is associated with high blood bilirubin level, not methamphetamine use. D. Urticaria, also known as hives, is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by sever pruritus. Urticaria is not associated with methamphetamine use. References:

Answer 527

Correct Answer: B. Migraine headaches Migraine headaches are not a differential diagnosis for ADHD. Incorrect Answers A. Lead poisoning symptoms can mimic ADHD symptoms and must be ruled out as a differential diagnosis of ADHD. C. Symptoms of sleep disorders, such as obstructive sleep apnea, may mimic ADHD symptoms. D. Patients with bipolar disorder may exhibit symptoms similar to ADHD. References:

Answer 528

Correct Answer: B. Medulla The medulla is located in the brainstem. It controls respiration/ventilation by chemoreceptors that detect changes in the acidity of the blood and increase or decrease the respiratory rate accordingly. Incorrect Answers: A. Cerebral cortex. The cerebral cortex contains sensory and motor functions. C. Pons. The pons relays signals between the cerebellum and the cerebrum. Cranial nerves V-VIII originate in the pons. D. Cerebellum. The cerebellum coordinates body movements and balance and coordination. References:

Answer 529

Correct Answer: B. Bipolar disorder patients are 15 times more likely to commit suicide than the general population Patients with bipolar disorder are 10-30x more likely to commit suicide than the general population. Bipolar disorder likely accounts for 3-14% of all suicide deaths. Suicidality is commonly seen in these patients while they are in a depressed or mixed condition. Up to 4-19% of patients with bipolar disorder end their life by suicide, and 20-60% attempt suicide at some point in their life. Incorrect Answers: A. Women with bipolar I usually demonstrate an initial depressive episode. C. Bipolar disorder is more common in higher-income countries D. Rapid cycling is more common in women. Vital Concept: The increased risk of suicide in patients with bipolar disorder is significant. References:

Answer 530

Correct Answer: D. Paternalism Paternalism refers to making a decision for a patient that someone “believes” is in the patient's best interests, despite expressed wishes to the contrary, or the opinions or wishes of the patient are ignored or minimized. Patients who are competent adults have the right to make their own healthcare choices, including refusal or denial of treatment. Incorrect Answers: A. The right to make one's own medical decisions is based upon the concept of patient autonomy. B. Beneficence refers to doing good. C. Non-maleficence refers to doing no harm. In this case, intubating the patient against her wishes would be maleficence. Vital Concepts: Paternalism refers to making a decision for a patient that someone “believes” is in the patient's best interests, despite expressed wishes to the contrary, or the opinions or wishes of the patient are ignored or minimized. References:

Answer 531

Correct Answer: C. Justice Lobbying for underserved clients is an example of justice, which is the duty to treat all clients fairly, without regard to age, socioeconomic status, or other variables. Incorrect Answers: A. Autonomy is the client’s right to self-determination without outside control. B. Nonmaleficence is the duty to prevent or avoid doing harm, whether intentional or unintentional. D. Veracity is the duty to tell the truth. Vital Concepts: Lobbying for underserved clients is an example of justice, which is the duty to treat all clients fairly, without regard to age, socioeconomic status, or other variables. References:

Answer 532

Correct Answer: A. Naloxone Naloxone is included as a part of emergency overdose response kits distributed to heroin and other opioid drug users. This has been shown to reduce rates of fatal overdose. Naltrexone and buprenorphine are used primarily in the management of alcohol use disorder and opioid dependence. Incorrect Answers: B. This is a competitive benzodiazepine antagonist used to treat drowsiness after surgery or drug overdose; it doesn't reverse the effect of opioids. C, D. These are used primarily to manage alcohol use disorder and opioid dependence References:

Answer 533

Correct Answer: C. Paroxetine (Paxil) Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that may be is associated with small increased risk of fetal heart defects during the first-trimester use. However, the results are inconsistent. Only pregnancy complication associated with paroxetine use is a mild increase in postpartum hemorrhage. Incorrect Answers: A. Sertraline (Zoloft) is considered an option during pregnancy and appears to have little to no risk associated with birth defects. Associated with a mild increase in postpartum hemorrhage. B. Citalopram (Celexa) is considered an option during pregnancy and appears to have little to no risk associated with birth defects. Associated with a mild increase in postpartum hemorrhage. D. Fluoxetine (Prozac) is considered an option during pregnancy and appears to have little to no risk associated with birth defects. Associated with a mild increase in postpartum hemorrhage. Vital Concept: Most SSRIs are safe to use during pregnancy. Paroxetine has conflicting reports on an association with use during the first trimester and a small increase in risk of fetal heart defects. References:

Answer 534

Correct Answer: D. 2.6% The overall fetal malformation rate with SSRIs is 2.6%. This rate is consistent with reports in the general population. Incorrect Answers: A, B, and C. These rates are all too low — the actual rate is 2.6%. References:

Answer 535

Correct Answer: D. It will cover certain prescription medications Medicare Part D, known as the Medicare prescription drug benefit, is only available to individuals who are enrolled in or eligible for Medicare Part A and/or Part B. All prescription drug plans have a list of preferred drugs known as the formulary. If a non-formulary drug is used, it may not be covered and the patient will be responsible for “out of pocket” costs. Durable medical equipment, outpatient visits for medical care, and flu shots are covered under Medicare Part B. Incorrect Answers: A. B. and C. These are all covered under Medicare Part B Vital Concepts: Medicare Part D, known as the Medicare prescription drug benefit, is only available to individuals who are enrolled in or eligible for Medicare Part A and/or Part B. All prescription drug plans have a list of preferred drugs known as the formulary. References:

Answer 536

Correct Answer: C. Correlational Correlational research is used when researchers are studying the effect of a potential cause that cannot be manipulated. In this example, the researchers cannot manipulate the barometric pressure, but they hope to find a correlation between barometric pressure and blood pressure in patients with hypertension. Incorrect Answers: A. An experimental study is a study of the effects of a treatment or intervention on a population compared to a “control” population that does not receive the same treatment. Study selection includes groups of people matched for important characteristics, usually randomly assigned to treatment or control groups. B. A case-control study is a retrospective study that looks at people with a condition (cases) and another group of people without the condition (controls). D. A retrospective study looks backward at variables and their effect on an outcome that is already determined. Vital Concepts: Correlational research is used when researchers are studying the effect of a potential cause that cannot be manipulated. References:

Answer 537

Correct Answer: C. The sign-in sheet at the front window is blacked out after each sign-in to prevent visibility by other patients. This is not a violation of HIPAA. Incorrect Answers: A. Only the first name should be used. B. Unless the son has power of attorney or is her designated legal care provider, this is a breach of HIPAA. Also, leaving actual results on voicemail may be consider a breach, unless the patient has specifically approved the leaving of results. The voicemail should just ask the patient or designated person to return the call to receive the results. D. The receptionist cannot be certain that her conversation is not being overheard by those waiting in the waiting area. This type of call should be made away from any public areas. Vital Concept: HIPPA was created to “improve the portability and accountability of health insurance coverage” for employees between jobs. Once it was established, the Privacy Rule was enacted for Protected Health Information (PHI) giving patients permission the right to privacy of their health information and the ability to withhold it in certain circumstances. Under HIPPA, patients have a right to privacy of their PHI. References:

Answer 538

Correct Answer: D. Receive and transmit information Brain cells are divided into neurons and glial cells. Neurons are made up of a cell body, an axon, dendrites, and synaptic specializations; their primary function is to receive, process, and transmit information. Neurons are capable of transmitting information because they are both electrically and chemically excitable. Incorrect Answers: A. Hold neurons in place is incorrect as this is not the function of neuronal cells. Ion channels embedded in the cell’s plasma membrane can respond to voltage (voltage-gated channels), neurotransmitter binding (ligand-gated channels), or pressure or stretch (mechanically gated channels). Glial cells serve a multitude of functions. B. Secrete cerebrospinal fluid is incorrect as this is not the function of neuronal cells. Ependymal cells make up the walls of the ventricles, secrete cerebrospinal fluid (CSF) and help to circulate CSF. C. Insulate neurons is incorrect as this is not the function of neuronal cells. Astrocytes provide the scaffolding of the brain, form the blood-brain barrier, guide neuronal migration during development, remove neurotransmitters from within the synaptic cleft (preventing toxic buildup), regulate the external chemical environment, and are capable of cell-cell signaling. Oligodendrocytes produce the myelin sheath that speeds conduction of action potentials along axons in the CNS. Schwann cells, like oligodendrocytes, produce myelin in the peripheral nervous system. Microglia are the macrophages of the brain. When activated by injury, they remove pathogens or dead neurons. References:

Answer 539

Correct Answer: B. They are inclined to use excessive denial and elaborate rationalization. Individuals with poor coping skills are inclined to use excessive denial and elaborate rationalization. Along with this, they’re unable to focus on salient problems. Incorrect Answers: A. Individuals with poor coping skills tend to be more passive, not proactive, than usual. C. Individuals with poor coping skills may show unexpected compliance. D. Individuals with poor coping skills allow little room for tolerance. References:

Answer 540

Correct Answer: D. Selective serotonin reuptake inhibitors (SSRIs) The more seriously ill a person becomes, the more likely he or she is to develop major depression. At Memorial Sloan Kettering Cancer Center, Breitbart and Holland compared terminally ill patients with cancer and those with acquired immunodeficiency syndrome (AIDS) with suicidal ideation to similar patients without suicidal ideation. The primary difference was the presence of depression in patients with suicidal thoughts. Aggressive treatment of depression is a cornerstone of care, as it dramatically decreases suffering and improves quality of life. The antidepressant TCA, SSRI, and MAOI drugs are all equally effective in alleviating depressive symptoms. However, SSRIs are considered the first-line therapy for depression because of their significantly better tolerability and side effect profile compared to MAOIs and TCAs. Incorrect Answers: A. Benzodiazepines. Benzodiazepines are not used for alleviating depressive symptoms. B. Monoamine oxidase inhibitors (MAOIs). SSRIs have significantly better tolerability and side effect profile then MAOIs and therefore are preferred. C. Narcotics. Narcotics are not utilized to treat depression. References:

Answer 541

Correct Answer: C. Presynaptic alpha-2 adrenergic receptor antagonist Mirtazapine (Remeron) is a serotonin, norepinephrine receptor antagonist and alpha-2 adrenergic antagonist. Blocks alpha-2 adrenergic presynaptic inhibitory autoreceptors and heteroreceptors increasing norepinephrine and serotonin neurotransmission. Mirtazapine also increases serotonin at the 5HT-1A receptor. It accomplishes this action with a unique mechanism where it blocks the 5HT-2A, 5HT-2C and 5HT-3 receptors resulting in serotonin being directed towards the 5HT-1A receptor, the primary serotonin receptor effecting mood. Activation of 5HT-2A receptor in other antidepressants (e.g. SSRIs) causes diminished libido and inhibiting orgasm/ejaculation. Since mirtazapine blocks the 5HT-2A receptor there is less sexual side effects compared to other antidepressants. Side effects like weight gain and sedation are caused by mirtazapine's potent histamine (H1) receptor antagonism. Lower doses are more sedating because higher antihistaminergic effect compared to higher doses where there is increased noradrenergic effect. If prescribing this medication with intentions of improving patients’ appetite and/or sleep prescribe at lower doses. Incorrect Answers: A. Prazosin is a postsynaptic alpha-1 adrenergic receptor antagonist. It is only FDA approved for hypertension but is used off-label for PTSD associated nightmares. B. Guanfacine is a postsynaptic alpha-2 adrenergic receptor agonist. It is FDA approved for ADHD (in children only) and for hypertension. Also used off-label in opioid detoxification, tics, and autism spectrum disorder behavioral disturbances. D. Clonidine is a nonselective alpha-2 adrenergic receptor agonist. It is FDA approved to treat ADHD and hypertension. Also used off-label in anxiety disorders, PTSD and substance use withdrawal. References:

Answer 542

Correct Answer: B. Critical period The "critical period" is a stage in the lifespan of an organism when it acquires a developmental skill that is indispensable to life or survival. Incorrect Answers: A. The "sensitive period" is a general time during which an individual is more receptive (sensitive) to some types of environmental stimuli, usually because the nervous system development is especially sensitive to those stimuli. C. Social learning theory states that learning is a cognitive process that takes place in a social context and can occur purely through observation or direct instruction, even in the absence of motor reproduction or direct reinforcement. D. Modeling refers generally to a process in which persons serve as models for others. References:

Answer 543

Correct Answer: D. Expert opinion Expert opinion is considered the lowest form of evidence as there is little to no evidence associated. Systemic reviews are considered the highest. Incorrect answers: A. Case studies are typically considered a level three and would be considered higher evidence than expert opinion. B. A single randomized controlled trial are a level two and is considered a higher level of evidence than expert opinion. C. Systematic review of non-randomized trials is a level two and is considered a higher level of evidence than expert opinion. Vital Concept: Expert opinion is considered the lowest form of evidence as there is little to no evidence associated. Systemic reviews are considered the highest. References:

Answer 544

Correct Answer: D. Attempt to use another medication with fewer teratogenic effects. Given there is an increased risk for teratogenic effects when using valporate acid in pregnancy it is recommended to use another mood stabilizer with less side effects. Incorrect Answers A. Valproate acid teratogenic effects are most likely to occur in conception to week three which makes it difficult to switch medication without causing effects. This is incorrect as it is more likely to cause the teratogenic effects during the third and eight week of pregnancy. B. Often clients with Bipolar disorder that are pregnant can be switched to a SSRI to manage the symptoms as these are safer to use in pregnancy. This is incorrect as SSRIs have caused clients with bipolar disorder to cause mania. Another mood stabilizer should be used. C. Valproate acid can be safer at low doses during pregnancy without causes the teratogenic effects is incorrect as the effects are not dose dependent and is not worth the risk. References:

Answer 545

Correct Answer: A. Validating the emotional status of the client This is a way for the PMHNP to form an effective relationship with the patient. Incorrect Answers: B. Self-disclosure by the PMHNP is neither recommended nor constructive towards their clients. C. The PMHNP should use a nonjudgmental approach to the patient. Sharing their judgments of the patient runs contrary to this principle. The PMHNP should have open and respectful engagement with the patient using a nonjudgmental approach D. The PMHNP should learn about the patient's interest and motivation for care. Focusing only on measurable health outcomes doesn't achieve this goal. References:

Answer 546

Correct Answer: B. 2-3% Panic attacks are episodes of abrupt onset of intense fear. Attacks reach a peak within minutes and can last up to an hour. During the episodes, patients can experience symptoms such as palpitations, shortness of breath, heat sensations, paresthesia, and a feeling that something terrible is happening. A diagnosis of panic disorder is made when one or more attack is followed by persistent concern about additional attacks and/or a maladaptive change in behavior related to the attacks. In the United States, the 12-month prevalence of panic disorder is estimated at 2-3%. Lower rates are seen in Latinos, African Americans, and Asian Americans. Increased rates are seen in American Indians and females. Panic disorder prevalence increases in adolescence and peaks during adulthood. Incorrect Answers: A. The 12-month prevalence rate of panic disorder in the US is 2-3%, not 1-2% C. The 12-month prevalence rate of panic disorder in the US is 2-3%, not 5-10% D. The 12-month prevalence rate of panic disorder in the US is 2-3%, not 10-15% Vital Concept: The 12-month prevalence rate of panic disorder in the US is estimated at 2-3%. References:

Answer 547

Correct Answer: D. Haloperidol Haloperidol has the fewest anticholinergic side effects of the medications listed (see chart below). Haloperidol (Haldol) is a typical antipsychotic that is FDA indicated for psychosis, Tourette's disorder, and second line for severe behavior problems in children of combative hyperexcitability. Used off-label for bipolar disorder, behavioral disturbances, and delirium. It is a dopamine D2 receptor antagonist. Dopamine blockade can lead to adverse effects of extrapyramidal symptoms, parkinsonism, tardive dyskinesia, and galactorrhea/amenorrhea (from prolactin elevation). Side effects from alpha 1 adrenergic blockade can cause dizziness, sedation, and hypotension. There is a low risk of anticholinergic side effects (e.g., sedation, dry mouth, constipation, blurred vision). Incorrect Answers: A. Clozapine has a high risk of anticholinergic side effects. B. Thioridazine has a high risk of anticholinergic side effects. C. Chlorpromazine has a high risk of anticholinergic side effects. Vital Concept: Antipsychotics with increased anticholinergic side effects (e.g., sedation, dry mouth, constipation, blurred vision) include clozapine, thioridazine and chlorpromazine. References:

Answer 548

Correct Answer: D. 10x Schizophrenia affects less than 1% worldwide. It is characterized by positive symptoms (hallucinations, delusions, and disorganized speech and behavior) and negative symptoms (flattened affect and alogia), as well as other symptoms including inattentiveness. Most patients also have a lack of insight regarding their condition. There is usually significant impairment of their social, occupational, and interpersonal lives. To diagnose schizophrenia, symptoms must be present for at least 6 months, including at least 1 month of positive or negative symptoms. The diagnosis of schizophrenia was expanded in the DSM-5. Criterion A includes 5 items: delusions; hallucinations; disorganized speech (e.g. frequent derailment or incoherence); grossly disorganized or catatonic behavior; and negative symptoms (diminished emotional expression or avolition). At least two of the five symptoms must be present for at least 1 month, and one of the two symptoms must be delusions, hallucinations, or disorganized speech. Negative symptoms, which impair function the most, are now official. Incorrect Answers: A. People with a biological parent with schizophrenia have a 10x greater risk of having schizophrenia as compared to the general population, not 2x. B. People with a biological parent with schizophrenia have a 10x greater risk of having schizophrenia as compared to the general population, not 3x. D. People with a biological parent with schizophrenia have a 10x greater risk of having schizophrenia as compared to the general population, not 20x. Vital Concept: Twin studies conducted on schizophrenia indicate a significant genetic component, with monozygotic (identical) twins displaying a 40-50% relative risk rate. References:

Answer 549

Correct Answer: C. ≤40% This is postulated to be due to poor long-term adherence, lack of insight, and other factors that impair adherence. Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics, such as haloperidol, bind the dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, a blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while a lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each of the second-generation drugs has a different binding affinity (e.g. risperidone is high, and clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors as well, which may also contribute to their clinical effects. Second-generation drugs are more effective for treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis (and at higher than maintenance dosage). Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used to treat their depression or anxiety disorders. ECT can also be used in schizophrenia for catatonia. Early studies also suggest that TMS might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT are also important in the treatment success of schizophrenia. Incorrect Answers: A. B. These percentages are too high. About ≤40% of schizophrenic patients will relapse each year. C. This percentage is too low. About ≤40% of schizophrenic patients will relapse each year. References:

Answer 550

Correct Answer: C. Ask if the patient is in immediate danger The patient’s immediate safety is always the most important consideration of domestic violence. Incorrect Answers: A. Avoid providing “should” advice to patients who are already scared and intimidated. B. There are increasing reports from male victims, both heterosexual and homosexual relationships. D. After making sure the patient is safe, obtain a complete history of the types and patterns of the patient’s abuse. Vital Concept: The patient’s immediate safety is always the most important consideration of domestic violence. References:

Answer 551

Correct Answer: C. 24 months or longer The diagnostic criteria within the DSM-5-TR for persistent depressive disorder include: · A poor disposition characterizes this disorder, present most days for most of the day for 24 months or more in adults. · This should not include any asymptomatic periods lasting longer than 8 weeks. · The disposition may be cantankerous and crabby in teens and pediatric patients for 12 months or more. · In addition to the poor disposition, at least two of the following co-occur: changes in sleep, resulting in poor sleep or excessive sleep a decreased sense of self-worth and self-regard a sense that nothing good will happen and that the current situation will never improve changes in food intake or interest, resulting in no desire to eat or eating significantly more than typical a sense of being tired or worn out despite adequate rest or sleep, without much drive or vigor poor decision-making or an inability to maintain focus · The patient should not exhibit symptoms meeting the diagnostic criteria for a manic or hypomanic episode. · The patient may exhibit symptoms meeting the diagnostic criteria for a major depressive disorder for 24 months. A separate diagnosis of MDE or MDD should also be documented in this case. A specifier should be added to the persistent depressive disorder of with persistent major depressive episode or with intermittent major depressive episodes, with/without current episode. · The symptoms are not more appropriately due to another condition, such as a psychotic disorder (e.g., schizophrenia, schizoaffective DO, delusional disorder). · The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern · The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise · The following specifiers may be added: Mild/moderate/severe With anxious distress With atypical features Early onset (prior to age 21) Late onset (after age 21) In partial/full remission Incorrect Answers: A. For diagnosing persistent depressive disorder the person should not be without symptoms for more than 2 months at a time. B. At least one 1 year is the minimum duration of symptoms for diagnosing persistent depressive disorder in children and adolescents, not adults. D. The patient must be depressed on most days for at least 2 years for a diagnosis of persistent depressive disorder in adults, not 5 years. Vital Concept: A patient must be depressed on most days for at least 2 years for a diagnosis of persistent depressive disorder in adults. References:

Answer 552

Correct Answer: B. Syphilis Symptoms of mania can be caused by many disorders, including CNS tumors, syphilis, delirium, encephalitis, influenza, multiple sclerosis, and Q fever. Drugs such as amphetamines, cocaine, isoniazid, steroids, and other stimulants can also cause these symptoms. Incorrect Answers: (A) Hepatitis A. Hepatitis A is not associated with symptoms of mania. (C) Parkinson's disease. Parkinson's disease is not associated with symptoms of mania. (D) Chlamydia. Chlamydia is not associated with symptoms of mania. References:

Answer 553

Correct Answer: C. Most addictive substances usurp normal limbic reward pathways, producing greater firing than usual rewards experienced in day-to-day survival-relevant functioning. Dopamine fired in the ventral tegmental area and the nucleus accumbens marks the importance of the substance to be consumed. Feedback during the experience among different parts of the limbic system reinforces the reward and the significance of the experience. Afterward, there is further reprocessing of the event and stimuli by the prefrontal cortical areas, leading to a form of associative learning and attaching a high level of significance to both substance effect and the cues related to substance use. Incorrect Answers: A. This describes physical dependence on a drug for functioning at homeostasis after a long history of abuse. B. This incorrectly implicates a solely sympathetic system, but the limbic system is in coordination with other areas of the brain. D. The structures implicated are located in the limbic system, and dopamine is not the sole neurotransmitter involved. References:

Answer 554

Correct Answer: D. Propranolol Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first line treatment for generalized anxiety disorder. This patient is already on an SSRI and looking for an adjunct medication to specifically target physical symptoms of anxiety, palpitations and tremors. Propranolol is a beta-blocker, antagonizes peripheral beta 2 receptors, offering relief from tremors. This is not an FDA approved medication to treat anxiety but is used off label as a scheduled or as needed medication as an adjunct for anxiety treatment. Incorrect Answers: A. Clonidine. Clonidine, centrally acting alpha 2 agonist, is used off label for the treatment anxiety. However, this patient is specifically interested in a medication adjunct for tremors and palpitations of which a beta-blocker would be the best answer choice. B. Quetiapine. Second generation antipsychotics (e.g. quetiapine), has a large side effect profile and is not a first line adjunct treatment for anxiety. C. Venlafaxine. SNRIs (e.g. venlafaxine) are first line treatment for generalized anxiety disorder. This patient is already on an SSRI and you would not adjunct a SNRI with a SSRI; this would increase the risk for serotonin syndrome. References:

Answer 555

Correct Answer: D. Variable interval A variable-interval schedule provides reinforcement for responses that occur after varying amounts of time. Checking email is an example of this phenomenon, as the reinforcement (having a new message in the inbox) does not occur with each check but varies with time. Because of the indirect relationship between behavior and response in interval schedules, interval scheduling tends to produce slower response rates than ratio schedules. Incorrect Answers: A. A fixed-ratio schedule provides reinforcement every set period of responses. B. A variable-ratio schedule provides reinforcement at a varying response rate. C. A fixed-interval schedule provides reinforcement for a response that occurs after a set time. References:

Answer 556

Correct Answer: D. Most prescription and non-prescription medications can be used safely with stimulants. Concomitant use of stimulants with MAOIs is a formal contraindication, but they can be used with caution in treatment-resistant cases. Incorrect Answers: A. Use of stimulants with MAOIs is formally contraindicated, but they can be used with caution in treatment-resistant cases. B. Excessive caffeine intake with stimulants may decrease the effectiveness of the stimulant and increase sleep problems. C. Monitoring is warranted when stimulants are used in conjunction with tricyclic antidepressants and anticonvulsants. Due to decreased effects of the anticonvulsants, dosage adjustments and blood levels of both medications should be tailored. References:

Answer 557

Correct Answer: D. The criteria no longer require delusions to be non-bizarre In 2013, the APA adjusted their criteria for delusional disorder, characterized by the presence of either bizarre or non-bizarre delusions that have persisted for at least 1 month. Other changes to this section included a new exclusion criterion that the symptoms must not be better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs. Also, the DSM-5 no longer separated delusional disorder from shared delusional disorder. If the criteria are met for delusional disorder, then that diagnosis is made. If the diagnosis cannot be made, but shared beliefs are present, use the diagnosis of “other specified schizophrenia spectrum and other psychotic disorder.” DSM-5 and DSM-5-TR criteria for delusional disorder: To meet the criteria, the patient must present with at least one delusion lasting for at least one month The patient should not meet criterion A for schizophrenia If the patient reports hallucinations, they must be secondary to the delusions and associated with the primary delusion (e.g., hearing voices of aliens related to a delusion of being controlled by aliens) The patient’s behavior and ability to function should be relatively unchanged from baseline without apparent dysfunction or peculiar behaviors If mood symptoms are present, they have been short in duration in comparison to the delusion The patient’s delusion is not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and is not due to a more appropriate psychiatric condition Incorrect Answers: A. The DSM-5 no longer separated delusional disorder from shared delusional disorder. B. The criteria include a duration of delusions for at least one month. C. The criteria state that behavior should NOT markedly odd. Vital Concept: Changes made for diagnoses of delusional disorder from the DSM-IV to DSM-5 are that delusions can be non-bizarre or bizarre, and shared delusional disorder is no longer a separate diagnosis. References:

Answer 558

Correct Answer: C. It undergoes significant hepatic metabolism. Desvenlafaxine is minimally transformed through oxidative metabolism. Incorrect Answers: A.Desvenlafaxine is weakly protein-bound (27%) and has a reduced likelihood (compared to other antidepressants) of displacing tightly protein-bound medications like phenytoin and warfarin. B. Desvenlafaxine is not a potent inhibitor of the CYP 2D6 enzyme and does not interact with inhibitors of 2D6 like some SSRIs or inducers like carbamazepine. D. The SNRIs, venlafaxine, duloxetine, desvenlafaxine, and milnacipran can give an earlier onset of action compared to the SSRIs. This effect is hypothesized to be secondary to the rapid down-regulation of the beta-adrenergic receptor-coupled cAMP. References:

Answer 559

Correct Answer: D. The Mental Health Parity Act provided equal lifetime and annual limits for mental and physical health care. The Mental Health Parity Act of 1996 was an effort to help insure equal coverage for mental and physical illness. It provided for equal lifetime and annual limits for mental and physical illness, when previously patients with health insurance were usually limited to $5,000 annual lifetime coverage. Incorrect Answers: A. The Mental Health Act of 1996 failed to mandate mental health coverage and it also excluded treatment for substance use disorders. B. The Mental Health Parity Act did not mandate mental health coverage. C. The bill did not specify what mental illnesses should be covered. References:

Answer 560

Correct Answer: C. Emergency Medical Treatment and Labor Act (EMTALA) The federal Emergency Medical Treatment and Labor Act, EMTALA, is also known as the Patient Anti-Dumping Law and requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition. This is an example of a public policy that was enacted to reduce financial access barriers to health care. Incorrect Answers: A. Stark law concerns self-referrals to ancillary services in which physicians have a financial interest (self-dealing). B. The Affordable Care Act (ACA) targets the provision of quality health care and access to health care for Americans. It expands healthcare coverage and insurance issues. D. The Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH Act concerns health information technology. Vital Concept: The federal Emergency Medical Treatment and Labor Act (EMTALA) requires most hospital emergency rooms to provide an examination and stabilizing treatment, without consideration of insurance coverage or ability to pay. References:

Answer 561

Correct Answer: B. Cochrane Review When investigating current evidence, use of available resources that synthesize current research can help to limit the time needed to collect evidence. Some resources that are available to synthesize this information include the Cochrane Library, Clinical Practice Guidelines, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PubMed. Incorrect Answers: A. The Journal of the American Medical Association publishes selected articles, limited in scope. C. Social media is not an appropriate source for evidence-based practice. D. Medical and nursing texts often fail to include the latest research information, due to delays in publication. References:

Answer 562

Correct Answer: A. Interpersonal rejection sensitivity Interpersonal rejection sensitivity is an excessive level of awareness of the behavior and feelings of others. It stems from the idea that early rejection experiences could reduce one's ability to cope with future social interactions. Or in otherwords, it is a tendency to anxiously expect, readily perceive and overract to rejection. Other features include increased appetite, marked mood reactivity, leaden paralysis, and weight gain. Atypical features are commonly found in patients with bipolar I and II; these patients should be screened for manic symptoms carefully. Atypical features are more common in women, occur at an earlier age, are more chronic, and have a lower chance of inter-episodic recovery. MAOIs have shown particularly good results in depressed patients with atypical features. Incorrect Answers: B. Weight loss. Weight gain is an atypical feature of depression, not weight loss. C. Decreased appetite. Increased appetite is an atypical feature of depression, not decreased appetite. D. Panic attacks. Panic attacks are not an atypical feature of depression. Can elaborate further and see if a specifier of anxious distress would be correct or a separate anxiety diagnosis. References:

Answer 563

Correct Answer: C. The Superego The superego is the consciousness that determines right from wrong which is regulated by guilt and shame; the superego says, “I should or ought.” The id says, “I want” and the ego says, “I think, I evaluate.” The superego is responsible for the sense of guilt which is felt in extreme by this patient. Incorrect Answers: A. The id is selfish, which is the opposite of what the patient is expressing. B. The ego is logical, which is the opposite of what the patient is expressing. D. The id is selfish and the ego is logical; neither is what the patient is expressing. References:

Answer 564

Correct Answer: D. It is more frequent in people with lower levels of education and socioeconomic status. Somatic symptom disorders are more frequent in people with lower levels of education and socioeconomic status. Persistent somatic symptoms are also associated with female gender, older age, and unemployed status. The diagnostic criteria include: At least one somatic symptom that substantially impacts the patient’s daily functioning or leads to anguish The patient then develops extraordinary actions, emotions, or ruminations regarding the symptom(s) or related medical condition(s), as evidenced by one or more of the following: · consistent worry or concern about their physical wellbeing · extraordinary devotion of resources (e.g., energy, time) to the symptom(s) or related medical condition(s) · ruminations that are consistent and unbalanced regarding the gravity and meaning underlying these symptoms These conditions persist for at least 6 months, although the specific symptom of focus may vary or shift during that time Specifiers include: · with prominent pain if the symptoms involve physical discomfort · persistent if the symptoms are severe, enduring (greater than 6 months), and cause substantial dysfunction · mild/moderate/severe based on the number of symptoms listed above that are present (1/2/2+ multiple symptoms) Incorrect Answers: A. Somatic pain is a real condition, and patients aren't "faking it" to pretend to be sick. B. Since opioids would only be prescribed if clinically warranted, there's no secondary gain in this regard. C. Patients with somatic symptom disorder are preoccupied with physical symptoms, not bodily functions. Vital Concept: The risk factors for SSD include negative affectivity (neuroticism), decreased years of education, lower SES, recent stress or health-related event, adverse childhood events, female sex, older age, and unemployed status. References:

Answer 565

Correct Answer: D. Sexual side effects are due to antipsychotic effects on alpha-2 receptors. Sexual side effects of typical antipsychotics are due to action at alpha-2 receptors, cholinergic antagonism also contributes to sexual dysfunction. Other long-term effects include weight gain, photosensitivity, and hyperprolactinemia. Incorrect Answers: A. EPS are more common in higher-potency typical antipsychotics. B. TD is associated with all typical antipsychotics and occurs at a rate of approximately 5% per year. C. The initial side effects of low-potency typical antipsychotics are similar to TCAs. Fewer TCA-like initial side effects occur with mid-potency typical antipsychotics. These effects are relatively uncommon in high-potency agents. References:

Answer 566

Correct Answer: A. The parent should be educated about treatment alternatives but may not refuse the treatment. In most states, until a patient is 18 years old, his or her parent will need to give informed consent on the patient's behalf. Incorrect Answers: B. C. D. These are all important things to review by providers for informed consent about a treatment. References:

Answer 567

Correct Answer: C. Administer care as needed. Failure to pay a bill is not an adequate reason for termination of care, although financial responsibilities and expectations should be clarified at the initiation of the healthcare provider-patient relationship. The healthcare provider should provide resources to assist the patient with the transfer of care if he/she is unable to continue to provide care after it has been established. Incorrect Answers: A. The healthcare provider is ethically obligated to provide appropriate care for the child's benefit. B .The healthcare provider should provide resources to assist the patient with the transfer of care if he/she is unable to continue to provide care after it has been established. D. Providers who can't provide patient care need to give the patient (or their parent) reasonable written notice to allow them to find new healthcare Vital Concept: The primary duty of the healthcare provider is to the patient. This is a fiduciary relationship and not a financial relationship, so the healthcare provider is obligated ethically to provide appropriate care for the benefit of the child. References:

Answer 568

Correct Answer: C. Prevalence will increase. The prevalence of a disease is positively correlated with the incidence and duration of the disease. If the duration of survival is prolonged and the incidence of the disease does not change, the prevalence of the disease will increase. Incidence refers to the number of new cases per time period and is not affected in this case. Incorrect Answers: A. Prevalence will increase, not decrease, as more people live longer with HCV. B. and D. Incidence will be unaffected. Vital Concepts: The prevalence of a disease is positively correlated with the incidence and duration of the disease. If the duration of survival is prolonged and the incidence of the disease does not change, the prevalence of the disease will increase. Incidence refers to the number of new cases per time period and is not affected in this case. References:

Answer 569

Correct Answer: A. Using timeline method The timeline method is used to identify dependence criteria and the psychosocial stressor (e.g. a divorce). If dependence is present before the mood symptoms occurred, then the depressed mood is more likely attributable to the alcohol. However, if criteria for depression was met before dependence, then the patient likely has a comorbid substance problem. Using strict DSM-5 criteria is important when screening for prior mood episodes. Examination of prolonged sober periods is preferred when screening for a prior history of mood episodes. It is important for the psychiatrist to follow a patient with a suspected substance-induced mood disorder for 1 month without treating the condition, as symptoms will slowly subside during this time. If there is strong history suggestive of prior mood episodes or if symptoms do not resolve as expected, medications can be started to target those symptoms. Incorrect Answers: B. Using strict DSM-5 criteria is important when screening for prior mood episodes. C. Examination of prolonged sober, rather than not sober, periods is preferred when screening for a prior history of mood episodes. D. Symptoms should be observed for a month without treatment, not 1-2 weeks. References:

Answer 570

Correct Answer: D. Sleep disorders are common including restless leg and rapid eye movement in patients with Parkinson's Disorder Sleep disorders are common including restless leg and rapid eye movement in patients with Parkinson's Disorder. It affects up to 55-80% of patients with PD. Changes in sleep onset and insomnia are also common. Incorrect Answers: A. Psychosis rarely occurs but when it does it is primarily hallucinations based on past events that are inaccurate. Psychosis can occur in Parkinson Disorder. Commonly hallucinations that are visual and can often can have paranoia. It occurs in approximately 40% of patients with PD. B. Anxiety is common among older adults but it is not specifically related to Parkinson's Disease is inaccurate. Anxiety occurs in more than 1/3 of patients with PD. Often SSRIs are used. Nonpharmacological efforts can be used such as mindfulness but this has not been well studied. C. Depression is commonly noted in Parkinson's disease as it is often caused as a side effect from medications to treat this disorder is incorrect. Depression occurs in clients typically due to the stages of Parkinson's Disease as they have decreased ability in motor functions and quality of life. References:

Answer 571

Correct Answer: B. A win According to Team Technology, which is based on game theory, most people try to achieve a benefit or payoff in a conflict situation, which is called a win. Not getting a payoff is called a loss. Wins can range from a sense of satisfaction from completing a job or obtaining financial reward, to intangibles such as increased self-esteem. Incorrect Answers: A. Compromise is a lose-lose situation that is not the goal of most people in conflict. It can be a strategy for effective resolution of conflict in some situations. C. Most people in a conflict situation are primarily concerned with a solution that is agreeable to them, which is a “win.” D. Although an expedient resolution is often desired, it is not the primary goal of most people in conflict situations. Vital Concepts: According to Team Technology, which is based on game theory, most people try to achieve a benefit or payoff in a conflict situation, which is called a win. References:

Answer 572

Correct Answer: D. Overdose is associated with cardiac arrhythmias, hypotension, and EPS. These are symptoms of typical antipsychotic overdose Incorrect Answers: A. Symptomatic treatment is required in typical antipsychotic overdose B. Overdose is associated with seizure, but not with giddiness and mania. It is associated with lethargy and delirium C. Dialysis isn't beneficial in typical antipsychotic overdose; treatment of typical antipsychotic overdose is supportive and symptomatic care References:

Answer 573

Correct Answer: D. There are protective and stressful aspects to social circumstances. It is important to strengthen the protective aspects of patients' social situation and reduce stressful aspects. Incorrect Answers: A. This is a key area that may also require extended services from other clinicians. B. Patients' sexuality is important in terms of sexual relations, orientation, and sexual side effects from medications. C. Disability income support can be key for stabilizing a patient’s social situation. References:

Answer 574

Correct Answer: C. Longitudinal study A longitudinal study is a long-term study that follows the same group of subjects over a long period of time to observe and measure the same variables. There is no manipulation of variables, and the study is observational. An example of this type of study is the Framingham Heart Study, which tracked the same research subjects from the town of Framingham, Massachusetts, to study the development of cardiovascular disease and to identify the factors that are associated with it. Incorrect Answers: A. A case study is a study of one subject who has a condition. B. A randomized controlled trial is an experimental subject design in which subjects are randomly assigned to a control group or to a group that receives a treatment or intervention. D. A retrospective study is a study of events that have already occurred and can be performed through chart review or recall of events. Vital Concept: A longitudinal study is a long-term study that follows the same group of subjects over a long period of time to observe and measure the same variables. There is no manipulation of variables, and the study is observational. References:

Answer 575

Correct Answer: D. Response to ECT is similar in adolescents and adults. There have been few reports and literature reviews on the effectiveness of ECT in depressed and bipolar youth. The occurrence of side effects was similar to psychopharmacology, although memory impairment was much greater in patients who received ECT. Both indications and responses to treatment appear similar in adolescents and adults. ECT should be considered for a depressed adolescent who does not respond to conventional treatments and who remains completely dysfunctional or suicidal or who has a family history of depression and has not responded to any other treatment modality but ECT. Before ECT is used, 2 child and adolescent psychiatrists who are not the primary caregivers for the adolescent should be consulted and should agree that ECT is indicated. Incorrect Answers: A. ECT can be used in adolescents B. ECT should be considered for a depressed adolescent who doesn't response to conventional treatments, and who remains completely dysfunctional or suicidal, or who has a family history of depression and hasn't responded to any treatment modality other than ECT C. ECT response is similar in adolescents and adults References:

Answer 576

Correct Answer: A. Topiramate Topiramate is a pregnancy class D anticonvulsant medication. It increases the potential for an infant to be born with a cleft lip or palate and, in male newborns, increases the potential for hypospadias. The other medications listed are pregnancy class C anticonvulsant medications. Incorrect Answers: B, C, and D. These drugs are pregnancy class C anticonvulsant medications. This means that while there haven't been adequate, well-controlled studies in women, studies using animals have shown a harmful effect on the fetus, or there haven't been any studies in either women or animals. Therefore, caution is advised, but the medication's benefits may outweigh the potential risks. References:

Answer 577

Correct Answer: B. The patient resumed smoking 1 pack-a-day of cigarettes. Smoking causes enzyme induction. Inducers, such as smoking, will increase the metabolism of other drugs. In this case, his warfarin will be metabolized/cleared more quickly from the body while being a smoker. Therefore, he will need more warfarin while smoking to have the same levels as he did when he was a non-smoker. Smoking reduced the efficacy of warfarin and put the patient at an increased risk for a stroke. Full enzyme induction can take 1-2 weeks, which coincided with his stroke caused by the ineffective warfarin. Incorrect Answers: A. An increased level of activity would neither change the effectiveness of warfarin nor be a risk factor for stroke. C. One 2 oz. glass of wine is not a significant enough amount to alter his warfarin metabolism. Smoking 1 pack-a-day of cigarettes is much more troublesome for the metabolism of warfarin. Remember: acute, binge amounts of alcohol = inhibition; chronic ingestion of alcohol = induction. D. There are no drug interactions between warfarin and acetazolamide. References:

Answer 578

Correct Answer: C. Maximum effect (Emax) level of the drug has been reached, likely because of saturated binding sites. The problem is not in the absorption of the drug but because the maximum effect has been reached. At Emax, there will be no further response to a drug, no matter how much of the drug is given. This is likely due to the saturation of the enzyme binding sites. Incorrect Answers: A. B. D. Because the patient has previously shown a response to the drug, these explanations are unlikely. References:

Answer 579

Correct Answer: D. Could not afford cost of treatment. The Substance Abuse and Mental Health Services Administration conducted a national survey on drug use and health. They queried participants about their reasons for not seeking mental health treatment. The primary reason cited by individuals was that they could not afford the cost, a reason given by 42.5% of individuals polled. Incorrect Answers: A. Approximately 9.4 percent of participants in the SAMHSA survey listed “Did not feel need for treatment” as a reason for not seeking treatment. B. 17% of respondents stated they did not have time to seek treatment. C. 18.5% of respondents stated they did not know where to obtain services. References:

Answer 580

Correct Answer: B. Insulin-like effect Lithium has an insulin-like effect that is responsible for lowering blood glucose and increasing appetite and weight gain. Incorrect Answers: A. D. Neutropenia, myocarditis, and eosinophilic colitis are associated with clozapine. C. Lithium has an insulin-like effect, which is opposite from a glucagon-like effect. References:

Answer 581

Correct Answer: D. Broader representation from the NP community is necessary for NPs to have an impact on healthcare legislation There are many opportunities for NPs to engage in the healthcare policy process, but not enough NPs are currently engaged, which may result in leaving the practice dependent upon policy decisions made by others. Broader representation and personal commitment from members of the NP community are the only way that NPs can have an impact on formulating health care policy and legislation. Incorrect Answers: A. Nurse practitioners may be unaware of the extent to which policy decisions affecting their practice have been made by others, but there are multiple examples of other professionals making rules or passing resolutions that control advanced practice nursing. B. Many NPs are uncomfortable with advocacy, but can begin to test their ability to advocate for issues important to them within professional nursing organizations. C. Involvement with a professional organization can facilitate a novice nurse advocate’s knowledge of issues and can also help the NP develop advocacy strategies for a particular work environment. Professional nursing organizations facilitate opportunities for NPs to branch out on their own with advocacy, within the work environment, the community, or with legislators. Vital Concepts: Broader representation and personal commitment from members of the NP community are the only way that NPs can have an impact on formulating health care policy and legislation. References:

Answer 582

Correct Answer: C. Process measurement A process measure is used to measure a clinical process, which is a healthcare related activity performed for, on behalf of, or by a patient. Process measures generally assess the activities of healthcare providers to deliver services and these measures are typically guided by evidence-based clinical guidelines. The measure used in this case is supported by guidelines from organizations including the United States Preventive Services Task Force, the National Heart, Lung, and Blood Institute, and the Institute for Clinical Systems Improvement. They can be used to compare performance, to prepare public reports, or to set pay-for-performance incentives. Incorrect Answers: A. Structure measurement assesses the capacity of a clinician or healthcare organization to deliver care. B. Population management refers to features of the public health system relevant to administration, oversight, or staff. Population management measures are related population health measures that are not supported directly by evidence demonstrating a link to better or worse performance of population health activities. D. Clinical efficiency measures demonstrate the relationship between a specific level of quality healthcare provided and the resources used to provide that care. Vital Concepts: A process measure is used to measure a clinical process, which is a healthcare related activity performed for, on behalf of, or by a patient. Process measures generally assess the activities of healthcare providers to deliver services and these measures are typically guided by evidence-based clinical guidelines. They can be used to compare performance, to prepare public reports, or to set pay-for-performance incentives. References:

Answer 583

Correct Answer: A. It refers to the number of subjects in the study "N" refers to the number of subjects in the study. Incorrect Answers: B, C, and D. These are all true statements of the p-value. Vital Concepts: The p value helps determine whether the null hypothesis is true. It helps the researcher determine whether or not to reject the null hypothesis. References:

Answer 584

Correct Answer: C. Psychiatric directives can formalize a patient’s wishes about forced medication. Psychiatric advance directives are documents that are written while a person is competent that specify how decisions about treatment should be made if the person becomes incompetent. They may be particularly appropriate for individuals with mental illness who alternate between periods of incompetence and competence. They can be used to formalize the patient’s wishes about treatment setting, treatment approaches, forced medication, handling emergencies, and the willingness of an individual to participate in research studies. Incorrect Answers: A. Psychiatric advance directives are broader in scope than advance directives referring to life support decisions, although this may be included. B. To date, psychiatric advance directives have not had a major effect on psychiatric treatment. D. Federal regulations require all facilities that receive reimbursement from Medicare or Medicaid to inform patients at the time of admission about their rights under state law to sign advance directives. References:

Answer 585

Correct Answer: C. Match or mismatch between a person's temperament and features of his or her environment According to Chess and Thomas, "goodness of fit results when the properties of the environment and its expectations and demands are in accord with the organism’s own capacities, characteristics, and style of behaving." When there is a match, or "good fit" between a person's temperament and environment, he or she can develop in a healthy and functional way. When determining this "goodness of fit," other factors such as specific values, cultural differences, and socioeconomic levels must be taken into consideration. Incorrect Answers: A. This is one example of goodness of fit, but not the best definition. B. Goodness of fit is between a person's temperament and features of their environment, not between a mother and child. D. This is another example of goodness of fit, but not the best definition. References:

Answer 586

Correct Answer: B. Clonidine is particularly helpful in ADHD patients with comorbid tic disorders, conduct disorders, or oppositional defiant disorder. Clonidine is also helpful for ADHD patients with ADHD-associated sleep disturbances and may be helpful for reducing anxiety and hypervigilance in traumatized children. Incorrect Answers: A. Clonidine is an alpha-adrenergic agent used in hypertension. At low doses, it is associated with the stimulation of inhibitory presynaptic autoreceptors in the CNS. C. Overdoses of clonidine in children under age 5 can be life-threatening. D. The primary effect of clonidine is on blood pressure, and close monitoring of blood pressure is necessary when tapering clonidine. Ordering an EKG may be considered when adding an alpha-agonist to a stimulant and when reaching the therapeutic dose of the alpha-agonist due to the additive cardiac risk factors inherent to both medications. References:

Answer 587

Correct Answer: B. Diabetic peripheral neuropathy Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI). It has been shown in 3 randomized controlled trials to have superior pain relief in comparison to placebo in subjects with diabetic peripheral neuropathy. The Food and Drug Administration indications for duloxetine include major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain. Incorrect Answers: A. Radiculopathic pain is not an approved indication for duloxetine by the FDA. C. Duloxetine is not approved for chemotherapy-induced neuropathy. D. Duloxetine is not approved for post-herpetic neuralgia. It is used for this purpose off-label. E. HIV-related neuropathy is not an approved indication for duloxetine by the FDA. Vital Concept: The Food and Drug Administration indications for duloxetine include major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain. References:

Answer 588

Correct Answer: D. Alcohol use disorder, severe This patient has severe alcohol use disorder. Severity specifiers are determined by the number of substance use disorder criteria that are met. This disorder may be graded as mild (two to three symptoms), moderate (four or five symptoms), or severe (at least six symptoms). Incorrect Answers: A. This is a valid DSM-5-TR substance-related diagnosis but with the wrong severity. B. These are terms from DSM-4-TR that were since eliminated. C. This is not a valid DSM-5-TR diagnosis. Vital Concept: AUD may be graded as mild (two to three symptoms), moderate (four or five symptoms), or severe (at least six symptoms). References:

Answer 589

Correct Answer: C. Continue to treat the patient while respecting her wishes. Since the patient is a competent adult, she cannot be transfused against her will, and she retains the right to refuse lifesaving treatment. Legally, if she is in a state that supports abortion rights, the wishes of a pregnant woman must be respected, even when the fetus is in danger as a result of her medical decisions. Incorrect Answers: A. Assuming she is in a state that is supportive of abortion rights, the father cannot give consent that supersedes the mother's right to refuse treatment. B. E. Assuming she is in a state that is supportive of abortion rights, a fetus would not have superseding legal rights prior to delivery. D. Transfer of care could constitute abandonment and is inappropriate. References:

Answer 590

Correct Answer: A. Schizoaffective disorder Schizoaffective disorder is a condition in which the patient has symptoms of both schizophrenia and a major mood disorder, and both sets of symptoms are prominent in the patient's course of illness. According to DSM-5-TR criteria, schizoaffective disorder includes the following: The patient must have two sets of symptoms simultaneously: · Symptoms of a major depressive episode (MDE) or mania- the patient must meet the criteria, including poor or sad mood for the majority of the day most days · At least two primary symptoms of schizophrenia: speaking incoherently without logical organization* a misconception, belief, or thought that is firmly held despite not being grounded in reality* illusions or perceived experiences that do not exist (e.g., sounds, voices, smells, visions, feelings, etc.)* actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) decreased display of emotion or a lack of motivation · The symptoms of schizophrenia must be present for at least two weeks alone, without the mood symptoms listed above · Mood symptoms are then present for the majority of the episode/illness · The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition · The disorder should be classified as Bipolar type if mania is present or Depressive type if ONLY depressive symptoms are present. Incorrect Answers: B. Bipolar disorder is characterized by alterations in depressive mood and euphoria in a cyclical fashion. Psychotic symptoms are not seen in bipolar disorder. C. Schizoid personality disorder is not typically associated with psychotic symptoms. D. Depression with psychotic features is ruled out because the patient has no history of low mood or crying spells without psychotic symptoms. E. Schizophrenia alone is incorrect because both symptoms of mood disorder and schizophrenia are evident. Vital Concept: Schizoaffective disorder consists of mood disorder symptoms, including depression or hypomania/mania, and schizophrenia symptoms. It is characterized by an uninterrupted period of illness during which there is a major mood episode concurrently with 2 or more symptoms of schizophrenia: hallucinations, delusions, disorganized or catatonic behavior, disorganized speech, or negative symptoms. References:

Answer 591

Correct Answer: D. Ask the patient if they are in immediate danger If there is immediate danger, the NP should assist the patient in leaving the home immediately if possible. Incorrect Answers: A. If the patient is in immediate danger and cannot leave, the NP should encourage the patient to call the police. If that is not possible, the NP could offer to make the call with the patient. B. Although domestic abuse in an adult patient does not require the HCP to report in all states, as it is with pediatric victims, HCPs should take any domestic abuse report very seriously. Survivors of domestic violence should never be dismissed. C. The details of the abuse are vital information to collect throughout the visit, but the HCP should first ensure that the patient is safe from immediate danger. Vital Concept: The most critical initial intervention is for the NP to determine if the patient is safe. References:

Answer 592

Correct Answer: B. >1 month Several criteria must be met to receive a diagnosis of posttraumatic stress disorder (PTSD). The criteria within the DSM-5-TR for adults include: · The symptoms are related to a prior experience of potential or genuine fatality, severe harm, or sexual assault. o The patient may have been a participant, victim, or witness/bystander. Alternately, in the case of violent acts, the patient may have learned about a loved one’s experience as a victim or participant or had recurrent professional experiences with unsettling or unpleasant details (e.g., law enforcement officers, social workers, first responders, etc.). Professional incidents typically occur first-hand and not through images, videos, etc. · The unwanted and unpleasant symptoms begin after the initial traumatizing experience, last for at least 30 days, and must include at least one of the following: o recollections of the initial traumatizing experience that are repeated, compulsory, and anguishing/unpleasant (in older pediatric patients, this may include play scenarios resembling the experience in some aspect) o significant psychological reactions to environmental or inner triggers associated with the initial traumatizing experience o significant physical responses to environmental or inner triggers associated with the initial traumatizing experience o flashbacks, during which the patient temporarily mentally disconnects from their current environment and reality and has the sensation that the initial traumatizing experience is happening again o repetitious nightmares associated with the initial traumatizing experience · The patient consistently prevents exposure to internal or external triggers related to the initial traumatizing experience by performing at least one of the following o not allowing oneself to think, feel, or remember the initial traumatizing experience or things related to the experience o preventing exposure to things (e.g., locations, items, persons) that may provoke thinking, feeling, or remembering the initial traumatizing experience · The patient experiences a significant decline in disposition and mental function following the initial traumatizing experience, observed through at least two of the following: o a consistent and extreme negative opinion or outlook regarding the world, people, and themselves (e.g., people are not to be trusted, the world is not safe, I am damaged permanently) o a consistent predominance of undesirable feelings (e.g., rage, terror, remorse, disgrace) o a lack of closeness or connection with those around them o a lack of memory regarding a crucial portion of the initial traumatizing experience o a faulty thought pattern regarding the reason for or the repercussions of the initial traumatizing experience, leading to a sense of guilt directed at themselves or someone else o a significantly decreased desire for or engagement in substantial events o a consistent paucity of desirable feelings (e.g., joy, love, contentment) · The patient experiences a significant change in responsiveness following the initial traumatizing experience, observed through at least two of the following: o unsafe or self-harming actions o extreme edginess or precariously startled o poor ability to initiate or maintain adequate sleep o cantankerous disposition with frequent gratuitous fits of rage exhibited as loud outbursts or outwardly aggressive behavior o behavior that is overly cautious and alert o challenges maintaining focus · The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern · The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise Incorrect Answers: A. In acute stress disorder, symptoms are present for at least 3 days and up to a month. In PTSD, symptoms are present for longer than one month. C. In PTSD, symptoms must be present for longer than one month, not 3 months. D. In PTSD, symptoms must be present for longer than one month, not 6 months. Vital Concept: Symptoms must be present for at least one month in order to diagnose post-traumatic stress disorder. Symptoms include one or more intrusive symptoms, one or more avoidance behaviors, two or more negative alterations in mood, and two or more changes in arousal all associated with a traumatic experience. References:

Answer 593

Correct Answer: A. Early course of illness (from first episode to 5 years after episode) is considered a critical period, as up 80% of patients experience relapse. Early course of illness (from first episode to 5 years after episode) is considered a critical period, as up to 80% of patients experience a relapse. The course during the critical phase usually takes 4 weeks and develops in the following order: prodrome with nonpsychotic symptoms, emotional disturbance, then frank psychosis. Incorrect Answers: B. Around 10-15% have a single episode of psychosis, but 10-15% have chronic severe psychosis. C. The average time of untreated psychosis in developed countries is 1-2 years. This time tends to be much longer in men than in women. D. Premorbid events can have significant impacts on the development of schizophrenia, including perinatal complications, family trauma, and stress occurring under 21 years of age. References:

Answer 594

Correct Answer: B. Married 45-year-old woman whose mother died 1 week before, who is frequently tearful, and who is requesting medication to sleep Of the patients described, the married 45-year-old woman whose mother died 1 week before, who is frequently tearful, and who is now requesting medication to sleep presents the lowest statistical risk of suicide. Females have lower risk than males. Married individuals have decreased risk of suicide. Incorrect Answers: A. Single 60-year-old man who currently has major depression is incorrect. Men have increased risk of suicide as well as depression. C. Married 60-year-old woman with terminal lung cancer who often requests pain medicine is incorrect. Chronically ill and terminally ill patients have high risk of suicide attempts. D. Single 20-year-old man who frequently abuses alcohol is incorrect as substance abuse (alcohol) increases risks are well as younger adult males have higher incidents of suicide. References:

Answer 595

Correct Answer: C. Fixed interval A fixed-interval schedule provides reinforcement for a response that occurs after a set time. The child is reinforced at a fixed weekly schedule, as long as the behavior occurred. Incorrect Answers: A. A fixed-ratio schedule provides reinforcement every set number of responses. B. A variable-ratio schedule provides reinforcement at a varying response rate. D. A variable-interval schedule provides reinforcement for responses that occur after varying amounts of time. References:

Answer 596

Correct Answer: C. Medicines received in the hospital Medicare Part A covers medications received in acute care. Incorrect Answers: A. Medicare Part A does not cover concierge care. B. Long term nursing home care. Although Medicare Part A covers skilled care in a Skilled Nursing Facility (SNF), it does not cover long term care in a nursing home. This is covered by private pay or Medicaid. D. Medicare Part A does not cover fees for cosmetic surgery. Vital Concepts: Medicare Part A covers medications received in acute care. References:

Answer 597

Correct Answer: D. Major decline in state funding of mental health services is a significant barrier to access. Access refers to the degree to which information about healthcare and healthcare services are easily obtained. Access to mental healthcare faces many barriers, but a significant barrier has been the major decline in the states’ funding of mental health services. The most common reason given by patients with mental illness who do not seek treatment is cost. People who have serious mental illness are more likely than others to be uninsured. Incorrect Answers: A. Most people who seek mental health care, about two thirds, are treated by primary care providers. B. The reason most frequently given (41%) for failure to seek mental health treatment is cost. C. Although some access problems with mental health care apply to the entire health care system, including absence of care for people without health insurance or lack of providers in rural areas, other problems, including stigma associated with seeking care, are specific to mental health. References:

Answer 598

Correct Answer: D. Part A of Medicare is funded by a 2.9% tax on earnings paid by employers and workers Medicare is divided into four parts, each providing different healthcare benefits. Part A is the Hospital Insurance Program, funded by a 2.9% tax of earnings paid by employers and workers. It covers inpatient hospital services, home health, skilled nursing facilities, and hospice care. Incorrect Answers: A. Medicare was originally established to provide health insurance for persons over the age of 65, but has been expanded to include individuals younger than 65 years with certain medical conditions and disabilities. B. Medicare Part C allows beneficiaries to enroll in a private plan as an alternative to the traditional fee-for-service plan. These plans can include health maintenance organizations, preferred provider organizations, or private fee-for-service plans. Part B is a supplemental medical insurance program that is funded by general revenues and beneficiary premiums and helps to pay outpatient, home health, and preventive services. C. Prescription drug benefits are delivered through private plans in contract with Medicare under Part D. Vital Concepts: Part A is the Hospital Insurance Program, funded by a 2.9% tax of earnings paid by employers and workers. It covers inpatient hospital services, home health, skilled nursing facilities, and hospice care. References:

Answer 599

Correct Answer: A. Autonomy, beneficence, justice, nonmaleficence These are the four ethical principles that form the foundation of clinical care Incorrect Answers: B. Guidance isn't one of the four ethical principles that form the foundation of clinical care C. Judgment isn't one of the four ethical principles that form the foundation of clinical care D. Compassion isn't one of the four ethical principles that form the foundation of clinical care References:

Answer 600

Correct Answer: B. Prenatal care In most states, a child of 17 does not have to have parental consent for any pregnancy-related care. Incorrect Answers: A. In most states, a child of 17 does not have to have parental consent for contraception, but permanent surgical contraception is an exception. C. In most states, a child under the age of 18 must have parental consent for a school physical. The NP must know the laws that govern consent for treatment in the state where they practice. D. While 17-year-olds don't need parental consent for pregnancy-related care in most states, most states do require parental consent in a minor's decision to have an abortion. Vital Concept: Adolescent consent and confidentiality are a complex topic. Laws regarding consent and adolescent confidentiality vary from state to state and the NP must be aware of the laws in the state in which they practice to provide appropriate treatment to the adolescent while also maintaining their privacy and rights. References:

Answer 601

Correct Answer: D. Velocardiofacial syndrome This patient likely has velocardiofacial syndrome (VCFS) (22q11.2 deletion syndrome, related to DiGeorge syndrome). The mnemonic "CATCH-22" is used: Cardiac abnormality (especially tetralogy of Fallot), Abnormal facies (microcephaly, micrognathia), Thymic aplasia, Cleft palate, and Hypocalcemia/Hypoparathyroidism. Psychiatric illnesses are common late-occurring features in these patients. VCFS is associated with a high rate of psychiatric disorders in childhood. Adults with DiGeorge syndrome are at a high risk for developing schizophrenia. About 30% have at least 1 incident of psychosis, and about 25% develop schizophrenia. Incorrect Answers: A. Down syndrome. Down syndrome (Trisomy 21) is the most common causes of genetic intellectual disability. Physical characteristics include flat facies, single palmar crease and epicanthal folds. Associated with early onset Alzheimer Disease. B. Trisomy 18. Edwards (Trisomy 18) features include intellectual disability, micrognathia, rocker bottom feet, clenched fists with overlapping fingers, congenital heart defects and typically die within one year of life. C. Fragile X. Fragile X results from CGG repeats increasing methylation of the FMR1 gene causing decreased expression of FMR1 gene. Features associated with Fragile X include intellectual disability, macroorchidism, macrognathia, long faces, large ears, mitral valve prolapse and autism. References:

Answer 602

Correct Answer: D. Melatonin MT1 and MT2 receptor agonist Ramelteon is a synthetic agonist of the melatonin MT1 and MT2 receptors, which binds with much higher affinity than endogenous melatonin. GABA-a receptor agonists are better known as benzodiazepine receptor agonists. Incorrect Answers: A, B. GABA-a receptor agonists are benzodiazepine receptor agonists C. This is partially correct, as ramelteon is a Melatonin MT1 agonist; however, it's also a Melatonin MT2 agonist References:

Answer 603

Correct Answer: C. Identify child's legal guardian(s) The initial step in the assessment is identifying the child’s legal guardian(s). In routine cases, the legal guardians are the biological parents who accompany the child to the hospital. In complex cases, the child’s legal guardian may be court-ordered to be only 1 parent, another relative, a foster parent, or a representative of the state agency responsible for the care and protection of children. Incorrect Answers: A. Children shouldn't be interviewed without a legal guardian present B. Children shouldn't be treated with medication without a legal guardian's consent D. The child's social situation isn't as important as finding their legal guardian References:

Answer 604

Correct Answer: B. Linking external occurrences to oneself when there is little or no basis for making these associations Personalization involves linking external occurrences to oneself when there is little or no basis for making these associations. Incorrect Answers: A. This is selective abstraction. C. This is absolutist thinking. D. This is magnification or minimization. References:

Answer 605

Correct Answer: C. Buprenorphine Buprenorphine is indicated in the treatment of opioid use disorders. It is an opioid partial agonist. Methadone is another opioid agonist used to treat opioid use disorder. Incorrect Answers: A. Naloxone is a medication designed to rapidly reverse an opioid overdose, it is an opioid antagonist B. D. Disulfiram and acamprosate are indicated in the treatment of alcohol use disorders. Naltrexone is an opioid antagonist and may be useful in highly motivated patients, patients employed in safety-sensitive positions that prohibit the use of methadone or buprenorphine, and in patients who have not responded to treatment with an opioid agonist. It is approved by the FDA for the treatment of opioid use disorders. References:

Answer 606

Correct Answer: B. MZ twins have higher concordance rates for chronic alcohol use disorder than DZ twins. Chronic alcohol use disorder tends to run in families. The closer the genetic relationship, the greater the risk. Familial patterns provide only suggestive evidence of genetic factors because families share a common environment as well as common genes. More definitive evidence comes from twin and adoptee studies. Monozygotic (MZ) twins have identical genes, whereas fraternal or dizygotic (DZ) twins share only half of their genes. MZ twins may share greater environmental and genetic similarity than DZ twins. Incorrect Answers: A. Chronic alcohol use disorder reflects an oral-dependent personality, according to traditional psychodynamic theory. Excessive alcohol use is associated with other oral traits, such as dependence and depression. C. Alcohol dependence is generally more common among people of lower income and educational levels. D. Men are more than 2x as likely as women to develop chronic alcohol use disorder. References:

Answer 607

Correct Answer: C. Hyponatremia Side effects of carbamazepine include aplastic anemia, thrombocytopenia, hyponatremia, toxic epidermal necrolysis, hepatitis, agranulocytosis, rash, erythema multiforme, Stevens-Johnson syndrome, edema, SLE, arrhythmias, and potential as a teratogen. Hyponatremia may result in dizziness, headache, lethargy, mental confusion, weakness, and slurred speech. Incorrect Answers: A. This leaves the sufferer feeling fatigued, but not the other symptoms listed B. This is often asymptomatic, but can lead to purpura (easy or excessive bruising) and prolonged bleeding from cuts D. This is characterized by erythema, necrosis, and bullous detachment of the epidermis and mucous membranes References:

Answer 608

Correct Answer: B. Symmetrical A symmetrical relationship is characterized by each member contributing a similar behavior so that each partner compounds and exacerbates the difficulties. Incorrect Answers: A. A complementary relationship pattern requires each member to contribute something quite different in a mutually interlocking manner to maintain the relationship. A classic example of a complementary relationship is the distancer-pursuer, in which one member does most of the asking for intimacy and connection, while the other pulls back to do work, take care of the children, or be alone. C. and D. These are not examples of relationship types. References:

Answer 609

Correct Answer: D. Dialectical Behavioral Therapy This patient has a borderline personality disorder and the Dialectical Behavioral Therapy (DBT) is the most commonly used to treat this population. While Psychoanalytical Therapy and Behavioral Therapy may be useful with this patient as well, DBT is the best answer. Incorrect Answers: A, B. These could be useful for this type of patient, but DBT is more appropriate. C. This isn't useful for this type of patient. References:

Answer 610

Correct Answer: C. Viewpoint of relationship as an entity that is greater than either member's version A clinician using systemic thinking in treating a couple in couples therapy is likely to concentrate on the couple’s collective ideas about the relationship and communication between the couple. Therefore, the clinician will focus on ideas about the relationship as an entity that’s greater than either member’s version. Incorrect Answers: A. Healthy communication between the therapist and each client is helpful but not the primary focus of systemic thinking. B. Systemic thinking focuses on identifying dysfunctional relationship patterns, not healthy relationship patterns. D. While it may be appropriate to highlight microanalytic sequences on occasion, focusing on those sequences isn't the goal of systemic thinking — it's, in fact, its inverse. References:

Answer 611

Correct Answer: C. Tertiary Tertiary prevention is defined as activities that prevent the deterioration or reduce complications after a disease is already present. Examples include metabolic monitoring of patients on antipsychotics, use of assertive community treatment with schizophrenics, and intensive case management. Incorrect Answers: A. Primary prevention keeps a disease from occurring by removing its causes. Primary prevention includes counseling about lifestyle changes like drinking and smoking, immunizations, and suicide-prevention programs. B. Secondary prevention detects diseases early when patients are asymptomatic and addresses treatment to halt its progression. Examples include HIV testing, screening for nutrition and exercise, depression screening for at-risk teens, urine drug testing, or identification of prodromal schizophrenia. D. Quaternary care is an extension of tertiary care. It is even more specialized. An example is experimental medicine or specialized surgery. References:

Answer 612

Correct Answer: D. Drafting a bill See the referenced link for the steps involved Incorrect Answers: A, B. These steps are after the bill is drafted C. This is after a bill is introduced References:

Answer 613

Correct Answer: D. Access to firearms Access to firearms is a serious threat. Firearms are the number-one means of committing suicide, followed by hanging and poisoning. Although all of these modifiable risk factors are concerning, red flags should be raised if the patient also has access to a gun. Sleep disorders, medical illness, panic attacks, impulsivity, and difficult psychosocial situations are other modifiable risk factors. Incorrect Answers: A, B, and C. These factors don't have as much predictive power as access to firearms for predicting a bad outcome for a suicidal patient. References:

Answer 614

Correct Answer: A. Hydroxyzine Hydroxyzine, blocks histamine one receptors and can work in 15-20 minutes. Therefore can be used as an as needed medication to offer immediate anxiety relief. The antihistamine hydroxyzine most common side effects include dry mouth, sedation and tremor. Non-habit forming which addresses patient’s desire to avoid addictive medications. Incorrect Answers: B. Paroxetine. Selective serotonin reuptake inhibitors (SSRIs) are utilized for long-term management of anxiety and require several weeks to take full effect. This patient is looking for immediate relief. C. Lorazepam. Benzodiazepines (e.g. lorazepam) can be used for the acute management of anxiety. They have been shown to reduce symptoms within minutes. However there is a potential for tolerance and dependence and the patient wants to avoid medications with addictive properties, therefore, hydroxizine is a better option. D. Doxepin. Tricyclic antidepressants (TCAs) (e.g. doxepin) are not first line for short or long-term treatment of anxiety. TCAs could be considered for treatment-resistant anxiety. References:

Answer 615

Correct Answer: B. Fidelity Fidelity refers to dedication and loyalty to one’s patients and to keeping promises to the patient. In this case, if the nurse practitioner keeps the information from the patient’s family at her request, she is exercising the concept of fidelity. Incorrect Answers: A. Veracity refers to the duty to present information honestly and truthfully. C. HIPAA (Health Insurance Portability and Accountability Act) is also known as the HIPAA Privacy Rule and is not a principle of medical ethics, but a legal construct. D. Paternalism refers to deciding what is best for a patient without regard for the patient's wishes, or despite the patient's wishes to the contrary. If the NP decided to tell the family “in the best interests of the patient,” that would represent paternalism. Vital Concepts: Fidelity refers to dedication and loyalty to one’s patients and to keeping promises to the patient. In this case, if the nurse practitioner keeps the information from the patient’s family at her request, she is exercising the concept of fidelity. References:

Answer 616

Correct Answer: C. Theory of Self-Care Dorothy Orem developed Theory of Self-Care to promote the ability of the patient or the patient’s family to be able to complete activities of daily living. This patient is unable to complete the necessary daily activities of life to ensure physical wellness, which is only worsening her mental wellness. The Health Promotion Theory, Theory of Adaptation, and Caring Theory are more advanced than ADLs and this client is not in place where these theories can be applied successfully. Incorrect Answers: A. B. D. These theories are more advanced than activities of daily living (ADLs); the client isn't in a place where these theories can be successfully applied. References:

Answer 617

Correct Answer: C. Self-efficacy Self-efficacy is part of Albert Bandura’s Self-Efficacy/Social Learning Theory and is defined by the perception of one’s ability to perform a certain task at a certain level of accomplishment. Kelly lacks self-efficacy as evidenced by her lack of feelings that she can accomplish things or be successful. There is not enough information to determine if or which cognitive distortions Kelly has. Teaching Kelly to have external locus of control will not benefit her and explaining who qualifies for disability is not appropriate at this time. Incorrect Answers: A. There's not enough information to understand what cognitive distortions Kelly may or may not have. B. Teaching Kelly to have an external locus of control won't help her. D. Telling Kelly who qualifies for disability won't help Kelly. Vital Concept: Self-efficacy is part of Albert Bandura’s Self-Efficacy/Social Learning Theory and is defined by the perception of one’s ability to perform a certain task at a certain level of accomplishment. References:

Answer 618

Correct Answer: B. All health professions have individual professional competencies According to Barr (1998), there are three types of competency. Common competencies overlap more than one health care profession, although not necessarily all health care professions, and are competencies expected of all health professionals. Complementary competencies enhance the qualities of other professions in provision of care. Collaborative competencies are those that each individual profession must possess to work with others, including those who practice within different specialties within a profession; between professions; with patients and their families; with non-professionals and volunteers; within the community; within and between organizations; and at a policy level. Incorrect Answers: A. Interprofessional collaboration is patient-centered. C. The goal of interprofessional teamwork is better healthcare. D. Competency in interprofessional collaborative practice relies upon the relationship between the patient and the team of health professionals. The goals of interprofessional collaborative practice are centered on the patient. Vital Concepts: According to Barr (1998), there are three types of competency. Common competencies overlap more than one health care profession, although not necessarily all health care professions, and are competencies expected of all health professionals. Complementary competencies enhance the qualities of other professions in provision of care. Collaborative competencies are those that each individual profession must possess to work with others, including those who practice within different specialties. References:

Answer 619

Correct Answer: D. Limiting access to preferred items is part of behavioral therapy. Behavioral therapy is part of the treatment of pica, and response blocking is another form of behavioral therapy. Incorrect Answers: A. Coprophagia (eating of feces) is an example of copraxia. Pica involves eating nonfood items such as dirt, paper clips, and sometimes even feces or cigarette butts. B. Pica occurs in children with normal cognition as well as in patients with intellectual disability (formerly mental retardation). C. Psychopharmacological treatment is not usually successful with pica. References:

Answer 620

Correct Answer: B. It is chronic with a waxing/waning course. The course is chronic and waxes and wanes over time. Illness anxiety disorder is characterized by an obsession with having an illness or developing an illness. DSM criteria for illness anxiety disorder include: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months, but the illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Findings with respect to age and gender prevalence are inconsistent, but the prevalence in the general population is 1-5%. Onset is most commonly in early adulthood. Incorrect Answers: A. Illness anxiety disorder doesn't decrease in intensity in adulthood; it waxes and wanes over time. C. Illness anxiety disorder is chronic, but it doesn't worsen into middle and older age before improving slightly; it waxes and wanes over time. D. Illness anxiety disorder is chronic, but it doesn't steadily increase in severity over time; it waxes and wanes over time. Vital Concept: Illness anxiety disorder is chronic and waxes and wanes over time. References:

Answer 621

Correct Answer: C. Depersonalization/derealization disorder Patients with depersonalization/derealization disorder (DDD) describe feelings of unreality, being detached from their body or thoughts, or being outside themselves and observing their thoughts and actions. They also describe their surroundings and other people with detachment or a sense of unreality or distortion and can appear flat or unemotional despite internal turmoil. These symptoms can be episodic, chronic, or episodic progressing to chronic, and there is no minimum duration of symptoms to make this diagnosis. However, treatment with psychotherapy and/or medication is recommended after at least 1 month of symptoms. Unlike psychosis, reality testing for these patients remains intact, but DDD still affects areas of social and occupational functioning. Incorrect Answers: A. Although depersonalization/derealization disorder and major depressive disorder can be comorbid conditions, the patient’s symptoms suggest depersonalization. He does currently meet the criteria for major depressive disorder. B. Depersonalization/derealization disorder is also comorbid with anxiety disorders, but this patient does not describe any anxiety symptoms. D. A critical differentiation between depersonalization/derealization disorder and psychosis is reality testing. Reality testing is intact in this patient, and some level of impairment would be expected in psychosis. E. In Capgras syndrome, patients believe familiar people have been replaced by imposters. It is most commonly a consequence of neurodegenerative diseases such as Lewy body dementia or Alzheimer’s disease. Vital Concept: Patients with depersonalization/derealization disorder (DDD) describe feelings of unreality, being detached from their body or thoughts, or being outside themselves and observing their thoughts and actions. This disorder often co-occurs with depression and/or anxiety. References:

Answer 622

Correct Answer: A. Carbamazepine These symptoms of bone marrow suppression are caused by carbamazepine and can lead to agranulocytosis or aplastic anemia (see table below). Aplastic anemia, thrombocytopenia, and agranulocytosis occur so rapidly that a daily blood count would be required to detect them. The product label of valproate also reports dose-related thrombocytopenia and recommends discontinuation of valproate if signs of bleeding develop. Incorrect Answers: B, C, and D. These drugs don't have bone marrow suppression as a potential problem, and therefore bone marrow suppression's common symptoms don't need to be monitored during their use. References:

Answer 623

Correct Answer: D. Meditation Relaxation training, breathing exercises, and meditation can be taught to patients with generalized anxiety disorder easily and can effective in mild cases. Incorrect Answers: A. Accupressure. While there's some evidence this can help for anxiety, this isn't a behavioral therapy. B. Self-hypnosis. Meditation is more evidence based than self-hypnosis for anxiety. C. Carotid massage. Carotid massage isn't used for anxiety; it's usually used for tachyarrhythmias in which the atrial activity is either absent or intermittently present. Vital Concept: Meditation has been associated with decreased anxiety. References:

Answer 624

Correct Answer: C. HIPAA forbids disclosure of laboratory results or other patient medical information to a third party for whom the patient has not given written consent The Health Insurance Portability and Accountability Act, known as HIPAA, was enacted in 1996 by Congress to provide protections for the use and disclosure of individuals’ health information by covered entities, which refers to providers or organizations subject to the Privacy Rule. These covered entities include any health care provider, health insurance company, health care plans, and third party administrators who “electronically transmit health information.” HIPAA requires health providers to provide each patient with a copy of their office HIPAA policy. The patient must sign the form, which must be reviewed and signed annually by the patient. Patients also have the right to review their medical files. A mental health provider has the right to refuse patient requests to view their psychiatric and mental health records, but in other cases, health care providers have up to 30 days to comply with patient requests to review their medical records. Patients are allowed to correct errors in their medical records. Healthcare providers must keep identifying information private except in the case of allowed exceptions. Incorrect Answers: A, B, D. Lab results can't be released to a spouse or any other third party without a patient's written consent Vital Concepts: The Health Insurance Portability and Accountability Act, known as HIPAA, was enacted in 1996 by Congress to provide protections for the use and disclosure of individuals’ health information by covered entities, which refers to providers or organizations subject to the Privacy Rule. References:

Answer 625

Correct Answer: C. Quality improvement program Quality improvement programs involve systematic activities that are organized and implemented by an organization for the purpose of monitoring, assessment, and improvement of the quality of the organization’s healthcare. Incorrect Answers: A. Bylaws outline the day-to-day operational rules of an organization in order to facilitate smooth operations in all aspects of the organization’s business, not specifically patient care. B. Medical staff rules are the rules by which the medical staff of an organization have agreed to abide. Some rules are intended to deliver better patient outcomes, but medical staff rules apply to a narrow segment of the organization. D. Team-building activities are activities designed to foster cooperation and trust among individuals in an organization. Vital Concepts: Quality improvement programs involve systematic activities that are organized and implemented by an organization for the purpose of monitoring, assessment, and improvement of the quality of the organization’s healthcare. References:

Answer 626

Correct Answer: A. The therapist is trained in psychoanalysis at a psychoanalytic institute and has had his or her own psychoanalysis. Psychoanalysts — who perform psychoanalysis — are trained at psychoanalytic institutes. They must also have undergone their own analysis. One cannot call themself a psychoanalyst without having gone through their own analysis. This makes psychoanalysis training different from psychotherapy, as not all psychotherapists have gone through their own therapy. Incorrect Answers: B. Patients present for analysis 3-5 times a week, not once a week C. Countertransference is not the focus of the analysis D. Psychoanalysis usually takes three or more years, not a year or less References:

Answer 627

Correct Answer: D. Naloxone Opioid intoxication is a medical emergency that is treated by adequate hydration, mechanical ventilation, and naloxone. Nausea, vomiting, and severe itching can also occur as part of opioid intoxication. Opioid intoxication may occur in persons who intend to commit suicide or who restart an opioid after a certain period of time. Overdose involving opioid drugs is a life-threatening situation. Fatal respiratory depression can occur due to direct suppression of respiratory centers in the midbrain and medulla. Naloxone is a strong antagonist of µ-opioid receptors, a medium antagonist of kappa-opioid receptors, and a weak antagonist of delta-opioid receptors. Incorrect Answers: A. Acamprosate is an anti-craving drug used for maintenance therapy of alcohol withdrawal. B. Bupropion is used for nicotine withdrawal and acts on dopamine and noradrenaline receptors. C. Buprenorphine is used for detoxification and as part of maintenance therapy in opioid withdrawal. References:

Answer 628

Correct Answer: D. Routine random audits should be conducted to identify potentially inappropriate access Compliance with hospital privacy regulations and policies should be enforced by routine random audits. If potentially inappropriate access is identified, an EMR system can identify the name of the person who gained access, and information about the time, date, screens, and duration of access, which can determine if the access was an error or if it was an unauthorized review of protected health information. Incorrect Answers: A. Patients have the right to a log of all individuals who have accessed their personal health record. B. Although the use of EMR by creates special issues with respect to privacy, there are safeguards to limit the content and recipients of released data, such as a telefax report. C. Legal action can be the outcome of any privacy and confidentiality violations, so in addition to creating a policy, the facility must be diligent in enforcement of the policy through monitoring and follow-up. Vital Concepts: Health care providers should only be accessing necessary information about their patients in order to continue providing care for them. Any additional access can be potentially inappropriate and in violation of the patient's privacy. References:

Answer 629

Correct Answer: A. Self-injurious behavior ABA is a form of therapy most notably used for individuals with autism spectrum disorder. It can be effective in addressing self-injurious behaviors in this population by evaluating the functional role of the behavior and implementing reinforcement strategies to extinguish the behavior. ABA is not an evidence-based therapy for separation anxiety disorder, borderline personality disorder, primary enuresis, or post-traumatic stress disorder. Incorrect Answers: B, C, and D: ABA isn't an evidence-based therapy for any of these conditions. References:

Answer 630

Correct Answer: D. Specific Gravity 1.045 Specific gravity measures the ratio of urine density compared with water density and provided information on the kidney's ability to concentrate urine. Specific gravity of urine is compared to the weight of distilled water, which has a specific gravity of 1.000. the normal range of urine specific gravity can be measured easily with a dipstick. Factors that increase specific gravity are fluid volume deficit, Syndrome of Inappropriate Diuretic Hormone, Congestive Heart Failure, Acidosis and Prerenal failure. Because the patient has been working and running, sweating can lead to fluid volume deficit and dehydration. Incorrect Answers: A. Normal values for Hematocrit for males is 38-50. A hematocrit that demonstrates dehydration would be higher, >50%. When there is less plasma (liquid part of blood) the percentage of RBCs would increase. B. Glomerular Filtration Rate is the amount of blood filtered by the kidneys per minute. The normal values of GFR is 90-120mL/min, but is most often reported on the laboratory report as >60mL/min, therefore, this patient would have a normal GFR. Kidney disease, not dehydration, is most closely associated with decreased GFR. C. Creatinine 1.0. Normal value for creatinine is 0.7-1.4, therefore this patient's creatinine is normal. Creatinine is the end product of muscle metabolism. Creatinine is an indicator of renal function. Serum levels increase when renal function decreases, not when a patient is dehydrated. References:

Answer 631

Correct Answer: C. Agranulocytosis Agranulocytosis is the most serious side effect of mirtazapine (approximately 1 in 1,000) and is usually reversible when discontinued. Incorrect Answers: A. Mirtazapine improves nausea and vomiting due to 5-HT3 receptor blockade. B. Urinary frequency, not retention, can occur with mirtazapine use. D. Neutropenia, hypotension, and hyponatremia are other serious reactions. References:

Answer 632

Correct Answer: B. GABA Acamprosate structurally resembles GABA. It is modestly superior to placebo. A combination of naltrexone and acamprosate is more effective than either drug used alone. Incorrect Answers: A. C. D. Acamprosate's structure doesn't resemble these neurotransmitters. References:

Answer 633

Correct Answer: A. The lack of adequate measures for the theoretical concepts. The lack of adequate measures for theoretical concepts is a major roadblock in many areas of research, and particularly so with more abstract theories. Incorrect Answers: C. More abstract concepts tend not to be studied in lab settings. B. D. Prior studies always provide information about the theory, even when they were conducted in other countries. References:

Answer 634

Correct Answer: C. Patient-driven In nursing, critical thinking is patient-driven, purposeful, and outcome-focused thought based on both knowledge and experience. A group or an individual can do critical thinking. It is often intuitive. It takes the patient’s values into account when applying standards, policies, and procedures. Critical thinking is a process of constant evaluation and reevaluation. Incorrect Answers: A. Critical thinking is outcome-focused. B. Critical thinking is based on knowledge and experience and is often intuitive. D. Critical thinking is often group thinking, talked-out thinking, and reflective thinking. Vital Concepts: Critical thinking is patient-driven, purposeful, and outcome-focused thought based on both knowledge and experience. References:

Answer 635

Correct Answer: C. Affordable Care Act The affordable Care act also prevents insurance companies from limiting or denying coverage due to preexisting medical conditions. Incorrect Answers: A, B, and D. These acts do not discuss children remaining on a parent’s insurance policy until age 26. Vital Concepts: The affordable Care act also prevents insurance companies from limiting or denying coverage due to preexisting medical conditions. References:

Answer 636

Correct Answer: D. Contingency management has been widely accepted and is effective. Contingency management involves positive contingencies (usually a point system that leads to some sort of prize) and negative contingencies that involve the removal of privileges. Lifestyle can be reinforced using these principles. A large multisite trial comparing CBT and supportive-expressive therapy to standard drug counseling showed little difference between the 2. Presently, there are no FDA-approved medications to treat cocaine addiction. Multiple medications including TCAs, SSRIs, dopamine antagonists, and anticonvulsants have not been shown to reduce relapse. Psychiatric comorbidities are much more common in patients who abuse stimulants compared to the general population. When used to treat a comorbid psychiatric condition, the use of medication is justified and may help prevent relapse. Incorrect Answers: A. B. There are currently no FDA-approved medications to treat cocaine addiction. SSRIs and dopamine antagonists are among a number of drugs (also including TCAs and anticonvulsants) that haven't been found to reduce relapse. C. CBT and supportive-expressive therapy hasn't been found to be more effective than drug counseling, based on the results of a large multisite trial. References:

Answer 637

Correct Answer: D. Blocks reuptake of norepinephrine Reboxetine and atomoxetine inhibit the reuptake of norepinephrine. In microdialysis studies, it increased NE and DA levels by 3x in the prefrontal cortices but did not alter DA levels in the striatum or nucleus accumbens. Reboxetine is indicated for the treatment of depression, although NOT approved in the U.S., and atomoxetine is indicated for the treatment of ADHD in children and adults. Increased NE has been shown to improve depressive symptoms, including fatigue, hypersomnia, motoric retardation, and anhedonia. Common side effects are dry mouth, insomnia, constipation, and urinary hesitancy. Incorrect Answers: A.Increases reuptake of dopamine and norepinephrine. Atomoxetine blocks the reuptake of norepinephrine, not increases reuptake. B. Causes release of norepinephrine. Atomoxetine does increase norepinephrine by blocking the reuptake of norepinephrine, not by increasing the release of norepinephrine. C. Blocks reuptake of serotonin and norepinephrine. Atomoxetine does block the reuptake of norepinephrine but does not affect the neurotransmitter serotonin. References:

Answer 638

Correct Answer: C. Secondary prevention Secondary prevention strategies refer to strategies that are designed to detect a disease or condition before it is symptomatic. Secondary prevention strategies are designed to facilitate early detection and treatment allow early detection and treatment of diseases or conditions in individuals with certain risk factors before the disease or condition is clinically apparent. Screening tests are secondary preventive measures that may allow the natural course of disease to be altered to maximize patient well-being as a result of early diagnosis. Primary prevention strategies are designed to minimize risk factors to prevent onset of the targeted disease or condition. Tertiary prevention strategies manage existing diseases to restore the patient to the highest possible function, to minimize negative consequences, and to prevent complications of a disease. Incorrect Answers: A. This is a tool for identifying and predicting which patients are at high risk and prioritizing the management of their care B. Primary prevention strategies minimize risk factors, which this doesn't do D. Tertiary prevention strategies manage existing diseases, and there isn't an existing disease here Vital Concepts: Secondary prevention strategies refer to strategies that are designed to detect a disease or condition before it is symptomatic. Secondary prevention strategies are designed to facilitate early detection and treatment allow early detection and treatment of diseases or conditions in individuals with certain risk factors before the disease or condition is clinically apparent. Screening tests are secondary preventive measures that may allow the natural course of disease to be altered to maximize patient well-being as a result of early diagnosis. References:

Answer 639

Correct Answer: C. In patients presenting with dementia, paraneoplastic limbic encephalitis should be considered. Early signs are confusion, agitation, and memory loss progressing to dementia. Incorrect Answers: A. Tumors tend to be less symptomatic than ischemic strokes affecting comparable brain volume. B. Gliomas determine gradual, pancortical dissemination that results in equally diffuse symptomatology (e.g. cognitive decline). D. Brain tumors in adults are associated with psychiatric symptoms in 50% of patients. References:

Answer 640

Correct Answer: C. Reawakening of hope and engagement in life The lead principle of plans for transformation of mental health care in paradigms suggested by SAMHSA, NAMI, the IOM, and the President’s New Freedom Commission is recovery, which emphasizes the reawakening of hope, engagement in life, and empowerment over illness. Incorrect Answers: A. Although understanding the neurobiological basis of more severe forms of mental illness has resulted in development of more efficacious psychotropic medications, psychosocial factors remain important considerations. B. Psychiatric mental health nurses should play a leadership role in transforming mental health care delivery and should articulate the need for nursing leadership in a transformed mental healthcare system. D. The President’s New Freedom Commission Transformation Plan calls for community-level service systems to coordinate multiple agencies to provide care. Team leaders for complex case management should be experienced, trained mental health professionals, and psychiatric nurses are have been identified as a key ingredient in provision of optimal case management leadership. Vital Concepts: The lead principle of plans for transformation of mental health care in paradigms emphasizes the reawakening of hope, engagement in life, and empowerment over illness. References:

Answer 641

Correct Answer: C. Critics view his schema as Western, predominately male, and hierarchical. Critique of Kohlberg’s theories is that there is a Western, male, and hierarchical bias. Cultures that focus on moral decisions based upon the wellbeing of family or community do not score high on the Kohlberg’s highest stage (postconventional). Incorrect Answers: A. Kohlberg’s theories are an expansion of Piaget’s theories on cognitive development and moral development. Kohlberg describes 6 stages of moral reasoning determined by a person’s thought process rather than the moral decision reached. B. Research has not shown any difference in moral decisions by gender. However, there may be gender differences in what factors are involved in decision-making. D. Moral decisions are based upon individual thought process. References:

Answer 642

Correct Answer: B. Cigarettes Clozapine blood levels are significantly lowered by cigarette smoking (see chart below). Some patients may experience a doubling of clozapine blood levels after smoking cessation, as well as attendant sedation and worsening of other side effects. Cigarette smoke is a potent inducer of cytochrome P450. As a result, drugs that are substrates for CP450 are affected by cigarette use. Other antipsychotics, including haldol and olanzapine, react like clozapine when smoking cessation occurs. Incorrect Answers: A, C, D. These substances don't lower clozapine levels in the blood. Therefore, patients wouldn't experience a doubling of clozapine blood levels after their cessation. References:

Answer 643

Correct Answer: C. Sertraline or paroxetine are preferred agents for treating postpartum depression in breastfeeding mothers. If a patient has had beneficial results form a particular medication in the past, that may factor into the decision. A medication that was used successfully during pregnancy may be continued while breastfeeding. Escitalopram and fluvoxamine use while breastfeeding has been studied less than the other SSRIs, while paroxetine and sertraline serum levels in breastfeeding infants are typically are low to undetectable. However, significant complications related to neonatal exposure in breast milk appear to be rare for all SSRIs. Sertraline, paroxetine, nortriptyline, and imipramine are the most evidence-based medications for use during breastfeeding. For mild to moderate postpartum unipolar major depression, psychotherapy is always recommended. Interpersonal psychotherapy, cognitive-behavioral therapy, and behavioral activation are evidence-based options and many are also used in a group format. Incorrect Answers: A. In trials studying the efficacy of antidepressants, fluoxetine is the most efficacious. Fluoxetine, however, presents in appreciable levels in breast milk. Treatment with an antidepressant requires careful risk/benefit analysis. All patients should be offered psychotherapy. The risks of depression for the child include poor attachment, delayed development, and cognitive impairment; more serious implications include an inability physically and emotionally to provide adequate care for the newborn. B. Major depression with peripartum onset as defined by the APA begins within 4 weeks of delivery. The WHO uses a time frame of 6 weeks from delivery. Other definitions vary all the way up to 12 months following delivery. D. Compared to other depressive episodes, anxiety is much more prevalent. Vital Concept: The use of an SSRI is generally considered safe in breastfeeding patients with severe depressive symptoms, although the individual risks and benefits should be discussed with each patient and collective decision-making utilized. References:

Answer 644

Correct Answer: A. Halo effect Numerous biases can be present in research. Measures such as appropriate participant selection, randomization, and blinding are used to help eliminate some of these biases. The halo effect occurs when a researcher’s evaluation of a subject’s current performance is altered based on his or her opinion of the previous performance of the subject. Incorrect Answers: B. Berksonian bias is a subtype of selection bias that causes hospital cases and controls in a case-control study to be systematically different from each other because the combination of exposure to risk and occurrence of disease increases the likelihood of being admitted to the hospital. C. A sample bias occurs when a researcher uses a sample that is not representative of the population. For example, if a researcher only uses males in a study, this study is not a good representation of the population, as the population is composed of males and females. D. The Hawthorne effect occurs when a participant changes his or her normal patterns of behavior when he or she is a member of a study or is being watched or observed. References:

Answer 645

Correct Answer: C. The mean age of bipolar I presentation is 18 years, and bipolar II is 20 years. Most cases of bipolar disorder present when patients are ages 15-19 years. The next common age of onset is 20-24 years. Bipolar disorder usually presents in young people. When new-onset bipolar disorder starts after age 59, it is usually secondary to a medical condition, drug usage, or medication. Some patients diagnosed with recurrent major depression may have bipolar disorder and later develop their first manic episode after age 50. These individuals may have a family history of bipolar disorder. However, for most patients, the onset of mania after age 50 should prompt an investigation for medical or neurologic disorders, such as cerebrovascular disease. Incorrect Answers: A. Patients with bipolar disorder often have a worse prognosis than patients with MDD. B. Delusions and hallucinations may occur during mania. D. Rapid cycling may be more common in women than in men, although some studies have found that sex is irrelevant in rapid-cycling disease with equivalent rates in males and females. Vital Concept: Bipolar disorder typically presents in adolescents and young adults. References:

Answer 646

Correct Answer: A. Cross-tolerant, less harmful medication is substituted for drug of abuse, and dosage is adjusted until withdrawal symptoms are minimized (e.g. nicotine for tobacco smoke, diazepam for alcohol, methadone for heroin). This is a generally accepted method of treatment for benzodiazepine, alcohol, nicotine, or tobacco withdrawal symptoms in a hospital setting. Incorrect Answers: B. Non-cross-tolerant medication is not used. C. D. Cold-turkey quitting isn't generally viable in hospital settings. Most patients who try to quit this way do so at home without a physician's supervision. References:

Answer 647

Correct Answer: C. Intermittent explosive disorder This seems less likely to be a personality disorder, in which a pattern of maladaptive behavior has become problematic. This patient is perplexed and unsure why this is happening. Depression and chronic alcohol use disorder could both explain his reactions, but the small incidents provoking these attacks of anger seem to point toward intermittent explosive disorder. Incorrect Answers: A. Not indicated by these symptoms B. No sign of multiple personalities, so doesn’t fit D. While depression could explain his reactions, the small incidents provoking the attacks seem to point towards intermittent explosive disorder References:

Answer 648

Correct Answer: C. Secondary prevention Mammography is considered secondary prevention. This is a measure designed for early detection of a disease so that morbidity and mortality may be reduced. Primary prevention prevents the disease or condition from occurring. Primary prevention measures in public health include programs like WIC and promotion of workplace safety laws designated by OSHA. Tertiary prevention includes rehabilitation and prevention of complications of a disease. An example of tertiary prevention is a support group for a disease or condition, or exercise for an obese patient. Incorrect Answers: A. Mammograms are not a form of health maintenance B. Primary prevention prevents disease or condition occurrence - mammograms do not meet that criteria D. Tertiary prevention involves disease rehabilitation and prevention - mammograms do not meet that criteria Vital Concepts: Mammograms are considered secondary prevention. This is a measure designed for early detection of a disease so that morbidity and mortality may be reduced. References:

Answer 649

Correct Answer: C. Symptoms usually resolve within 2 weeks. Symptoms may resolve in 2 weeks; if the same antidepressant is restarted or another SSRI is substituted, symptoms usually resolve within 24 hours of reinitiation. Incorrect Answers: A. SSRI discontinuation syndrome is most common with SSRIs with shorter half-lives (paroxetine and fluvoxamine). It rarely occurs with fluoxetine whose metabolite has a half-life of >1 week. B. Although rare, when this syndrome occurs with fluoxetine discontinuation, symptoms may begin 7-10 days after discontinuation; in SSRIs with shorter half-lives, symptoms may occur in 1-3 days. D. Sensory issues (e.g. paresthesias), sleep problems (e.g. vivid dreams), and psychological symptoms (e.g. anxiety, agitation) frequently occur, along with somatic signs such as flu-like symptoms and disequilibrium. References:

Answer 650

Correct Answer: B. Authorization bill Legislation usually falls into the category of either authorization or appropriations. Authorization bills are passed by Congress to establish laws and programs. Incorrect Answers: A. Appropriations bills provide spending authority for a single fiscal year. C. Amendments are additions to a bill and may be added to a bill that was passed to establish a program. D. Rules are guidelines or principles for the conduct of actions in Congress. Vital Concepts: Legislation usually falls into the category of either authorization or appropriations. Authorization bills are passed by Congress to establish laws and programs. References:

Answer 651

Correct Answer: D. It has activity at α4β2 subtype of nicotinic receptor and is effective for nicotine/tobacco cessation. Varenicline is a water-soluble partial agonist at the α4β2 subtype of the nicotinic receptor, competitively inhibiting nicotine. In addition, it has some affinity towards the serotonin receptor. The remaining descriptors are true of naltrexone, which is an opioid antagonist in the same family as naloxone and nalorphine. It likely works with the mesolimbic system and reward pathways and as an opioid antagonist, but the mechanism of action is not completely understood. Incorrect Answers: A. The mechanism of action in the mesolimbic reward pathways isn't completely understood. B. This is not thought to be the MOA. C. There is some affinity towards the serotonin receptor. References:

Answer 652

Correct Answer: D. Prednisone Steroids are a known cause of anxiety symptoms. Other drugs that can cause anxiety include amphetamines, appetite suppressants, albuterol, caffeine, cocaine, decongestants, and other stimulants. Medical conditions that can cause anxiety include adrenal tumors, chronic alcohol use disorder, hypoglycemia, hyperthyroidism, Cushing’s disease, arrhythmias, parathyroid disorders, and some types of seizures. Incorrect Answers: (A) Metformin. Metformin, utilized to treat diabetes, has not been associated with increased anxiety. (B) Glipizide. Glipizide, utilized to treat type 2 diabetes, has not been associated with increased anxiety. (C) Angiotensin-converting-enzyme (ACE) inhibitor. ACE inhibitors, utilized to treat hypertension and heart failure, have not been associated with increased anxiety. References:

Answer 653

Correct Answer: A. Autistic phase, symbiotic phase, separation-individuation Mahler’s theory is based on psychoanalytic observation of children ages 6 months to 3 years. Phase sequence is autistic phase, symbiotic phase, seperation-individualization phase. The autistic phase occurs during the first weeks of life and is characterized by a total detachment and self-absorption with goal of reaching equilibrium. Symbiotic stage is the next stage until 5 months old. The child recognizes mother's existance and knows this is where his or her needs are going to be met. This is how future relationships form. It is critical that mother provides infant needs. Separation-individuation has 3 phases: 1) Hatching, in which the infant shows increased interest in the outside world 2) Practicing (9-14 months), in which the infant develops the physical ability to separate from mother 3) Rapprochement (14-24 months), in which the infant explores the outside world but requires the mother to be present and to able to support the child emotionally in completing the task Incorrect Answers: B. C. and D. are all listed in incorrect order. Satges and rationale listed above. Mahler’s work has been expanded by other theorists to understand the basis of personality disorder. Disturbance of the rapprochement subphase is associated with a persistent longing for and a dread of fusion with the object that is thought to be secondary to aggression or withdrawal in the mother. Disruption of the rapprochement subphase may contribute to the development of borderline personality disorder. Narcissistic personality disorders may be due to inadequate soothing during the symbiotic phase and inadequate refueling during separation-individuation. Object constancy describes the child’s understanding that the mother is a separate individual and that he or she is also separate. Object constancy leads to the formation of internalization, which allows the child to have an internal representation of the mother, allowing healthy separation, exploration, and development of self-esteem. References:

Answer 654

Correct Answer: A. Paroxetine Paroxetine is FDA approved for treatment of PTSD Incorrect Answers: B. While commonly used for PTSD, this drug doesn't have an FDA indication for PTSD. C. While initial studies have shown promising results for PTSD, there's no FDA approval for this drug's use in PTSD. D. While used off label for PTSD, there's no FDA approval for this drug's use in PTSD. Vital Concept: Paroxetine and sertraline are the only two medications approved for the treatment of PTSD. Venlafaxine has shown promising results with its initial studies for the treatment of PTSD. Other SSRIs are commonly used but do not have an FDA indication. References:

Answer 655

Correct Answer: B. The duration of symptoms A diagnosis of schizophreniform disorder requires a symptomatic psychotic episode that lasts for at least 1 month but still <6 months. Schizophrenia requires continuous signs of the illness to be present for at least 6 consecutive months, including at least 1 month of Criterion A symptoms: delusions, hallucinations, disorganized speech, gross disorganization, catatonic behavior, or negative symptoms. Incorrect Answers: A. If major mood symptoms are present during active psychosis, then both schizophrenia and schizophreniform are ruled out; the correct diagnosis in this scenario would be either schizoaffective or a mood disorder with psychotic features. If mood symptoms are absent, this does not delineate between the two diagnoses. C. Symptoms for both diagnoses are the same: delusions, hallucinations, disorganized speech, disorganized behavior, catatonic behavior, and/or negative symptoms. Hallucinations can be present or absent in both diagnoses. D. The DSM criteria mandate that in order to make a diagnosis of schizophrenia or schizophreniform disorder, symptoms cannot be due to the effects of a substance. However, this does not help differentiate the two diagnoses. Vital Concept: Schizophreniform disorder includes psychosis that persists for 30 days or more, but not for 6 months. Schizophrenia is characterized by psychosis that persists for 6 months or more, with a period of one month with consistent symptoms present. References:

Answer 656

Correct Answer: C. Employees “go beyond the call of duty” to identify unsafe conditions and behaviors A strong safety culture is the result of shared beliefs, practices, and attitudes at an establishment, which result in shaping behavior. Everyone is responsible for safety, and employees in a strong safety culture often “go beyond the call of duty” to identify unsafe conditions or behaviors, intervening to correct them. In a strong safety culture, any employee will feel comfortable walking up to another, whatever their respective ranks or positions, and reminding the other person of a safety practice, which is a behavior that is encouraged because it is valued by the organization and rewarded within the culture. Incorrect Answers: A. The size of an organization is not a determinant of the safety culture. It results from priorities, actions, policies, procedures, attitudes, beliefs, and training, of both management and workers. B. Since establishment of a safety culture is dependent upon shared values and beliefs within an organization, all workers and managers are responsible for safety. D. In a strong safety culture, all employees take responsibility for safety, although top management support of a safety culture may result in hiring a safety director, provision of resources for investigation of incidents, and safety training. Vital Concepts: A strong safety culture is the result of shared beliefs, practices, and attitudes at an establishment, which result in shaping behavior. Everyone is responsible for safety, and employees in a strong safety culture often “go beyond the call of duty” to identify unsafe conditions or behaviors, intervening to correct them. References:

Answer 657

Correct Answer: B. Coercive power Coercive power is based on the ability to punish. It is rooted in fear of one person or agency by another. Ultimately, the primary power of government is coercion. People generally obey laws and regulations carefully when submitting Medicare claims, because failure to do so can result in punishment by fines or imprisonment. Incorrect Answers: A. Referent power is power that is derived from respect and admiration. C. Expert power is a power base derived from possession of expert knowledge or skill not possessed by another. D. The power of numbers is power derived from a group of people with similar goals. Vital Concepts: Coercive power is based on the ability to punish. It is rooted in fear of one person or agency by another. Ultimately, the primary power of government is coercion. References:

Answer 658

Correct Answer: C. Motivation for change evolves into action or plan In the preparation stage of change, the individual’s motivation for change begins to evolve into action or planning for action. Incorrect Answers: A. These are associated with the precontemplation stage. B. This is associated with the contemplation stage. D. This is associated with the action stage. References:

Answer 659

Correct Answer: C. Amphetamines This patient likely used an amphetamine such as methylphenidate or other stimulant. Symptoms of stimulant intoxication include nausea, vomiting, psychomotor agitation, weight loss, perspiration or chills, tachycardia, pupillary dilation, and elevated or low blood pressure. The DSM criteria for intoxication include: Must have recently used a stimulant (either prescribed or illicit). Problematic behavior that impacts the patient clinically or the development of psychological changes shortly after stimulant use must be present. May include: elation excessive vigilance heightened startle response anxiety agitation poor decision making flat affect At least two of the following symptoms must be present during or after the use of a stimulant: dilation of the pupils diaphoresis or chills hypertension or hypotension tachycardia or bradycardia weakness, bradypnea, angina, or dysrhythmia nausea or vomiting decreased body weight increase in psychomotor activity (psychomotor agitation) or decrease in psychomotor activity (psychomotor retardation) neurological changes (confusion, coma, dyskinesia, or dystonia) Symptoms cannot be attributed to a medical condition, another mental health disorder, or the use of another substance. Treatment is generally supportive in mild cases of intoxication such as this one. Amphetamines are routinely included on urine drug screens. A positive urine toxicology screening would confirm the diagnosis. Incorrect Answers: A. Common presenting signs of cannabis intoxication are conjunctival injection, dry mouth, and increased appetite. B. Common presenting signs of alcohol intoxication are slurred speech, unsteady gait, and incoordination. D. Common signs of opioid intoxication are drowsiness, slurred speech, respiratory depression, and miosis. Vital Concept: Symptoms of stimulant intoxication include nausea, vomiting, psychomotor agitation, weight loss, perspiration or chills, tachycardia, pupillary dilation, and elevated or low blood pressure. References:

Answer 660

Correct Answer: D. Loxapine Loxapine is a typical tetracyclic antipsychotic with antidepressant properties. Its active metabolite is amoxapine, which is a secondary amine tricyclic antidepressant. Incorrect Answers: A. Amoxapine is the active metabolite of loxapine. B. Atomoxetine is a norepinephrine reuptake inhibitor approved for the treatment of ADHD. C. Phenelzine is an MAOI. Patients with atypical depression respond particularly well to phenelzine. References:

Answer 661

Correct Answer: D. Inadequate disclosure of errors to patients and families Communication is an essential core competency for team collaborative care. This includes indication of willingness to work together, demonstrated by availability, being receptive, conveying openness, and being willing to discuss. Open and honest communication is necessary to manage emotionally difficult information with patients and families, including error disclosure or end-of-life information. In addition to openness, understanding and the ability to convey messages in a sensitive and respectful manner is necessary for effective healthcare. Incorrect Answers: A. Literature related to safe care focuses on overcoming hierarchical communication patterns by placing responsibility on all members of a team to speak up. All team members should learn to give and receive timely, sensitive, and instructive feedback with confidence in order to improve teamwork and patient care. B. All team members should speak up in a firm and respectful way if they have concerns about quality or safety of care. C. Use of informatics is one of the five core competencies in team-based collaborative care defined by the IOM. Vital Concepts: Communication is an essential core competency for team collaborative care. Open and honest communication is necessary to manage emotionally difficult information with patients and families, including error disclosure or end-of-life information. References:

Answer 662

Correct Answer: D. Hyperlipidemia occurs frequently. Hyperlipidemia occurs commonly and thought to be secondary to increased food intake and weight gain. Incorrect Answers: A. Diabetic ketoacidosis is rare but typically occurs in the first month of treatment; patients on olanzapine are at increased risk of type 2 diabetes due to weight gain and insulin resistance. B. EPS occurs less frequently than with risperidone or high-potency typical antipsychotics. C. NMS with olanzapine presents with fewer motor symptoms than those seen with typical antipsychotics. References:

Answer 663

Correct Answer: B. 14 year old, male, football player, complaining of headaches and trouble focusing in class. This is the best answer choice for several factors. Issues focusing in class could be from ADHD diagnosis and ADHD diagnosis are considered neurological and would be referred to neuropsychological testing. He also is a football player that has been experiencing headaches that could be caused by head trauma in contact sports. Neuropsychological assessments are used for comprehensive assessments of cognitive processes for a variety of reasons. Different domains can be accessed with neuropsychological testing: intelligence, attention, achievement, language, memory/learning, visual-spatial abilities, motor control, autism, behavioral, and executive functioning. Incorrect Answers: A. 29 year old, female, mood has been more depressed and irritable. Has recently started cutting her inner thighs is incorrect. Psychological testing could evaluate this client with mood related concerns and rule out personality disorders. C. 45 year old, female, that describes having long-term anxiety and depression is incorrect. Anxiety and depression based symptoms could be evaluated with psychological testing. D. 59 year old male that reports that he has been taking depression medication and is having erectile functioning is incorrect. Psychological testing can evaluate depression but this client may be experiencing a side effect from the antidepressant. Vital Concept: Neuropsychological testing can be utilized to access intelligence, attention, achievement, language, memory/learning, visual-spatial abilities, motor control, autism, behavioral, or executive functioning. References:

Answer 664

Correct Answer: A. Amphetamine and dextroamphetamine/increased blood pressure Amphetamine and dextroamphetamine has a warning of potential sudden death, myocardial infarction, and strokes in patients who are susceptible to cardiovascular issues. It can cause increased heart rate, dizziness and increased blood pressure. Incorrect Answers: B. Although tic development has been described in stimulant use, further study indicates no increase in tics in children taking stimulants. Stimulants are thought to unmask underlying tic disorders or temporarily to worsen long-standing tic disorders. Although atomoxetine is commonly used to address ADHD with comorbid tics, stimulants are more effective and typically worsen tics for a short interval, and then the tics go back to baseline. C. Atomoxetine has a black box warning regarding suicide ideations. D. No withdrawal syndrome is noted with discontinuation of modafinil. References:

Answer 665

Correct Answer: D. Storing data at multiple sites Security breaches are a threat to patient privacy when an individual's protected or confidential health information is made available to others without the individual’s consent or authorization. Stored data is vulnerable to compromise, even with protections like firewalls and encryptions. Some practices that threaten patient privacy include storing records in files that are not password protected; leaving computers unattended; storing data at multiple sites, such as when using an original and a backup server; and password sharing. Incorrect Answers: A. Use of a waver to permit the release of information is a safeguard that should be observed to protect patient privacy. B. In role-based access privacy systems, there is limited access to digital records based on the need to perform specific work functions. This can serve as a safeguard to unauthorized access. C. Monitoring of record utilization by a privacy officer is a safeguard to protect patient privacy. Vital Concepts: Security breaches are a threat to patient privacy when an individual's protected or confidential health information is made available to others without the individual’s consent or authorization. Stored data is vulnerable to compromise, even with protections like firewalls and encryptions. References:

Answer 666

Correct Answer: B. Cognitive Therapy Cognitive Therapy should be recommended for this patient as he is demonstrating through his thoughts that he has negative cognitive distortions, irrational beliefs, and faulty conceptions. Cognitive Therapy helps the patient view reality more clearly through an examination of their central distorted cognitions. Humanistic Therapy focuses on assisting the patient to self-actualization and self-directed growth. Behavioral Therapy focuses on changing maladaptive behaviors through the use of behavioral modification techniques. Existential Therapy is for reflection on life and self-confrontation are encouraged which is not appropriate for this teenage boy. Incorrect Answers: A. This concerns life and self-confrontation; it isn't appropriate for a patient of this age. C. This concerns helping the patient self-actualize and achieve self-directed growth; it won't address this boy's problems. D. This concerns changing maladaptive behaviors through behavioral modification therapy, but there aren't maladaptive behaviors to address, so it's not appropriate here. References:

Answer 667

Correct Answer: C. Placing electromagnetic coil on scalp and running electricity through it TMS uses an electromagnetic coil that creates a strong magnetic field for microseconds at a time. TMS is able to enter the brain very easily, as opposed to electrical currents that are slowed by tissues and bone. Once the magnetic field enters the neurons, it is converted into electrical currents, acting similar to ECT. Some studies have suggested that TMS is effective for treating depression and anxiety, and research is ongoing for further uses such as pain, schizophrenia, and hallucinations. Incorrect Answers: A, B, and D. These aren't how TMS is performed. References:

Answer 668

Correct Answer: A. Journaling Self-reflective journaling can help students in reflecting on their clinical experiences and provide an avenue for addressing the theory-practice gap (Landeen et al., 1995, Hancock, 1999). It also helps develop narrative skills; integrate theory, research, and practice; release feelings about clinical experiences; see different truths in a clinical situation; and increase observational skills (Callister, 1993). Incorrect Answers: B. Discussion can facilitate reflective learning when teachers allocate time for students to engage in discussion about a clinical situation, to identify and challenge assumptions, beliefs, values, and ideologies that underlie nursing practice. C. Clinical supervision can facilitate reflection when the reflection is externalized as a dialogue between two people, enabling discussion of what happened, why, and how it could have been handled differently. D. Montage is a collection of images, often created from pictures, words, and symbols cut from old magazines and newspapers. As nurses look for images to express their thoughts and feelings about clinical issues, they reflect more fully, so that the emergent montage is a comprehensive representation of the sense they are making of practice events. Vital Concepts: Self-reflective journaling can help students in reflecting on their clinical experiences and provide an avenue for addressing the theory-practice gap. References:

Answer 669

Correct Answer: D. Chi-square test A chi-square test is used to compare samples with non-measurable nominal/categorical variables (as opposed to ordinal or interval measurements). Color is an example of this type of variable. Incorrect Answers: A. A student’s t-test is used to compare the means of 2 independent and different sample populations. An example is comparing the average height of men in Texas and New York. B. A paired t-test is used to compare the means of 2 related (“paired”) sample populations. An example is measuring a disease metric in the same population before and after treatment. C. A z-test is similar to a t-test, but the z-test requires either a large sample or a known population variance. Vital Concepts: A chi-square test is used to compare samples with non-measurable nominal/categorical variables (as opposed to ordinal or interval measurements). Color is an example of this type of variable. References:

Answer 670

Correct Answer: D. Outpatient dialysis Medicare Part B is outpatient insurance, a voluntary program with monthly premiums. Participants must enroll during an annual general enrollment period. It will pay for the following medically necessary services: Durable medical equipment and necessary ambulance services Laboratory and other diagnostic tests Second opinions Outpatient visits Mental health care Outpatient kidney dialysis, doctor services for organ transplants Health prevention services (including flu shots, screening mammogram once every 12 months for women older than 40, screening colonoscopy and flexible sigmoidoscopy, etc.) It does not cover eyeglasses or routine eye examinations, except after cataract surgery that implants an intraocular lens. It does not cover dental care, dentures, hearing aids, over the counter drugs, most prescription drugs, or cosmetic surgery. What each Medicare part entails: Part A: Care at inpatient hospital, skilled nursing facility, hospice, or home health Part B: Outpatient care that is medically necessary and mental health care Part C (Medicare Advantage Plans): Includes part A and B with additional benefits Part D: Prescription drug coverage Incorrect Answers: A. Routine eye examinations. Medicare Part B does NOT cover eyeglasses or routine eye examinations, except after cataract surgery that implants an intraocular lens. Some Medicare Advantage plans (Medicare Part C) offer additional benefits like vision, hearing, or dental. The patient will have to contact the plan for additional information. B. Over the counter (OTC) medications. Medicare Part B does NOT cover OTC medications. Some Medicare Advantage plans (Medicare Part C) cover OTC medications. However, Medicare drug plans are not required to but some do as an additional benefit. C. Hearing aids. Medicare Part B does NOT cover hearing aids or exams. Some Medicare Advantage plans (Medicare Part C) offer additional benefits like vision, hearing, or dental. The patient will have to contact the plan for additional information. Vital Concept: Medicare Part B covers outpatient care that is medically necessary and mental health care. References:

Answer 671

Correct Answer: A. Excessive health-related behaviors In illness anxiety disorder, the criteria include performing excessive health-related behaviors or exhibiting maladaptive avoidance. Illness anxiety disorder differs from somatic symptom disorder (SSD) in that physical symptoms are less prominent, while anxiety or preoccupation with having or acquiring a serious medical condition is the core symptom. Criteria for illness anxiety disorder include: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months, but the illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Incorrect Answers: B. C. Somatic symptoms such as pain are either not present or minimal in illness anxiety disorder. D. Anxiety in illness anxiety disorder is attributed to the disorder itself, not to a comorbid generalized anxiety disorder. Vital Concept: Illness anxiety disorder is characterized by an obsession with having an illness or developing an illness. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). References:

Answer 672

Correct Answer: D. 2-sample t-test Systolic blood pressure measurement is a continuous variable, and this study addresses independent data from 2 different groups. The independent 2-sample t-test is the most appropriate test to analyze continuous data from 2 separate samples with normal distributions and can be used in this case to compare the mean blood pressure measurements of the 2 groups. Incorrect Answers: A. A chi-square test is normally used to analyze non-continuous data. B. Analysis of variance (ANOVA) is used to compare the means of 2 independent groups. In this case, it will yield the same p-value as the t-test, but it is more difficult to calculate. C. A paired t-test is used to compare the means of samples that are correlated. This cannot be used in this study since the 2 sample groups are independent. Vital Concepts: The independent 2-sample t-test is the most appropriate test to analyze continuous data from 2 separate samples with normal distributions and can be used in this case to compare the mean blood pressure measurements of the 2 groups. References:

Answer 673

Correct Answer: B. Dignity It is important for healthcare providers to protect human dignity; respect for human dignity is an important aspect of medical ethics. Patients’ differing cultural, ethical, personal, and religious beliefs may influence what they consider dignified treatment. Incorrect Answers: A. Confidentiality is the obligation to protect the patient’s identity, personal information, test results, and medical records. C. Autonomy refers to the right of mentally competent adults to make their own healthcare decisions. D. Paternalism refers to making decisions for a patient when it is your belief that it is the patient’s best interest, while you may be ignoring or discounting the beliefs and desires of the patient. Vital Concepts: Respect for human dignity is an important aspect of medical ethics. Patients’ differing cultural, ethical, personal, and religious beliefs may influence what they consider dignified treatment. References:

Answer 674

Correct Answer: D. Ergot fungus LSD is manufactured from lysergic acid, which is found in the ergot fungus that grows on rye and other grains. LSD is a hallucinogen derived from morning glory seeds, ergot alkaloids, and rye fungus. Incorrect Answers: A. Cocaine is derived from the leaves of the plant erythroxylon coca. B. Cannabis is derived from the plant cannabis sativa. C. Opium is extracted from poppy pods. References:

Answer 675

Correct Answer: B. Nurse practitioners can be reimbursed directly by Medicare Part B Medicare’s coverage of nurse practitioner services was broadened by the Balanced Budget Act of 1997. Nurse practitioners (NPs) can be reimbursed directly by Medicare Part B, Medicaid, Tricare, and some health insurance plans. Medicare will reimburse nurse practitioners at 85% of the usual and customary fee paid to a physician. The NP should file charges under his or her name and provider number for reimbursement. Previously, Medicare only directly paid NPs who practiced in certain rural/designated areas in the United States. Incorrect Answers: A, B. NPs can be reimbursed directly regardless of location D. NPs are reimbursed at 85% of the usual and customary fee paid to a physician Vital Concepts: Nurse practitioners (NPs) can be reimbursed directly by Medicare Part B, Medicaid, Tricare, and some health insurance plans. Medicare will reimburse nurse practitioners at 85% of the usual and customary fee paid to a physician. The NP should file charges under his or her name and provider number for reimbursement. References:

Answer 676

Correct Answer: A. An anxiety disorder Selective mutism is classified as an anxiety disorder since most children with selective mutism are anxious. The diagnostic criteria, however, are unchanged from DSM-IV: symptoms must persist for at least 1 month, must not be due to a lack of language skills, a general medical condition, or better explained by another mental health or communication disorder. It involves a lack of speech in one or multiple settings where speech is expected (e.g., school). This lack of communication affects school or work performance or social interactions. Incorrect Answers: B, C, and D. Selective mutism is not classified as a mood, psychotic, or intellectual disorder. Vital Concept: Selective mutism is considered an anxiety disorder. References:

Answer 677

Correct Answer: D. Functional neurological symptom disorder The underlying characteristic of functional neurological symptom disorder (FNSD, previously conversion disorder) is a lack of intent. FNSD is more common in young females, those with low SES, in rural residential areas, and those not well-educated. They experience real neurological symptoms that are unexplained by a neurological or medical cause. These symptoms can result in problems functioning and considerable distress. Symptoms include weakness or paralysis, loss of balance, seizures, episodes of unresponsiveness, tremors and other abnormal movements, numbness or loss of sensation, speech problems, blindness or double vision, or hearing loss. Although the cause is not known, risk factors include a comorbid or prior neurological disorder, recent significant stressors, emotional or physical trauma, comorbid mood or anxiety disorders, dissociative disorder or cluster B personality disorder, and a family history of FNSD. Similarly, those with factitious disorder portray their symptoms intentionally in order to obtain sympathy and receive attention as a patient. The primary difference is that clients with FNSD honestly believe that their symptoms are real and do not deceive for secondary gain. Incorrect Answers: A. If the patient was malingering, there would be a clear secondary gain, such as worker's compensation or legal reparations. This patient is indifferent about receiving care or a diagnosis. B. The patient shows no other signs of ischemia, and her symptoms are not transient. C. Brachial plexus injuries are almost always caused by trauma, and an EMG would be abnormal. Vital Concept: Functional neurological symptom disorder, previously conversion disorder, is characterized by neurological symptoms that cannot be explained by a neurological disease or other medical condition. Symptoms are real and may cause distress and disturbances in function. References:

Answer 678

Correct Answer: C. ICD-10-CM codes will increase by tenfold the amount of data that describes clinical conditions The HIPAA laws for the protection of individually identifiable health information and provisions for payments of care also mandated standard rules for the electronic exchange of health care data, naming specific code sets for all Medicare-related transactions, including the International Classification of Diseases (ICD) Version 10 and the Clinical Modification component (ICD-10-CM). These codes provide more detailed information in electronic transactions and the deadline for compliance with ICD 10 was October 2015. The ICD-10 coding system significantly increases the amount of data by tenfold to accurately describe clinical conditions, but conversions are expensive and the ICD-10-CM conversion is expected to pose hardships to providers and institutions. Federal policy mandates the implementation of this coding standard. Incorrect Answers: A. ICD-10-CM is more detailed and doesn't simplify the coding process B. ICD-10CM doesn't have bearing on medical practices D. ICD-10CM implementation is mandated by federal policy Vital Concepts: The ICD-10 coding system significantly increases the amount of data by tenfold to accurately describe clinical conditions, but conversions are expensive and the ICD-10-CM conversion is expected to pose hardships to providers and institutions. Federal policy mandates the implementation of this coding standard. References:

Answer 679

Correct Answer: C. Honor the patient’s wishes. The minimum age to enlist in the army is 17 and minors can become emancipated by joining the military or by getting married, although laws vary between states. Minors who are considered emancipated are authorized to consent to medical care. This includes the refusal of care. The healthcare provider should inform the patient of the risks of refusing care and explain that evidence will be collected for the police if the patient consents to care. A healthcare provider cannot perform a medical procedure in the direction of the police without a patient’s consent. Incorrect Answers: A. If the patient’s life is not in imminent danger and the patient is able to refuse care, the wishes of the patient must be followed. While evidence can be collected for the police if the patient is cared for, care can't be provided for the purposes of complying with the police request. B While evidence can be collected for the police if the patient is cared for, care can't be provided for the purposes of complying with the police request. A healthcare provider can't perform a medical procedure at the police's direction without a patient's consent. D. While evidence can be collected for the police if the patient is cared for, care can't be provided for the purposes of complying with the police request. A healthcare provider can't perform a medical procedure at the police's direction without a patient's consent. Vital Concepts: A healthcare provider cannot perform a medical procedure in the direction of the police without a patient’s consent. References:

Answer 680

Correct Answer: D. Kava-kava Kava-kava is made from the root of the kava (piper methysticum) plant. It is utilized for its sedative and anesthetic qualities and is commonly ingested as a beverage; several commercial brands are available. Like benzodiazepines and alcohol, kava acts on GABA receptors. Long-term use has been linked with liver toxicity, and it should not be taken with alcohol, benzodiazepines, or barbiturates due to potentiated CNS depression. Incorrect Answers: A. Ginkgo biloba has several perceived effects on blood flow and cognitive enhancement, although studies in humans have been equivocal. Its use should be avoided with antiplatelet and anticoagulant medications. B. Echinacea purpurea is thought to have anti-inflammatory and immune-enhancing properties. Echinacea may cause a flu-like syndrome but has no known drug interactions. It is generally recommended to avoid echinacea in immune-related conditions such as post-transplant immune suppression as well as autoimmune and immune deficiency conditions (e.g. AIDS, cancer). C. Allium sativum is garlic, which is known to have mild cholesterol-lowering characteristics. Garlic has reported antiplatelet effects and should be used cautiously with antiplatelet and anti-clotting medications. References:

Answer 681

Correct Answer: C. Disinhibited social engagement disorder This child likely has disinhibited social engagement disorder. The criteria state that the patient demonstrates two or more of the following: decreased avoidance or skepticism of strangers a lack of concern when leaving and going with a stranger reduced need to touch base or remain close to their caregiver when venturing out in public new places extremely friendly behavior with minimal social boundaries They are not reported to have a history of impulsivity, which might otherwise explain socially disinhibited behaviors. The child has experienced neglect and multiple transitions in primary caregiver, which is presumed to be responsible for the behavioral concerns, and they have a developmental age of at least 9 months. Incorrect Answers: A. Intrusive symptoms associated with trauma, persistent avoidance of stimuli, negative alterations in cognitions and mood associated with trauma, and marked alterations in arousal and reactivity associated with trauma are not described. The symptoms of PTSD are not described here. B. D. RAD, inhibited and disinhibited types, are no longer diagnoses in the DSM–V-TR. Children with reactive attachment disorder show a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers. Vital Concept: The behaviors and reactions described in this scenario meet the diagnostic criteria for disinhibited social engagement disorder according to the DSM-V-TR. References:

Answer 682

Correct Answer: B. Use of these agents minimizes unpleasant side effects and may improve therapeutic alliance. Development of unpleasant side effects can contribute to nonadherence and an unstable therapeutic alliance. Attention to minimizing side effects is key. Incorrect Answers: A. Prophylactic use of antiparkinsonian agents is warranted primarily with first-generation antipsychotics and high-dose risperidone. C. Use of these agents is warranted in patients taking medications with a high incidence of producing parkinsonian symptoms and in patients with a history of these side effects. D. Lowering the dose of the antipsychotic to the EPS threshold (dose with minimal rigidity on exam) is the first step in reducing these symptoms. Parkinsonian symptoms include rigidity, slow movements, lack of movement, and tremor. If this occurs, use antiparkinsonian agents or switch to second-generation antipsychotic with fewer side effects. References:

Answer 683

Correct Answer: B. Cupping Traditional Chinese medicine is based, among other things, on the belief that an imbalance or blockage in chi (qi) or life energy is the cause of disease. Acupuncture and cupping are two traditional practices that are used to correct energy imbalance. Cupping refers to the method of creating a vacuum on the patient's skin to dispel stagnation (stagnant blood and lymph), thereby improving qi flow, in order to treat respiratory diseases. This may be misinterpreted as abuse. A nurse practitioner should be culturally aware of this practice and should inquire of the patient how the lesions occurred. Incorrect Answers: A. Acupuncture wouldn't result in these marks C, D. While these could be causes of the bruising, they'd likely look different from the characteristic roundness of cupping marks. Vital Concepts: Traditional Chinese medicine is based, among other things, on the belief that an imbalance or blockage in chi (qi) or life energy is the cause of disease. References:

Answer 684

Correct Answer: C. Restrictive covenant Restrictive covenants in employment contracts often include non-compete clauses, which are clauses that restrict an employee from practicing within a set number of miles from an employer’s business for a set period of time after the employee leaves the business. They are legal and enforceable in many states as long as they are reasonable. When determining whether or not a restrictive covenant is reasonable, a judge will balance the needs of the employer against harm to the employee and will also consider any potential injury to the public if the restrictive covenant is enforced. A bonus formula specifies conditions under which an employer rewards an NP for superior performance. Termination clauses often specify that the employer may end the agreement without cause with 30 days notice. Incorrect Answers: A. Specifies conditions under which an NP is rewarded for superior performance. B. Governs ending employment, and generally specifies that the employer can end the agreement without cause with 30 days' notice. D. This doesn't exist. Vital Concepts: Restrictive covenants in employment contracts often include non-compete clauses, which are clauses that restrict an employee from practicing within a set number of miles from an employer’s business for a set period of time after the employee leaves the business. They are legal and enforceable in many states as long as they are reasonable. References:

Answer 685

Correct Answer: B. 3 days This man has classic symptoms of delirium tremens (DTs) and should be transferred to a setting where close monitoring is available such as the intensive care unit. The hallmark features of delirium tremens include confusion, altered vital signs with tachycardia, hypertension, and fever. The peak timing after the last drink for the occurrence of DTs is 2 to 3 days. By contrast, mild alcohol withdrawal occurs a few hours after the last drink and is characterized by tremor, and alcohol-withdrawal-related seizures may occur about 1 to 2 days after the last drink. Incorrect Answers: A. B. If the patient were 1-2 days out from their last hospital admittance and has chronic alcohol use disorder, they'd be in mild alcohol withdrawal. This would be characterized by tremor, and there would be a possibility of alcohol-withdrawal-related seizures. D. If the patient were a week out from their last hospital admittance and has chronic alcohol use disorder, they wouldn't be in the range for either mild alcohol withdrawal or delirium tremens (DTs). References:

Answer 686

Correct Answer: B. I and III Women are more affected by alcohol than men for a number of reasons. Women have smaller body sizes, lower blood volume and higher body fat concentrations. With less blood volume there is less water for alcohol to dilute in causing a higher blood alcohol content. Body fat has less water and therefore less water for the alcohol to dilute in. Women metabolize alcohol slower because they have less alcohol dehydrogenase and decreased gastric/esophageal oxidation of alcohol. Incorrect Answers: Answer II. Higher fat content in women's bodies means that alcohol gets stored instead of being broken down. Higher fat content in women's bodies is one reason why alcohol affects women more than men but the mechanism of why is incorrect in this answer. Alcohol is not stored in fat. If it were stored in fat it would result in a longer dose effect but likely a lower constant level of alcohol in the bloodstream. Higher fat content in women makes them more affected by alcohol because body fat has less water and therefore less water for the alcohol to dilute in causing a higher blood alcohol content. Answer IV. Hormonal fluctuations during the menstrual cycle lead to a decreased rate of liver metabolism of alcohol at certain times in the cycle, due to cytokine imbalance. While it is theorized that hormonal fluctuations during menstruation could possibly contribute to women's rate of metabolizing alcohol, the data are still unclear, and the mechanisms not fully elucidated. References:

Answer 687

Correct Answer: C. Abstraction When assessing abstraction, the patient need not reply with a definitive interpretation, because the assessment has more to do with the patient’s approach then with the “correctness” of his or her answer. Educational level is a strong determinant of a person’s ability abstract. Concrete answers are more commonly given by individuals with less than a high school education, schizophrenia (whose interpretations are also often bizarre), and dementia. The ability to abstract can also be assessed more subtly by observing the patient’s response to and use of figures of speech, analogies and metaphors. Incorrect Answers: A. When assessing memory the clinician should ask the patient to remember four unrelated items, such as tulip, bottle, courage, and olive. The patient should immediately repeat all four words to ensure that he or she has properly heard, understood and registered them. After about 3 minutes of conversation or examination, the clinician should ask the patient to repeat the words. If the patient cannot recall the words, the clinician should give the patient clues to determine whether the words were not encoded into memory or were encoded but are difficult to retrieve. Patients who did not learn the words are not aided by prompting, whereas patients who learned the words, but have difficulty assessing them usually will recall with prompting. B. The capacity to direct and maintain one’s attention while screening out extraneous and irrelevant stimuli is a fundamental yet highly complex cognitive function. Inattention and distractibility are common and clinically significant neuropsychiatric symptoms. Standard tests for attention include digit span, spelling a five-letter word backward, reciting the months of the year backward, or subtracting serial 7s (or 3s for those who cannot do 7s). D. Language disturbances, specifically aphasias, refer to defects in word choice, comprehension, and syntax. The clinician should consider whether the patient’s language is fluent and whether the words the patient chooses form a unified whole and make sense. Next, comprehension must be tested, which is particularly important when a patient is on a ventilator and normal speech is not possible. The clinician can ask yes-no questions such as “Can an elephant ride a tricycle?” to establish comprehension and avoid being fooled by an interactive but uncomprehending patient. References:

Answer 688

Correct Answer: C. 1.2–3.8 A 95% confidence interval refers to the range in which the mean is expected to fall 95% of the time if the experiment is repeated multiple times. The p-value (alpha) describes the probability that a positive result is due to chance. A statistically significant study with a 95% confidence interval cannot include the null value, which would indicate that there is no difference in the probability of an outcome between 2 groups. In the case of relative risk, the null value refers to a relative risk of 1.0. The only choice given that does not include the null value is 1.2–3.8. Incorrect Answers: A, B, and D. All include the null value. Vital Concepts: A 95% confidence interval refers to the range in which the mean is expected to fall 95% of the time if the experiment is repeated multiple times. The p-value (alpha) describes the probability that a positive result is due to chance. A statistically significant study with a 95% confidence interval cannot include the null value, which would indicate that there is no difference in the probability of an outcome between 2 groups. References:

Answer 689

Correct Answer: D. Early discontinuation Early discontinuation is one of a number of common reasons for inadequate response to antidepressants. Other reasons include inadequate dosing, patient non-compliance, misdiagnosis, and substance abuse (especially of alcohol, which causes failure of antidepressant response). Incorrect Answers: A. This would lead to overdose, not inadequate response. B. The effectiveness of antidepressants rely on accumulated substances over the long term, so occasionally taking antidepressants with food doesn't affect their overall effectiveness. C. Moderate to heavy alcohol intake can cause failure of antidepressant response, but light alcohol intake should not affect antidepressant response. References:

Answer 690

Correct Answer: C. In some states, when advance directives fail, clinicians may administer pharmacologic treatments involuntarily. Laws vary from state to state. A patient who is stabilized and competent to make decisions can sign advance directives. It is used at a future time when a patient becomes incapacitated and is unable to make an appropriate decision. Traditionally have been utilized in end of life care but are also utilized in mental health settings. An advance directive can be used even when there is not an emergent risk of danger. Family and friend support are key in encouraging patients to take medication. Incorrect Answers: A. Laws on this issue VARY from state to state regarding judicial hearings for permission to treat an incapacitated patient, therefore it is not always required. B. Advance directives CAN be used in patients with schizophrenia if they're stabilized and competent to make decisions when the advance directive is signed. D. Family SHOULD BE engaged to encourage medication compliance. Friends should be engaged, as well. Vital Concept: In some states, when advance directives fail, clinicians may administer pharmacologic treatments involuntarily. References:

Answer 691

Correct Answer: C. Run chart A run chart is a graph that provides a graphic depiction of the progress of a quality improvement activity over time. Changes in the process and their relationship to quality measures can be easily seen when using a run chart. It can be used to publicly recognize the improvements that result from implementation of a quality improvement measure. The figure below is a run chart that shows a decreasing trend in accident frequency over time. Incorrect Answers: A. and B. Check sheets and spread sheets do not provide graphic depictions of progress. D. Likert scales are psychometric scales that are used in questionnaires and surveys. Vital Concepts: A run chart is a graph that provides a graphic depiction of the progress of a quality improvement activity over time. Changes in the process and their relationship to quality measures can be easily seen when using a run chart. It can be used to publicly recognize the improvements that result from implementation of a quality improvement measure. References:

Answer 692

Correct Answer: C. Perception of sensory process in the absence of external source The diagnostic criteria for schizophrenia include: To confirm the diagnosis, at least two of the following symptoms must be present for a substantial period during a month or more timeframe: · speaking incoherently without logical organization* · a misconception, belief, or thought that is firmly held despite not being grounded in reality* · illusions or perceived experiences that do not actually exist (e.g., sounds, voices, smells, visions, feelings, etc.)* · actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) · decreased display of emotion or a lack of motivation *at least one of the two symptoms displayed must be among the first three symptoms described above · In a patient with a prior diagnosis of ASD, significant misconceptions or illusions (see second and third symptoms listed above) must persist for more than a month · An incidence of this disorder should persist for more than 6 months, with symptoms present for at least one month of that period unless adequately treated · The episode must significantly affect the patient’s ability to function professionally or socially and/or care for themselves. · The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition · There have been no (or minimal) concurrent periods of depressive or manic symptoms that would satisfy the requirements for schizoaffective DO, major depressive disorder, or bipolar disorder with psychotic features · Episodes can be categorized after one year as a first episode, multiple (if not the first), or continuous. · Episodes can be categorized after one year as acute (active symptoms satisfying diagnostic standards) or in partial/full remission (following an acute episode with fewer symptoms that no longer satisfy diagnostic standards or no symptoms) Incorrect Answers: A. Mood swings are not part of the DSM criteria for schizophrenia. B. Tremors aren't a DSM criteria for schizophrenia D. While incoherent speech is a DSM criteria for schizophrenia, aphasia (loss of speech) isn't Vital Concept: The diagnostic criteria for schizophrenia include five broad descriptions, including incoherent speech, hallucinations, delusions, disorganized behavior, and negative symptoms. References:

Answer 693

Correct Answer: D. Adverse reaction to malaria medication Mefloquine is used for malaria prophylaxis and treatment. For those traveling to malaria-afflicted areas, prophylaxis is usually begun 2 weeks before departure. There is now a black box warning on this medication, as it may cause anxiety, paranoia, depression, or hallucinations. These psychiatric symptoms may persist long after the patient stops taking the drug. Mefloquine is recommended as a second-line treatment for chloroquine-sensitive or resistant malaria. Incorrect Answers: A. New-onset schizophrenia. Schizophrenia typically is preceded by a prodromal phase of changes in subjective and behavioral symptoms prior to clinical psychotic symptoms. B. Stress reaction to upcoming travel. It is rare to experience auditory hallucinations in response to a stressor. Mefloquine induced psychosis is the best answer. C. Malingering. Malingering is when someone makes up symptoms for secondary gain. There is no indication in this prompt of secondary gain from the psychotic symptoms the patient is experiencing. References:

Answer 694

Correct Answer: B. Clonazepam: Long-acting Clonazepam is a long-acting benzodiazepine. The use of benzodiazapines in the adolescent population is generally limited. However in certain situations like panic disorder, acute psychosis, and detoxification from alcohol, benzodiazepines can be extremely valuable. Severe obsessive-compulsive disorder also responds to low-dose clonazepam, especially with comorbid panic disorder. Relative contraindications are intellectual disability, autism (due to cognitive effects and propensity for disinhibition), and personal or family history of substance abuse. Incorrect Answers: A. Alprazolam is a short-acting benzodiazepine. C and D. Temazepam and lorazepam are intermediate-acting benzodiazepines. Vital Concept: Benzodiazepines bind to receptors and enhance the effects of GABA in the brain, creating a sedative effect. Alprazolam is short-acting, temazepam and lorazepam are intermediate, and clonazepam is long-acting. References:

Answer 695

Correct Answer: B. Repudiation of significant others This patient is demonstrating repudiation of significant others by rejecting or antagonizing family, friends, or professional sources of support. Incorrect Answers: A. Truculence/annoyance is displayed by an embittered patient who lacks any openly angry feelings and who feels mistreated, victimized, and duped by forces or people. C. In denial/avoidance, the patient speaks or acts as if threatening aspects of illness are minimal, almost showing a jolly interpretation of related events or a serious disinclination to examine potential problems. D. In painful isolation/abandonment, the patient is lonely and feels ignored by and alienated from significant others. References:

Answer 696

Correct Answer: B. NPI The National Provider Identifier Number, or NPI, is a unique identification number for covered health care providers and health plans. It is a 10-digit numeric identifier and covered health care providers must use the NPI in administrative and financial transactions adopted under HIPAA. Incorrect Answers: A. The ICD-10 refers to the International Classification of Diseases, 10th Edition, a code used in the United States to indicate a diagnosis, including family history of disorders. Each disease is assigned an ICD-10 code. C. CPT refers to “current procedural terminology,” a list of descriptive identifying codes used to identify procedures and other medical services. The CPT is owned by the American Medical Association. D. The ACA is the Affordable Care Act of 2010. It has been in effect since 2014 and it is a comprehensive bill to reform health care insurance law in the United States, to provide “comprehensive reforms that improve access to care for our most vulnerable.” Vital Concept: The National Provider Identifier Number, or NPI, is a unique identification number for covered health care providers and health plans. It is a 10-digit numeric identifier and covered health care providers must use the NPI in administrative and financial transactions adopted under HIPAA. References:

Answer 697

Correct Answer: D. Erythromycin Erythromycin is a common inhibitor. A mnemonic to remember common inhibitors is shown in the image below. Incorrect Answers: A. B. C. All of those options are inducers. References:

Answer 698

Correct Answer: D. Memantine Memantine is a low-affinity voltage-dependent uncompetitive antagonist at glutamatergic NMDA receptors. The interaction of memantine with NMDA receptors plays a major role in the symptomatic improvement that the drug produces in Alzheimer's disease. Incorrect Answers: A. Galantamine is a potent allosteric potentiating ligand of human nicotinic acetylcholine receptors. B. Rivastigmine is an acetylcholinesterase inhibitor. It inhibits both butyrylcholinesterase and acetylcholinesterase (unlike donepezil, which selectively inhibits acetylcholinesterase). C. L-DOPA is the precursor to the neurotransmitters dopamine, norepinephrine, and epinephrine (collectively known as catecholamines). References:

Answer 699

Correct Answer: C. Process of offering support and acknowledgment of patient's thoughts, feelings, and behaviors Validation is a process of offering support and acknowledgment of a patient’s thoughts, feelings, and behaviors. Incorrect Answers: A. Validation has nothing to do with verifying the truth of a patient’s thoughts, feelings, and behaviors. B. Validation has nothing to do with accepting the truth of a patient’s thoughts, feelings, and behaviors. D. Validation has nothing to do with critiquing a patient’s statements. References:

Answer 700

Correct Answer: C. Folate deficiency Folate deficiency results in macrocytic anemia. Alcoholics are at increased risk of folate deficiency because of poor dietary habits and intestinal malabsorption. Folate is required for maturation of cells and folate deficiency results in defective erythropoiesis. Incorrect Answers: A. Rheumatoid arthritis. Rheumatoid arthritis can be associated with several types of anemia. However, with the provided history of a chronic alcohol use disorder, folate deficiency is the best answer. B. Chronic autoimmune disorders. Chronic autoimmune disorders can be associated with several types of anemia. However, with the provided history of a chronic alcohol use disorder, folate deficiency is the best answer. D. Systemic lupus erythematosus. Systemic lupus erythematosus can be associated with several types of anemia. However, with the provided history of a chronic alcohol use disorder, folate deficiency is the best answer. Vital Concepts: Folate deficiency results in macrocytic anemia. Alcoholics are at increased risk of folate deficiency because of poor dietary habits and intestinal malabsorption. Folate is required for maturation of cells and folate deficiency results in defective erythropoiesis. References:

Answer 701

Correct Answer: D. Cessation of drug Antipsychotic-induced parkinsonism is treated by cessation of the offending drug. If the patient must continue treatment with antipsychotics, they may be switched to an atypical antipsychotic. ANTIPSYCHOTIC MEDICATIONS Incorrect Answers: A. Levodopa is utilized to treat parkinsonism, but is ineffective in the treatment of antipsychotic-induced parkinsonism. B. Selegiline is utilized to treat parkinsonism, but is ineffective in the treatment of antipsychotic-induced parkinsonism. C. Amantadine can help control symptoms of antipsychotic-induced parkinsonism short term. In many patients, it becomes ineffective after 12-24 months of use. Therefore, for long-term treatment of antipsychotic-induced parkinsonism, the best answer choice is cessation of the offending drug. References:

Answer 702

Correct Answer: D. Nothing (failure to speak is due to lack of comfort with English) This child's lack of comfort with the English language precludes the diagnosis of selective mutism. Selective mutism is now classified as an anxiety disorder (since most children with selective mutism are anxious). In selective mutism, there is a consistent failure to speak for >1 month in a certain situation. It cannot be due to lack of knowledge of the specific language. Incorrect Answers: A. Selective mutism. Selective mutism cannot be due to lack of knowledge of the specific language. B. Pervasive developmental disorder. Since the child speaks Spanish, it doesn't seem that there's a developmental disorder affecting speech C. Autism. There's only a speech-related symptom, and nothing else — autism isn't suspected. Vital Concept: In selective mutism, there is a consistent failure to speak for >1 month in a certain situation and it cannot be due to lack of knowledge of the specific language. References:

Answer 703

Correct Answer: B. Schizophrenia incidence has been stable over time, countries, and cultures. The incidence of schizophrenia has been stable across time, nations, and cultures. Incorrect Answers: A. The mean peak ages of onset are 20–28 years for males and 26–32 years for females. Females have a trimodal age of onset with peaks at 22.4, 36.6, and 61.5 years. Males have a bimodal age of onset with peaks at 21.4 years and 39.2 years. C. There is controversy about whether early and late-onset schizophrenia represent similar or different syndromes/disorders. D. About 20-40% of patients experience their first psychotic symptoms before age 20. References:

Answer 704

Correct Answer: B. Phenelzine Phenelzine, a monoamine oxidase inhibitor (MAOI), has been tested extensively in placebo-controlled studies for social phobia and has the longest record of use for social anxiety disorder (SAD). Multiple trials found that phenelzine is an efficacious treatment for SAD. SSRIs or SNRIs are generally used as first-line medications for generalized SAD due to the side effect profile of MAOIs. MAOIs are often reserved for SAD that is refractory to other medications. Incorrect Answers: A. Second generation antipsychotics (e.g. risperidone) have a large side effect profile and have not been shown to be efficacious for social anxiety disorder. C. Second generation antipsychotics (e.g. quetiapine) have a large side effect profile and have not been shown to be efficacious for social anxiety disorder. D. Valproic acid is a mood stabilizer and is not utilized to treat social anxiety disorder. References:

Answer 705

Correct Answer: A. Increases availability of dopamine and norepinephrine in the synaptic cleft in the brain Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder that manifests in early childhood and is characterized by inattention, hyperactivity, and impulsivity that is developmentally abnormal. Boys are more commonly diagnosed than girls. The inattentive, hyperactive, and impulsive behaviors must cause significant impairment in two separate environments to merit a diagnosis. Stimulant medications are the first-line psychopharmacological management for children with ADHD. Eight of 10 children started on a stimulant medication will demonstrate an improvement in focus and a decrease in impulsive behavior. Methylphenidate is a stimulant and enhances central nervous system catecholamine action by increasing the availability of dopamine and norepinephrine in the synaptic cleft in the brain. Stimulants are available in short-acting and long-acting preparations. The onset of action occurs in about 30 minutes. If stimulant medications are stopped, children will not experience withdrawal. Treating children with ADHD with stimulants actually decreases the risk of drug abuse later in life. Incorrect Answers: B. Atomoxetine can be used to treat ADHD but is not a first-line drug. It selectively inhibits presynaptic norepinephrine reuptake in the central nervous system. C. Tricyclic antidepressants (TCAs) can be used to treat ADHD but are not a first-line option. They work by inhibiting 5-HT and norepinephrine reuptake. D. Guanfacine is a non-stimulant alpha-2 agonist that can be used to treat ADHD, but it is not a first-line drug. Vital Concept: ADHD treatment includes stimulant medications (e.g. methylphenidate) or non-stimulant medications (guanfacine, clonidine, TCAs, or atomoxetine) and cognitive behavioral therapy. References:

Answer 706

Correct Answer: C. Naloxone blocks effects of buprenorphine when injected. When naloxone is injected, it is active and will induce withdrawal symptoms. Incorrect Answers: A. and D. Buprenorphine has a ceiling effect on respiratory depression effects, but higher doses do produce more euphoria. It has been associated with a few deaths in Europe when used in conjunction with benzodiazepines. B. When ingested sublingually, naloxone is not readily available and is not active. References:

Answer 707

Correct Answer: D. Communication analysis Communication analysis allows the therapist to identify maladaptive communication patterns to help the patient communicate effectively. Incorrect Answers: A. Exploratory techniques are used to collect information about the patient’s problems and symptoms. B. Encouragement of affect involves helping the patient recognize, accept, and express painful feelings and to use these feelings positively in interpersonal relationships. C. Clarification is used to restructure the patient’s communication. References:

Answer 708

Correct Answer: A. Give a blood transfusion because the patient is a minor. Patient autonomy is the right of a competent and informed patient to determine his or her own healthcare decisions, even when doing so may be harmful. Children under 18 years of age are minors and deemed legally incompetent. Parents of a minor cannot withhold treatment to save life or limb from their children; if there is an immediate emergency, the patient should be treated appropriately. If the danger is not immediate but still critical, a court intervention or referral to an ethics committee may be indicated. Incorrect Answers: B. A court order isn't needed to perform a life-saving treatment and could potentially prolong life saving measures. C. Although the caregivers should be informed of the situation, given that it is a lifesaving treatment, they can't withhold treatment to save life or limb of children. D. In a life-threatening situation, care should be administered. Vital Concept: The NP is tasked with the protection of the patient and the NP’s decision should be based on the best interest of the patient. If treatment is required urgently, the NP can proceed without consent from the caregiver. References:

Answer 709

Correct Answer: B. Bruxism Bruxism, associated with grinding teeth, is an adverse effect of amphetamines like MDMA (ecstasy, a popular recreational drug), methamphetamine, dextroamphetamine, and others. After ingestion, there is an initial phase of disorientation, followed by a “rush.” Common features of amphetamine ingestion are pallor, tremors, muscle twitching, bruxism, perspiration, chills, vomiting, decreased appetite, insomnia, euphoria, agitation, elation, tachycardia, hypertension, and anxiety. Resolution occurs by 24-48 hours after ingestion. Incorrect Answers: A. Diarrhea is mainly associated with opioid withdrawal. C. Dilated pupils are a feature of MDMA intoxication as well as opioid withdrawal and cocaine intoxication. D. Lacrimation and a runny nose are symptoms of opioid withdrawal. Vital Concepts: Bruxism, associated with grinding teeth, is an adverse effect of amphetamines like MDMA (ecstasy, a popular recreational drug), methamphetamine, dextroamphetamine, and others. References:

Answer 710

Correct Answer: C. Identified neurological condition accounting for intellectual disability In the DSM-5-TR, intellectual disability is defined as: Typically includes deficits in intellect, social skills, and the ability to perform everyday tasks. Deficits in intellectual functioning must be obvious, including logical thinking, preparation, finding solutions, comprehension, discernment, and acquiring new knowledge through school or life lessons. Clinical assessment and intelligence testing confirm the lack of these skills. Deficits in adaptive functioning must hinder the individual's ability to perform the tasks required to have independence and life responsibilities. Without external support, these deficits affect the individual's ability to complete at least one activity of daily living, such as living independently, participating in social situations, and verbal communication with others in various settings. The disorder must develop during normal childhood development. With "profound" severity, individuals have very limited ability to communicate (primarily nonverbal, nonsymbolic communication), minimal ability to obtain concrete academic or conceptual skills, and require daily high-intensity supervision in all areas of life. Incorrect Answers: A. Intellectual disability should not be diagnosed in a patient with a traumatic brain injury. B. Most individuals with intellectual disability that is profound have impairments in their socialization and communication skills D. Most individuals with intellectual disability, profound have considerable sensorimotor impairment. Vital Concept: Most people with intellectual disability, profound have an identified neurological condition that accounts for their intellectual disability. References:

Answer 711

Correct Answer: C. Collaborating There are five styles of dealing with conflict that are identified in the Thomas-Killman Instrument, a tool that has been developed to further understanding of conflict resolution. Collaborating is true problem-solving by finding a mutual solution when different interests are too important to be compromised. Incorrect Answers: A. Accommodating, or smoothing things over, may be useful if one issue is clearly more important and one party is willing to yield to preserve harmony. B. Compromising is a bargaining process that results in concessions that may lead to a less-than-ideal solution. It can be useful as a quick fix for issues of mild to moderate importance. D. Avoiding conflict can create a delay to allow parties to gather information or cool down, but experts recommend this tactic only when the issue is of small importance or when a confrontation is potentially damaging. Vital Concepts: Thomas-Killman Instrument has 5 types of understanding of conflict resolution. 1. Competing 2. Collaborating 3. Compromising 4. Avoiding 5. Accommodating Collaborating is true problem-solving by finding a mutual solution when different interests are too important to be compromised. References:

Answer 712

Correct Answer: A. Narrative By focusing on their effects on people's lives rather than on problems as inside or part of people, distance is created. This externalization or objectification of a problem makes it easier to investigate and evaluate the problem's influences. Incorrect Answers: B. In behavioral therapy, a functional behavioral analysis is completed. C. In psychoeducational therapy, skills such as communication, problem-solving, and coping strategies are explored. D. In systemic therapy, circular questions are used. References:

Answer 713

Correct Answer: C. Phenytoin Phenytoin is an inducer. A mnemonic to remember common inducers is shown in the image below. Incorrect Answers: A. B. D. Those medications are all INHIBITORS. References:

Answer 714

Correct Answer: A. Initiative vs. guilt Initiative vs. guilt is the stage in which the Oedipus complex presents. The Oedipus complex is when the child competes with the same-sex parent for the other parent’s attention. Jealousy and rivalry are the typical themes present during the Oedipus complex and the developmental stage of initiative vs. guilt. Incorrect Answers: B. This stage is from birth to a year old; the girl is too old for this. C. This stage is from birth to a two-year-old; the girl is too old for this. D. This stage is from six to eleven years; the girl is too young for this. References:

Answer 715

Correct Answer: B. Talk to the parents and child together and help the family discuss the girl's depression. The NP must walk the fine line between respect for the child's request for confidentiality and the concern for the child's safety. One technique that can be used is to let the child know before the conversation begins that her privacy will be respected unless her health or the health of others is threatened. The NP should sit with the parents and child as she discusses her issues with her parents. Incorrect Answers: A. The child should be involved in the conversation with her parents so that she knows exactly what is said and not said. C. It is important that the NP protects the child's safety even though it means that her request for confidentiality cannot be honored. Therefore, the NP cannot keep the information from the child's parents. D. Although admission to a psychiatric unit might be necessary, a psych consult should NOT be the initial intervention for this patient. Vital Concept: Adolescent confidentiality is a complex topic. Laws regarding consent and adolescent confidentiality vary from state to state and the NP must be aware of the laws in the state in which they practice to provide appropriate treatment to the adolescent while also maintaining their privacy and rights. References:

Answer 716

Correct Answer: D. 6 months The specifier of "with delayed expression" is added to a posttraumatic stress disorder (PTSD) diagnosis when the full criteria for PTSD are not met until 6 months or more after the traumatic event. Several criteria must be met to receive a diagnosis of PTSD: One either experiences a traumatic event, witnesses an event, learns about the event happening to a close friend or family member, or experiences repeated exposure to details of traumatic events. One or more intrusive symptoms (e.g., nightmares or flashbacks) At least one avoidance behavior where the patient either avoids the memories or feelings associated with trauma or avoids external reminders that trigger symptoms At least two indicators of a significant decline in disposition and mental function related to the traumatic event (e.g., inability to remember trauma, negative beliefs about oneself, or persistent negative emotional state) Two or more alterations in responsiveness related to the traumas (e.g., hypervigilance) Symptoms are present for one month or more The symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise Incorrect Answers: (A) Symptoms that present within one week are not considered delayed. (B) Symptoms that present within one month are not considered delayed. (C) Symptoms that present within three months are not considered delayed. Vital Concept: The specifier with delayed onset is only applicable if the patient develops PTSD symptoms 6 months or more after the stressful event or experience. References:

Answer 717

Correct Answer: A. Tetrabenazine Tetrabenazine is known to cause depression with long-term use due to deletion of dopamine at the synapse. It is prescribed for tardive dyskinesia. Incorrect Answers: B. This is an SNRI, and is an antidepressant C. This is a Tricyclic antidepressant D. This is not known to cause depression Vital Concept: Tetrabenazine is known to cause depression with long-term use due to deletion of dopamine at the synapse. It is prescribed for tardive dyskinesia. References:

Answer 718

Correct Answer: C. Primary care and mental health providers work together closely to deliver effective treatment for depression and other common psychiatric disorders in primary care settings Numerous studies have demonstrated the effectiveness of delivering treatment for depression and other common and uncomplicated psychiatric disorders in primary care settings. The model of “collaborative care” is an evidence-based, systematic approach in which primary care and mental health providers work together closely to deliver effective treatment for depression and other common psychiatric disorders in primary care settings. Core characteristics of this model are as follows: patient-centered, evidence-based, measurement-based treatment to target, population-based, and accountable. Incorrect Answers: (A) Mental health providers of multiple disciplines work together closely to deliver effective treatment for depression and other common psychiatric disorders in mental health settings. Primary care and mental health providers work together closely to deliver effective treatment for depression and other common psychiatric disorders in primary care settings. (B) Primary care doctors and nurses work together closely to deliver effective treatment for depression and other common psychiatric disorders in primary care settings. Primary care doctors and mental health providers work together closely to deliver effective treatment for depression and other common psychiatric disorders in primary care settings. (D) Primary care and mental health providers work together closely to deliver effective treatment for depression and other common psychiatric disorders in mental health settings. Primary care and mental health providers work together closely to deliver effective treatment for depression and other common psychiatric disorders in primary care settings, not mental health settings. References:

Answer 719

Correct Answer: D. 0.55 When determining the probability that either of two independent conditions or events will occur, the probability is the sum of their probabilities minus the probability that both will occur. In this diagram, A represents the probability of lung cancer and B represents the probability of leukemia. If the probabilities are added, the probability of getting both lung cancer and leukemia (A and B) will be counted twice. To prevent this, the probability of (A and B) must be subtracted from the sum of probabilities. In this example, the two conditions are independent. Therefore, the probability that both will occur is the product of their probabilities: p(A and B) = pA x pB. The equation in this case is: pA + pB – (pA)(pB) or 0.1 + 0.5 – (0.1)(0.5) = 0.55. When calculating the probabilities for two mutually exclusive events, the probability that either one will occur is the sum of their probabilities. Incorrect Answers: A, B, and C. Incorrect results. the probability is the sum of their probabilities minus the probability that both will occur. Vital Concepts: The probability is the sum of their probabilities minus the probability that both will occur. References:

Answer 720

Correct Answer: A. CBC with differential Patients require a CBC with a differential weekly for the first 6 months they are using clozapine to monitor ANC for agranulocytosis. Agranulocytosis is a life-threatening possible side effect of clozapine. Incorrect Answers: B. C. D. These labs should be monitored at some point within the first 3 months of treatment to screen for the development of metabolic syndrome, a side effect of almost all atypical antipsychotics. Screening can be done annually if the first check does not demonstrate signs of metabolic syndrome. References:

Answer 721

Correct Answer: C. 2mg Alprazolam (Xanax) at 1mg is equivalent to 30mg phenobarbital, 25mg chlordiazepoxide (Librium), 1mg clonazepam (Klonopin), 10mg diazepam (Valium), and 2mg lorazepam (Ativan). Incorrect Answers: A. 0.5mg. This is 1/4 of the correct equivalent — one milligram of Xanax is approximately equivalent to two milligrams of Ativan. B. 1mg. This is 1/2 of the correct equivalent — one milligram of Xanax is approximately equivalent to two milligrams of Ativan. D. 5mg. This is more than double the correct equivalent — one milligram of Xanax is approximately equivalent to two milligrams of Ativan. References:

Answer 722

Correct Answer: D. First panic attack often occurs "out of the blue" while doing everyday things. Panic disorders tend to begin with a panic attack that is seemingly out of the blue. This usually occurs when people are young adults (average is 30s) but can appear later. Although the person thinks the first panic attack is completely out of the blue and unrelated to the activity he or she was engaging in, there is often a correlation with some type of life event (including serious illness of a family/friend, an accident, loss or major change in relationship, or separation from family in some way like moving for a new job). It is also not uncommon for the first panic attack to occur postpartum or while abusing substances. Upon examination, although the patient feels like he or she is “going crazy” or having a “heart attack," the only symptom present is sinus tachycardia. Incorrect Answers: A. First panic attack usually happens in a stressful environment. Panic attacks tend to begin with a panic attack that is seemingly out of the blue, not in a stressful environment. B. First panic attack is usually mild and might be missed altogether. A panic attack is subjectively described as a feeling of intense terror/doom and can cause people to feel like they are "losing control." The first panic attack is not usually mild or missed. C. First panic attack usually occurs when facing a fear/phobia. First panic attack tends to begin with a panic attack that is seemingly out of the blue, not when facing a fear/phobia. Vital Concept: Physical symptoms of a panic attack can include chest pain, palpitations, difficulty breathing, dizziness, sweating, and paresthesias. The key symptom of panic is hyperventilation, and it likely causes some of the other symptoms (such as dizziness, confusion, etc.). This usually lasts anywhere from 5-20 minutes. Panic attacks alone do not merit the diagnosis of panic disorder; they must occur fairly frequently and regularly as well. References:

Answer 723

Correct Answer: B. 25,000 The human genome consists of approximately 20,000 to 25,000 genes, a number far below the original estimate of 250,000. Complex organization and expression of these genes together with functional diversity is what appears to set humans apart from the rest of life on earth. Most evolutionarily new genes code for brain functions, immune system functions, and tissue-specific developmental regulation. Chromosomes differ from each other about once every 1,000 base pairs. Taking into account chromosomal differences between maternal and paternal DNA, the genomic variation between humans is only about 0.5%, mostly occurring in the form of single nucleotide polymorphisms (SNPs). Incorrect Answers: (A) 2,500. The human genome consists of approximately 20,000 to 25,000 genes, not 2,500. (C) 250,000. The human genome consists of approximately 20,000 to 25,000 genes, not 250,000. The original estimate of the human genome was 250,000 genes. (D) 2,500,000. The human genome consists of approximately 20,000 to 25,000 genes, not 2,500,000. References:

Answer 724

Correct Answer: D. Schizophrenia is premature dementia, emphasizing early onset and progressive clinical decline. Bénédict Augustin Morel in the 18th century first used the term "dementia praecox" to describe schizophrenia as premature dementia, emphasizing early onset and progressive clinical decline. This appears to be the first biological model of mental illness that explicitly considered hereditary factors. Later, Emil Kraepelin noted that the age of onset, family history, premorbid personality, and a deteriorating clinical course were useful in the distinction of dementia praecox from manic-depressive illness. This was regarded at the time, and remains, a fundamental clinical distinction in psychiatric nosology. Incorrect Answers: A. Ernst Kretschmer described the risk of developing psychiatric illness on the basis of body habits. The pyknic build is more prone to developing bipolar disorder, and an asthenic build is more prone to developing schizophrenia. B. Galen in the second century held that mental disorders originated from the brain, a prescient notion that has reemerged in the contemporary "remedicalization" of mental illness. C. Karl Ludwig Kahlbaum studied the course of illness in these patients, appropriating methods used to study medical illness. He categorized these symptoms and derived subtypes of schizophrenia (now removed from the DSM-5), such as catatonia and hebetic paraphrenia. Vital Concept: Bénédict Augustin Morel in the 18th century first used the term "dementia praecox" to describe schizophrenia as premature dementia, emphasizing early onset and progressive clinical decline. References:

Answer 725

Correct Answer: C. Provide calm environment with minimal stimuli The management of acute PCP intoxication starts by providing an environment that is calm and has little stimulation. Incorrect Answers: A. This is a little premature. B. A urine sample can probably wait. D. It may be challenging to get a coherent history at the moment. References:

Answer 726

Correct Answer: D. Adenosine Adenosine, produced by cells in the hypothalamus and basal forebrain, promotes NREM sleep. The other neurotransmitters listed promote wakefulness. Incorrect Answers: (A) Dopamine. Dopamine, produced by cells in the substantia nigra and ventral tegmental area, promotes wakefulness. (B) Acetylcholine. Acetylcholine is the only wakeful hormone present in REM. It is responsible for why we dream. (C) Norepinephrine. Norepinephrine, produced by cells in the locus coeruleus, promotes wakefulness. References:

Answer 727

Correct Answer: B. Sensory gating is the ability to suppress information; people with schizophrenia are often part of various endophenotypes that may process these stimuli abnormally. Sensory gating is the ability to suppress information; people with schizophrenia are often part of various endophenotypes that may process these stimuli abnormally. Schizophrenia affects 1% of the population worldwide. It is characterized by positive symptoms (e.g. hallucinations, delusions, and disorganized speech and behavior), negative symptoms (e.g. flattened affect and alogia or impoverished speech), and other symptoms, including inattentiveness. Some people with schizophrenia also have a lack of insight regarding their condition. There is usually significant impairment in their social, occupational, and interpersonal lives. To diagnose schizophrenia, the symptoms must be present for at least 6 months and include at least 1 month of positive or negative symptoms. The diagnosis of schizophrenia was expanded in DSM-5. Criterion A includes five items: · speaking incoherently without logical organization* · a misconception, belief, or thought that is firmly held despite not being grounded in reality* · illusions or perceived experiences that do not actually exist (e.g., sounds, voices, smells, visions, feelings, etc.)* · actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) · decreased display of emotion or a lack of motivation At least two of the five symptoms must be present for at least one month, and 1 of the two symptoms must be delusions, hallucinations, or disorganized speech. Negative symptoms, which impair function the most, were added to the diagnostic criteria in 2013. Incorrect Answers: A. This is too general and falsely states that aberrant thoughts are related to sensory gating. C. This is an overly simplistic explanation of sensory gating and fails to explain the mechanism that links sensory gating to schizophrenia. D. This does not explain sensory gating and gives a simplistic, false answer about ERP waveforms in people with schizophrenia. Studies have shown that first-degree relatives of people with a diagnosis of schizophrenia have abnormal P50 waveforms. Vital Concept: Sensory gating involves the selective suppression of incoming sensory information, which is often abnormal in patients with schizophrenia. References:

Answer 728

Correct Answer: C. Carbamazepine/oral contraceptives (OBC) - decreased levels of OBC This pairing is correct. Incorrect Answers: A. Carbamazepine/fluoxetine increases, not decreases, carbamazepine levels B. Carbamazepine/lithium increases, not decrease, risk of neurotoxicity D. Carbamazepine/valproate increases carbamazepine levels and decreases valproate levels References:

Answer 729

Correct Answer: B. Initiation of patient-centered medical homes Patient-centered medical homes (PMCH) were initiated by the Centers for Medicare and Medicaid Services in response to a mandate for the provision of targeted, accessible, continuous, and family-centered care to Medicare beneficiaries with chronic diseases that require regular monitoring and care. They incorporate care based on patient preference and needs, integrating these concepts with the implementation of infrastructures to improve coordination and communication when delivering care. Incorrect Answers: A. Federally qualified health centers refer to a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the US Dept. of Health and Human Services. C. Meaningful use refers to the incorporation of electronic health records and health information technology in meaningful ways to improve the quality of healthcare. This program is slated for implementation in stages by Medicare. D. A preferred provider organization is a managed care organization of medical doctors, hospitals, and other healthcare providers who have agreed with a third-party administrator or insurance company to provide healthcare at reduced rates to an enrolled or covered population. Vital Concept: Patient-centered medical homes (PCMH) were initiated by the Centers for Medicare and Medicaid Services in response to a mandate for the provision of targeted, accessible, continuous, and family-centered care to Medicare beneficiaries with chronic diseases that require regular monitoring and care. References:

Answer 730

Correct Answer: C. Limbic The limbic system is the key area for smell and emotion. Incorrect Answers: A. The occipital lobe is key for visual functions. B. The frontal lobe is key for executive function, social conduct, judgment, insight, and some motor function. D. The parietal lobes are key areas for sensory integration and somatosensory function. References:

Answer 731

Correct Answer: D. Isoniazid Isoniazid is known to cause mania. Incorrect Answers: A. Marijuana is not known to cause mania B. Olanzapine is an atypical antipsychotic, and is not known to cause mania C. Levonorgestrel is used in birth control, and is not known to cause mania References:

Answer 732

Correct Answer: B. Positive predictive value Positive predictive value (PPV) is calculated by dividing the number of true positives by all positive results (true and false positives). PPV (and the opposite negative predictive value) is dependent on the prevalence of a disease in a given population. Assuming that the sensitivity and specificity of the test are equal, the PPV will be higher when applied to a population with a higher prevalence of disease. Sensitivity, specificity, likelihood ratios, odds ratios, and relative risk are all independent of disease prevalence and incidence. Incorrect Answers: A, C, and D. These variables are independent of disease prevalence and incidence.

Answer 733

Correct Answer: D. Autoinduction Carbamazepine stimulates the transcriptional upregulation of genes involved in its own metabolism, which is called autoinduction. This causes autoinduction of CYP3A4 and CYP2D6. Autoinduction is usually complete 3-5 weeks after the initiation of a fixed dose when taken consistently. Incorrect Answers: A. Carbamazepine serum levels may be increased if taken with food and/or grapefruit juice. B. Cimetidine generally increases the serum concentration of carbamazepine, usually temporarily. C. Erythromycin increases the serum concentration of carbamazepine.

Answer 734

Correct Answer: D. Clinicians must agree to “hold harmless” the program developer for negative outcomes Although there is hope that electronic health records can help to alert clinicians of new medical evidence that may be incorporated into practice, in reality clinical decision support systems are created by private firms or individuals. Incorrect Answers: A. It is often unclear if clinical decision support guidelines are based on local norms, best practices, evidence, or even ethical or personal preferences. Although these systems can offer suggestions and prompts, ethical concerns arise when clinicians must respond to information from an unverified source. B. Clinical decision support guidelines do not have any warranty of effectiveness, and responsibility lies with the clinician when using these guidelines or systems for clinical decision-making. C. Although the FDA is responsible for oversight of medical devices, including electronic health records, with clinical decision support systems there is no method to publicly report failures or safety issues. Vital Concepts: Clinical decision support systems are created by private firms or individuals are clinicians must agree to hold harmless against them for negative outcomes.

Answer 735

Correct Answer: C. Kasanin - schizoaffective disorder The term "schizoaffective disorder" appears to have originated with Kasanin, who referred to acute schizoaffective psychosis to describe patients with the acute onset of perceptual distortions and "emotional turmoil" that were typically precipitated by a "difficult environmental situation." The construct of schizoaffective disorder addresses individuals who have prominent features of both schizophrenia and major mood disorders. Incorrect Answers: A. The term schizophreniform psychosis was initially used by Gabriel Langfeldt in the 1930s to distinguish patients with schizophrenia who had a relatively better prognosis. B. Emil Kraepelin has undoubtedly exerted the single greatest influence in this area, evident in part by the "neo-Kraepelinian" orientation of the diagnostic criteria for schizophrenia found in recent editions of the DSM. He divided the psychotic illness into 2 major subcategories: dementia praecox (now schizophrenia) and manic-depressive psychosis (now bipolar). D. Eugene Bleuler coined the term “schizophrenia.” Vital Concept: Kasanin coined the term "schizoaffective disorder" and Eugene Bleuler coined the term “schizophrenia.”

Answer 736

Correct Answer: A. Null hypothesis The null hypothesis states that no real relationship exists between two groups that cannot be explained by chance alone. Incorrect Answers: B. A nondirectional hypothesis proposes a relationship exists between two variables, but does not predict the relationship (for example: cholesterol changes when supplements are used). C. A directional hypothesis states a positive or a negative relationship exists between two variables (for example, cholesterol decreases with use of supplement). D. A simple hypothesis expresses an expected relationship between an independent and dependent variable. Vital Concepts: The null hypothesis states that no real relationship exists between two groups that cannot be explained by chance alone.

Answer 737

Correct Answer: B. Dialectical behavioral therapy Only dialectical behavioral therapy has been effective for women with opioid dependency. Incorrect Answers: A, C, and D. These have not been found to be effective for women with opioid dependency

Answer 738

Correct Answer: B. Valproate sodium Both lithium and valproate sodium, among other anticonvulsants, are first-line treatments for bipolar disease. Valproate blocks voltage-sensitive sodium channels and increases GABA, both by an unknown mechanism. A reduction in her dosage likely brought her into a manic state. Risperidone is also used. The other medications are not first-line treatments of bipolar disease. Incorrect Answers: A. Fluoxetine. Selective serotonin reuptake inhibitors (SSRIs) (e.g. fluoxetine) do not treat mania. SSRIs can induce mania. Lowering this medication is not likely to induce mania. C. Bupropion. Bupropion, a norepinephrine and dopamine reuptake inhibitor, does not treat mania. Lowering this medication is not likely to induce mania. D. Mirtazapine. Mirtazapine, serotonin/norepinephrine receptor antagonist and alpha 2 antagonist, does not treat mania. Lowering this medication is not likely to induce mania.

Answer 739

Correct Answer: D. Collaborative models have demonstrated reduced lengths of stay and increased hospital profits Training is usually focused on individual responsibilities, despite the fact that most care is delivered by teams of people. As a result, health care practitioners are unprepared to work in complex settings, which creates “silos” that impede safety improvements. There is a high premium placed on medical autonomy and perfection with a historical lack of interprofessional cooperation and effective communication. Most research to date has explored the cost implications of team-delivered care, not the quality. However, studies have demonstrated reduced lengths of hospital stay and increased hospital profits in a collaborative model compared to physician-only care. Incorrect Answers: A. Training is usually focused on individual responsibilities B. There's a high premium placed on medical autonomy and perfection, with a historical lack of interprofessional cooperation and effective communication C. Most research to date has explored cost implications of team-delivered care, not quality Vital Concepts: Studies have demonstrated reduced lengths of hospital stay and increased hospital profits in a collaborative model compared to physician-only care.

Answer 740

Correct Answer: C. There is no withdrawal syndrome associated with abrupt discontinuation of bupropion. Although gradual tapering of bupropion is recommended when stopping therapy, abrupt cessation does not generally result in any significant withdrawal symptoms. The total daily dose should not exceed 450mg/day, and a single dose should not exceed 150mg for the immediate-release form, 200mg for the sustained-release form. There is an extended-release form that can be given as a single dose up to 450mg for patients who have already reached that dose. Incorrect Answers: A and B. Due to increased risk of seizures, bupropion should not be used in patients with a seizure history or those at increased risk of seizures (e.g. those with eating disorders, head trauma, or alcohol abuse). The risk of seizures is dose-dependent. D. Bupropion is a dopamine/norepinephrine reuptake inhibitor. Initial side effects can include headaches, dizziness, dry mouth, anxiety, restlessness, anorexia, nausea, and insomnia.

Answer 741

Correct Answer: D. Mammillary bodies This patient exhibits signs of Korsakoff syndrome, with anterograde and retrograde amnesia and a flat affect. Declarative memory is affected, while procedural memory remains intact. Other clinical signs of this disease include apathy, lack of insight, and confabulation (a relatively rare but striking symptom). Wernicke-Korsakoff syndrome, a severe consequence of thiamine deficiency, shares the same etiology. Wernicke encephalopathy (WE) is an acute syndrome that also involves oculomotor dysfunction and gait ataxia and requires emergent medical treatment; it is frequently fatal if untreated. Korsakoff syndrome is a chronic disease that often occurs after WE. Although Wernicke-Korsakoff syndrome results from thiamine deficiency from any cause, it usually affects patients with chronic alcoholism. The classic neuroanatomical localization for Korsakoff syndrome consists of the mamillary bodies, although other areas of the brain like the anterior thalamus and the corpus callosum can demonstrate T2-hyperintense changes on MRI and/or atrophy. Memory changes have been associated with the involvement of the anterior thalamus more than the mammillary bodies. A useful mnemonic to remember issues associated with vitamin B1 is the following: Thiamine pyrophosphate (TPP) is needed for a number of enzymatic reactions but is rarely required alone. Whenever you need B1, you usually need FAD (B2), NAD (B3), CoA (B5), and Lipoic Acid, so just group them together to remember: B1,2,3,5+LA. Enzymes that use B1, 2, 3, 5 + LA: Glycolysis/TCA: PDH (X = lactic acidosis; Tx: ketogenic Leucine, Lysine + high-fat diet) TCA: alphaKGDH HMP: transketolase branched chain AADH (X = Maple Syrup Urine Disease –> severe CNS defects, MR, and death) Related problems: Lipoic acid is antagonized by Arsenic, which causes rice water diarrhea and garlic breath. B1 deficiency in alcoholics –> Wernicke-Korsakoff, beriberi PDH deficiency/dysfunction –> inability to continue TCA –> diversion to lactic acidosis; brain starves for energy –> neurologic defects. To keep brain from starving, Tx with ketogenic amino acids LEUCINE and LYSINE and high fat diet (beta oxidation of fats will produce acetyl CoA –> TCA/ketogenesis). Incorrect Answers: A. The hippocampus is associated with epilepsy and Alzheimer's disease. B. Although apathy can sometimes occur with frontal lobe disorders, it is characterized by inappropriate behavior, including table manners, impulsivity, and, not infrequently, hypersexuality. It is not specifically related to alcohol use disorder. Causes include normal pressure hydrocephalus, brain tumors, trauma, cerebral vascular disease, and infection. C. Schizophrenia and schizoaffective disorder have been associated with disorders of the ventroposterior thalamus. Neuro-ophthalmologic findings also occur, including third nerve palsy, nystagmus, and problems with convergence. Vital Concept: Korsakoff syndrome, a complication of chronic alcohol abuse, has been associated with atrophy in several parts of the brain, notably the mamillary bodies, the anterior thalamus, and the corpus callosum.

Answer 742

Correct Answer: D. The patient (or healthcare agent) must consent to be admitted to a hospice program Hospice is a model of care designed for terminally ill patients in the end phase of their disease. The focus of care is the alleviation of pain and improvement of quality of life. Hospice care is based on palliative care, not curative care. Most hospice care programs are home-based; patients remain at home and receive care there. Pain management is an important aspect of this model of health care. The patient must give consent to be admitted to a hospice program. Incorrect Answers: A. The physician must certify that the patient has a life expectancy of less than 6 months. B. In order for a patient to be admitted to hospice care, a physician must write an order. Currently, Medicare does not allow NPs to refer patients to hospice. C. In some states NPs are allowed to sign the death certificate, this varies state to state. Vital Concepts: Hospice is a model of care designed for terminally ill patients in the end phase of their disease. The focus of care is the alleviation of pain and improvement of quality of life. The patient must give consent to be admitted to a hospice program.

Answer 743

Correct Answer: D. Improving access to accurate, timely information Nine categories that provide opportunities to improve patient safety were identified by the IOM, including the incorporation of user-centered designs and improving access to accurate and timely information. Other categories include attending to work safety (work hours, staffing ratios, and interruptions); training for team collaboration; expecting the unexpected; and involving patients in their care. Incorrect Answers: A. The IOM recommends avoiding reliance on vigilance by providing checklists, well-designed alarms, and adequate breaks for staff. B. The IOM recommends avoiding reliance on memory and instead suggests standardized and simplified processes, and the use of protocols and checklists. C. The IOM suggests planning for the unexpected and designing a process of recovery for times when inevitable errors occur. Vital Concepts: Nine categories that provide opportunities to improve patient safety were identified by the IOM, including the incorporation of user-centered designs and improving access to accurate and timely information.

Answer 744

Correct Answer: D. Bupropion (Zyban) Bupropion is a norepinephrine dopamine reuptake inhibitor utilized to treat depression and for smoking cessation. For nicotine dependence use bupropion SR taken at a dose of 150 mg daily for three days and then increased to 150 mg twice a day. Therapy should start one week before the target quit date and continued for 7-12 weeks. If the patient successfully quits after 7-12 weeks, the nurse practitioner can consider ongoing maintenance therapy based on the individual patient risk or benefit. There is a "black box warning" of increased suicidality in children, adolescents, and young adults taking antidepressants for major depressive disorder. When used for smoking cessation, there have been serious neuropsychiatric events, including depression, suicidal ideation, attempted and complete suicide. Patients should be monitored closely for changes in behavior. Incorrect Answers: A. Diazepam. Diazepam is a benzodiazepine and has no evidence to treat nicotine dependence. B. Sertraline. There is no evidence to use Sertraline to treat nicotine dependence. Sertraline is a selective serotonin reuptake inhibitor utilized for and FDA approved for major depressive disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and premenstrual dysphoric disorder. Used off label to treat generalized anxiety disorder. C. Multivitamin. There is no evidence to use multivitamins to treat nicotine dependence. Vital Concepts: There is a "black box warning" with Buproprion that causes an increased suicidality in children, adolescents, and young adults taking antidepressants for major depressive disorder.

Answer 745

Correct Answer: C. Whether they have achieved recognition of certain advanced skills and knowledge Certification provides recognition of the achievement of predetermined criteria in a particular field. A nurse practitioner that is certified has met certain requirements of education, experience, and examination. Certification is a voluntary process and certifying agencies are non-governmental organizations and professional associations. Incorrect Answers: A. Certification does not imply licensure, which is a separate process of meeting requirements set forth by a governmental organization, the state Board of Nursing. B. The requirements of state law will determine whether a nurse practitioner can practice independently and to what extent. D. Licensure is awarded if a nurse meets minimal levels of skill and knowledge for safe practice. Certification does not imply licensure. Vital Concept: Certification provides recognition of the achievement of advanced skills and knowledge in a particular field. A nurse practitioner that is certified has met certain requirements of education, experience, and examination.

Answer 746

Correct Answer: B. 50% The case-fatality rate is the number of fatalities due to a specific illness that occurs among all individuals with that illness. The number of fatalities should be divided by the number of cases of the illness. When calculating a case-fatality rate for a specific disease, focus on the information about that disease. Adding the number of fatalities to the number of cases is incorrect and results in 33%. 7% refers to the percentage of fatal cancer cases in the population due to esophageal cancer. 4% refers to the percentage of all cancer cases in the population due to esophageal cancer. Incorrect Answers: A. Not a meaningful number. C. Percentage of all cancer cases in the population due to esophageal cancer. D. Percentage of fatal cancer cases in the population due to esophageal cancer. Vital Concepts: The case-fatality rate is the number of fatalities due to a specific illness that occurs among all individuals with that illness. The number of fatalities should be divided by the number of cases of the illness. When calculating a case-fatality rate for a specific disease, focus on the information about that disease.

Answer 747

Correct Answer: C. Some patients on chronic lithium treatment may have gradually increased creatinine. Lithium has 50 years of data demonstrating its efficacy. About 70% of patients have some degree of reduction in mania with use of lithium. Acute side effects include tremor, polyuria and polydipsia, cognitive problems, poor memory and concentration, GI distress, benign leukocytosis, acne, and edema. Chronic effects include hair loss, weight gain, possible kidney damage, and thyroid dysfunction. ECG effects commonly include changes in the repolarization phase, worsening existing arrhythmias and (less commonly) inducing new ones. Lithium causes impaired concentration by reducing the effect of ADH on the kidney. Polyuria and polydypsia can be managed by giving a single bedtime dose, managing fluid intake, and starting a thiazide diuretic. Hypothyroidism is an issue in 5-35% of patients treated with lithium; this commonly occurs in the first 6-18 months of treatment and is easily treated with thyroxine. Development of hypothyroidism that is not responsive to thyroxine constitutes a valid reason to consider discontinuation of lithium. About 10-20% of people on lithium for over a decade will have renal changes. These issues could be continued problems with water reabsorbtion and no change in GFR or development of renal insufficiency. Increasing creatinine can be a problem for a minority of patients on chronic lithium. Worsening psoriasis has also been described. Toxicity occurs at levels >1.5meq/L, and >2.0meq/L can become life-threatening. Symptoms at levels >1.5meq/L include: marked tremor, GI symptoms, blurred vision, increased deep-tendon reflexes, vertigo, and confusion. At levels >2.5meq/L, seizures, coma, arrhythmias, and permanent neurological impairment may occur. Treating toxicity includes supportive care, gastric lavage, or induction of emesis. In acute toxicities and a level 6-8meq/L, hemodialysis is the only way to get lithum out of the bloodstream. With chronic lithium patients, hemodialysis should be considered at levels >4.0meq/L. Any patient with cardiac disease or renal impairment and lithium toxicity should be considered for hemodialysis. Progressive symptoms of deterioration and severe intoxication are grounds for hemodialysis. The elderly are much more likely to have toxicity at lower levels and have a narrower therapeutic window. Medications and other factors associated with rise in lithium levels include diuretics, ACEIs, NSAIDs, COX-2 inhibitors, salt-restricting diets, dehydration, high heat, and poor PO intake. Baseline tests include ECG (in patients older than 40), thyroid function, blood counts, renal function, and a pregnancy test. Further testing should be based on clinical evidence suggesting a change in treatment. Levels should be checked 5 days after an increase (sooner in acute mania) or any time prior to an increase. The target range for the treatment of mania is 0.8-1.0meq/L. Fewer side effects are seen at levels of 0.4-0.6meq/L, but more episodes are recorded. The optimal level varies between patients and should be balance side effects verses the possibility of relapse. In stable patients on chronic treatment, levels should be drawn every 6 months. Renal function should be evaluated every 2-3 months during the first 6 months of treatment, and afterwards renal and thyroid functions should be checked every 6 months to 1 year or as clinically indicted. Incorrect Answers: A. Kidney function should be evaluated every 2-3 months during the first six months of treatment, and then every six months to a year afterward, or as clinically indicated. B. While kidney damage is a chronic effect of lithium treatment, it isn't inevitable D. Lithium reduces, not increases, ADH's effect on the kidney

Answer 748

Correct Answer: B. Transactional A transactional model of leadership is useful when there is an assignment or short-term project to be completed. The effects of transactional leadership are episodic, short-lived, and task-based. In this form of leadership, the leader only intervenes when something goes wrong, providing negative feedback. Incorrect Answers: A. The transformational model of leadership shapes and transforms the goals and values of other staff to achieve a collective purpose. This model of leadership has a positive effect on team building and communication and studies have shown that transformational leaders contribute more to individual performance and motivation than transactional leaders. C. A strategic model of leadership is demonstrated in the three-circle model proposed by Adair. In this model, the needs of the task, individual, and team are all taken into consideration to promote better cooperation for support of common goals. D. This is also an example of the democratic model of leadership, in which opinions of those who carry out the task are considered and individuals and groups are involved in decision-making processes that affect their work. Vital Concepts: A transactional model of leadership is useful when there is an assignment or short-term project to be completed. The effects of transactional leadership are episodic, short-lived, and task-based. In this form of leadership, the leader only intervenes when something goes wrong, providing negative feedback.

Answer 749

Correct Answer: C. Psychodynamic group This describes psychodynamic group therapy. Incorrect Answers: A. A day hospital group is designed for acute or chronic major mental illness and is focused on a plan to return to baseline. B. A supportive group is designed for patients for shared universal dilemmas, such as loss of a child, and focuses on loss and life management skills. D. Cognitive-behavioral group therapy is designed for patients with phobias and compulsive problems and focuses on cognitive distortions.

Answer 750

Correct Answer: D. Hyperthyroidism 20% of patients with untreated endocrine disorders can have psychotic symptoms. Common causes include hyper- and hypothyroidism, parathyroidism, and adrenalcorticism. Other medical causes of psychosis include alcohol/substances, dementia, HIV and other infections that can affect the brain, steroids, stimulants, epilepsy, or cerebral infarctions. The diagnostic criteria for acute psychositic disorder due to another medical condition include: This condition is characterized by significant delusions (a misconception, belief, or thought that is firmly held despite not being grounded in reality) or hallucinations (illusions or perceived experiences that do not actually exist [e.g., sounds, voices, smells, visions, feelings, etc.]) that lead to significant anguish or dysfunction (professionally, socially, academically, professionally). The patients test results, examination findings, and history content that indicate the symptoms are related to another medical condition and not more accurately attributed to delirium or another mental health condition (e.g., schizophrenia, acute stress disorder, brief psychotic disorder). The condition should be specified with delusions OR hallucinations Incorrect Answers: A. Migraines do not commonly lead to psychotic symptoms. B. NPH typically presents with balance issues, confusion, and mood changes, but not psychotic symptoms C. UTIs d may cause, fever, confusion, and acute delirium, but don't commonly lead to psychotic symptoms. Vital Concept: Of patients with untreated endocrine disorders, up to 20% may present with psychosis symptoms.

Answer 751

Correct Answer: B. 5-10% Approximately 2.5% of preschool children stutter, and approximately 5% of children have childhood-onset fluency disorder at some point in childhood. Females tend to have a higher recovery rate, but overall recovery rates from childhood-onset fluency disorder are over 65%. Children who have a first-degree relative with childhood-onset fluency disorder are 3x more likely to develop the disorder. Incorrect Answers: A. Approximately 2.5% of preschool children and 5% of all children and adolescents stutter. C. Approximately 5% of children have childhood-onset fluency disorder at some point in childhood, not 10-15%. D. Approximately 5% of children have childhood-onset fluency disorder at some point in childhood, not 15-20%. Vital Concept: Approximately 5% of children have childhood-onset fluency disorder at some point in childhood.

Answer 752

Correct Answer: D. It can lead to barriers for organizational productivity Unresolved conflict can lead to barriers for employees and teams, and for organizational growth and productivity. Incorrect Answers: A. Marshall notes that “Conflict is neither good nor bad, it just is.” B. Conflict is neither good nor bad. C. Conflict can occur as a result of disagreement or difference in the values, attitudes, needs, or expectations of two groups or individuals, but it can also occur as a result of miscommunication or lack of information. Vital Concepts: Unresolved conflict can lead to barriers for employees and teams, and for organizational growth and productivity.

Answer 753

Correct Answer: C. Nurse advocates succeeded in getting language put into the Congressional Reconciliation Act that included NPs as leaders in medical home demonstration projects The NP Roundtable, an advocacy organization composed of advanced practice nursing organizations, was successful in getting language included into the Reconciliation Act that allowed the Secretary of Health and Human Services to include NPs as leaders in medical home demonstration projects. Incorrect Answers: A. Although the Congressional Reconciliation Act of 2010 recognizes the importance of advanced practice nursing roles, provider-inclusive language was not included in the bill. B. Although the Reconciliation Act recognized the importance of advanced practice nursing roles, including nurse midwives, the bill did not include NPs working with children and families, an advocacy goal of the Health Policy Committee of the National Association of Pediatric Nurse Practitioners. D. Scope of practice restrictions were not addressed in the Reconciliation Act. Vital Concepts: The NP Roundtable, an advocacy organization composed of advanced practice nursing organizations, was successful in getting language included into the Reconciliation Act that allowed the Secretary of Health and Human Services to include NPs as leaders in medical home demonstration projects.

Answer 754

Correct Answer: A. Ginkgo biloba Ginkgo biloba has several perceived effects on blood flow and cognitive enhancement, although studies in humans have been equivocal. It should be avoided with antiplatelet and anticoagulant medications. This patient is taking warfarin for atrial fibrillation and should avoid using ginkgo. Incorrect Answers: B. Echinacea purpurea is thought to have anti-inflammatory and immune-enhancing properties. Echinacea may cause a flu-like syndrome but has no known drug interactions. It is generally recommended to avoid echinacea in immune-related conditions such as post-transplant immune suppression as well as autoimmune and immune-deficiency conditions (e.g. AIDS, cancer). C. Allium sativum is garlic, which is known to have mild cholesterol-lowering characteristics. Garlic has reported anti-platelet effects and should be used cautiously with antiplatelet and anti-clotting medications. While garlic use should be avoided in patients on warfarin, garlic is not used as a cognitive enhancer. D. Ephedra may increase the risk of heart attack or stroke and should be discontinued at least 24 hours before any surgery. It is not associated with increased risk of bleeding.

Answer 755

Correct Answer: A. Increase the sample size Statistical power is the probability that the study will detect a difference between two populations if one actually exists. Reducing the standard deviation of values when comparing means can also increase the power of a study. By convention, alpha (p-value) is usually 0.05, but it can be increased to increase the power of the study. However, increasing the p-value may result in attributing statistical significance to results that are not truly significant. Effect size can also be increased to raise the power of a study: the greater the effect size, the greater the power of the study. Incorrect Answers: B. This would decrease the power of the study. C. This wouldn't affect the power of the study. D. This would decrease the power of the study. Vital Concepts: Increasing the p-value may result in attributing statistical significance to results that are not truly significant. Effect size can also be increased to raise the power of a study: the greater the effect size, the greater the power of the study.

Answer 756

Correct Answer: B. A prisoner A prisoner may feel that they have no choice as to whether or not to participate in research and may feel that they can gain privileges only if they participate. Incorrect Answers: A. A 20-year-old is not considered vulnerable unless other conditions confer vulnerability because a 20-year-old is usually capable of providing informed consent or refusing to participate. C. An adult with cognitive impairment does not have the capacity to make an informed decision about participation in a research study, so they should be considered part of a vulnerable population. However, a personality disorder does not imply cognitive impairment. It is frequently a maladaptive pattern of coping with stressors and is considered an Axis II psychiatric disorder. D. In terms of a research project, a man with testicular cancer is not considered part of a vulnerable population because he has the ability to make decisions about whether or not participating in a research project is in his best interest. Vital Concept: A prisoner may feel that they have no choice as to whether or not to participate in research and may feel that they can gain privileges only if they participate.

Answer 757

Correct Answer: B. Prazosin Prazosin is an alpha-1 postsynaptic antagonist used to reduce nightmares in patients with PTSD. Prazosin is only FDA approved for hypertension but is used off-label for PTSD associated nightmares. Dosage range is 1-16mg/day. Side effects include dizziness, headache, blurred vision and nausea. Increase dose slowly with risk of orthostatic hypotension that could result in syncope. When stopping prazosin, taper slowly to avoid rebound hypertension. Incorrect Answers: A. Eszopiclone is a Z-drug selective for GABA-A alpha-1 subunit agonist that is utilized for sleep onset/maintenance; not used for nightmares in patients with PTSD C. Nefazodone is a norepinephrine and serotonin reuptake inhibitor and 5-HT2 antagonist that is similar in chemical structure to trazodone. It is FDA approved for major depression and used off-label for anxiety and insomnia; not utilized for nightmares in patients with PTSD. D. Buspirone is a serotonin 5-HT1A receptor partial agonist. FDA approved for generalized anxiety disorder and is utilized off-label for treatment-resistant depression but not for nightmares in patients with PTSD. Vital Concept: Prazosin is an alpha-1 postsynaptic antagonist used off-label for PTSD associated nightmares.

Answer 758

Correct Answer: B. Laboratory evaluation of possible secondary causes of obesity Obesity is generally considered to be consistent with a BMI greater than 30 kg/m². After identifying obesity in a patient, patient evaluation should determine if the obesity is the result of an underlying pathological condition. The three most common causes of secondary obesity include Cushing syndrome, hypothyroidism, and genetic conditions. In this patient, evidence of hirsutism and menstrual irregularity suggest possible endocrine or genetic causes that should be ruled out. Active intervention is indicated for all patients with a BMI > 30 kg/m². Obesity is associated with an increased risk of developing diabetes, hypertension, cardiovascular disease, pulmonary dysfunction, osteoarthritis, cholelithiasis, and some cancers. Although all patients who are obese should be counseled about the risks associated with obesity and the advantages of weight loss, the best choice in immediate management of this patient is to rule out a cause of secondary obesity. Incorrect Answers: A. Ruling out a possible secondary cause of obesity is needed before referring to a nutritionist for a very-low-calorie diet. C. Pharmacologic treatment isn't indicated until a diagnosis is certain. D. While this discussion is needed, the NP should wait until secondary causes of obesity are ruled out prior to addressing these issues. Vital Concept: Obesity is the leading nutritional problem among children in the United States. It is associated with an increased risk for significant health conditions, including insulin resistance, Type 2 diabetes mellitus, renal disease, hepatic disease, hyperlipidemia, hypertension, cardiovascular disease, and adult obesity.

Answer 759

Correct Answer: C. Do not start CPR and explain the advance directive to the son. With a valid DNR order and signed advance directive, a family member does not have the right to overrule the decision to NOT do CPR. Incorrect Answers: A. The son does not have the right to make health decisions that would overrule a DNR order and an advance directive. B. CPR should not be started since a valid DNR and advance directives are on the chart. Vital Concepts: With a valid DNR order and signed advance directive, a family member does not have the right to overrule the decision to NOT do CPR.

Answer 760

Correct Answer: B. Conversion disorder Loss of motor control or sensory function that is not fully explained by physiological mechanisms and that is associated with some type of psychological conflict suggests a conversion disorder. Patients with conversion disorder often exhibit emotional blunting that is sometimes referred to as “la belle indifference.” Incorrect Answers: A. C. D. Phobias, obsessive-compulsive disorder, and illness anxiety disorder are often associated with anxiety.

Answer 761

Correct Answer: A. Trust vs. Mistrust This child is experiencing trust vs. mistrust. (See table below) Incorrect Answers: B. This applies to 18-month-years to three-year-olds and involves the task of developing control and independence. C. This applies to three-year-olds to six-year-olds and involves the task of taking control of the environment and purpose D. This applies to six-year-olds to 12-year-olds and involves the task of building confidence, competence, and social skills

Answer 762

Correct Answer: A. Continue fluoxetine 40 mg per day Depression is a common condition among pregnant women. If the patient has a long-standing history of depression and a prior suicidal attempt, the clinician must weigh the risks vs the benefits of continuing vs discontinuing fluoxetine during pregnancy. Since there has been no consistent evidence that SSRIs cause congenital anomalies, then it may be warranted to continue it. Additionally, most teratogenic medications affect the fetus during organogenesis before the third trimester. This patient has taken the medication all throughout the 1st and 2nd trimesters and the ultrasound of the fetus during the third trimester shows no abnormalities. Therefore, it is reasonable to continue fluoxetine at the current dose. Incorrect Answers: B. Decreasing fluoxetine by halving the dose may exacerbate the patient’s depression without any added benefit to the mother or the fetus. As discussed earlier, teratogenicity does not typically happen during the third trimester. Decreasing the dose at 28 weeks may simply exacerbate the mother’s depression without any added benefit to the fetus. C. Until now, there has been no solid evidence that SSRIs cause teratogenic effects. However, paroxetine has been shown to cause some congenital defects and received a category “D” in the older classification. Therefore, it is safe to avoid it during pregnancy and possibly consider using another SSRI if needed. D. As discussed above, evidence demonstrating fluoxtine’s teratogenicity has not been well established. However, Haldol, which is a 1st generation anti-psychotic, has been shown to cause some birth defects. Therefore, it is advised to avoid it. Further, the patient has depression that is well controlled on an SSRI, and she denies any psychotic symptoms. Therefore, Haldol is not even indicated in this case.

Answer 763

Correct Answer: C. Healthcare Common Procedure Coding System (HCPCS) CMS uses the HCPCS to determine reimbursement to providers which includes the CPT codes, but also includes other codes for services not covered by CPT codes. Incorrect Answers: A. CPT codes were developed by the American Medical Association to describe medical, surgical and diagnostic services. B. DRG codes classify hospital cases into groups which have similar resource needs. D. ICD codes identify conditions based on symptoms, signs, diseases and injuries. These codes facilitate the study of mortality and morbidity. Vital Concepts: CMS uses the HCPCS to determine reimbursement to providers which includes the CPT codes, but also includes other codes for services not covered by CPT codes.

Answer 764

Correct Answer: D. Tardive dyskinesia Patients who have had long-term treatment with antipsychotics demonstrate tardive dyskinesia, consisting of choreoathetotic movements that often start in the fingers and tongue. Later, the movements become more generalized. Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics, such as haloperidol, bind the dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, a blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while a lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each of the second-generation drugs has a different binding affinity (e.g. risperidone is high, and clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors as well, and this may also contribute to their clinical effects. Second-generation drugs are more effective for treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis (and at higher than maintenance dosage for this use). Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used to treat their depression or anxiety disorders. ECT can also be used in schizophrenia for catatonia. Early studies also suggest that TMS might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT can also be very important in the treatment success of schizophrenia. Incorrect Answers: A. C. Akathisia is characterized by motor restlessness. Parkinsonism is characterized by resting tremor and bradykinesia. Both akathisia and Parkinsonism can be caused by antipsychotics. B. Huntington’s disease and Wilson’s disease are also characterized by writhing movements, but these usually have an earlier onset.

Answer 765

Correct Answer: B. Halve starting dose, as valproate doubles half-life of lamotrigine. The elimination half-life of lamotrigine is doubled when valproic acid is administered concurrently. A dosage reduction of lamotrigine by half is necessary with concurrent valproic acid therapy to avoid lamotrigine toxicity (fatigue, ataxia, life-threatening rashes). Incorrect Answers: A. The starting dose is halved, not doubled, due to valproate's effect of doubling the half-life of lamotrigine C. The starting dose is halved, not 4x; and valproate doubles, not quadruples, lamotrigine's half-life D. The starting dose is halved, not reduced to 25%; and valproate doubles, not quarters, lamotrigine's half-life

Answer 766

Correct Answer: D. Alert nephrology for emergent hemodialysis The patient has progressively deteriorated with her current care. Any signs of severe intoxication such as coma, convulsions, cardiovascular symptoms, or respiratory failure require hemodialysis. Any patient with signs of lithium toxicity should be given large amounts of IV fluids, and emesis and gastric lavage should be done. Given the clinical picture, APA guidelines support the immediate use of hemodialysis. Waiting for a second blood lithium level will only prolong the time to dialysis. With the sustained-release form, duration of the toxicity is likely to be drawn out, necessitating repeat dialysis. Incorrect Answers: A. Emergent hemodialysis should be performed before gastric lavage (although this should also be performed) B. Emergent hemodialysis should be performed before emesis (although this should also be performed) C. Emergent hemodialysis should be performed increasing fluid intake through IV fluids (although this should also be performed)

Answer 767

Correct Answer: A. The Id The id is the motivating psychic for this child in this scenario. The id operates on the pleasure principle and seeks immediate satisfaction. This child isn’t thinking of consequences, she is simply thinking “I want.” The ego says “I think, I evaluate” and the superego says “I should or ought;” neither is involved with this 18 month old thought process. Incorrect Answers: B. The ego says, "I think, I evaluate," which is beyond an 18-month-old's thought process C. The superego says, "I should or ought," which is beyond an 18-month-old's thought process D. While the id is involved in saying, "I want," the ego's thinking, "I think, I evaluate," is beyond an 18-month-old's thought process

Answer 768

Correct Answer: D. Therapeutic alliance involves mutual collaboration between therapist and patient. The therapeutic alliance involves a sense of mutual collaboration between the therapist and the patient. Incorrect Answers: A. A therapeutic alliance is strongly related to a good treatment outcome. B. Ruptures are not uncommon but actually indicate withdrawal or detachment from the therapy process by the patient. C. The patient must feel attached to the therapist and that he or she is helpful.

Answer 769

Correct Answer: D. Discuss treatment options and listen sympathetically but do not distort the patient's functional status to help him and his family. A healthcare provider has the ability to justify exemption from work and to legitimize other forms of financial support in cases where patients may have chronic, overwhelming, or catastrophic illnesses. In some cases, a patient may not meet a standard definition of disability but may seem deserving of assistance. A healthcare provider should never distort medical information or misrepresent a patient’s functional status in an attempt to be helpful to a patient. This action would jeopardize the healthcare provider’s trustworthiness and ability to advocate for those who truly meet criteria for disability. Although healthcare providers will often be confronted with patients who seem deserving of assistance, disability evaluation forms should reflect the truth and must be completely honest. Incorrect Answers: A. Unethical to not reflect the truth in disability evaluation forms; a healthcare provider should never distort or misrepresent medical information B. Don't discontinue the relationship — work with the patient and work with them on their concerns C. The wife doesn't fulfill criteria for disability, so can't fill out a disability form for this for her Vital Concepts: A healthcare provider has the ability to justify exemption from work and to legitimize other forms of financial support in cases where patients may have chronic, overwhelming, or catastrophic illnesses. In some cases, a patient may not meet a standard definition of disability but may seem deserving of assistance. A healthcare provider should never distort medical information or misrepresent a patient’s functional status in an attempt to be helpful to a patient.

Answer 770

Correct Answer: B. A substance that decreases the metabolism of drugs. Inhibitors decrease the metabolism of drugs. Enzyme inhibition can lead to a deadly build-up of drugs or other substances in the blood as a result of a failure to clear the drug. The enzyme that would “clear” or “metabolize” the drug has been inhibited; therefore, reducing the clearance of drugs in the body leading to higher levels of a toxic drug. Incorrect Answers: A. This is the definition of an inducer. Cauliflower and cabbage are common foods that are inducers. C. Foods can serve as inhibitors. For example, grapefruit juice inhibits CYP3A4-mediated enzymes. Echinacea, an herbal supplement, is an inhibitor. D. This is the definition of the pharmacokinetic principle, ‘volume of distribution.’

Answer 771

Correct Answer: D. Olanzapine Of the medications listed, olanzapine is the most likely drug to cause hyperglycemia and obesity. Incorrect Answers: A. B. First-generation antipsychotics such as perphenazine and haloperidol typically cause little or no weight gain and are not associated with hyperglycemia. C. Second-generation antipsychotics like aripiprazole and ziprasidone may cause hyperglycemia and obesity in some patients but are less likely to have these effects than olanzapine.

Answer 772

Correct Answer: D. Lorazepam (Ativan) Because older individuals generally have an increased sensitivity to and decreased metabolism of benzodiazepines, patients in this population are at higher risk for the side effects and toxicity of benzodiazepines. The 2019 Beers Criteria recommends avoiding all benzodiazepines due to the risk of gait instability, confusion, dizziness, and falls. All benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. However, there are situations in which benzodiazepines may be used with caution. This patient has intense, function-limiting anxiety related to a short-term stressor for which benzodiazepines can be used as a temporary anxiolytic. Medications such as selective serotonin reuptake inhibitors can take several weeks to take therapeutic effect and would be of limited benefit in this patient, whose anxiety is likely to resolve after surgery. If a benzodiazepine is going to be used in an older person, it should be short-acting, and the dose should be reduced due to altered pharmacokinetics and pharmacodynamics. Lorazepam (Ativan) has a half-life of 12-15 hours and would be the most appropriate choice. Long-acting benzodiazepines have much longer half-lives (up to 74 hours) and should be avoided. Short-half-life benzodiazepines such as oxazepam, alprazolam, and triazolam are also recommended for older adults because these agents are less likely to accumulate with repeated doses, given their rapid clearance from circulation. Incorrect Answers: A. Flurazepam (Dalmane) is a long-acting benzodiazepine with a half-life of 74 hours. B. Diazepam (Valium) is a long-acting benzodiazepine with a half-life of 20-70 hours. C. Chlordiazepoxide (Librium) is a long-acting benzodiazepine with a half-life of 10-30 hours. Vital Concept: Benzodiazepines should generally be avoided in elderly patients due to the risk of confusion and falls. If a benzodiazepine is warranted, it should be used for short periods. Benzodiazepines with short or intermediate half-lives are recommended in this population.

Answer 773

Correct Answer: C. At least four major depressive, manic, or hypomanic episodes in the past year Rapid cycling requires at least four major depressive, manic, or hypomanic episodes that met the criteria in the past year. These episodes must be distinct (have at least a partial remission for at least two months or switch directly into an opposite type of episode). Incorrect Answers: A. At least two major depressive, manic, or hypomanic episodes in the past month is incorrect; the requirement is at least four in a year. B. At least two major depressive, manic, or hypomanic episodes in the past year is incorrect; the requirement is at least four in a year. D. At least ten major depressive, manic, or hypomanic episodes in the past year is incorrect; the requirement is at least four in a year. Vital Concept: The DSM currently defines rapid cycling as the presence of at least four distinct episodes (of depression, mania, or hypomania) within a period of one year.

Answer 774

Correct Answer: C. Hypertelorism Hypertelorism is associated with fetal phenytoin syndrome, while the remaining phenotypic attributes present are descriptions of fetal valproate syndrome and include stereotypical facial features such as bifrontal narrowing, midface hypoplasia, a broad nasal bridge, a short nose with anteverted nares, epicanthic folds, micrognathia, a shallow philtrum, a thin upper lip, and a thick lower lip. Incorrect Answers: A, B, and D. These are characteristics of fetal valproate syndrome, which is caused when a fetus is exposed to valproic acid (VPA).

Answer 775

Correct Answer: B. GI disturbances (diarrhea, nausea) Gastrointestinal side effects are common with the use of galantamine and other cholinesterase inhibitors. These include nausea, vomiting, and diarrhea. Because cholinesterase inhibitors cause actions in the parasympathetic nervous system, they can cause bradycardia, hypotension, hypersecretion, bronchoconstriction, GI tract hypermotility, and decreased intraocular pressure. GI side effects usually decrease over time. Incorrect Answers: A. While a side effect of galantamine, this is less common than GI disturbances. C, D. These side effects were seen in fewer than 1% of patients.

Answer 776

Correct Answer: D. Somatic Delusional disorder is defined by delusions that exist for a month or more. Subtypes that exist are: erotomanic, grandiose, jealous, persecutory, somatic, mixed and unspecified. Somatic type occurs when the central delusion involves bodily functions or other believed sensations such as a foul odor, infestation with parasites or insects, or a misshapen, ugly, anatomically incorrect, or malfunctioning body part. Incorrect Answers: A. Patients with erotomanic subtype believe that someone is in love with them. B. Patients with grandiose subtype believe that they have an immense but concealed skill or perspective or have revealed/learned something crucial. C. In the persecutory type, the patient often believes that others are colluding or plotting against them, watching them, harming them, being deceitful, interfering with their progress, bothering them, or speaking out against them with the intent to harm them. Vital Concept: Delusional disorder somatic subtype is characterized by a central delusion related to physical symptoms, feelings, or processes of the body.

Answer 777

Correct Answer: D. GI upset Donepezil (Aricept) is a centrally acting, reversible acetylcholinesterase inhibitor used in the treatment of Alzheimer’s dementia. Its side effects are principally related to acetylcholine excess, most commonly GI upset (nausea, vomiting, and diarrhea). Donepezil can cause heart block and symptomatic bradycardia in some individuals, especially those with sick sinus syndrome. Incorrect Answers: A. Muscle rigidity is seen in rare neuroleptic malignant syndrome and is likely caused by dopamine receptor blockade in the hypothalamus, leading to autonomic instability. B. As an acetylcholinesterase inhibitor, donepezil can cause hypotension. C. Flushing is caused by muscarinic blockade (e.g. atropine).

Answer 778

Correct Answer: B. It is metabolized in the liver by CYP3A4. Carbamazepine is metabolized in the liver by CYP3A4 Incorrect Answers: A. Carbamazepine decreases, not increase, risperidone's effectiveness C. Carbamazepine requires monitoring for signs of bruising and bleeding D. Topiramate (not carbamazepine) causes this

Answer 779

Correct Answer: B. 6 months Specific phobia is diagnosed when there is fear about a specific situation/object and that stimulus always provokes an immediate response. Criteria for diagnosis include: · Terror or significant concern about a certain condition or item (small spaces, spiders, heights). · The terror or concern is consistent for at least 6 months. · The patient evades the condition or item. · The terror/concern or active evasion of the condition or item leads to dysfunction (academic, professional, social, or otherwise) or considerable anguish. · The patient reports sudden terror or significant concern almost every time they are presented with the certain condition or item. · The actual risk or threat posed by the condition or item is insignificant compared to the patient’s emotional response and concern. · The patient’s symptoms are not due to a more appropriate psychiatric condition such as panic attacks (i.e., panic disorder), past trauma (i.e., post-traumatic stress disorder), gaining weight (i.e., eating disorders), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). · In pediatric patients, phobias may manifest as dependence, immobility, outbursts, or fits. Incorrect Answers: A. Symptoms must be present for at least 6 months, not 2 months. C. Symptoms must be present for at least 6 months, not 12 months. D. Symptoms must be present for at least 6 months, not 2 years. Vital Concept: DSM-5-TR criteria for specific phobia include terror or significant concern about an item/condition that is out of proportion to that item/condition's danger, always having intense anxiety/fear when presented with the phobic stimulus, avoiding the phobia, and the fear impairs functioning for 6 or more months.

Answer 780

Correct Answer: D. Ganja - flowering tops It is true that ganja is obtained from flowering tops. Its THC content is approximately 6-20%. Incorrect Answers: A. Bhang is obtained from dried leaves only, not leaves and flowers. It contains 1-3% THC content. B. Hashish is obtained from resin, not flowers. It has a 6-20% THC content. C. Marijuana is obtained from leaves and flowers, not just leaves.

Answer 781

Correct Answer: C. Consider changing to a long-acting injectable formulation Patient outcomes, particularly regarding the risk of relapse and rehospitalization, may be improved with medications. Mirror image studies comparing periods on an LAI with periods on oral medication in the same individuals show a strong advantage with LAIs. The same effect has been difficult to demonstrate in controlled clinical trials, however. This is potentially an artifact of trial design, which requires patients who are cooperative and more likely to take their oral medications. There is a consensus that patients who have a history of poor medication adherence or drug refusal are likely to have better outcomes on an LAI. Incorrect Answers: A. While this might work, it's less effective than the LAI at taking compliance out of the equation B. Lithium shouldn't be added if not clinically indicated D. This won't affect compliance, so won't help

Answer 782

Correct Answer: C. Classified as unethical by APA This is not a standard or accepted practice and is considered "exploitation of a patient under the guise of psychotherapy, which may include gratification of the psychiatrist at the expense of the patient" by the APA. There are some therapy practices where a patient who has admitted to having "feelings" for the therapist, will help the patient to talk through these "feelings" but it would be unethical to ask the patient to describe in detail the various fantasies and thoughts about the therapist for the therapist's pleasure. Incorrect Answers: A. This is not commonly used in psychotherapy, nor is it ethical. B. This is not commonly used in psychotherapy, nor is it ethical. D. This is not standard therapy for dispelling sexual feelings between patient and therapist. Vital Concept: "Exploitation of a patient under the guise of psychotherapy, which may include gratification of the psychiatrist at the expense of the patient" is not a standard or accepted practice by the APA.

Answer 783

Correct Answer: D. Carbamazepine Over 50% of patients have side effects when using carbamazepine. Multiple serious adverse reactions and drug-drug interactions make its use challenging. Common dose-related side effects include diplopia, blurry vision, ataxia, and gastrointestinal symptoms. Less common side effects include skin rash, leukopenia (mild and asymptomatic), thrombocytopenia (mild and asymptomatic), hyponatremia, and (rarely) hypo-osmolality. About 5-15% of patients have elevated LFTs. Decreasing the dose can resolve leucopenia, thrombocytopenia, or elevated LFTs. Hyponatremia, caused by the medication's antidiuretic effects, occurs in 6-31% of patients. Hyponatremia is more common in the elderly and generally presents within a few months after starting the medication. Weight gain is another common side effect. Rare idiosyncratic side effects include agranulocytosis, aplastic anemia, hepatic failure, Stevens-Johnson syndrome, and pancreatitis. If an idiosyncratic side effect occurs, it normally happens within the first 6 months of treatment. Patient report is the primary way of ruling out these syndromes, so patients must be educated about the symptoms of these side effects. In overdose, side effects are mainly neurological and cause altered mental status, ataxia, dizziness, and diplopia. Patients commonly present with nystagmus, ophthalmoplegia (eye that is fixed in position), cerebellar and extrapyramidal signs, problems breathing, altered mental status, and convulsions. Cardiac, GI, and anticholinergic symptoms may also occur. The dose range is 200-1800mg/day. Carbamazepine may be better than lithium when treating rapid-cyclers and mixed episodes. It is also the preferred medication when treating interictal psychosis and mood symptoms secondary to temporal lobe epilepsy. It is effective for pain syndromes like trigeminal neuralgia, postherpetic neuralgia, diabetic neuropathy, phantom limb pain, and multiple sclerosis. Other uses include management of behavioral outbursts and withdrawal of benzodiazepines or alcohol. Incorrect Answers: A. Divalproex overdose symptoms include drowsiness, ataxia, tachycardia, and nystagmus (uncontrollable rapidly moving eyes). B. Lithium overdose symptoms include diarrhea, vomiting, stomach pains, tremors, and fatigue. C. Lamotrigine overdose symptoms present as altered mental state, and include convulsions, tremor, and impairment of consciousness ranging in severity to deep coma.

Answer 784

Correct Answer: D. A 22-year-old who is telling her friends about her affair with cricketer Ricky Ponting Erotomanic delusions are present in this 22-year-old who is telling her friends about her affair. Erotomanic delusions are associated with a belief that another person, usually of higher status, is in love with the patient (e.g. a TV/film star, a famous social personality, or a rich person). Incorrect Answers: A. This 35-year-old male is most likely suffering from delusions of grandiosity. Delusions of grandiosity revolve around being great because of a discovery or talent. B. This 22-year-old student is suffering from bizarre or unspecified delusions. Bizarre delusions are not plausible and do not stem from ordinary experiences. C. This 24-year-old female is suffering from somatic delusion. Somatic delusions revolve around body functions/sensations. Vital Concept: Erotomanic delusions are associated with a belief that another person, usually of higher status, is in love with the patient.

Answer 785

Correct Answer: B. The nurse practitioner should remove the information or record the dispute in the record Individuals have the right to have erroneous information corrected in their individually identifiable health information or to have a dispute documented if their request is denied. Incorrect Answers: A. The medical record can be corrected if erroneous information is detected by the patient. C. Seeking independent corroboration could constitute a violation of the patient’s privacy rights. D. Any information that is incorrect should be removed at the request of an individual and should not be shared without authorization. If there is a dispute about the accuracy or integrity of information in an individually identifiable health record, the NP should document that in the record. Vital Concepts: Individuals have the right to have erroneous information corrected in their individually identifiable health information or to have a dispute documented if their request is denied.

Answer 786

Correct Answer: B. Identity vs. role confusion This adolescent is facing identity vs. role confusion (see table below). Incorrect Answers: A. This applies to ages 6-12 (too young) and relates to confidence, competence, and social skills (not applicable). C. This applies to ages 18-35 (too old) and relates to forming a relationship and commitment (not applicable). D. This applies to ages 36-65 (too old) and relates to building a family and having a productive career (not applicable).

Answer 787

Correct Answer: C. 75/125 Negative predictive value (NPV) is the probability that patients with a negative screening test actually do not have the disease. NPV reflects the accuracy of the test. It can only be estimated from population based or cross-sectional study, since it is related to prevalence of the condition in the population. Negative predictive value is defined as: #True negatives/(#True negatives + #False negatives). In this case, it is 75/125. Incorrect Answers: A. 75/200. #True negatives / total number of people studied; this is not the NPV. B. 50/75. #True positives/(#True positives + #False positives) is the positive predictive value (PPV). D. 75/100. #True negatives/(#True negatives + #False positives) is the specificity. Vital Concept: Negative predictive value (NPV) is the probability that patients with a negative screening test actually do not have the disease. NPV= #True negatives/(#True negatives + #False negatives).

Answer 788

Correct Answer: C. Aldehyde dehydrogenase The genes most studied for their role in the development of substance use disorders encode alcohol dehydrogenase and aldehyde dehydrogenase. Alcohol dehydrogenase metabolizes ethanol to acetaldehyde, which is converted to acetate by aldehyde dehydrogenase. While most of this work has confirmed the role of these genes in the dopamine pathway, specific work with dopamine receptor and transporter genes has been largely negative. Incorrect Answers: A. Gain-of-function polymorphisms of the SLC6A4 promoter have been linked to OCD, although a few studies have noted that the short form of this promoter polymorphism shows an association with increased alcohol consumption. B. DOPA decarboxylase converts L-DOPA to dopamine. D. Tryptophan hydroxylase is the rate-limiting step in serotonin synthesis. Vital Concept: Genes encoding alcohol dehydrogenase and aldehyde dehydrogenase are often studied in connection with substance use disorders.

Answer 789

Correct Answer: C. Case management Health care case managers are usually experienced RNs who work to coordinate outpatient care management for patients with certain diagnoses, often chronic diseases. Case management is usually done by telephone. Examples of chronic diseases that frequently benefit from case management include diabetes, COPD, and chronic heart failure. Incorrect Answers: A. Quality improvement programs are programs within a health system in which patient outcomes are used as an indicator of the quality of the health system in order to improve care, improve patient satisfaction, and reduce systems errors, adverse outcomes and complications. B. Risk management is a systemic organizational process that is used to identify risky practices to minimize adverse patient outcomes and corporate liability. Some areas of concern for risk management include iatrogenic infections, falls, and medication errors. D. Discharge planning may include assignment of a case manager when a patient is discharged from the hospital. Vital Concepts: Health care case managers are usually experienced RNs who work to coordinate outpatient care management for patients with certain diagnoses, often chronic diseases.

Answer 790

Correct Answer: C. CPT Current Procedural Terminology (CPT) is a list of identifying codes owned by the American Medical Association and used to describe procedures, including suturing, I & D, and so on. Incorrect Answers: A. ICD-10 refers to the International Classification of Diseases, 10th edition, the code used in the United States to indicate diagnosis. B. V-codes are modifiers that indicate the reason for a visit, but cannot be used for procedures. D. DRG stands for Diagnosis Related Group, which is a statistical system of classifying inpatient stay into groups for the purpose of payment. Vital Concepts: Current Procedural Terminology (CPT) is a list of identifying codes owned by the American Medical Association and used to describe procedures, including suturing, I & D, and so on.

Answer 791

Correct Answer: B. The ego Dealing with conflict through defense mechanisms is a function of the ego, which is part of Freud’s Psychodynamic Theory. Incorrect Answers: A. This is related to basic needs, urges, and desires. C. This controls the id's impulses, particularly around sex and aggression and strives for perfection. D. This is false; the ego deals with conflict through defense mechanisms.

Answer 792

Correct Answer: C. Evidence-based practice Evidence-based practice is the result of the use and integration of solid clinical evidence into clinical care. A nurse practitioner who uses evidence-based clinical practice will critically evaluate research evidence results from experiments and studies for validity and impact of effect to determine if the evidence is applicable for use in the treatment of patients. Incorrect Answers: A. Case management refers to coordination of outpatient management of patients with certain diagnoses, usually chronic diseases. It is often done by telephone by an experienced RN. B. Quality improvement programs are programs that are instituted in a system in response to identification of a problem. These programs are designed to improve quality of care, decrease complications, decrease hospitalizations, lower patient mortality, decrease system errors, and increase patient satisfaction. D. Risk management is an organizational process within a health system that is designed to identify risky practices to minimize adverse outcomes and corporate liability. Vital Concepts: Evidence-based practice is the result of the use and integration of solid clinical evidence into clinical care. A nurse practitioner who uses evidence-based clinical practice will critically evaluate research evidence results from experiments and studies for validity and impact of effect to determine if the evidence is applicable for use in the treatment of patients.

Answer 793

Correct Answer: C. Current Procedural Terminology codes must have all corresponding levels of required history taking, physical examination, and medical decision-making supported in the NP’s documentation The US Department of Justice has increased efforts to tackle healthcare fraud and abuse, which are estimated to account for 7% to 8% of healthcare spending. NPs are responsible to ensure that all billing for their services matches the level of care given and that the documentation supports each level of the CPT code in history taking, physical examination, and medical decision-making. NPs are expected to understand how to bill correctly and ignorance is not a valid defense. Under-coding is not prosecuted but results in lower revenues for the practice. Incorrect Answers: A. and B. NPs are responsible for ensuring billing for services matches the level of care given, and that the documentation supports each level of the CPT code in history taking, physical examination, and medical decision-making D. Under-coding isn't prosecuted, but results in lower revenues for the practice Vital Concepts: NPs are responsible to ensure that all billing for their services matches the level of care given and that the documentation supports each level of the CPT code in history taking, physical examination, and medical decision-making. NPs are expected to understand how to bill correctly and ignorance is not a valid defense.

Answer 794

Correct Answer: D. Positive symptoms decrease and may remit, negative symptoms decrease, and cognitive symptoms stay constant. Positive symptoms decrease and remit in 80% of patients with schizophrenia, but they may take 3 months or longer to remit. Negative symptoms decrease but do not go away altogether, but the cognitive deficit present at diagnosis does not usually change. Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics, such as haloperidol, bind the dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each of the second-generation drugs has a different binding affinity (e.g. risperidone is high, and clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors as well, which may also contribute to their clinical effects. Second-generation drugs are more effective for treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis (at higher than maintenance dosage). Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used for depression or anxiety disorders. ECT can also be used in schizophrenia for catatonia. Early studies also suggest that TMS might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT aid the treatment success of schizophrenia. Incorrect Answers: A. Positive symptoms will decrease and may remit; they don't stay roughly constant. Additionally, negative symptoms decrease. B. Negative symptoms decrease; they don't remit. Cognitive symptoms stay constant; they aren't drastically reduced. C. Positive symptoms decrease and may remit; they don't stay constant. Negative symptoms decrease; they don't remit.

Answer 795

Correct Answer: D. Ask the parents and teachers to complete the Vanderbilt ADHD Rating Scale Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that appears in early childhood. It is characterized by inattention, hyperactivity, and impulsivity that is developmentally abnormal. Boys are more commonly diagnosed than girls. There is no single test that can establish the diagnosis of ADHD. Information should be gathered directly from both parents and teachers on how the child’s behavior impacts the ability to function at home, at school, and with other children. The inattentive, hyperactive, and impulsive behaviors must cause significant impairment in two separate environments to make a diagnosis. Validated rating measures such as the Conners-3 and the Vanderbilt ADHD Rating Scale (VARS) can help make the diagnosis. Incorrect Answers: A. A complete blood count (CBC) is a good screening test for anemia. Anemia should be in the differential diagnosis of disorders that can cause symptoms like ADHD. No specific values on the CBC would confirm a diagnosis of ADHD. B. Interviewing the parents is a great first step toward diagnosing ADHD, but input is needed from multiple adults in a minimum of two situations to confirm the diagnosis. C. This child is more likely to have ADHD if a parent or sibling also has the diagnosis. There is a high concordance of ADHD in identical twins, and multiple different genes contribute to the disorder. There is no specific genetic test currently for ADHD. Vital Concept: ADHD is characterized by the onset of limited attention span or impulse control that starts before the age of 12 and last for more than 6 months. There must be impairment in more than one setting (e.g., at school and at home). Symptoms often persist into adulthood. Treatment includes stimulant medications or non-stimulant medications and cognitive behavioral therapy.

Answer 796

Correct Answer: C. Sertraline Sertraline (Zoloft) is generally the preferred selective serotonin reuptake inhibitor (SSRI) to use while breastfeeding as little to no amounts are detected in the breast milk. In studies breastfed infants of mothers taking sertraline had undetectable sertraline plasma levels. There are controversies about the use of antidepressants in pregnancy and during breast-feeding. The risk and benefits should be discussed. Untreated depression in pregnancy can cause harm due to missing prenatal visits, poor diet, substance abuse, risky behaviors, suicidal gestures, and increase in premature deliveries. Also depression can interfere with a mother bonding with the infant. Incorrect Answers: A. Fluxetine (Prozac), a SSRI, has higher amounts detected in breast milk than most other SSRIs and given the long half life can be found in breast milk for up to 2 months. In one study the range of infants fluoxetine plasma levels was 0-59% of their mothers' fluoxetine plasma levels. B. Citalopram (Celexa), a SSRI, is detected in small amounts in breast milk. One study reported infants’ plasma level of citalopram was on average 7% of their mothers’ plasma levels. The manufacturer reports that weight loss and drowsiness has occurred in breastfed infants whose mothers are taking citalopram. D. Doxepin (Silenor), a tricyclic antidepressant, is detected in breast milk and can cause an increase in sedative like effects. It is not recommended to use this medication. Vital Concept: Sertraline (Zoloft) is generally the preferred SSRI to use while breastfeeding as little to no amounts are detected in the breast milk.

Answer 797

Correct Answer: B. Designated titles by which nurse practitioners are known vary by state Each state develops its own laws regulating nursing, so the designated limits, functions, and titles for nurses may differ from state to state, particularly at the Advanced Practice level. Incorrect Answers: A. All states in the United States license nurse practitioners through the state board of nursing, although their scope of practice may vary according to state law. C. All but two states currently require NP certification by a national certifying organization for nurses. D. An APRN who is employed by the VA can work at any VA facility under a single unrestricted license, although rules concerning physician supervision, prescriptive authority, and admissions may vary between facilities and practice settings. Vital Concepts: Each state develops its own laws regulating nursing, so the designated limits, functions, and titles for nurses may differ from state to state, particularly at the Advanced Practice level. References:

Answer 798

Correct Answer: A. Consent is not required; intubate and ventilate the patient. In medical emergencies, consent for treatment to sustain life or restore health is usually presumed based on implied consent, unless the patient’s wishes to the contrary are known clearly. Although a surrogate can make decisions with the physician, the physician should take reasonable care to ensure the surrogate’s decisions are consistent with both the patient’s preferences and best interests, not the interests and preferences of the surrogate. Treatment should conform to what the patient has expressed orally or in writing or based on the patient’s values, previous choices, and beliefs. In cases where the patient’s wishes are unclear, the physician should act in the patient’s best interest. Where a conflict exists, the physician can refer to an ethics committee and, in some cases, to the court system, if that is in the patient’s best interest. Incorrect Answers: B. Intubation and ventilation should be used C. Ethics committee can be consulted, but doesn't have to be consulted before providing care D. The physicians should make reasonable efforts to follow the patient's wishes instead of the mother's Vital Concepts: In medical emergencies, consent for treatment to sustain life or restore health is usually presumed based on implied consent, unless the patient’s wishes to the contrary are known clearly. Although a surrogate can make decisions with the physician, the physician should take reasonable care to ensure the surrogate’s decisions are consistent with both the patient’s preferences and best interests, not the interests and preferences of the surrogate. Treatment should conform to what the patient has expressed orally or in writing or based on the patient’s values, previous choices, and beliefs. References:

Answer 799

Correct Answer: A. Thyroid disease In a longitudinal study of 85 DS patients up to 25 years of age, 35 percent had hypothyroidism. One-half developed the disorder before age eight years. Two percent had hyperthyroidism (UpToDate). Incorrect Answers: B. Dementia symptoms often begin in patients in their 40s and 50s. C. Self-injury is characteristic of patients with Lesch-Nyhan syndrome. D. Intellectual disability can be variable in patients with Down syndrome. Vital Concepts: Hypothyroidism is common in patients with Down syndrome and may mimic depression. Patients with similar clinical signs should have thyroid bloodwork completed to rule out any thyroid-related issues. References:

Answer 800

Correct Answer: D. Inhalant abuse This patient demonstrates signs of inhalant abuse. The specks of silver paint found on his clothes and in the corners of his mouth suggest inhalant abuse of spray paints containing aromatic hydrocarbons such as toluene or xylene. Aromatic hydrocarbons are the most commonly used inhalant due to their reputation of causing an intense euphoric rush when inhaled; the highest concentration appears in gold- and silver-colored spray paint. Inhalants are volatile substances that produce vapors that can be inhaled. The inhaled vapors are absorbed by pulmonary mucosa and reportedly produce a mind-altering "buzz" or high. Inhalants are dangerous, and their use represents an abuse problem in both the United States and abroad. Adolescents in their early teenage years have the greatest risk of inhalant abuse. Due to the unregulated sale of products containing inhalant chemicals, these agents are easy to obtain and use. Inhalants use is associated with multiple respiratory symptoms such as wheezing, rhonchi, or rales. Inhalant abuse can also lead to aspiration of gastric contents, pneumonitis, or full aspiration causing respiratory distress. The chest X-ray with diffuse and patchy infiltrates indicates inhalant abuse, as chemical pneumonitis is a known consequence. Incorrect Answers: A. A “psychotic break” refers to an initial episode of psychosis that is usually caused by schizophrenia and less often by bipolar disorder or depression. The first psychotic break is characterized by delusions, hallucinations, and “disorganized” speech. In the United States, about 100,000 teenagers and young adults each year experience their first episode of psychosis, with the peak onset between the ages of 15 and 25. B. Hallucinogenic mushrooms have significant psychoactive effects. The most common hallucinogenic mushrooms in the United States contain psilocybin. Alterations in perception include euphoria, visual and spiritual hallucinations, and perceived motion of stationary objects or surfaces. C. Anticholinergic toxicity may follow the ingestion of a wide variety of prescription and over-the-counter medications. Systemic effects also have resulted from topical eye drops. Symptoms include flushing, dry skin and mucous membranes, altered mental status, and fevers. Vital Concept: Inhalant abuse can cause acute mental status changes and confusion. They are often abused by adolescents and can cause serious health problems, including chemical pneumonitis. References:

Answer 801

Correct Answer: C. Most prominent comorbidities are ADHD and social anxiety disorder. The most prominent comorbidities are attention deficit/hyperactivity disorder and social anxiety disorder. One study estimated that up to 75% of males will have some form of social anxiety, it is common in both sexes. ADHD is found in most males, and around 30% of females. Incorrect Answers: A. Female carriers of this disorder may have cognitive disabilities. Females carry the gene abnormality more frequently than males. However, only around 33% of females who carry the abnormal gene have decreased intelligence. B. Fragile X syndrome can coexist with autism spectrum disorder in 50-60% of patients. Autism is diagnosed in 20-30% of individuals with fragile X syndrome, and another 30% of patients with fragile X syndrome are also diagnosed with autistic spectrum disorder. D. The intelligence quotient (IQ) is typically 35-70. Affected patients can also have other associated learning disabilities, aggressive tendencies, and decreasing IQ with increasing age. References:

Answer 802

Correct Answer: A. Switching to longer-acting SSRI Given this patient's history of intermittent noncompliance, she would benefit from a longer-acting agent that is less likely to precipitate withdrawal symptoms after a missed dose. Physical symptoms of discontinuation syndrome include but are not limited to dizziness, nausea, abdominal cramps, sweating, dysesthesias, and irritability. SSRIs with short half-lives (such as paroxetine) may cause withdrawal symptoms with a single missed dose. Switching to an SSRI with a longer half-life (e.g. fluoxetine or citalopram) and tapering off that drug may eliminate withdrawal symptoms. Incorrect Answers: B. Switching to shorter-acting SSRI. Patient is currently taking a shorter-acting SSRI, paroxetine. With patient's noncompliance a longer acting SRRI is a better choice to avoid withdrawal symptoms from missed doses. C. Initiating treatment with benzodiazepine. As benzodiazepines and alcohol have a synergistic depression effect on the CNS and increase the risk for memory impairment when combined, the patient's regular drinking is a reason to consider not treating with benzodiazepine. D. Initiating treatment with mood stabilizer. This patient does not meet criteria for bipolar disorder, so a mood stablizer is not indicated. References:

Answer 803

Correct Answer: D. ADHD stimulants should be discontinued after onset of psychosis and mania. This statement is included in medication labeling. Incorrect Answers: A. Aggression generally responds to stimulant treatment. B. A recent study shows that rates of mania and psychosis in children may be 0.25% or 1 in 400. C. The black box warning for stimulants includes the potential for substance abuse. References:

Answer 804

Correct Answer: A. An evidence review An evidence review is the most important factor in developing evidence-based practices. Incorrect Answers: B and C. If there is inadequate evidence to review, rely on personal experience and staff surveys. D. Cost-effectiveness is an issue, but not your overriding concern. Vital Concepts: An evidence review is the most important factor in developing evidence-based practices. References:

Answer 805

Correct Answer: C. 30% Although most children with ODD will outgrow their diagnosis, approximately 30% of children with ODD will develop conduct disorder. Incorrect Answers: A, B. These percentages are too low (actual percentage is 30%). D. This percentage is too high (actual percentage is 30%). References:

Answer 806

Correct Answer: C. Present the concerns to the ED physician, including the basis for medical decision-making, and ask the ED physician to explain the reasoning for this treatment plan. As always, Dr. B should first discuss the case with the ED physician using evidence-based medicine. If, after discussion, Dr. B believes the patient's outcome will be negatively impacted, Dr. B should consult a higher authority in the department or hospital. Incorrect Answers: A. Dr. B. should not discuss the disagreement with the patient. Dr. B should not go directly to risk management since they deal with legal matters and not with medical treatment. B. and D. It is inappropriate to bypass local authorities by going directly to the state medical board or chairperson. References:

Answer 807

Correct Answer: A. Time of exposure to fixed current The dosage of ECT is varied by increasing the time of exposure to a fixed current. This is possible with “constant current” ECT devices, which are the most commonly used type in the U.S. Incorrect Answers: A, C, and D. These are not how the ECT dosage is changed References:

Answer 808

Correct Answer: A. Durable medical equipment Medicare Part B is outpatient insurance, a voluntary program with monthly premiums. Participants must enroll during an annual general enrollment period. It will pay for the following medically necessary services: * Durable medical equipment * Laboratory and other diagnostic tests * Second opinions * Outpatient visits * Kidney dialysis, organ transplants * Health prevention services (including flu shots, screening mammogram once every 12 months for women older than 40; screening colonoscopy and flexible sigmoidoscopy, etc.) It does not cover eyeglasses or routine eye examinations, except after cataract surgery that implants an intraocular lens. It does not cover dental care, dentures, hearing aids, over the counter drugs, most prescription drugs, or cosmetic surgery. Incorrect Answers: B. Mammograms are covered for women over 40, but not women under 40 C, D. Both not covered at all under Medicare Part B Vital Concepts: Medicare Part B is outpatient insurance, a voluntary program with monthly premiums. Participants must enroll during an annual general enrollment period. It will pay for the following medically necessary services: * Durable medical equipment * Laboratory and other diagnostic tests * Second opinions * Outpatient visits * Kidney dialysis, organ transplants * Health prevention services (including flu shots, screening mammogram once every 12 months for women older than 40; screening colonoscopy and flexible sigmoidoscopy, etc.) References:

Answer 809

Correct Answer: B. Serotonin syndrome This patient’s symptoms indicate serotonin syndrome, which is characterized by brisk reflexes. NMS is characterized by rigidity. She likely used MDMA (ecstasy) at the party, which resulted in serotonin syndrome. This is a known risk of intoxication with MDMA because the mechanism of action involves the release of serotonin. Incorrect Answers: A. The patient doesn't display the symptoms of high fever, confusion, rigid muscles, variable blood pressure, sweating, and fast heart rate that would raise suspicion of this. C. The patient doesn't display the symptoms of delusions, hallucinations, disorganized speech, disorganized behavior or lack of normal behaviors (the "negative" symptoms, including lack of emotional expression, interest, or speech) that would raise suspicion of this. D. The patient doesn't display the symptoms of headaches, nausea, tremors, anxiety, hallucinations, or seizure that would raise suspicion of this. Incorrect Answers: A. This is characterized by high fever and confusion — neither of which is present C. Serotonin is an amino acid that helps regulate blood pressure, not a condition D. Anxiety, headaches, nausea, or shaking hands would happen if this were the case. References:

Answer 810

Correct Answer: C. Treating the patient for a sexually transmitted disease (STD). Regulations require that STDs must be reported by the NP to the public health agency in the community or region. Incorrect Answers: A. The family must have the consent of the patient before information can be released to them. B. The patient must sign a release of information to another physician to be sent the patient's medical information. D. The patient's place of employment should never be given access to patient information. Instead, the NP should write an excuse for the patient. Vital Concepts: Adolescent confidentiality is a complex topic. Laws regarding consent and adolescent confidentiality vary from state to state and the NP must be aware of the laws in the state in which they practice to provide appropriate treatment to the adolescent while also maintaining their privacy and rights. References:

Answer 811

Correct Answer: D. Depolarization of cell membranes of neurons in brain synchronously The electrical stimulus must be strong enough to cause synchronous depolarization of the neurons in the brain. ECT works by Ohm’s law (voltage = current x resistance). Incorrect Answers: A. Depolarization of cell membranes of neurons in brain synchronously, not asynchronously. B. A seizure with ECT occurs when there is depolarization of cell membranes of neurons, not a wave of depolarization traveling across neurons. C. Depolarization of cell membranes of neurons in brain synchronously, not repolarization. Vital Concept: A seizure with ECT occurs when there is synchronous depolarization of neurons in the brain. References:

Answer 812

Correct Answer: B. The surrogate has the right to abort if her health or life is at risk. A surrogate retains the right to terminate a pregnancy that threatens her health or life. If there is no threat to the health of the surrogate, the decision to abort depends on whether she is genetically related to the fetus. In cases where the surrogate is a genetic parent, she can choose to continue a pregnancy even when the sperm donor wants to void the contract. However, if the surrogate receives both ovum and sperm from a couple, the surrogate has no right to choose to continue the pregnancy if the genetic parents disagree. Incorrect Answers: A, B, and D. The surrogate retains the right to terminate the pregnancy if it's putting her health or life at risk. Vital Concepts: A surrogate retains the right to terminate a pregnancy that threatens her health or life. If there is no threat to the health of the surrogate, the decision to abort depends on whether she is genetically related to the fetus. In cases where the surrogate is a genetic parent, she can choose to continue a pregnancy even when the sperm donor wants to void the contract. However, if the surrogate receives both ovum and sperm from a couple, the surrogate has no right to choose to continue the pregnancy if the genetic parents disagree. References:

Answer 813

Correct Answer: D. Hallucinations Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics, such as haloperidol, bind dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, a blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while a lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each of the second-generation drugs has a different binding affinity (e.g. risperidone is high, and clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors, which may also contribute to their clinical effects. Second-generation drugs are more effective for treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis at higher than maintenance dosage. Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used to treat their depression or anxiety disorders. ECT can also be used in schizophrenia, most often for catatonia. Early studies also suggest that TMS might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT can also be very important in the treatment success of schizophrenia. More recent studies have shown that TMS is effective for impulsivity in OCD. Incorrect Answers: A, B, and C. These symptoms aren't improved by TMS as much as hallucinations are References:

Answer 814

Correct Answer: B. The services must be provided subject to restrictions and supervision requirements of the state Services provided by a nurse practitioner are subject to state restriction and supervision requirements. When these provisions are met, the NP may bill Medicare. The NP must meet educational and licensure requirements for nurse practitioners and must bill using a National Provider Identification number (NPI number). Although some states may require direct supervision by a physician on the premises, other states may only require indirect or periodical supervision. Medicare allowed NP services must be medically necessary, equivalent to physician services, and must be accurately documented on a medical record and correctly billed. If state law allows, Medicare may directly reimburse a nurse practitioner. Incorrect Answers: A. Only some states require direct supervision by a physician. C. Some state laws allow Medicare to directly reimburse an NP. D. State, not federal, standards set where Medicare services can be provided. Vital Concepts: Services provided by a nurse practitioner are subject to state restriction and supervision requirements. When these provisions are met, the NP may bill Medicare. The NP must meet educational and licensure requirements for nurse practitioners and must bill using a National Provider Identification number (NPI number). References:

Answer 815

Correct Answer: B. The NP should call child protective services Healthcare providers are legally obligated to report suspected child abuse or neglect. It is important to act to protect the vulnerable child from potential additional abuse. Incorrect Answers: A. Unless the NP is specifically trained for child maltreatment assessment and diagnosis, the NP should limit questioning and refer to CPS as well as an appropriate child abuse team if available. C. While a family meeting will be an important intervention for the protection of the patient, the immediate first step will be to contact CPS. D. In this case, the ethics committee does not need to be called at this point. The priority is the safety of the patient. Vital Concept: NPs are legally obligated to report suspected child abuse or neglect. References:

Answer 816

Correct Answer: B. Subjects were not treated The Tuskegee syphilis experiment was an infamous study of approximately 600 African American sharecroppers in Alabama that took place from 1932 to 1972. The study tested subjects for syphilis, but those subjects who were found to have syphilis were never treated nor told they had syphilis. As a result of this study, laws were passed to protect human subjects and their rights. Informed consent was mandated as a result of this study. Incorrect Answers: A, C, and D. These aren't true Vital Concepts: Laws were passed to protect human subjects and their rights. Informed consent was mandated as a result of this study. References:

Answer 817

Correct Answer: D. Immediately begin cross-titration When clinicians switch to an antidepressant of the same class, no washout is necessary, except for the change from phenelzine to tranylcypromine. In this case the new SSRI may be started while tapering the first SSRI, although the period of overlap increases the possibility of drug-interaction side effects. Incorrect Answers: A. 1 week. No washout period is necessary when switching the patient already on an SSRI to a second SSRI. This is the washout period for switching to a monoamine oxidase inhibitor (MAOI) from TCAs or atypical antidepressants. B. 2 weeks. No washout period is necessary when switching the patient already on an SSRI to a second SSRI. This is the washout period for switching to monoamine oxidase inhibitor (MAOI) from SSRIs, except fluoxetine which requires at least 5 weeks. C. 5 weeks. No washout period is necessary when switching the patient already on an SSRI to a second SSRI. This is the washout period for switching to monoamine oxidase inhibitor (MAOI) from fluoxetine.

Answer 818

Correct Answer: B. The daughter can make a decision to terminate life support for her mother The agent or surrogate named in a medical durable power of attorney is designated by the patient to make all medical decisions in the event the patient becomes incapacitated and is unable to make his or her decisions. No one, not even the spouse, has the right to overrule the surrogate’s decisions. As the daughter is also her financial POA, she is able to make her mother's financial decisions as well. Incorrect Answers: A. Daughter's decisions are legally binding C. As the daughter is the surrogate decision-maker, the spouse can't overrule her D. The daughter's financial power of attorney means she can make financial decisions for her mother Vital Concepts: The agent or surrogate named in a medical durable power of attorney is designated by the patient to make all medical decisions in the event the patient becomes incapacitated and is unable to make his or her decisions. As the daughter is also her financial POA, she is able to make her mother's financial decisions as well.

Answer 819

Correct Answer: A. 0.25 The attributable risk is the difference in rate of disease in an exposed population compared to an unexposed population. Attributable risk = (Incidence of disease/outcome in exposed group) – Incidence of disease/outcome in nonexposed group) AR = 90/200 – 40/200 = 0.25 Incorrect Answers: B. This represents the relative risk (RR). C. This represents the odds ratio. When a = number in exposed group with the bad outcome; b = no. in the exposed group with the good outcome; c = number in control group with a bad outcome; and d = number in control group with a good outcome. The odds ratio represents the odds of a certain event occurring in one group compared to the odds of the event occurring in another group. D. These are calculated from the numbers needed to harm and number needed to treat and aren’t appropriate in this context. Vital Concepts: The attributable risk is the difference in rate of disease in an exposed population compared to an unexposed population. Attributable risk = (Incidence of disease/outcome in exposed group) – Incidence of disease/outcome in nonexposed group)

Answer 820

Correct Answer: C. Provided based on state regulations The NP can bill for services subject to state requirements. Incorrect Answers: A. Although some states require that a physician be present on the premises where a NP practices, this is not universal and is not required by Medicare. B. Many NPs practice in underserved areas, but this is not a requirement for Medicare reimbursement. D. Medicare does NOT require that the services of the NP be billed through a physician's clinic or hospital. Unless prohibited by the state, Medicare may directly reimburse the NP for services. Vital Concept: Nurse Practitioners must use a National Provider Identification (NPI) number and must meet licensing requirements for advanced practice in order to bill. Medicare does not require that the services of the NP be billed through a physician's clinic or hospital. Unless prohibited by the state, Medicare may directly reimburse the NP for services.

Answer 821

Correct Answer: B. Theophylline Theophylline can cause prolonged seizures and status epilepticus. Other medications that should be used with caution or avoided with ECT are hypoglycemics (insulin and orals), B-blockers (can cause asystole), lidocaine (can reduce seizure induction), and lithium (can cause prolonged seizure and confusion). Incorrect Answers: A, C, and D. These medications aren't contraindicated in ECT

Answer 822

Correct Answer: B. Behavioral interventions should precede pharmacologic treatment for aggression. Behavioral treatment is usually the first-line treatment for aggression. Aggression can create many difficulties for a patient with intellectual disability (ID). The degree of aggression can negatively impact relationships with family and affect school performance. Severe aggression is often the reason for institutional placement or specialized school programs. Treatment of aggression is often step-wise; behavioral interventions should be employed before pharmacological interventions. Incorrect Answers: A. Reinforcement of positive behaviors may be beneficial for patients with an ID. C. Mental health conditions such as depression and anxiety are common in patients with an ID. D. Providing the negative behavior is not dangerous to self or others, ignoring negative behaviors can be helpful in encouraging their non-use. Vital Concept: Many developmentally disabled patients require a combination of behavioral and pharmacological interventions. Medication must be optimized for the patient’s level of function and type of placement and to minimize cognitive slowing.

Answer 823

Correct Answer: C. Childhood neglect, OCD Body dysmorphic disorder is characterized by a preoccupation with a defect in physical appearance that is not observable to others or excessive concern with a minor physical anomaly. Criteria also include repetitive behaviors in response to the preoccupation (e.g., mirror-checking, skin-picking, or grooming). Risk factors include childhood neglect and abuse, and the prevalence of BDD is increased in first-degree relatives of people with OCD. Incorrect Answers: A. Body dysmorphic disorder is neither associated with childhood depression as a risk factor (childhood neglect and abuse are risk factors) nor a family history of schizophrenia (a family history of OCD is a risk factor). B. Body dysmorphic disorder is neither associated with childhood anxiety disorders as a risk factor (childhood neglect and abuse are risk factors) nor a family history of bipolar disorder (a family history of OCD is a risk factor). D. Body dysmorphic disorder is associated with childhood neglect and abuse as a risk factor but not with a family history of borderline personality disorder (a family history of OCD is a risk factor). Vital Concept: Childhood abuse/neglect is a risk factor for body dysmorphic disorder, as is a first-degree relative with OCD. References:

Answer 824

Correct Answer: A. Protecting the rights of human subjects who agree to participate in research being done in that institution Every research institution has an IRB. They review all research conducted in that institution. The most important role of the IRB is protecting test subjects. Incorrect Answers: B. The IRB protects the institution by carefully evaluating all research to ensure that best practices and methodology are being utilized without placing the test subject at risk. C. The IRB does not provide legal representation for the researcher or team. D. This is one important role of the IRB. Vital Concepts: Every research institution has an IRB. They review all research conducted in that institution. The most important role of the IRB is protecting test subjects. References:

Answer 825

Correct Answer: B. It often has a chronic course and may fluctuate in intensity. The course is chronic and waxes and wanes over time. Illness anxiety disorder is characterized by an obsession with having an illness or developing an illness. DSM criteria for illness anxiety disorder include: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months, but the illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Findings with respect to age and gender prevalence are inconsistent, but the prevalence in the general population is 1-5%. Onset is most commonly in early adulthood. Incorrect Answers: A. Illness anxiety disorder is chronic and fluctuating, it does not decrease in intensity from early adulthood. C. Illness anxiety disorder fluctuates over time, it does not follow a course of worsening in middle and older age before improving. D. Illness anxiety disorder fluctuates over time, it does not steadily increase in severity over time. Vital Concept: Illness anxiety disorder is chronic and symptoms may fluctuate. References:

Answer 826

Correct Answer: B. Talking to oneself may not be related to psychosis, as this is observed in many individuals with developmental disabilities without psychosis. Talking to oneself may not be related to psychosis. This can be observed in many individuals with developmental disabilities in the absence of psychosis, especially those with Down syndrome. Incorrect Answers: A. Diminished and confabulatory self-reporting is characteristic of patients with intellectual disability. C. Adult patients' cognitive and developmental levels must be taken into consideration. D. Observable signs of responding to internal stimuli must be witnessed in multiple settings. References:

Answer 827

Correct Answer: D. Hearing test It is important to be familiar with developmental milestones. This child shows no delay in reaching his motor milestones. However, he is showing delays in language development, and by age 3 he should be using real sentences with grammatical function, and his vocabulary should consist of around 895 words. In assessing a child with developmental delays, particularly delays in language, it is important to rule-out sensory impairments. A hearing test should be recommended as part of the initial assessment. Incorrect Answers: A, B, and C. None of these tests will help identify if there's a hearing problem interfering with the child's language development (the most likely case) References:

Answer 828

Correct Answer: C. The study subjects should be informed of alternative treatments Informed consent must be obtained from subjects participating in research. Research subjects must be informed that they have the right to withdraw from the research study at any time without penalty or adverse consequences. The study subject must also be given a description of the study, including what he or she is expected to do, information about questionnaires, laboratory studies, and so on. If there is compensation or reward for participation, this should be clear before the study begins. Subjects must be informed of the risks and benefits of participating in a study and confidentiality and protection of their data should be clearly outlined. With any discussion of risks and benefits, subjects must also be fully informed about other available treatment options so they can make a fully informed decision. All study subjects should have the number and/or email address of the contact for the study, so they can contact that person is there are concerns or problems with the study. The design of the study (randomized, blinded) will determine whether or not the study subjects are informed of the treatment group to which they are assigned. Incorrect Answers: A. Study design determines whether patients are told which treatment group they're in B. Study subjects should know who's conducting the study and have contact information for the study D. Study subjects can be compensated Vital Concepts: Informed consent must be obtained from subjects participating in research. Research subjects must be informed that they have the right to withdraw from the research study at any time without penalty or adverse consequences. The study subject must also be given a description of the study, including what he or she is expected to do, information about questionnaires, laboratory studies, and so on. References:

Answer 829

Correct Answer: C. 18 Numerous movement tics and at least one voice tic have occurred (although may not be simultaneous) These tics have occurred for at least 12 months, although their frequency may fluctuate The patient has experienced the tics since childhood or adolescence (prior to 18) The symptoms are not more appropriately related to another medical condition or a substance Incorrect Answers: A. The criteria specify a cutoff of 18, not 10. B. The criteria specify a cutoff of 18, not 12. D. The criteria specify a cutoff of 18, not 25. Vital Concept: The diagnostic criteria for Tourette's specify an age cutoff of 18 years old for symptoms to present. References:

Answer 830

Correct Answer: D. Potent anticholinergic medications Potent anticholinergic medications should be avoided to decrease the risk of cognitive blunting. Incorrect Answers: A. Grief work is especially useful around transitional times in development. B. CBT can be modified to fit the patient’s cognitive level. C. Nonverbal techniques such as art, music, and play therapy are helpful. Vital Concepts: Side effects of anticholinergic medications include dry mouth, cognitive blunting, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating. References:

Answer 831

Correct Answer: A. The patient can see any specialist within the HMO but must first see a PCP enrolled in the HMO network Patients in a health maintenance organization are assigned to a primary care provider who acts as a gatekeeper. The participating healthcare provider is paid a set amount each month per patient. The check comes from the HMO. It is the same, regardless of services provided. If the patient sees a specialist or consultant, the PCP must approve the referral. Patients are limited to specialists and consultants within the HMO network. Physicians who are out of network or not referred by the PCP may not be covered or may be subject to lower reimbursement. In an HMO, patients typically pay a set co-pay at each visit, in addition to the monthly fee paid on the patient’s behalf by the HMO. Incorrect Answers: B. The PCP needs to refer a patient's referral to a specialist or consultant C. Out-of-network physicians or those not referred by the PCP may not be covered, or may be subject to a lower reimbursement (below 100%) D. In HMOs, patients typically pay a set co-pay at each visit in addition to the monthly fee the HMO pays to the HMO on the patient's behalf Vital Concepts: Patients in a health maintenance organization are assigned to a primary care provider who acts as a gatekeeper. The participating healthcare provider is paid a set amount each month per patient. The check comes from the HMO. It is the same, regardless of services provided. If the patient sees a specialist or consultant, the PCP must approve the referral. Patients are limited to specialists and consultants within the HMO network. Physicians who are out of network or not referred by the PCP may not be covered or may be subject to lower reimbursement. In an HMO, patients typically pay a set co-pay at each visit, in addition to the monthly fee paid on the patient’s behalf by the HMO. References:

Answer 832

Correct Answer: D. Discuss the patient’s wishes nonjudgmentally and continue to treat her pain while exploring other coping modalities. It is always unethical for a healthcare provider to assist a patient with suicide directly, although a healthcare provider can prescribe potentially dangerous pain medication for legitimate medical reasons. The death of the patient cannot be the goal of treatment, but it may be a possible outcome of pain management in a terminally ill patient. If the intent is relief of suffering and the patient’s life is shortened as a result, then treatment is still acceptable. This is known as the Law of Double Effect. Even in states where healthcare provider-assisted suicide is legal, a healthcare provider cannot administer the drug directly. Although the subject of healthcare provider-assisted suicide is controversial, healthcare provider-assisted suicide is always wrong in the context of board examinations. A healthcare provider cannot honor a request from a patient to provide the means to commit suicide. Incorrect Answers: A. The morality of suicide is irrelevant — it's unethical for a health care provider to assist in suicide B. Antidepressants aren't likely to help, and there's no indication there are symptoms of depression in play C. The provider needs to respect the patient's desire for confidentiality, so can't notify the husband Vital Concepts: It is always unethical for a healthcare provider to assist a patient with suicide directly, although a healthcare provider can prescribe potentially dangerous pain medication for legitimate medical reasons. The death of the patient cannot be the goal of treatment, but it may be a possible outcome of pain management in a terminally ill patient. If the intent is relief of suffering and the patient’s life is shortened as a result, then treatment is still acceptable. This is known as the Law of Double Effect. Even in states where healthcare provider-assisted suicide is legal, a healthcare provider cannot administer the drug directly. References:

Answer 833

Correct Answer: D. Pheochromocytoma Apart from pheochromocytoma, there are no absolute contraindications to ECT. Care should be taken in patients with cardiac disease, cerebral aneurysm, recent stroke, and trauma. Situations do exist in which the risk of ECT may outweigh its potential benefits. The presence of a space-occupying intracerebral lesion has traditionally been considered a contraindication, as ECT increases intracerebral pressure. Several recent reports have indicated that slow-growing meningiomas without mass effect and other similar lesions do not present a high risk of ECT. ECT has also been safely administered to patients with a history of brain surgery, deep brain stimulators, cardiac pacemakers, automatic implanted defibrillators, and vagus nerve stimulators. Appropriate subspecialty consultation is recommended in such situations. Incorrect Answers: A, B, and C. There's no absolute contradiction for ECT other than pehochromocytoma, none of these answers can be an absolute contraindication to the administration of ECT. Pheochromocytoma is contraindicated due to the risk for exterme hypertension and hemodynamic instability immediately following the procedure. References:

Answer 834

Correct Answer: C. Improve communication between the providers in the hospital and those within the community The ACA created and provided $500 million for CCTP to reduce 30-day readmissions for patients with chronic disease. The goal of these programs is to improve communication between providers both within the hospital and between providers in the hospital and in the community. These efforts also treat transparency of care and come together with other programs synergistically for patient-centered care. Incorrect Answers: A. and B. The ACA doesn't seek to reduce profitability in health care D. The ACA seeks to improve interactions between providers and the community, not providers and settings Vital Concepts: ACA created a program to improve communication between providers both within the hospital and between providers in the hospital and in the community. These efforts also treat transparency of care and come together with other programs synergistically for patient-centered care. References:

Answer 835

Correct Answer: B. 1-5% Illness anxiety disorder is characterized by an obsession with having an illness or developing an illness. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels. DSM criteria for illness anxiety disorder include: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months, but the illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Findings with respect to age and gender prevalence are inconsistent, but the prevalence in the general population is approximately 1-5%. Onset is commonly in early adulthood and displays a chronic, waxing/waning course. Incorrect Answers: A. This percentage is too low — illness anxiety disorder has about a 1-5% prevalence in the general population. C. D. These percentages are too high — illness anxiety disorder has about a 1-5% prevalence in the general population. Vital Concept: The prevalence of illness anxiety disorder is 1-5% in the general population. References:

Answer 836

Correct Answer: D. To ensure that participants understand their rights and responsibilities in the study The primary purpose of informed consent is to make certain that participants in a study understand their role in the study and their rights and responsibilities, including the right to withdraw at any time without adverse consequences or penalties. Patient confidentiality should be discussed so that patients understand how their confidentiality and data will be protected. Informed consent should have no bearing on experimental bias. Although informed consent is a legal requirement for research subjects who participate in a study, the primary purpose of informed consent is not to release the researcher from legal liability. Incorrect Answers: A. Informed consent doesn't affected patient confidentiality B. Doesn't affect experimental bias C. Doesn't release the researcher from legal liability Vital Concepts: The primary purpose of informed consent is to make certain that participants in a study understand their role in the study and their rights and responsibilities, including the right to withdraw at any time without adverse consequences or penalties. References:

Answer 837

Correct Answer: B. The NP should educate the patient about hypertension and the importance of taking his medication each day It is important for a nurse practitioner to be culturally aware and sensitive. Patients do often stop taking prescription medicine when symptoms resolve, and it is not unusual for these patients to save large quantities of leftover prescription drugs. Of note, some Vietnamese patients fear blood tests because they believe blood loss worsens illness; some also believe that Western medicine will put their body out of balance. These patients generally have respect for doctors and may be uncomfortable disagreeing with the treatment plan. Incorrect Answers: A. The NP should tell the patient she will reduce the dose to 12.5 mg daily. The patient still needs to take the hydrochlorothiazide 25 mg daily to treat hypertension. The next best step is to focus on education regarding why the patient has to continue the medication. C. The NP should advise patient to continue not taking hydrochlorothiazide. The patient still needs to take the hydrochlorothiazide 25 mg daily to treat hypertension. The next best step is to focus on education regarding why the patient has to continue the medication. D. The NP should confront the patient about his failure to follow directions. The NP should focus on education of why the patient has to continue the medication, not scold and alienate the patient. Vital Concepts: Patients do often stop taking prescription medicine when symptoms resolve, and it is not unusual for these patients to save large quantities of leftover prescription drugs. References:

Answer 838

Correct Answer: A. Unchanging, abnormal motor behaviors or action sequences without obvious reinforcement Stereotypies are unchanging, abnormal motor behaviors or action sequences without obvious reinforcement. Behavioral treatment is first-line. The determination to utilize more aggressive medication is based upon the level of dysfunction these behaviors represent. SSRIs are generally considered for initial psychopharmacological treatment due to the compulsive nature of the behaviors. Incorrect Answers: B. Stereotypies are unchanging, and don't have obvious reinforcement C. Stereotypies are unchanging D. Stereotypies aren't harmless, and are more than simply tics References:

Answer 839

Correct Answer: A. Short duration of symptoms Functional neurological symptom disorder (FNSD) is demonstrated by unintentional symptoms or deficits that affect voluntary motor or sensory function. Positive prognostic factors include acceptance of the diagnosis and a short duration of symptoms. Poor prognostic factors may include maladaptive personality traits, the presence of comorbid physical disease, and the receipt of disability benefits. FNSD is 2-3x more common in females. Anxiety disorders, especially panic disorder, and depressive disorders are commonly comorbid. Incorrect Answers: B. Comorbid physical illness is a poor prognostic factor. C.Comorbid anxiety disorder is a poor prognostic factor. D. Maladaptive personality traits is a poor prognostic factor for conversion disorder. Vital Concept: FNDS is characterized by physical symptoms not related to any identifiable medical or neurological disorder that are not intentionally portrayed for secondary gain. A short duration of symptoms is a positive prognostic indicator, while comorbid illness and maladaptive personality traits are poor prognostic factors. References:

Answer 840

Correct Answer: C. Human papilloma virus (HPV) HPV is not nationally reportable or required by CDC to be reported. Some states do have reporting requirements. Incorrect Answers: A. Gonorrhea is a reportable disease in all states. B. Lyme disease is a reportable disease in all states. D. Syphilis is a reportable disease in all states. Vital Concepts: HPV is not nationally reportable or required by the CDC to be reported. Some states do have reporting requirements. References:

Answer 841

Correct Answer: D. Autonomy Making one’s own decisions is the basis for informed consent and the ethical response. Incorrect Answers: A and C. Doing good and avoiding harm are ethical principles usually cited as the basis for other health care activities, such as maintaining professional competency. B. Respect for a person is a more global principle supporting much of a nurse’s personal philosophy of caring. Vital Concepts: Making one’s own decisions is the basis for informed consent and the ethical response. References:

Answer 842

Correct Answer: B. Escape-avoidance behavior is an example of a functional behavior. Escape-avoidance behavior is a functional behavior type (e.g. using aggression to get out of doing something). The four main functions that maintain behaviors are: Escape/Avoidance: The individual behaves in order to get out of doing something he/she does not want to do. Attention Seeking: The individual behaves to get focused attention from parents, teachers, siblings, peers, or other people that are around them. Seeking Access to Materials: The individual behaves in order to get a preferred item or participate in an enjoyable activity. Sensory Stimulation: The individual behaves in a specific way because it feels good to them. Incorrect Answers: A. Functional behaviors are generally not driven by underlying psychiatric conditions. C. Functional behavior is defined as a behavior that serves a purpose for the individual that is ongoing. D. Functional behaviors are not always employed with direct conscious awareness. References:

Answer 843

Correct Answer: D. Fear of retribution is a barrier to advocacy Advocacy has long been a part of the history of the nursing profession, within which nurses have advocated on behalf of and alongside patients, families, and communities to promote health, justice, and equality. Advocacy is derived from the Latin word advocatus, which means to plead the cause of another. The definition of advocacy has expanded from its association with legal and political issues and settings to encompass a wide range of activities that are undertaken in support of patients, families, issues, and communities. Advocacy can range from ensuring patients understand their health issues to working alongside residents and leaders in the community to effect positive change in social determinants of health. Despite the centrality of the concept of patient advocacy in nursing, it is a poorly understood concept for which nurses do not always receive adequate training in schools and institutions. Barriers to successful advocacy include lack of education and training in advocacy during formal nursing education. Institutional barriers and fear of retribution also pose formidable barriers to advocacy by nurses. Incorrect Answers: A. While associated with legal and political issues, advocacy has expanded in definition to encompass a wide range of activities that support patients, such as ensuring patients understand their health issues B. Patient advocacy isn't well-understood in nursing practice C. Nursing advocacy can take place in the community as well as clinical setting Vital Concepts: The definition of advocacy has expanded from its association with legal and political issues and settings to encompass a wide range of activities that are undertaken in support of patients, families, issues, and communities. Institutional barriers and fear of retribution also pose formidable barriers to advocacy by nurses. References:

Answer 844

Correct Answer: C. Injuries are typically seen on the torso instead of the extremities. Injuries on an abused patient will typically be found in the areas of the body that are easily covered by clothing -- the torso rather than the extremities. Incorrect Answers: A. A typical victim of abuse will describe a history of the injury that is not supported by the assessment of the injury. B. A typical victim of abuse will try to hide the fact that they are abused and will not seek treatment until after several episodes of abuse or until the injury is so extensive that it cannot be hidden. D. Studies show that the incidence of domestic abuse increases during pregnancy. Vital Concepts: Injuries on an abused patient will typically be found in the areas of the body that are easily covered by clothing -- the torso rather than the extremities. References:

Answer 845

Correct Answer: D. Laboratory results are provided to a spouse This is a violation of confidentiality unless the patient has expressly indicated this is acceptable to her- or he/she requests it. Incorrect Answers: A, B, and C. This is not a violation of patient confidentiality. Vital Concepts: This is a violation of confidentiality unless the patient has expressly indicated this is acceptable to her- or he/she requests it. References:

Answer 846

Correct Answer: A. Integrity vs. Despair Helga demonstrates difficulty with the developmental task of integrity vs. despair. Her lack of involvement, isolation, bitterness, and disappointment all suggest she is falling into despair. Generativity vs. self-absorption or stagnation is evidenced by lack of ability to care for others, which may be true for Helga. Integrity vs. despair is the better answer due to her bitterness and disappointment with life. (C) (D) These are not actual developmental tasks created by Erikson. Incorrect Answers: B. This relates to contributing to the world through work and family; Helga is past this stage of her life. C, D. Neither of these is one of Erikson's developmental stages. References:

Answer 847

Correct Answer: B. Accreditation Accreditation is a voluntary process of evaluation and certification of a healthcare facility or organization that indicates the organization or facility has met certain requirements and excels in its class. The American Nurses Credentialing Center is an example of an accreditation organization. Incorrect Answers: A. Licensure is a legal requirement for healthcare professionals, through which a governmental entity ensures they have met the minimum standards of skill and knowledge required to practice safely. C. Risk management is a systemic organization process that is designed to identify risky practices in order to minimize adverse patient outcomes and corporate liability. D. Quality improvement programs identify problems and use outcome measures to improve quality of care, decrease complications and hospitalization, decrease system errors, and increase patient satisfaction. Vital Concepts: Accreditation is a voluntary process of evaluation and certification of a healthcare facility or organization that indicates the organization or facility has met certain requirements and excels in its class. References:

Answer 848

Correct Answer: B. "I need to obtain collateral information from their teacher." At least six symptoms of inattention OR hyperactivity/impulsivity are required when diagnosing pediatric patients up to age 16 years. Symptoms must frequently occur for at least 6 months and appear inappropriate given the patient’s developmental level. Multiple signs and symptoms must be obvious by age 11, even if identified in retrospect as an adult. Signs and symptoms occur in at least two environments (such as at work, school, home, socially, etc.). The next step is to obtain collateral information from the teacher. If the behavior is only occurring at home, other causes for the behavior (such as problems in the home environment related to parental management of the behaviors) should be explored. DSM-5-TR has no exclusion criteria for people with autism spectrum disorder since symptoms of both disorders co-occur. It is obvious that the signs impede purpose or cause dysfunction at school, work, or with friends/family. Another disorder (such as an anxiety, personality, dissociative, or mood disorder) does not provide an enhanced reason for the symptoms, and they do not happen only during periods of psychosis. Incorrect Answers: A. This behavior should be investigated and not ignored C. The child's teacher should be involved in a diagnosis to assess behavior at school. D. Family history of ADHD isn't required for an ADHD diagnosis Vital Concept: The diagnosis of ADHD is made clinically based on the criteria published in the DSM-5-TR. The observation of inattentive or hyperactive behavior in at least two environments is a requirement for the diagnosis. References:

Answer 849

Correct Answer: C. Loss of taste sensation in the anterior 2/3rd of the tongue The facial (CN VII) and vestibulocochlear nerves (CN VIII) exit the skull through the internal acoustic meatus. A mass compressing that opening may jeopardize the function of these two nerves. CN VII is responsible for innervating muscles of facial expression, in addition to carrying fibers for taste sensation of the anterior 2/3rd of the tongue through a branch called the chorda tympani. CN VIII is responsible for hearing and balance. Of the options listed above, taste in the anterior 2/3rd of the tongue is mediated by CN VII, which is compromised in this scenario. Incorrect Answers: A. B. Clenching the jaw is mediated by the muscles of mastication (masseter, temporalis, lateral and medial pterygoids), which are all innervated by the mandibular branch (V3) of CN V. The same branch carries sensory fibers to the lower part of the face and the area immediately anterior to the ear. V3 exits through the foramen ovale, and is therefore not affected by the mass. D. If CN VIII became affected by the mass, the symptoms experienced by the patient might be tinnitus (ringing in the ears), loss of hearing, dizziness, and/or fullness in the ears. However, this patient is much less likely to experience auditory hallucinations, since hallucinations are more likely to be associated with psychosis and/or intracerebral lesions, rather than lesions compressing the cranial nerves peripherally. References:

Answer 850

Correct Answer: D. Nothing, as this is a culturally sanctioned practice Pica is excluded since this is a culturally sanctioned practice in certain African cultures. Incorrect Answers: A. This isn't related to schizophrenia B. Pica is excluded since this is a culturally sanctioned practice in certain African cultures C. Anemia doesn't relate to the consumption of kaolin References:

Answer 851

Correct Answer: D. Do not write a prescription in one patient’s name that is meant for another patient since this is insurance fraud. Physicians may be confronted with a patient who has limited resources and asks for help to manipulate insurance benefits. To distort information or to provide false information with the intent to defraud is a criminal act, but it is also an unethical action that could jeopardize the patient’s care and result in a loss of patient trust in the doctor. There are multiple avenues to pursue, including the use of a less expensive medication, and the physician should explore alternative treatments with Mr. Jones' daughter while encouraging her to apply for some type of insurance. Incorrect Answers: A and B. Distorting information or providing false information with the intent to defraud is a criminal act. Physicians should be aware that a beneficent intention for patients who are financially stressed may nonetheless be fraud under current law. C. Reporting the patient to his insurance company is not necessary in this case. Vital Concepts: Physicians must always act honestly, openly, and fairly. Physicians should be aware that a beneficent intention to forgive copayments for patients who are financially stressed may nonetheless be fraud under current law. References:

Answer 852

Correct Answer: B. Educate the mother on the importance of early intervention for speech delay and contact Child Protective Services This child shows signs of neglect. Educating his mother on the importance of early intervention for his speech delay should be completed; however, at this point, it is also appropriate to contact social services, as the child has inadequate supervision at home and has a high risk of sustaining further harm.Child neglect can occur without malintent on the part of caregivers. Incorrect Answers: A. It is also appropriate to contact social services, as the child has inadequate supervision at home and has a high risk of sustaining further harm. C. Admitting a child to the hospital is an option when the child has an emergent condition or if the caregivers are unable to care for the child (e.g., due to parental hospitalization) and other forms of temporary care are not possible. D. Calling Child Protective Services and stopping the family from leaving the office is appropriate when the child is at immediate risk of significant harm. Vital Concept: Child neglect can take many forms, including medical neglect and lack of adequate supervision. References:

Answer 853

Correct Answer: D. Amygdala Imaging studies have shown that the amygdala in those with generalized anxiety disorder (GAD) has a larger volume. The amygdala may be involved in GAD due to its fear-related roles. GAD is characterized by excessive anxiety and worry that causes impairment of at least 1 realm of the patient’s life. Patients with GAD often worry about small things and have plenty of fear while expecting the worst from most situations. They might also present with muscle tension, sleep problems, fatigue, or irritability. Prevalence of GAD is highest among women and the elderly as well as patients with low socioeconomic status. Major depression and other anxiety disorders are commonly comorbid with GAD (up to 59%). Incorrect Answers: A. Pons. Pons is a group of nerve fibers in the brainstem connecting the medulla with the cerebellum. Cranial nerves 5-8 originate in the pons. B. Occipital cortex. Occipital cortex is visual processing center of the brain. C. Hippocampus. Hippocampus is part of the limbic system and has several functions regarding forming new memories, learning, and emotions. Damage of the hippocampus is involved in Alzheimer's disease. References:

Answer 854

Correct Answer: D. Create a safety plan using the safety planning intervention (SPI) or similar A safety plan is a personalized plan for the patient to use in a crisis situation. This will help assess the patient's coping skills and identify available resources. Within the safety plan, it is important to review triggers and/or warning signs. There are numerous safety planning tools available based on the patient population being served and the clinical setting. While hospitalization may be considered in this case due to the potential for active suicidal ideations, the patient is currently denying suicidal intent or a plan, making them a moderate risk. With significant safety planning and risk reduction as well as direct outpatient referrals, this patient could be managed safely as an outpatient. Incorrect Answers A. Prescribing another antidepressant at this point is unwarranted, as there is not enough information to determine if the current medication is working. The most important first step is safety. B. Contracting for safety is no longer recommended. C. This is an important component of treatment after the patient's safety plan is established. However, a moderate level of suicide risk warrants direct and personal referrals to other providers. The patient is not reliable enough at this point to make the appointment for themselves. Vital Concept: Safety planning in collaboration with patients at risk for suicide is a vital component of suicide prevention. Various clinical tools, such as the SPI, as available for this purpose and should be individualized based on the clinical setting and patient population being served. References:

Answer 855

Correct Answer: A. Lithium Medically necessary medications or those that have a protective effect with regard to ECT (e.g. most cardiac agents and antireflux preparations) should be administered prior to ECT on treatment days while keeping fluid intake to a minimum. In general, agents that have a potentially deleterious effect—either diminishing the efficacy of ECT or increasing risks—should be reduced, discontinued, or substituted with another agent. Medications that may interfere with the efficacy and safety of ECT include theophylline, lithium, benzodiazepines, and anticonvulsants. It is currently debated whether lithium increases the risk of cerebral toxicity. Although this patient has not taken any medication in the past two weeks, if he had been taking his lithium regularly, holding the lithium dose for 24 hours before each ECT treatment may decrease the risk of cerebral toxicity and is standard practice at some centers. When benzodiazepines cannot be withdrawn, held, or reduced, the antagonist flumazenil can be used to reverse their anticonvulsant effect during ECT. In such cases, a parenteral benzodiazepine (e.g. intravenous midazolam) should be administered immediately after the seizure to avoid withdrawal symptoms. Antipsychotic medication should be continued during ECT in patients with psychosis, particularly those with schizophrenia or schizoaffective disorder, as the two treatment types may have a synergistic action. Currently, the augmentation of ECT with antidepressant medications is widespread, but only preliminary data directly address this practice. Incorrect Answers: B. Should be continued during ECT C. Should be continued during ECT D. Not indicated for cessation before ECT References:

Answer 856

Correct Answer: D. Illness anxiety disorder Illness anxiety disorder is characterized by an obsession with having an illness or developing an illness. DSM criteria for illness anxiety disorder include: An obsession with having an illness or developing an illness Usually, there are no physical symptoms of illness present; if present, symptoms are mild. If there is a medical condition present or a strong family history that puts the patient at an increased risk of developing a medical condition, the preoccupation with developing the condition is unequal and excessive compared to the individual's risk The individual exhibits extreme anxiety surrounding their health. The individual performs unnecessary or excessively frequent health checks to monitor the development of illness and seeks medical treatment and screening more frequently than recommended or indicated based on presentation or health history (care-seeking type); may also avoid medical care, including routine check-ups with their provider or visits to the hospital when indicated due to fear of being diagnosed with an illness (care-avoiding type). The preoccupation with health status has persisted for greater than 6 months, but the illness that the patient fears developing may change over the 6-month period The obsession with the development of an illness cannot be attributed to the presence of another mental health disorder. Incorrect Answers: A. Patients with somatic symptom disorder must have a somatic complaint. This patient does not report any symptoms, but feels something is not right. B. The patient does not complain of pain. C. Functional neurological symptom disorder (conversion disorder) is characterized by blindness, paralysis, or other neurologic symptoms that cannot be explained by medical evaluation. Vital Concept: Illness anxiety disorder is the fixed false belief of having a grave medical illness in spite of multiple medical evaluations and reassurance that no such issue exists. References:

Answer 857

Correct Answer: B. Reversible acetylcholinesterase inhibition Donepezil is believed to improve memory in neurocognitive disorder by increasing the amount of acetylcholine available in the synaptic cleft by inhibiting its breakdown by acetylcholinesterase. This inhibition is reversible, separating this drug from agents that cause organophosphate poisoning. Incorrect Answers: A. This is the mechanism of action in organophosphate poisoning. C. D. These are the mechanisms of action of some types of antidepressants. They are not used in neurocognitive disorders. References:

Answer 858

Correct Answer: C. Mini-mental state exam The mini-mental state exam is used to test for cognitive impairment. It is a 30-point questionnaire used extensively in research and clinical settings to screen for dementia. Incorrect Answers: A. The Romberg test is a test of balance. B. The neurological examination can include assessment of the cranial nerves, strength, reflexes, coordination, balance and other functions. D. A Babinski test is a test of upper motor neuron dysfunction, also known as the plantar response. Vital Concepts: The mini-mental state exam is used to test for cognitive impairment. It is a 30-point questionnaire used extensively in research and clinical settings to screen for dementia. References:

Answer 859

Correct Answer: A. Habit reversal Medication and behavioral therapy are indicated for the treatment of trichotillomania. Habit reversal involves awareness training, in which patients learn to recognize when, where, and how they carry out the compulsive behavior and to apply barriers (e.g. gloves or a hat) to avoid pulling their hair. In a controlled trial, habit reversal was more effective than negative practice (in which the patient is taught to go through the motions of hair-pulling but to stop short of actually pulling it); benefits remained at a 4-month follow-up. Incorrect Answers: B. Negative practice isn't as effective as habit reversal C, D. These aren't useful for this behavior References:

Answer 860

Correct Answer: A. Psychosocial treatments include cognitive-behavior therapy, creating environment to reduce risk of repeat trauma, and safety and anticipatory planning with family. Psychosocial treatments include cognitive-behavioral therapy and anticipatory planning with the family to create an environment of safety and reduce the risk of repeat trauma. These strategies help children separate from the traumatic event and victim role. Incorrect Answers: B. Beta-blockers such as propranolol can decrease arousal symptoms of PTSD. C. Children have a higher rate of disinhibition syndrome (excess silly behavior or agitation) vs. adults when on benzodiazepine therapy for PTSD. D. Atypical neuroleptics may be used short-term in low doses for patients experiencing fear or terror. References:

Answer 861

Correct Answer: C. Clarify your role to the patient and parents and carefully consider proceeding. One of the main differences between clinical and forensic evaluations is the role the psychiatrist plays. In a clinical role, the purpose is to relieve suffering and provide treatment. In a forensic role, the purpose is to answer a legal question and to respond to the court as a fact-finder. Although there is a therapeutic bias with the patient, it is acceptable to take the case when there are no other professionals able to perform the work. Privilege typically is waived, as the information is reported to the court in a testimony, written report, or deposition. If there is a court order for the evaluation, the waiver of privilege is implied. The physician must identify this potential conflict of interest to the court. Failure to respond to the subpoena may result in a contempt-of-court action. A fact witness is an individual who has personal knowledge of events pertaining to the case and can testify regarding things they have personally observed or witnessed. They do not offer opinions. Expert witnesses offer opinions that may assist the judge in understanding technical knowledge to support their ability to make a sound ruling in a case. Incorrect Answers: A, D. Although there's a therapeutic bias with the patient, it's acceptable to take this case when there are no other professionals able to perform the work — in such cases, privilege is typically waived and the information is reported to the court in a testimony, written report, or deposition. Additionally, if there's a court order for the evaluation, the waiver of privilege is implied. B. Failure to respond to the subpoena may result in a contempt-of-court action; therefore, this course of action is not advisable. References:

Answer 862

Correct Answer: D. They should continue to use universal precautions but is not required to disclose their HIV status to patients Healthcare workers should use universal precautions at all times. Whether or not an infected NP should disclose the condition depends upon the likelihood or risk to the patient and relevant regulations or laws that may be in place, but if it becomes clear that the risk to a patient associated with contact or with a procedure is high despite the use of appropriate preventive measures, then the NP should remove themself from caring for the patient. It there was clinically significant exposure to the patient, the NP must inform the patient after the fact. Healthcare providers have an ethical obligation (not legal) to inform the employer or hospital, but the information cannot be used to terminate employment. Incorrect Answers: A. The hospital can't terminate the NP's employment based on their status. B. No obligation to disclose status to patients. C. The hospital needs to be told, but there's no obligation to disclose status to patients. Vital Concept: Healthcare workers should use universal precautions at all times. Whether or not an infected NP should disclose the condition depends upon the likelihood or risk to the patient and relevant regulations or laws that may be in place, but if it becomes clear that the risk to a patient associated with contact or with a procedure is high despite use of appropriate preventive measures, then the NP should remove him/herself from caring for the patient. It there was a clinically significant exposure to the patient, the NP must inform the patient after the fact. Healthcare providers have an ethical obligation (not legal) to inform the employer or hospital, but the information cannot be used to terminate employment. References:

Answer 863

Correct Answer: D. It's regulated by individual states The State Legislative statues define the PMHNP scope of practice. Each state varies in the scope of practice for the PMHNP, for example, some states allow PMHNP to prescribe controlled substances while others do not. The Consensus Model was developed in attempts to provide consistency amongst the states regarding the PMHNP role. Incorrect Answers: A. B. Since states regulate PMHNPs' scope of practice, the federal government doesn't define the PMHNP's scope of practice. C. Since states regulate PMHNPs' scope of practice, individual physicians don't define the PMHNP's scope of practice. References:

Answer 864

Correct Answer: B. A neurological soft sign called astereognosis that may be the result of a lesion in the parietal lobe. This is a soft neurological sign that could be a dysfunction of coordination and fine motor skills. This could warrant a neurological evaluation to r/o any lesions, which are commonly, found in the parietal lobe or other pathology. Soft neurological signs are minor neurological signs indicating non-specific cerebral dysfunction. An example of soft signs include motor overflow, clumsiness, or sensory issues are a few that could be noted. Incorrect Answers: A. Astereognosis is a neurological soft sign, not hard, and is not included in the diagnostic criteria for ASD. C. This is not the definition for agraphesthesia, which is the inability to distinguish letters and numbers written in the palm of the hand. D. This is not likely caused by a CVA and it would be impossible to tell when the CVA was timed, certainly not at birth. Vital Concept: The inability to distinguish common objects through touch and feel is termed astereognosis. This is commonly associated with cerebral dysfunction, specifically related to lesions in the parietal lobe. References:

Answer 865

Correct Answer: D. Intentionally deceives by feigning mental/physical symptoms or induces injury/disease The DSM-5-TR diagnostic criteria for factitious disorder on self include: Exaggerating or fabricating physical or phycological manifestations of an injury or medical condition or the intentional self-infliction of an injury. The individual manipulates themselves to appear to others as unwell, disabled, or wounded. The false and misleading behavior persists despite the lack of an apparent benefit to the individual. The behavior cannot be attributed to another mental health disorder. There is also factitious disorder imposed on another, which is when the patient intentionally deceives by feigning mental/physical symptoms or induces injury/disease in another, and they present that individual to others as ill or injured. Incorrect Answers: A. The deceptive behavior is evident in the absence of obvious external rewards B. The prognosis for factitious disorder is poor, and recovery appears to be infrequent, especially among patients who are identified later in their course. C. The treatment of factitious disorder is psychotherapy. Humiliation should be minimized, and the patient should be helped to "save face." Confession is not required for initial management and treatment, and the entire differential diagnosis, not just factitious disorder, should be discussed. Vital Concept: In factitious disorder imposed on self, the patient intentionally deceives by feigning mental/physical symptoms or induces injury/disease, presenting to others as ill or injured without external rewards. References:

Answer 866

Correct Answer: D. Report suspected elder abuse immediately to adult protective services. Elder abuse is treated similarly to child abuse, and a healthcare provider has a responsibility to report this suspicion even when the patient denies abuse, as the patient may be fearful of repercussions. Breaching patient confidentiality is acceptable if the interests of a vulnerable patient are best served by reporting. Incorrect Answers: A. Good-faith reports of elder abuse can be made without fear of liability to the healthcare provider. B. and C. In cases of elder abuse, a delay may result in additional harm to a vulnerable person. Vital Concepts: Elder abuse is treated similarly to child abuse, and a healthcare provider has a responsibility to report this suspicion even when the patient denies abuse, as the patient may be fearful of repercussions. References:

Answer 867

Correct Answer: C. The NP must have parental permission to speak with the minor in order to obtain the assent of the minor "Assent" is not the same thing as "consent." Minors cannot, in most cases, legally give "consent." However, they can agree to participate. Minors are any persons under 18 years of age. Emancipated minors include those minors with legal court documents declaring the minor is “emancipated”; minors on active duty in the US military; and minors in a legal binding marriage (or divorced from a legally binding marriage). A minor who is between the age of 7 and 17 but is not emancipated can give “assent” to participate in a research study, but the minor cannot give legal consent. Before a researcher can speak to the minor to get the minor’s assent for participation, the researcher must obtain parental consent (or consent from the legal guardian) for the minor’s participation in the study and to speak with the minor to obtain assent - which refers to the minor's agreement - from the minor. The minor will then sign a second document (assent.) Incorrect Answers: A and D. Non-emancipated minors can give "assent" but not legal consent. B. Consent needs to be obtained from the parent or legal guardian. Vital Concept: "Assent" is not the same thing as "consent." Minors cannot, in most cases, legally give "consent." However, they can agree to participate. Minors are any persons under 18 years of age. Emancipated minors include those minors with legal court documents declaring the minor is “emancipated”; minors on active duty in the US military; and minors in a legal binding marriage (or divorced from a legally binding marriage). A minor who is between the age of 7 and 17 but is not emancipated can give “assent” to participate in a research study, but the minor cannot give legal consent. References:

Answer 868

Correct Answer: C. Patient advocate Healthcare providers often act as advocates for patients. An advocate can communicate the concerns and wishes expressed by the patient to the patient’s family and other loved ones. Incorrect Answers: A. An educator explains concepts and facts, demonstrates procedures like self-care, reinforces learning, and evaluates the progress of the patient in learning. B. Case managers are usually RNs who communicate with a patient and involved parties by telephone to facilitate outpatient management of selected diseases and conditions. D. When acting as a caregiver, the nurse practitioner is helping the patient meet all healthcare needs, for restoration of patient well-being. Vital Concepts: Healthcare providers often act as advocates for patients. An advocate can communicate the concerns and wishes expressed by the patient to the patient’s family and other loved ones. References:

Answer 869

Correct Answer: A. Dextroamphetamine/amphetamine A review by Arnold (2000) suggested that approximately 44% of study subjects with ADHD respond preferentially to 1 of the 2 classes of stimulants (methylphenidate and amphetamines) and that the initial response rate to stimulants may be as high as 85% if both stimulants are tried. If the first stimulant fails, a second stimulant should be tried. In this case, the patient did not seem to respond to methylphenidate and should be tried on an amphetamine prior to changing to another class of medication. Incorrect Answers: B. Atomoxetine is a noradrenergic reuptake inhibitor that is FDA-approved for ADHD and is considered for patients with substance abuse problems, comorbid anxiety, or tics. C. Bupropion and TCAs are also used for ADHD but are not FDA-approved. D. Desipramine should be used with extreme caution in children and adolescents due to reports of sudden death. References:

Answer 870

Correct Answer: B. COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA), also known as “COBRA coverage,” provides for the continuation of preexisting group health insurance (from the employer) for persons who lose coverage, whether between jobs, if they quit a job, or are fired. Coverage continuation is extended for a fixed period of time. Incorrect Answers: A. ACA refers to the Affordable Care Act of 2010, a national bill that reformed healthcare insurance law in the country. C. HIPAA refers to the Healthcare Insurance Portability and Accountability Act, sometimes known as the HIPAA Privacy Law. D. HMO stands for health maintenance organization, which is a type of insurance plan. Vital Concepts: The Consolidated Omnibus Budget Reconciliation Act (COBRA), also known as “COBRA coverage,” provides for the continuation of preexisting group health insurance (from the employer) for persons who lose coverage, whether between jobs, if they quit a job, or are fired. Coverage continuation is extended for a fixed period of time. References:

Answer 871

Correct Answer: A. Medicaid Medicaid is a combined federal and state welfare program to assist low-income people of all ages with payments for medical care. Incorrect Answers: B. Medicare, a federal health insurance program for those who have social security or have bought into Medicare. C. Social Security is a federal pension program that provides old age, survivors, and disability insurance, with the monthly amount based on prior earnings. D. Supplemental Security Income (SSI), a federal program, provides additional money to seniors older than 65, the blind, or disabled people with low incomes and few resources. Vital Concept: Medicaid is a combined federal and state welfare program to assist low-income people of all ages with payments for medical care. References:

Answer 872

Correct Answer: A. Dexmethylphenidate (Focalin IR): 20mg daily Dexmethylphenidate (Focalin) is a stimulant that inhibits reuptake of dopamine and norepinephrine. It is the d-isomer of methylphenidate and twice as potent as methylphenidate. It is FDA approved for ADHD in adults (XR only) and in children 6 years or older (XR and IR). Focalin (IR) and Focalin XR are the available formulations. Focalin (IR) can be started at 2.5 mg twice a day and the FDA maximum is 20 mg/day. The recommended starting dose of Focalin XR for adults is 10 mg/day and the FDA maximum for adults is 40 mg/day. The recommended starting dose of Focalin XR for children is 5 mg/day and the FDA maximum for children is 30 mg/day. Incorrect Answers: B. FDA-indicated maximum for methylphenidate is 60 mg daily, not 40 mg. C. FDA-indicated maximum for methylphenidate LA is 60 mg daily, not 80 mg. D. FDA-indicated maximum for methylphenidate-OROS (Concerta) is 72mg, not 108 mg. Vital Concept: Focalin (IR) FDA maximum is 20 mg/day and Focalin XR (used for adults only) FDA maximum is 40 mg/day. References:

Answer 873

Correct Answer: C. Serotonin, norepinephrine, and dopamine Monoamine oxidase inhibitors were the first antidepressant class used clinically but have an extensive side effect profile. They are still used in some cases and are effective for treatment resistant depression. MAOIs affect the oxidative deamination of neurotransmitters serotonin, norepinephrine, and dopamine. The dietary precautions are necessary because blockade of monoamine oxidase in the GI tract prevents metabolism of tyramine, which then enters the general circulation and can lead to a severe hypertensive crisis. Incorrect Answers: A. Glutamate is the major excitatory neurotransmitter in the CNS and is not significantly affected by MAOIs. B. Dopamine is affected by MAOIs, but GABA is not affected. D. GABA is the major inhibitory CNS neurotransmitter and plays a role in regulation of anxiety. References:

Answer 874

Correct Answer: E. Attention-deficit/hyperactivity disorder Autism spectrum disorder (ASD) is often associated with intellectual disability and structural language disorder. 70% of those with ASD have one comorbid mental health disorder, and 40% have two or more comorbid mental health disorders. Individuals with autism spectrum disorder often have comorbid attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and depressive disorders. The largest study regarding comorbid mental health disorder diagnoses in children with ASD reported comorbid rates of 78% with ADHD, 73% with ODD, 56% with anxiety disorders, and 30% with mood disorders (e.g., depression and mania). Also identified the following patterns of comorbidity (mutually exclusive): ASD with ADHD + ODD + anxiety (17%), ASD with ADHD + ODD + anxiety + mood (16%), ASD with ADHD + ODD (15%), ASD with ADHD only (10%), ASD with ADHD + anxiety (9%), and ASD with anxiety only (7%). Incorrect Answers: A. Anxiety disorders are commonly comorbid with ASD but less often than ADHD and ODD. B. Tic disorders occur in patients with ASD but are far less common than anxiety, ADHD, and ODD. C. Depression is commonly comorbid with ASD but less commonly than anxiety, ADHD, and ODD. D. Eating disorders may occur with ASD but are less common than anxiety, ADHD, and ODD. Vital Concept: Children with autism spectrum disorder often have comorbid intellectual disability, attention deficit hyperactivity disorder, oppositional defiant disorder, and anxiety disorders. References:

Answer 875

Correct Answer: C. 9-12% Studies suggest that ADHD is present in most cultures in approximately 9% of children. There is a 2:1 male:female ratio in children and a 1.6:1 ratio in adults. Incorrect Answers: A, B. These percentages are too low D. This percentage is too high References:

Answer 876

Correct Answer: C. Autism spectrum disorder should be included in the differential diagnosis of intellectual disability Although autism spectrum disorder is a separate diagnostic category from intellectual disability, it should be included in the differential diagnosis of intellectual disability. It was once believed that around 70-80% of those with autism spectrum disorders also had an intellectual disability. However, this number is likely much lower as a result of including milder cases of autism in addition to catching the disorder much earlier and incorporating better therapies. The diagnostic criteria for ASD include the statement that ASD should not be diagnosed in a patient if a diagnosis of ID provides an enhanced explanation for their symptoms. Incorrect Answers: A. Autism spectrum disorder should be included in the differential diagnosis of intellectual disability, as current estimates range from 30-70% of those with ASD also have ID. B. Although it was once believed that around 70-80% of those with autism spectrum disorders have an intellectual disability, it's now believed to be as low as 30%. D. Although it was once believed that around 70-80% of those with autism spectrum disorders have an intellectual disability, it's now believed to be as low as 30%. Vital Concept: Current estimates regarding the finding of comorbid ASD with intellectual disability are 30-70%. In a patient with ID, ASD should be included in the list of differentials. References:

Answer 877

Correct Answer: D. Herpes zoster In 2017, the ACIP (Advisory Committee on Immunization Practices) updated their guidelines about the herpes zoster vaccine. A new subunit vaccine, Shingrix, is now recommended for patients >50 years old, regardless of whether they have received the older herpes zoster vaccine, Zostavax. Incorrect Answers: A. Pneumococcal vaccine is now routinely given to Native Americans, children, seniors over 65, immunosuppressed and the chronically ill. B. Hepatitis A vaccine is for patients with chronic liver disease, HIV, travelers to endemic areas, men who have sex with men, injection or non injection drug use, and homeless. C. Recommended for newborns and older adults at risk for infection. Vital Concepts: In 2017, the ACIP (Advisory Committee on Immunization Practices) updated their guidelines about the herpes zoster vaccine. A new subunit vaccine, Shingrix, is now recommended for patients >50 years old, regardless of whether they have received the older herpes zoster vaccine, Zostavax. References:

Answer 878

Correct Answer: C. Paternalism All adult patients are considered competent to make decisions about their medical care unless a court has declared them incompetent, although in practice a physician may determine a patient lacks decision-making capacity or does not have the capacity to understand the nature of the proposed treatment, alternatives, risks, benefits, and consequences. In the absence of evidence of incompetence, the patient’s wishes should be respected. In this case, the patient is competent and has not designated her husband as a proxy. Consequently, ceding authority for the patient’s decision-making to her husband represents paternalism. Incorrect Answers: A. This is opposite of patient autonomy (allowing patient to make their own decisions). B. Informed consent involves ensuring patients understand the procedures and drugs they're undergoing and taking, which isn't related to decision not to participate in a trial. D. Patient protection relates to patients' legal rights, not to their decision to participate in a trial. Vital Concepts: All adult patients are considered competent to make decisions about their medical care unless a court has declared them incompetent, although in practice a physician may determine a patient lacks decision-making capacity or does not have the capacity to understand the nature of the proposed treatment, alternatives, risks, benefits, and consequences. References:

Answer 879

Correct Answer: C. Sertraline Sertraline has the lowest risk of drug interactions, which has made it popular in the treatment of geriatric patients. Incorrect Answers: A. B. These drugs inhibit the 2D6 enzyme, which metabolizes TCAs, type 1C antiarrhythmic agents, benztropine, and many antipsychotics. D. Fluvoxamine is a potent CYP1A2 inhibitor. References:

Answer 880

Correct Answer: C. Avoidance of harm. This principle is based on the Hippocratic rule of first, do no harm. Incorrect Answers: A. This is the definition of beneficence. B. This is the definition of fidelity. D. This is the definition of justice. Vital Concept: The four principles of health care ethics delineate for providers certain guidelines to guide medical decision making. The four principles of health care ethics are autonomy, beneficence, non-maleficence, and justice. References:

Answer 881

Correct Answer: D. Nurse practitioners are more likely to serve in rural areas Nurse practitioners are a growing presence in primary care. Studies have shown that NPs are more likely to serve underserved urban populations and rural areas. Incorrect Answers: A. The IOM report called "Future of Nursing: Leading Change, Advancing Health" noted that state laws and regulations have not kept pace with the evolution of nursing over the past 40 years. In the report, the IOM criticized state laws that prevented APRNs, including NPs, from practicing to the full extent of their training. B. Reimbursement policies, scope of practice regulations, and licensure regulations for NPs are determined by individual states. Usually, NPs are regulated by the state board of nursing, but in some states, the task is jointly shared with the board of medicine or performed by a unique subsidiary board. Current rules and regulations for qualifications, practice and prescription authority, and reimbursement of NPs vary across states. In addition to state laws for reimbursement of NPs, private insurance reimbursement of NPs as primary care providers varies within individual states and across states. Only a few states have enacted laws that mandate direct reimbursement of NPs by third parties for covered services as a class of primary care providers. C. Nurse practitioners are the most common non-physician healthcare providers of primary care. Vital Concepts: Nurse practitioners are a growing presence in primary care. Studies have shown that NPs are more likely to serve underserved urban populations and rural areas. References:

Answer 882

Correct Answer: A. Specific learning disorder Specific learning disorder is a DSM-5-TR diagnosis that combines the prior diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Specific learning disorder in the DSM is now defined as Challenges acquiring or utilizing new mental skills or capabilities, as evidenced by one or more of the following for a period lasting 6 months or more despite attempts to address those challenges: · challenges with reading comprehension (reading to understand) · challenges writing with proper punctuation, grammar, organization, and intelligibility · challenges with numerical facts/calculation (math skills) OR reasoning (concepts) · challenges reading individual words (may guess, read words incorrectly, unable to sound them out, or read extremely slow) · challenges with spelling words correctly These challenges are not as expected given the patient’s age and substantially hinder educational, professional, or daily functioning as evidenced by standardized tests or clinical evaluation. In patients over 17, historical evidence of challenges may replace standardized testing. While these challenges emerge while in primary school, the patient may be capable of compensating, and thus delay their observation until the requirements exceed the patient’s abilities (e.g., a significant deadline, increased education responsibilities, time-based testing) These challenges are not more accurately attributed to a poor teaching/access to education, pervasive intellectual disability, decreased language proficiency, vision or hearing deficit, or another mental or medical condition. Specifiers: · r/t reading: word reading accuracy; reading rate/fluency; reading comprehension · r/t writing: spelling accuracy; grammar and punctuation accuracy; clarity or organization of written expression · r/t mathematics: number sense; memorization of arithmetic facts; accurate or fluent calculation; accurate math reasoning · mild: one or two domains affected but able to complete tasks with accommodations · moderate: substantial challenges in at least one domain requiring intense support/assistance · severe: several domains affected requiring intense support/assistance continuously and accommodations. Despite this, patient may still not complete all work. Incorrect Answers: B. This IQ is too high for mild intellectual disability (IQ range 52-69). This patient's IQ of 100 is in the average range C. There is no mention of any inattentive or hyperactive symptoms consistent with ADHD. Specific learning disorder is the best answer choice. D. Students with dyslexia are more likely to display lower scores in reading, not math. Vital Concept: Specific learning disorder is a neurodevelopmental disorder where learning difficulty and problems with academic skills are significantly below age-level and manifest in early school years. References:

Answer 883

Correct Answer: B. Affordable Care Act (ACA) ACA is the program that allows parents to provide insurance cover their children to the age of 26. Incorrect Answers: A. The OAA provides social services for Native Americans and older Americans. C. COBRA enables Americans who change employment to continue health insurance coverage for a certain amount of time while they look for other employment. D. The ADA protects disabled Americans from discrimination because of their disability. Vital Concepts: ACA is the program that allows parents to provide insurance cover their children to the age of 26. References:

Answer 884

Correct Answer: B. 10% Although it is the symptom that often receives the most attention, it is actually fairly rare. Incorrect Answers: A. This percentage is too low. C, D. These prevalence percentages are too high by 2 and 3 times, respectively References:

Answer 885

Correct Answer: C. In an emergency that threatens the life or limb of a child, a court order may need to be obtained if the parents choose to withhold treatment. When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking involvement of a State child protection agency or a court order might be necessary. Incorrect Answers: A. Caregivers cannot refuse life-saving care for their minor children. B. Caregivers cannot refuse life-saving care for their minor children. D. Consent from another relative isn't needed to administer life-saving care. Vital Concept: When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking involvement of a State child protection agency or a court order might be necessary. References:

Answer 886

Correct Answer: C. They are more likely to report fewer symptoms. Malingerers who are caught are more likely to report a larger number of symptoms and to include bizarre symptoms in these reports. Those who are able to avoid detection tend to be more subtle and include more common symptoms, as well as fewer overall symptoms. Although all malingerers tend to cluster symptoms in ways that do not fit a medical diagnosis, this can still be done in a subtle way to avoid detection. Incorrect Answers: A. Successful malingerers report a lower, not higher, number of symptoms. B. Successful malingerers report more common, not less common, symptoms. D. As hallucination is a "bizarre symptom," it's less likely to be reported by successful malingerers (they tend to report more common symptoms). Vital Concept: Successful malingerers report fewer symptoms than unsuccessful malingerers. Successful malingerers usually report common symptoms. References:

Answer 887

Correct Answer: B. Encourage the patient to tell his girlfriend, but counsel him that you are legally and ethically obligated to report to the health department in any case. Preserving confidentiality is important to foster trusting relationships between physicians and patients, but the duty to protect others sometimes outweighs confidentiality considerations. In this scenario, serious harm is both probable and preventable; therefore, the physician should act promptly to stop the spread of disease. There is no absolute patient right to privacy when confidentiality must be breached to protect others. The Tarasoff case in 1976 established a legal precedent that a healthcare provider must inform a potential victim to prevent harm. This includes partner notification of sexually transmitted diseases, including HIV and syphilis. Before breaking confidentiality, a reasonable attempt must be made to enlist the patient to inform the sexual partner. There is also a legal obligation to report the incident to the health department if the partners are not informed. States have different laws concerning partner notification. It is important to understand both the legal and ethical obligations involved in reporting HIV and other communicable diseases in the location of practice. Incorrect Answers: A. This shouldn't be the first step. Before breaking confidentiality, a reasonable attempt needs to be made to enlist the patient to inform the sexual partner. C. Before breaking confidentiality, a reasonable attempt needs to be made to enlist the patient to inform the sexual partner. D. The health department wouldn't notify the sexual partner (except in limited cases, such as health department investigations). Vital Concepts: Preserving confidentiality is important to foster trusting relationships between physicians and patients, but the duty to protect others sometimes outweighs confidentiality considerations. There is no absolute patient right to privacy when confidentiality must be breached to protect others. References:

Answer 888

Correct Answer: C. The claim will be covered Occurrence-based malpractice coverage is a type of malpractice insurance that is not affected by retirement or job changes. Under this type of policy, all claims derived from the period the policy is in effect will be covered. If she had a claims-made policy, the claim would not be covered after she left that employment and policy, unless she purchased “tail coverage.” A nurse can be sued in another state over actions that took place in that state. Incorrect Answers: A. The claim will be covered B. Tail coverage isn't needed for those with occurrence-based coverage D. A nurse can be sued in another state over actions that took place in that state Vital Concepts: Occurrence-based malpractice coverage is a type of malpractice insurance that is not affected by retirement or job changes. Under this type of policy, all claims derived from the period the policy is in effect will be covered. If she had a claims-made policy, the claim would not be covered after she left that employment and policy, unless she purchased “tail coverage.” A nurse can be sued in another state over actions that took place in that state. References:

Answer 889

Correct Answer: D. Nortriptyline TCAs (doxepin) and MAOIs (tranylcypromine, isocarboxazid, phenelzine) are more poorly tolerated in geriatric patients and are generally considered second- or third-line agents in this patient population. However, nortriptyline is still used as a first-line agent for elderly melancholic patients (see table below). Incorrect Answers: A, B. These are MAOIs, which are poorly tolerated in geriatric patients and generally considered second- or third-line in this population C. This is a TCA, which is poorly tolerated in geriatric patients and generally considered second- or third-line in this population References:

Answer 890

Correct Answer: C. It does not address the conflict There are distinct ways to respond to conflict, including avoidance, competition, accommodation, compromise, and collaboration. Styles of conflict resolution have been demonstrated to be predictive of the level of morale, burnout, and job satisfaction in the nursing profession. Avoidance does not address a conflict and results in a lose-lose situation. It results in ineffective and unproductive outcomes by postponing the conflict. When individuals are avoiding conflict, they neglect their own needs, goals, and concerns, while trying to satisfy those of others. Accommodation results in meeting the goals of the other person, which is a lose-win situation. This style of conflict resolution may be appropriate when the issue or the goal is more important than winning; when one individual is more powerful; or when an individual is wrong. Competition results in pursuing one’s own goals at the expense of another, and may be appropriate when a quick decision must be made. Compromise combines both assertiveness and cooperation and may be effective when individuals are of equal power and the conflict requires expedient resolution. Incorrect Answers: A. Avoidance results in neglecting one's own needs, goals, and concerns B. Avoidance tries to meet the other's needs, but doesn't meet them D. Avoidance isn't effective regardless of the individuals' power Vital Concepts: There are distinct ways to respond to conflict, including avoidance, competition, accommodation, compromise, and collaboration. Styles of conflict resolution have been demonstrated to be predictive of the level of morale, burnout, and job satisfaction in the nursing profession. References:

Answer 891

Correct Answer: D. Several ADHD symptoms must be obvious by age 11. Attention-Deficit Hyperactivity Disorder (ADHD) Criteria: pattern of inattention and/or hyperactivity-impulsivity 6 or more inattentive symptoms (only 5 symptoms if age 17 or older) for at least 6 months 6 or more hyperactivity-impulsivity symptoms (only 5 symptoms if age 17 or older) for at least 6 months several symptoms obvious by age 11 several symptoms present in at least two environments obvious dysfunction another disorder (such as an anxiety, personality, dissociative, or mood disorder) does not provide an enhanced reason for the symptoms, and they do not happen only during periods of psychosis Incorrect Answers: A. To meet inattention domain criteria, the symptoms must be present for the past 6 months, not 3 months. B. To meet hyperactivity-impulsivity domain criteria, the symptoms must be present for the past 6 months, not 12 months. C. To meet inattention domain criteria must have 6 or more of the inattentive symptoms (only 5 symptoms if an older adolescent or adult), not 8. Vital Concept: Patterns of inattention and/or hyperactivity-impulsivity should be present for at least 6 months for an ADHD diagnosis, and several symptoms should be obvious by age 11. References:

Answer 892

Correct Answer: A. Children who develop COS have abnormal cognitive and social development prior to the onset of psychosis. Schizophrenia typically presents in early adulthood. Early-onset schizophrenia (EOS) refers to when it presents before 18 years old and childhood-onset schizophrenia (COS) refers to when it presents before 13 years old. COS is rare. Schizophrenia consists of four phases including prodromal, acute, recovery and residual. The prodromal phase consists of decline in function prior to the onset of psychosis. In children with COS this phase can consist of cognitive decline, mood symptoms and impaired social development. Incorrect Answers: B. Children with psychosis do NOT typically report symptoms to parents and caregivers. C. The later the onset of COS, the better the prognosis. Better COS prognosis is associated with higher premorbid intelligence, more positive than negative symptoms of schizophrenia, and cooperation of family in treatment. D. Childhood psychosis is also seen in patients with major depression, bipolar disorder, and severe dissociative states such as PTSD. Vital Concept: Childhood-onset schizophrenia (COS) refers to when schizophrenia presents before 13 years old. The prodromal phase of COS can consist of cognitive decline, mood symptoms and impaired social development. References:

Answer 893

Correct Answer: D. Older Americans Act (OAA) The Older Americans Act (OAA) of 1965 was established to provide improved access to services for older adults (age 60+). In 1978 the OAA was amended to provide additional support services for Native Americans, including community services. It established the Administration on Aging and supports Meals on Wheels, senior centers, and various in-home services. These support services are available to anyone but targeted predominantly at those who are low-income, of minority racial background, non-English speaking, or within remote rural communities. Incorrect Answers: A. The Emergency Medical Treatment and Active Labor Act (EMTALA) is designed to prevent patient “dumping” from emergency departments due to premature discharge for economic reasons. B. The Omnibus Budget Reconciliation Act (OBRA) establishes guidelines for long-term care nursing facilities. C. The Americans with Disabilities Act (ADA) provides access to employment and community services for physically and mentally disabled individuals. Vital Concept: The OAA provides support and social services to Americans over the age of 60, with a heightened focus on the most vulnerable members of the age cohort: low-income, non-English speakers, minorities, and rural residents. References:

Answer 894

Correct Answer: C. Stark The Stark Law states that a physician cannot refer a patient covered by Medicare to a clinic or laboratory in which the physician or an immediate family member of the physician has a financial relationship. The physician may not refer a patient to designated health services including physical therapy services, occupational therapy services, radiation therapy services, radiology services, durable medical equipment and supplies, parenteral and enteral nutrients, prosthetics, orthotics, and prosthetic devices; home health services; outpatient prescription drugs; and inpatient and outpatient services in which the physician has a financial relationship with the facility offering the services. The Stark Law is aimed at physicians, but if a physician requires an NP employee to refer to an entity with which he or she has a financial relationship, the NP may become involved in a violation of the Stark Law. Incorrect Answers: A. The Affordable Care Act of 2010 seeks to expand access and improve quality of health care in the US. B. HITECH is legislation that concerns health information technology. D. HIPAA provides protection for confidential patient medical information. Vital Concepts: The Stark Law states that a physician cannot refer a patient covered by Medicare to a clinic or laboratory in which the physician or an immediate family member of the physician has a financial relationship. The Stark Law is aimed at physicians, but if a physician requires an NP employee to refer to an entity with which he or she has a financial relationship, the NP may become involved in a violation of the Stark Law. References:

Answer 895

Correct Answer: D. Fragile X, Down syndrome, and fetal alcohol syndrome are the most common causes of intellectual disability. Fetal alcohol syndrome is the most common acquired form of intellectual disability. Incorrect Answers: A. Fragile X is the most common inherited form of intellectual disability in males. It is associated with the FMRI gene on the X chromosome. B. Prevalence in the community is between 1-3%. C. Down syndrome or trisomy 21 is the most common genetic form of intellectual disability. References:

Answer 896

Correct Answer: B. Body dysmorphic disorder, absent insight In the DSM-5-TR, the absence of insight in body dysmorphic disorder often involves clients who are worried about imperfections in physical appearance that are not observable by others. Incorrect Answers: A. Agoraphobia does not correctly identify the underlying concerns regarding the patient's discomfort with walking in the halls amongst their classmates. BDD is a more appropriate diagnosis in this case. C. The patient's fears are directly related to walking or standing in front of others due to his perceived leg length discrepancy, so a diagnosis of BDD is more appropriate than the more generalized social anxiety disorder, although these two conditions often co-occur. D. Functional neurological symptom disorder, formerly conversion disorder, is characterized by sensory or motor dysfunction symptoms that can not be directly associated with a known medical or mental condition. Vital Concept: Body dysmorphic disorder is the most appropriate disorder based on the clinical scenario described here. References:

Answer 897

Correct Answer: D. Inhibits sodium channels, enhances GABA-a receptors, and antagonizes subtype of glutamate receptors Topiramate inhibits sodium channels, enhances GABA-a receptors, and antagonizes kainate and AMPA receptors. Incorrect Answers: A. Carbamazepine inhibits voltage-dependent sodium channels and pre-synaptic sodium channels. B. Depakote increases GABA in the brain. C. Lamotrigine inhibits glutamate and voltage-gated sodium channels. References:

Answer 898

Correct Answer: D. This is not considered ethical by the APA, even if consent was willingly given. This would not be considered ethical. First, having former patients participate like this would be a deviation from the initial treatment plan that was agreed upon with them. More importantly, even if they give willing consent, their decision will be strongly influenced by a desire to "please" their physician and their transference feelings. A financial reward (free travel and expenses), even if not paid for by the physician, is still for the physician's benefit and is also considered unethical and an exploitation of a patient for personal gain. Incorrect Answers: A, C. This would be a deviation from the former patients' initial treatment plans for the purpose of the physician's personal gain, which is unethical. Neither the patient nor the parents giving consent changes the facts of the situation. B. It doesn't matter who's paying for the expenses to former patients — the expenditures are still for the physician's gain, and are considered unethical and an exploitation of a patient for personal gain.

Answer 899

Correct Answer: B. Maintain the responsibility to those who require nursing care The primary responsibility of the psychiatric-mental health nurse is to those who require nursing care. In caring for detainees and prisoners, nurses are expected to adhere to human rights and ethical principles. Incorrect Answers: A. Nurses employed in prison health services do not assume functions of prison security personnel, such as restraints or body searches, for the purpose of prison security. C. Nurses who are aware of maltreatment and abuse take appropriate action to safeguard the rights of detainees and prisoners. D. Nurses collaborate with other health care professionals and prison authorities to reduce the impact of crowded and unhealthy prison environments on transmission of infectious diseases such as HIV, hepatitis and tuberculosis and improve their care and management.

Answer 900

Correct Answer: A. Formulation The three basic phases of policy making are the formulation phase, the implementation phase, and the evaluation phase. The formulation phase is the initial phase and consists of input of information, ideas, and research from key people, organizations, and interest groups; framing of the issue; identification of the purpose and outcomes; selection of strategies; and identification of needed resources. Incorrect Answers: B. Consideration is not a basic phase of the policy process. C. After formulation, implementation occurs and consists of dissemination of information about the adopted policy and putting it in place as a plan of action. If the policy is a public policy enacted by a government agency, it will usually be implemented through the regulatory process by creation of a set of rules that are then issued by the agency responsible for administering the policy. D. Policies may be amended or rewritten to adjust to circumstances over time, in an incremental manner. This is the final phase and most public policies are modified over time in this way. Vital Concepts: The formulation phase is the initial phase and consists of input of information, ideas, and research from key people, organizations, and interest groups; framing of the issue; identification of the purpose and outcomes; selection of strategies; and identification of needed resources.

Answer 901

Correct Answer: D. Intellectual disability, severe This description listed matches the definition of intellectual disability, severe. In the DSM-5-TR, intellectual disability: Typically includes deficits in intellect, social skills, and the ability to perform everyday tasks. Deficits in intellectual functioning must be obvious, including logical thinking, preparation, finding solutions, comprehension, discernment, and acquiring new knowledge through school or life lessons. Clinical assessment and intelligence testing confirm the lack of these skills. Deficits in adaptive functioning must hinder the individual's ability to perform the tasks required to have independence and life responsibilities. Without external support, these deficits affect the individual's ability to complete at least one activity of daily living, such as living independently, participating in social situations, and verbal communication with others in various settings. The disorder must develop during normal childhood development. In the DSM-5-TR, intellectual disability has a specifier of severity (mild, moderate, severe, profound) that is based on adaptive functioning. With “mild” severity, individuals have difficulty obtaining and comprehending complex language and academic skills but are able to do basic self-care, maintain home activities, and only need support intermittently to maintain independent living and employment. With “moderate” severity, individuals have difficulty with conceptual skills, typically develop only to an elementary academic level, and are able to develop some basic self-care/home activities but require consistent support to be able to live independently or maintain employment in adulthood. With "severe" severity, individuals have little understanding of written language, minimal conceptual skills (e.g., difficulty understanding time or money), and are dependent on others full-time for support in self-care, home activities, and employment. With "profound" severity, individuals have very limited ability to communicate (primarily nonverbal, nonsymbolic communication), minimal ability to obtain concrete academic or conceptual skills, and require daily high-intensity supervision in all areas of life. Incorrect Answers: A. This patient has more than moderate disability, given that they need help for ADLs. B. Patients with profound intellectual disability don't have much language skill and often need nursing care. C. This patient has more than moderate disability, given that they need help for ADLs. Vital Concept: According to DSM, a diagnosis of intellectual disability requires significant limitations in intellectual functioning as well as at least one domain of adaptive functioning (conceptual, social, practical). The identification of domains of impairment helps direct patients to appropriate assistive services and accommodations.

Answer 902

Correct Answer: A. They have a higher metabolic capacity. Pediatric patients have a higher metabolic capacity, and drugs must be given at shorter intervals (neuroleptics, tricyclics, and methylphenidate). Incorrect Answers: B. Pediatric patients have a more efficient renal elimination of drugs and will excrete drugs like lithium faster than adults. C. The lower content of adipose tissue in pediatric patients results in a larger concentration of lipophilic drugs when given the same weight-adjusted dose as adults. D. A greater volume of extracellular water in pediatric patients causes drugs like lithium, which distributes to total body water, to have a lower plasma concentration compared to adults.

Answer 903

Correct Answer: A. Loss of olfaction Basilar skull fracture is common in deceleration accidents. This patient is suffering from cribriform plate fracture, which has led to cerebrospinal fluid leaking from his nose. Further, olfactory nerves pass from the nose through the cribriform plate and attach to the olfactory bulbs. Disruption of the olfactory nerves is possible in cribriform plate fractures, making answer choice (A) reasonable. Incorrect Answers: B. Vision is mediated by the ocular nerve (CN II). It passes through the optic canal, superior to the cribriform plate. A basilar skull fracture involving the cribriform plate is less likely to affect CN II. C. Sensation of the upper lip is mediated by the maxillary branch (V2) of the trigeminal nerve (CN V). The maxillary branch passes through the foramen rotundum, and is therefore, not affected by a cribriform plate fracture. D. Eye abduction is controlled by the lateral rectus muscle, which is innervated by the abducens nerve (CN VI). CN VI passes through the superior orbital fissure, and is less likely to be affected by a cribriform plate fracture.

Answer 904

Correct Answer: D. It provides patients the right to view their mental health information and psychotherapy-related information. All of the above are correct except D. Mental health records can be released with the exception of the psychotherapy notes. Psychotherapy notes are those taken by a mental health professional during the course of a conversation related to treatment with the patient and "are kept separate from the patient’s medical and billing records." Incorrect Answers: A. Patients do have the right to review and correct their medical records except in the case of mental health records. B. There is federal protection in place for personal health information. There are steep fines for violating the HIPAA law. C. Any information disseminated either via internet, oral or written communication falls under the HIPAA law and must be protected. Vital Concepts: Psychotherapy notes are those taken by a mental health professional during the course of a conversation related to treatment with the patient and "are kept separate from the patient’s medical and billing records."

Answer 905

Correct Answer: B. Hypothesis A hypothesis is the formal statement of the expected relationship between two or more variables in a specific population that suggests the answer to a research question or predicts the outcome of a study. Incorrect Answers: A. An abstract refers to a short summary of the results of a study, usually published at the beginning of a research article. C. A literature review is part of a research article that delineates important and relevant results of studies to date. It may define the theoretical or conceptual framework of the study. D. Methodology refers to the methods or the research design of the subject, including sample descriptions and descriptions of the validity and reliability of instruments used in the study. Vital Concepts: A hypothesis is the formal statement of the expected relationship between two or more variables in a specific population that suggests the answer to a research question or predicts the outcome of a study.

Answer 906

Correct Answer: C. All states require a response to a subpoena request. According to the AACAP practice parameter for forensic evaluations, all states require a response to a court order. Failure to respond may result in a contempt-of-court action. Circumstances that allow you to object to a subpoena and potentially avoid having to produce documents or appear in court may include claims that the information sought is "privileged," lost, or violates your Fifth Amendment constitutional right against self-incrimination or that the request is overbroad or unduly burdensome. "Privileged" records are only released later if there is a court order signed by a judge specifically ordering the records related to the protected area to be released or if the patient authorizes the release of the protected records. Incorrect Answers: A. All states require a response to a court order. B. This may be a case in which you don't have to comply with a subpoena, but you still have to respond to the subpoena stating that the information is privileged. D. An attorney can file a motion to quash a subpoena. Vital Concept: According to the AACAP practice parameter for forensic evaluations, all states require a response to a court order.

Answer 907

Correct Answer: B. The patient's spouse is given information. If the patient has not consented to release of information, giving the spouse access is a violation of patient confidentiality. Incorrect Answers: A. The patient signs a release to allow his insurance company to pay the bill submitted by the NP. C. The NP is required to release information that is the subject of a lawful subpoena. D. By law, the NP must report infectious disease information that are labeled as "reportable". Each state has a list of diseases and conditions that must be reported by the clinician. It is the responsibility of the NP to know the list of reportable diseases in the state where they practice.

Answer 908

Correct Answer: B. Decline the invitation A pediatrician or other clinician should maintain professional boundaries with the families of patients. Because patients and family members depend on the knowledge and authority of the physician, there is an inherent risk of exploitation with any non-professional relationship. Patients and their family members should be able to trust the clinician completely and should feel both physically and emotionally safe in professional relationships with clinicians. The clinical judgment of health care professionals who are involved in an intimate relationship with a patient or their family may be clouded, resulting in a breach of professional responsibility. Incorrect Answers: A. There is no need to ask the medical board for advice, as this action is unethical. C. Because parents and family members depend on the clinician's knowledge and authority, there is an inherent risk of exploitation that makes this unethical even though the parent is not a patient. D. Even if the care of the child was transferred to another clinician, engaging in a relationship with a former patient or a member of their family is unethical. Vital Concept: Patients and family members depend on the knowledge and authority of the clinician. As a result, there is an inherent risk of exploitation with any non-professional relationship.

Answer 909

Correct Answer: D. A threat of imminent patient violence may constitute an exception to confidentiality. A threat of imminent patient violence may allow disclosure of confidential information to family members or law enforcement. Incorrect Answers: A. Confidentiality may be breached in cases where the patient or others are at imminent risk of death or serious injury. B. While mental health professionals may confer with each other about patients, the patients must not be identified in any way. C. In some situations, such as a shared social circle, it may be necessary for a therapist lie to protect confidentiality.

Answer 910

Correct Answer: C. Patient Protection and Affordable Care Act The PPACA, enacted in 2010 and known as “health care reform,” expanded health coverage to many Americans who were previously uninsured. It also provided for specific benefits for persons with mental illness, with inclusion of mental health and substance use disorders in an “essential benefits package.” Other mental health provisions included in the PPACA were creation of incentives to coordinate primary care and mental health and addiction services; inclusion of mental illness as a chronic illness in creation of “health homes;” prohibition of denial of coverage for preexisting conditions; expansion of treatment for mental illness and substance use disorders to include rehabilitation, medications, preventive and wellness services; provision for community education campaigns; support for interprofessional training programs for mental health and addiction services; and increased community based care. Incorrect Answers: A. The Mental Health Parity Act of 1996 provided equal lifetime and annual limits for mental illness. B. This bill took effect in 2010 and ended the annual cap on the number of visits for mental health treatment, and required insurance coverage for mental health care to equal that for physical health care if an insurance plan offered mental health care. D. The Americans with Disabilities Act was passed in 1990 and prohibits discrimination against people with physical and mental disabilities in hiring, firing, training, compensation, and advancement in employment. Additionally, employers are prohibited from asking job applicants whether they have a disability unless the concerns are related to the job and necessary.

Answer 911

Correct Answer: C. Public safety is promoted by license and regulating of NP prescribing authority solely by state boards of nursing The American Academy of Nurse Practitioners advocates unrestricted prescriptive authority for nurse practitioners, within their scope of practice. Additionally, the AANP recommends that prescribing authority for NPs should be solely regulated by state boards of nursing, since nurse practitioners serve as members of state boards of nursing and are competent to appropriately regulate nurse practitioner prescribing. The process of license and regulation exclusively by the nursing board promotes public safety and competent practice. Incorrect Answers: A. The AANP recommends unrestricted prescriptive authority for NPs, including legend and controlled medications, devices, health care services, durable medical equipment, and other equipment and supplies. B. The AANP recommends regulation of NP prescribing authority solely by state boards of nursing. D. Nurse practitioners have graduate education in pharmacology, pathophysiology, physical assessment, and clinical diagnosis and treatment that prepares them to diagnose and prescribe medications and treatments.

Answer 912

Correct Answer: D. Body dysmorphic disorder Within the DSM-5-TR, body dysmorphic disorder is defined as a constant perseveration of thought regarding a component of their physique that they consider flawed or imperfect; others do not share this perception. As a result, the patient displays recurrent thoughts (e.g., comparison) or actions (e.g., excessive brushing/grooming, acquiring compliments to remove doubt). These symptoms create substantial anguish or dysfunction in essential settings, such as work, school, or social settings. The symptoms are not more appropriately attributed to a concern with weight and body fat (i.e., eating disorder). The syndrome may be specified as: including muscle dysmorphia (symptoms pertain specifically to muscle mass/build) having good, fair, poor, or absent insight Incorrect Answers: A. The patient doesn't display severe social anxiety or other social problems, which are the key symptoms of this disorder. B. The patient is not experiencing any other hallucinations, delusions, or other psychotic symptoms, such as catatonia or disorganized speech. C. The patient isn't reporting an obsession or compulsion. The frequent checking of their nose is not unwanted or unpleasant, and does not occupy more than an hour of their day every day. Vital Concept: When an individual with body dysmorphic disorder is convinced that their perceived defects or flaws are truly abnormal, the specifier "with absent insight" can be added.

Answer 913

Correct Answer: B. Postural instability Parkinson’s disease is a movement disorder caused by destruction of dopaminergic neurons in the substantia nigra. Patients frequently exhibit a pill-rolling tremor, shuffling gait, difficulty initiating movement, postural instability, and a mask-like facies (decreased facial movement.) There are also non-motor manifestations of Parkinson’s disease, which include autonomic dysfunction, gastrointestinal dysfunction, rhinorrhea, sleep disturbances, fatigue, mood disorders, cognitive dysfunction, dementia, psychosis, and hallucinations. Incorrect Answers: A. Broad-based gait. Broad-based gait is seen in cerebellar disease and acute alcohol intoxication. C. Increased facial movement. Involuntary increased facial movements occur with tardive dyskinesias. D. Writhing movement. Writhing movements occur with Huntington’s chorea. Vital Concepts: Parkinson’s disease is a movement disorder caused by destruction of dopaminergic neurons in the substantia nigra. Patients frequently exhibit a pill-rolling tremor, shuffling gait, difficulty initiating movement, postural instability, and a mask-like facies (decreased facial movement.)

Answer 914

Correct Answer: D. Switch from bilateral to unilateral electrode placement Amnesia is the most commonly discussed side effect of ECT. Severe amnesia during the ECT course can be managed by increasing the interval between treatments (from 3 per week to 2 or even 1 per week), changing ECT type (e.g. bilateral to unilateral electrode placement), or, if necessary, ending treatment. Retrograde amnesia (i.e. difficulty remembering information learned before the ECT course) is more prominent with ECT use. This deficit is greatest for more recent memories, particularly those occurring several months before the ECT. Retrograde amnesia is more marked for information of an impersonal nature. The proportion of patients with persistent retrograde amnesia following ECT is unknown; patient surveys suggest that this may occur in a sizable minority. Pharmacological attempts to ameliorate ECT-induced amnesia (e.g. using nootropics, hormones, stimulants, and peptides) have not been reliably demonstrated. Amnesic effects with ECT are more prominent and may last longer in patients with preexisting cerebral disease, a greater number of treatments in a course, or bilateral stimulus electrode placement, particularly when treatment frequency is maintained at 3x weekly. Ironically, greater amnesia is generally associated with a greater antidepressant response. Incorrect Answers: A. Amnesia is not self-limited and adjustments should be made to try to alleviate the adverse effect. B. Attempts should be made to decrease this adverse effect prior to discontinuing the treatment. C. Severe amnesia during the ECT course can be managed by increasing the interval between treatments, not decreasing. Vital Concept: Increasing the interval between treatments or changing ECT type from bilateral to unilateral electrode placement can manage severe amnesia from ECT.

Answer 915

Correct Answer: D. Social relatedness, communication, and restricted interests and activities The diagnostic criteria for autism spectrum disorder require: 1) Current or historical struggles engaging with others across several domains: Building, sustaining, and comprehending relationships Challenges with the back-and-forth in a group setting, talking and interacting Body language, reading facial expressions 2) Actions, thoughts, and attention that are limited and very consistent are sometimes referred to as restricted repetitive behaviors (RRBs). At least two of the following (previously or currently): Curiosity and attention to a limited number of topics Patterns of speech and movement that are unchanging Significantly increased or decreased response or attention to sights/sounds/smells/touches/feelings from their environment Very consistent patterns in daily routines Both components 1 and 2 are required for the diagnosis of ASD, although social communication disorder may be diagnosed if no RRBs are present. 3) Signs may increase with age and elevated communication and interaction requirements but are initially evident at a very young age 4) The ability to perform successfully in crucial environments (home, school, work, friends) is significantly hindered by the condition 5) Another condition, such as developmental delay or intellectual limitation, does not provide an enhanced reason for the symptoms. Incorrect Answers: A. Diagnosis of autism also requires restricted interests and activities. B. Diagnosis of autism also requires disturbances in social relatedness and restricted interests and activities. C. Diagnosis of autism requires restricted interests and activities and doesn't require hypo-reactivity to sensory input. Vital Concept: ASD typically presents with symptoms that affect communication, socialization, and interests/hobbies/activities.

Answer 916

Correct Answer: D. APN (and their supervisor) and the psychologist: but the APN will retain full responsibility. This is called a “split treatment”. The psychiatrist/ APN retains full responsibility for the patients that are in a split treatment situation. This does not exclude any responsibility of any other healthcare providers. Incorrect Answers: A. The APN is the one who referred and initially evaluated the patient, therefore they are the ones who will be the most responsible, although all others will be involved in the lawsuit. B. Being or not being a licensed professional is not the reason that the APN would be responsible. C. Although the supervisor will be involved they will not be solely responsible, they were not directly involved and this is why the APN’s have their own malpractice.

Answer 917

Correct Answer: A. After talking to the patient and telling her what is involved, perform a modified physical examination Cultural awareness means the NP should be knowledgeable about his or her own preconceptions and sensitive to the way these preconceptions affect others. In traditional Muslim cultures, women cover both head and hair. Many times, Muslim women wear a cloak known as a burqa. Women are forbidden from being alone with men who are not family members. If a woman who is Muslim is seen by a male health provider, a male, her husband or another family member, must be present. A female patient may refuse to undress for an examination. In this case, the best course of action is to work within the constraints imposed by the patient’s beliefs. Incorrect Answers: B. Referral to a Muslim physician isn't necessary with a modified physical examination C. Women are forbidden from people alone with non-family member males, so referral to a male physician won't work D. A female patient may refuse to undress for an examination, in which case working within their beliefs is the best course of action Vital Concepts: In traditional Muslim cultures, women cover both head and hair. Many times, Muslim women wear a cloak known as a burqa. Women are forbidden from being alone with men who are not family members. If a woman who is Muslim is seen by a male health provider, a male, her husband or another family member, must be present. A female patient may refuse to undress for an examination. In this case, the best course of action is to work within the constraints imposed by the patient’s beliefs.

Answer 918

Correct Answer: C. Commit to a self-imposed ban on shopping The patient has kleptomania. She does not steal items for personal use, for monetary value, to express anger, or in respose to a delusion or hallucination. Instead, a tension is relieved by carrying out the act of stealing. Having the patient commit to a self-imposed ban on shopping is the most common approach to managing urges to shoplift, although this technique is often not practical as time progresses. Incorrect Answers: A. B. Speaking to the physician or her parole officer about her urges when they strike may not be practical, as it depends on their availability at any hour of the day as well as their ability to manage her urges over the phone. D. Even a short-acting benzodiazepine such as alprazolam may not take effect in time to counteract the urge to steal, and benzodiazepines have not been shown to be effective in treating patients with kleptomania.

Answer 919

Correct Answer: C. Premorbid function tends to be more impaired in childhood-onset than among adult-onset schizophrenia. Childhood-onset schizophrenia has a worse prognosis than adult-onset. It is quite rare and appears continuous in both clinical and biological features with the more common adult-onset form. Nevertheless, those who experience a more acute onset, a rapid response to acute treatment, and relatively more positive than negative, cognitive, or depressive symptoms have a more favorable prognosis. Premorbid function tends to be more impaired than among adult-onset patients, but those who were observed to be more social and intelligent or to have a more "well-integrated" premorbid personality had a better prognosis than did those childhood-onset patients with more impairment on these measures. In addition, a more benign course is observed among childhood-onset patients who lack a family history of schizophrenia or who have greater family support. Incorrect Answers: A. If patients can be identified at an EARLY stage in their illness and treated, outcomes for schizophrenia should improve. B. After the first psychotic episode, 33% of patients will experience a benign course. 66% relapse, fail to recover, or are rehospitalized in the first 2 years after a first hospitalization for psychosis. D. A more benign course is observed among childhood-onset patients who lack a family history of schizophrenia or who have greater family support. Vital Concept: Childhood-onset schizophrenia has a worse prognosis compared to adult-onset schizophrenia.

Answer 920

Correct Answer: A. Escitalopram SSRIs are the first-line treatment choice for depressive disorders in older patients. They are generally well-tolerated and safe. Treating depression in older patients requires a thorough review of comorbid illnesses and medications. There should also be careful follow-up and monitoring of side effects. Incorrect Answers: B. Tricyclic antidepressants (TCA) are generally advised against in patients with cardiac arrhythmias. They can also worsen or affect narrow angle glaucoma , constipation, and BPH. TCAs can cause confusion. C. Doxepin is also a TCA (see explanation for B) D. MAO inhibitors require special dietary and medication restrictions (many aged cheeses, meats, for example). This is not generally the first choice in medications for antidepressant medications. One positive of MAOIs is that MAOI medications have very little cardiac conduction effects. Vital Concepts: SSRIs are the first-line treatment choice for depressive disorders in older patients. They are generally well-tolerated and safe. Treating depression in older patients requires a thorough review of comorbid illnesses and medications. There should also be careful follow-up and monitoring of side effects.

Answer 921

Correct Answer: B. The right to pain control The right to pain control is part of the Patient’s Bill of Rights. Incorrect Answers: A and D. Affordable healthcare and access to the latest technology are not included. C. The right to sue is not directly included, but patients are entitled to a procedure for registering their complaints or grievances. Vital Concept: The right to pain control is part of the Patient’s Bill of Rights.

Answer 922

Correct Answer: D. Camphor Camphor has been used for convulsive therapy since the late 1700s. In the 1930s, IM camphor injections were used to induce seizures to treat catatonia. Camphor is a cyclic ketone of the hydroaromatic terpene group that was originally distilled from camphor tree bark but is now is created synthetically. Currently it is used in vaporized cold medications, topical anesthetics, moth repellants and antimicrobials. Camphor is also used in some religious ceremonies. Camphor exposure can cause gastrointestinal upset, headache, anxiety, hallucinations, myoclonus, hyperreflexia, hepatic damage, renal damage and seizures. There is an increased risk of tonic clonic seizures with an ingestion of camphor of >50mg/kg of body weight. Incorrect Answers: A. Insulin coma for convulsive therapy was introduced around the 1930s not 1700s. B. Malarial fever for convulsive therapy was introduced around the 1920s not 1700s. C. Electrocution (electroconvulsive therapy) for convulsive therapy was introduced around the 1930s not 1700s. Vital Concept: Camphor, from camphor tree bark, has been used for convulsive therapy since the late 1700s. Electroconvulsive therapy, malarial fever and insulin coma were not introduced until the 1900s for convulsive therapy.

Answer 923

Correct Answer: C. The bill is returned to the original house The legislative process begins when a bill is introduced. It is then assigned to a committee, which provides education for the committee members and public about the bill. If the bill is sent to the floor after committee hearings and passes, it is sent to the other chamber. If a bill is passed with amendments in the second chamber of the Congress, the bill is returned to the original legislative house for approval, after which the bill is sent to the president if the original house concurs with the amendments. Incorrect Answers: A. If a bill is passed on the floor with amendments by one house of Congress, it is returned to the original house for approval. If the original chamber concurs, the bill will then go to the president for signature or veto. B. A bill that has been passed on the floor of one house of Congress with amendments will go to the original house for approval of the amended bill. D. The original house that introduced the bill must concur with the amended bill before it is sent to the president, who must sign the bill before it becomes law. The president can also veto a bill. Vital Concepts: If a bill is passed with amendments in the second chamber of the Congress, the bill is returned to the original legislative house for approval, after which the bill is sent to the president if the original house concurs with the amendments.

Answer 924

Correct Answer: B. 6 months For most patients who respond to ECT for depression, continuation/maintenance (C/M) therapy is necessary. Specific indications for continuation ECT are: (1) history of recurrent episodes responsive to ECT and either (2) ineffectiveness of or intolerance to prophylactic pharmacotherapy or (3) patient preference Long-term use of C/M ECT is indicated either when the patient's history suggests a high risk of delayed relapse on medication alone or when evidence of decompensation occurs during attempts to stretch the interval between treatments during the continuation phase. The average duration of continuation ECT is 10 weeks. Continuation ECT following successful ECT typically involves gradually shifting from frequent (e.g. weekly) to monthly treatments over 1–3 months and then maintaining the monthly administration schedule for at least 6 months after remission (or longer if indicated). Decisions regarding scheduling should be made on an ongoing basis, based on the patient's history and present response. Concomitant psychotropic agents may be useful for patients who are unable to benefit fully from continuation C/M ECT alone. The need for C/M ECT should be reviewed by the practitioner and patient at least twice a year; consent should be reobtained at least every 6 months, as should anesthetic/medical and cognitive reevaluations. The presence of persistent memory deficits should be weighed against the anticipated benefits of continuing ECT. Incorrect Answers: A. This is 2x longer than maintenance ECT treatment is needed for (6 months) C. This is only half the length that maintenance ECT treatment is needed for (6 months) D. Maintenance ECT treatment is needed for at least 6 months after discharge

Answer 925

Correct Answer: B. Fluoxetine plus CBT The TADS study indicated that 60% of depressed youth respond to initial treatment with medication. Fluoxetine is FDA-indicated for the treatment of depression from ages 8-17. The TADS study indicated that 61% of the medication-only group improved, 71% of the combination CBT and medication group improved, 43% of those with CBT alone improved, and 35% of the placebo group improved. Incorrect Answers: A and C. Fluoxetine plus CBT in combination was more effective than either drug alone D. Fluoxetine alone was more effective than CBT alone

Answer 926

Correct Answer: B. It is illegal for insurance companies to deny insurance to patients with preexisting conditions The Affordable Care Act (ACA, 2010) took full effect in 2014. It is illegal for health insurance companies to deny coverage to individuals with preexisting conditions. Under the ACA, children under the age of 26 can be insured under their parents’ coverage. Not all employers are required to provide healthcare coverage for their employees. Incorrect Answers: A. Children can be covered under parents' insurance until they turn 26 C. Not all employers must provide healthcare coverage to their employees D. Patients can go directly to specialists Vital Concepts: The Affordable Care Act (ACA, 2010) took full effect in 2014. It is illegal for health insurance companies to deny coverage to individuals with preexisting conditions.

Answer 927

Correct Answer: C. Regulation A regulation is a specific parameter by which a program is run, which is set by an agency that runs a program or is responsible for enacting a policy. Incorrect Answers: A. Laws are set by legislative action. B. A bill affecting health policy may be passed, but the responsibility for enforcement of the policy will fall to a government agency, which will create regulations to aid in enforcement of the policy or to run the program. D. A mandate is the authority to carry out a policy or course of action.

Answer 928

Correct Answer: D. Lithium Lithium and SSRIs have been useful in kleptomania. Incorrect Answers: A. B. Risperidone and quetiapine are atypical antipsychotics, and lorazepam is a benzodiazepine. These have not been shown to help kleptomania. C. Dopamine agonists have not been helpful for kleptomania.

Answer 929

Correct Answer: C. Valium Schedule IV controlled substances have low potential for abuse, compared to substances in Schedule III. They include benzodiazepines such as lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin) and triazolam (Halcion). Schedule V controlled substances have a lower abuse potential relative to Schedule IV, and consist of preparations that contain limited quantities of certain narcotics, including cough preparations that do not contain more than 200 mg of codeine per 100 ml. Schedule III controlled substances include those substances with a higher potential for abuse, which may lead to moderate or low physical dependence or high psychological dependence, including anabolic steroids, ketamines, and narcotics such as buprenorphine. Schedule II substances have a high potential for abuse that may lead to severe psychological or physical dependence, and include stimulants, pentobarbital, and narcotics such as hydrocodone and oxycodone. Schedule I controlled substances have no current accepted medical use in the United States and include heroin and LSD. Marijuana is still classified as schedule I. Incorrect Answers: A. Marijuana is a schedule I drug. B. Lomotil is schedule V. D. Percocet is schedule II. Vital Concepts: Valium is a Schedule IV controlled substance.

Answer 930

Correct Answer: A. Fluoxetine: delayed but not decreased When taken with food, the peak plasma concentration of fluoxetine is delayed but not decreased. Incorrect Answers: B and C. The peak plasma concentration of paroxetine is increased by 6%, and sertraline is increased by 25%. D. Citalopram is not affected by food.

Answer 931

Correct Answer: C. Difficulty carrying on a conversation Patients with ASD have difficulty making social connections, and do not seem to take an interest in the perspectives of others. Incorrect Answers: A. ASD sufferers struggle with changes to routines B. Eye contact is difficult for AS sufferers D. Patients with ASD don't develop age-appropriate social relationships

Answer 932

Correct Answer: B. Health belief model The health belief model is a theoretical construct that attempts to explain why people engage in healthier behavior. This model proposes that people are more likely to engage in healthier behavior if they have “perceived susceptibility,” or feel that they are threatened by a health condition. Other components of this model is that the person must believe he or she can overcome the barriers (perceived barriers), will benefit from the change, and can successfully perform the action (self-efficacy). Incorrect Answers: A. Family systems theory is a theory that suggests that individuals cannot be understood in isolation from each other, but must be seen as a part of their family unit. C. The hierarchy of needs was a theory created by Maslow and includes a hierarchy of needs beginning with the basic to the more intangible needs: "physiological", "safety", "belongingness" and "love", "esteem", "self-actualization", and "self-transcendence". D. Evidence-based medicine is defined as a "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients". Vital Concepts: The health belief model is a theoretical construct that attempts to explain why people engage in healthier behavior. This model proposes that people are more likely to engage in healthier behavior if they have “perceived susceptibility,” or feel that they are threatened by a health condition.

Answer 933

Correct Answer: B. Consult child protective services and/or obtain a court order. Tetanus toxoid-containing vaccine and tetanus immune globulin (250 units intramuscularly) should be given to patients with puncture wounds who have received fewer than 3 doses of tetanus toxoid or whose immunization status is uncertain. Since failure to treat the patient can result in imminent harm, the healthcare provider should consult CPS or obtain a court order, which can usually occur quickly. For most vaccine refusals, the risks to the patient are low, so the healthcare provider should accept the caregivers’ decision. In this case, the healthcare provider should attempt to discuss the immediate risks to the child, but if the caregivers still refuse vaccination, it is the duty of the healthcare provider to seek legal means to protect the child. The patient is at high risk of tetanus infection, and the need to administer the vaccination is urgent (although not emergent). Up to 50% of patients who develop tetanus die, according to some studies. However, the provider should consider prophylactic antibiotics in the interim, in addition to wound care. If the refusal was immediately life-threatening, the healthcare provider must treat without caregiver consent. Healthcare providers may have many patients who choose not to take their medical advice, but in the case of a vulnerable patient who is not competent to make medical decisions, the healthcare provider must advocate appropriately. Incorrect Answers: A. With the caregiver’s consent the initial treatment of cleaning and irrigating the wound should be completed while consulting child protective services and discussing the importance of completing the treatment with the caregivers. C. The healthcare provider should respect caregivers’ religious beliefs, but if a child is in imminent danger of harm, the healthcare provider should treat the child. There is no indication in this presentation of immediate risk of loss of life or limb. In less urgent situations, so the provider should continue to communicate with the caregivers and consult child protective services. D. Ideally, a healthcare provider would continue to care for the patient, providing the best information about and evidence for treatments. However, if the healthcare provider terminates the relationship, she or he must give written notice and allow adequate time for transfer of care to another healthcare provider. The healthcare provider does not have legal liabilities with respect to enforcing regulations about vaccination. Vital Concept: Vaccination remains the best method to prevent communicable infectious diseases. A general understanding of vaccines and the illnesses they prevent is knowledge that is important for the pediatric provider to possess to educate and counsel parents and families about these vaccine preventable diseases. Resources such as the Centers for Disease Control (CDC) and the Advisory Committee on Immunization Practices (ACIP) will aid the provider in keeping current with vaccine schedules.

Answer 934

Correct Answer: C. Inform mother that father needs to agree to the evaluation Let the mother know that father needs to agree to the evaluation since it is non-urgent. In joint parenting agreements, both parents should be in agreement about the evaluation and, if possible, present at the initial evaluation. Scheduling an appointment with a parent without the other parent’s consent and/or involvement may result in potential legal implications, and involving both parents optimizes the patient’s chances for a successful treatment outcome. In an urgent situation, however, in the best interest of the child's wellbeing, a psychiatrist only needs 1 parent's permission to provide medical or psychiatric care. Incorrect Answers: A. Since the evaluation is non-urgent, the father needs to agree to the evaluation, as required by the joint parenting agreement (in joint parenting agreements, both patients should be in agreement about the evaluation and present at the initial evaluation if possible). Scheduling an appointment with one parent without the other parent's consent and/or involvement could have legal implications. B. As long as the father also consents to an evaluation, the therapist can schedule an evaluation and proceed from there. D. Court authorization would only be needed if the father refused to agree to the evaluation, and the mother wanted to compel him to agree — without having consulted the father yet, there's no reason to jump to this last resort.

Answer 935

Correct Answer: C. It is illegal for any person to use the title without a valid license Professional designations, including registered nurse (RN), nurse practitioner (NP), and advanced practice registered nurse (APRN), are legally reserved only for persons with a valid license. Title protection under the Nurse Practice Act protects the public from unlicensed “nurses.” Certification by a nongovernmental entity, such as a specialty organization or professional nursing association, is now mandatory for licensure in most states in the United States, but it does not confer the title. Incorrect Answers: A. The title nurse practitioner can be used by person with a valid license regardless of if they are in active practice or not. B. Certification by a nongovernmental entity, such as a specialty organization or professional nursing association, is now mandatory for licensure in most states in the United States, but it does not confer the title. D. The title nurse practitioner cannot be used if only the educational requirements have been satisfied. The NP designation must be coupled with a valid license. Vital Concept: The title of nurse practitioner may only be used by those with a valid license to practice within their certifying state. A valid license is only granted after all applicable educational requirements have been satisfied. title "nurse practitioner" is legally reserved only someone with a valid license.

Answer 936

Correct Answer: A. Names of all clinics where the NP practices if the practice has several clinics The NP’s prescription pad should contain the NP’s name, designation, and license number. The name of the clinic, address, and phone number should be printed on the pad. If the practice has several clinics, the other clinics where the NP practices should be listed on the pad. Some states do require the name of the physician(s) on the collaboration agreement to be printed as well. Incorrect Answers: B, C. Other NPs' names aren't required on the pad in all states; some states do require it. Some states also require the DEA number to be printed. D. Not required in any states Vital Concepts: The NP’s prescription pad should contain the NP’s name, designation, and license number. The name of the clinic, address, and phone number should be printed on the pad. If the practice has several clinics, the other clinics where the NP practices should be listed on the pad.

Answer 937

Correct Answer: C. Unilateral nondominant There are 2 main modalities of ECT based on electrode placement. The first is bilateral, and the second is unilateral. In bilateral ECT, the electrical stimulus travels through both hemispheres. In unilateral ECT, only the nondominant cerebral hemisphere is stimulated. A generalized seizure is elicited in both types. Although unilateral ECT causes fewer cognitive side effects, its efficacy compared to bilateral ECT has been a source of controversy. Incorrect Answers: A. Bilateral is associated with MORE cognitive side effects than unilateral. B. Unilateral dominant is associated with MORE cognitive side effects than unilateral nondominat but less than bilateral. D. Bifrontal is associated with MORE cognitive side effects than unilateral but similar to bilateral. Vital Concept: Unilateral ECT reduces cognitive side effects compared to bilateral ECT, but might be less effective in terms of symptom reduction.

Answer 938

Correct Answer: B. Countertransference Countertransference is essentially transference from the physician’s perspective (i.e., equating the patient with a person relevant to the physician such as a parent and projecting feelings associated with that person onto the patient). The more modern concept of countertransference depicts it as the emotional response a physician has to a patient. Incorrect Answers: A. Transference occurs when a patient projects unconscious feelings about a significant person in the patient’s life onto a physician, often as a result of some shared trait such as a physical resemblance or similarities in personality or interpersonal dynamics. C. Reaction formation describes an ego defense in which an individual overcompensates for an unacceptable unconscious impulse by exhibiting an opposite trait or behavior in an exaggerated way. For example, a man who holds unconscious beliefs that women are inferior may volunteer time and give money to a female candidate’s political campaign. D. Projection is another ego defense mechanism in which an individual projects unacceptable unconscious impulses on an external source. For example, a woman who feels vulnerable at work who bullies a subordinate could be a result of projection. Vital Concept: Countertransference, currently defined as a physician’s emotional response to a patient but classically described as unconsciously equating a patient with a person relevant to the physician, can impact the therapeutic relationship.

Answer 939

Correct Answer: B. Ramelteon Ramelteon may act on melatonin receptors in the brain, which are responsible for the sleep-wake cycle. Since it has no effects on the benzodiazepine receptor, it is not associated with abuse potential, rebound insomnia, motor deficits, or exacerbation of problems such as chronic obstructive pulmonary disease or obstructive sleep apnea. In addition, it is unlikely to contribute to confusion or memory problems. Incorrect Answers: A. Flurazepam is metabolized to desalkylflurazepam in the body. The drug and its metabolite have a combined half-life of about 40 hours. Metabolism and elimination are slowed in elderly patients. C. Elderly patients are sensitive to orthostatic hypotension due to alpha-1 adrenergic effects, as well as agitation secondary to antihistaminic/anticholinergic effects. D. Quazepam and other hypnotics with long half-lives should be avoided in the elderly, as they will contribute to prolonged sedation, dizziness, and falls. Vital Concept: Ramelteon is a preferred sleep agent for elderly patients.

Answer 940

Correct Answer: C. Negative reinforcement Negative reinforcement is the removal of an undesirable stimulus to increase a specific behavior. In this example, the undesirable stimulus (loud noise) is reduced by the behavior (turning down hearing aids). Incorrect Answers: A. Positive reinforcement is the addition of a desirable stimulus to increase a specific behavior. B. Positive punishment is the addition of an undesirable stimulus to reduce a specific behavior. D. Negative punishment is the removal of a desirable stimulus to decrease a specific behavior.

Answer 941

Correct Answer: A. They score in the definite range in 1 primary subscale. The SIRS test is designed to be used to determine if a patient is feigning symptoms. A person would be feigning if he or she scores in the definite range in a primary subscale or in the probable range in 3 subscales. With expanded scoring and classification, the SIRS-2 was developed to assess deliberate distortions in self-reported symptoms. Incorrect Answers: B. A patient scoring in the indeterminate range doesn't contribute to a determination of malingering on the SIRS scale. C. and D. A patient needs to score in the probable range in 3, not 1 or 2, subscales, to be considered malingering.

Answer 942

Correct Answer: B. You delegate client assessment tasks to an LPN who has been floated to your outpatient clinic for the day Assessment skills are presumed to be within the purview of the professional nurse, not those with fewer years of nursing education. Incorrect Answers: A, C, and D. Your license is not in jeopardy if you delegated appropriately, but an error was made by the delegate. Actions in C and D are appropriate for the role. Vital Concept: Assessment skills are presumed to be within the purview of the professional nurse, not those with fewer years of nursing education.

Answer 943

Correct Answer: D. OCD and adjustment disorder with depressed mood Adjustment disorder occurs within 3 months of a stressor and ceases within 6 months of a stressor ending. It is described as a change in emotional or behavioral symptoms that are out of proportion to the severity of the stressor and/or cause impairment. The symptoms should not be better explained by another psychiatric disorder. Specifiers of adjustment disorder include the following: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, unspecified. The specifier "with depressed mood" consists of predominant tearfulness, low mood, and hopelessness. Incorrect Answers: A. There is no OCD with a depressive aspect since they appear to be reacting to the stress of losing their job with poor social support. B. There is no evidence of current or previous manic or hypomanic episodes. C. This patient does not meet the criteria for a major depressive episode. Patients must have 5 or more of the nine potential symptoms present for at least 2 weeks (one symptom must be either depressed mood or anhedonia). Vital Concept: The most appropriate diagnosis for this patient scenario is OCD and adjustment disorder with depressed mood, as the patient is experiencing a few symptoms of depression in response to losing their job (stressor).

Answer 944

Correct Answer: A. The decisions made by the DPOAH are legally binding. Because the assignment of the DPOA is legally documented, the decisions made by that individual are legally binding. Incorrect Answers: B. The DPOA is allowed to make financial decisions about the patient's care. C. The patient's spouse cannot override decisions made by the DPOA. D. One of the primary decisions a DPOA must make is when aggressive treatments can be stopped. This should be based on previous discussions between the patient and DPOA, but that is not a specific requirement. Vital Concepts: Because the assignment of the DPOA is legally documented, the decisions made by that individual are legally binding.

Answer 945

Correct Answer: D. Lithium can induce mild dehydration. Lithium can induce mild dehydration. Patients on lithium need to stay well hydrated so that toxic levels do not accumulate. Incorrect Answers: A. Hydration can impact lithium levels. Patients with vomiting and diarrhea may need their lithium dose held to avoid toxic levels. B. Adverse side effects are dose-related and increase as the dose increases. Side effects include GI, kidney, and CNS issues. C. Lithium can increase or decrease thyroid endocrine function; thyroid function needs to be monitored. Lithium can cause goiter and hypothyroidism, and its use has been associated with thyroid autoimmunity and hyperthyroidism.

Answer 946

Correct Answer: C. PDSA (Plan-Do-Study-Act) PDSA stands for the “Plan-Do-Study-Act" cycle, which is a scientific model for improvement that has been implemented by the Institute for Healthcare Improvement to accelerate the process of bringing quality care to patients and facilitate change. Incorrect Answers: A. SWOT is strengths, weaknesses, opportunities, and threats, and is used to determine an organization's relative position in the marketplace against its competition B. In this context, parity refers to the Mental Health Parity Act, legislation signed into law in 1996 that requires the annual or lifetime limits on mental health benefits to be no lower than any dollar limits for medical or surgical benefits offered by health plans or health insurers. D. HITECH refers to the Health Information Technology for Economic and Clinical Health Act. Vital Concepts: PDSA stands for the “Plan-Do-Study-Act" cycle, which is a scientific model for improvement that has been implemented by the Institute for Healthcare Improvement to accelerate the process of bringing quality care to patients and facilitate change.

Answer 947

Correct Answer: D. Body dysmorphic disorder Within the DSM-5-TR, body dysmorphic disorder is defined as a constant perseveration of thought regarding a component of their physique that they consider flawed or imperfect; others do not share this perception. As a result, the patient displays recurrent thoughts (e.g., comparison) or actions (e.g., excessive brushing/grooming, acquiring compliments to remove doubt). These symptoms create substantial anguish or dysfunction in essential settings, such as work, school, or social settings. The symptoms are not more appropriately attributed to a concern with weight and body fat (i.e., eating disorder). The syndrome may be specified as: including muscle dysmorphia (symptoms pertain specifically to muscle mass/build) having good, fair, poor, or absent insight Incorrect Answers: A. Brief psychotic disorder consists of delusions, hallucinations, disorganized speech, and/or disorganized behavior. Also, in brief psychotic disorder, symptoms are only present for 1 day and up to one month; this patient has had symptoms for 2 years. B. With depersonalization disorder, the individual feels as if they are detached from their body, feelings, and/or actions. C. Somatic symptom disorder is characterized by physical symptoms - one or more current somatic symptoms that are long-standing and cause distress or psychosocial impairment. The patient also experiences excessive thoughts, feelings, or behaviors related to the symptom or symptoms. Vital Concept: When an individual with body dysmorphic disorder is convinced that their perceived defects or flaws are truly abnormal, the specifier "with absent insight" can be added.

Answer 948

Correct Answer: B. Autism spectrum disorder Autism spectrum disorder (ASD) is a neurodevelopment disorder characterized by defects in social skills and restrictive repetitive behaviors. The prevalence of ASD is about 1 in every 88 children in the United States. The first sign of ASD is a language delay that usually appears around 18 to 24 months of age. Children have difficulty reading body language and responding to non-verbal cues, leading to difficulty in maintaining relationships. Children with ASD also have trouble sleeping, restricted food interests, and hypersensitivity or hyposensitivity to touch, taste, sound, and smell. All children who are suspected to have ASD should undergo a complete physical examination to look for neurological abnormalities or physical features consistent with other syndromes. A thorough social history should be obtained to rule out post-traumatic stress disorder, reactive attachment disorder, and child abuse because these conditions may briefly mimic autism. Children under the age of 3 should be referred to early intervention services. Incorrect Answers: A. Bipolar disorder can be a comorbidity of ASD. Children with ASD can cycle quickly through periods of depression and times in which they require less sleep. This child does not exhibit any symptoms of bipolar disorder. C. Anxiety disorders occur in almost half of the children diagnosed with ASD. Children with ASD and anxiety that severely limits daily activities would benefit from a combination of therapy and psychopharmacology. D. Depression can occur in children with ASD, especially as they get older. Children who are bullied for poor social skills may present with crying and social withdrawal. This child in this question does not show any signs of depression. Vital Concept: Autism spectrum disorder is a neurodevelopmental disorder characterized by poor social skills, limited verbal communication, restricted interests, and repetitive behavior. This disorder usually appears in early childhood. Treatment involves speech, language, and occupational therapy.

Answer 949

Correct Answer: D. Discuss the patient’s condition honestly without providing an estimated survival time. A physician should not withhold medical information from a patient. In this case, the best course of action is to discuss the patient’s condition honestly with him. Because life expectancy estimates are often inaccurate, it is not recommended to relay such information routinely. However, even when it is uncomfortable for the physician, medical information that is essential should be disclosed to the patient. How and when to disclose the information should be determined based on the interests of the patient, and the information should be given in terms that the patient can understand. If the patient has a serious illness, the physician should present information in a way that minimizes distress. Incorrect Answers: A. Physicians shouldn't withhold medical information from a minor patient unless there is a compelling reason. B. A minor patient also has the right to receive medical information, especially in the case of a terminal illness. C. Life expectancy estimates are often inaccurate, so it's not recommended to relay this information routinely. Vital Concept: A physician should not withhold medical information from a patient.

Answer 950

Correct Answer: D. A legal representative of an incompetent patient can make decisions about sharing information from an electronic health record Many risks associated with patient privacy can result from implementation of electronic health records (EHR.) The patient or legal representative has responsibility for the care, custody, and control of the health record, whether on paper or in electronic format. A legal representative of an incompetent patient can make decisions about information-sharing for the patient’s best interests. Incorrect Answers: A. The patient or legal representative has responsibility for care and control of the health record. The provider has responsibility to safeguard protected medical information. B. Patients or their legal representatives have responsibility for the care, custody, and control of their health record, whether it is a paper or electronic record. C. Decisions about sharing medical information, including what is to be shared, rest with the patient or the patient’s legal representative. Vital Concepts: A legal representative of an incompetent patient can make decisions about information-sharing for the patient’s best interests.

Answer 951

Correct Answer: B. Cost-effectiveness of NPs begins with academic preparation A large body of evidence has demonstrated that nurse practitioners are consistently providers of high-quality, cost-effective care. Cost-effectiveness of nurse practitioners begins with academic preparation, which costs 20-25% of academic preparation for physicians. In 2009, the total tuition cost for nurse practitioner preparation was less than one year's tuition for MDs or DOs. Incorrect Answers: A. Cost-effectiveness of NP care is not dependent on practice setting and has been demonstrated in many different medical settings, including long-term care, acute care, and primary care. C. Evidence shows that NP managed care in the acute setting is associated with lower costs, including lower overall drug costs for patients. D. The hourly cost of an NP is one-half to one-third that of a physician. NP care is compensated by Medicare at 85% of the rate of physician-provided care. Vital Concepts: Cost-effectiveness of nurse practitioners begins with academic preparation, which costs 20-25% of academic preparation for physicians

Answer 952

Correct Answer: B. She argued with her parents earlier that day over a bad report card. This is a clinical picture of conversion disorder. The patient's acute symptoms were most likely initiated by the stress of the argument with her parents. Since she was doing her homework at the time of the attack, she may be experiencing these symptoms as a response to the stress of school and her family. Incorrect Answers: A. D. These are more suggestive of somatic symptom disorder. Conversion disorder does not show pain symptoms. C. This would suggest an organic cause and would indicate that this event could be a type of epilepsy or other seizure disorder.

Answer 953

Correct Answer: C. Major depression increases in prevalence with age. Major depression increases in prevalence with age. Based on epidemiological studies and estimates, the prevalence is about 0.3% in preschoolers, 2% in children, and 1.5-9% in adolescents. Incorrect Answers: A. ADHD is the most prevalent childhood psychiatric disorder. Data collected from a variety of sources from 2005-2011 show that children ages 3-17 years had ADHD (6.8%), behavioral or conduct problems (3.5%), anxiety (3.0%), depression (2.1%), autism spectrum disorders (1.1%), and Tourette syndrome (0.2% among children ages 6-17 years). Adolescents ages 12-17 years demonstrated illicit drug use disorder in the past year (4.7%), alcohol use disorder in the past year (4.2%), and cigarette dependence in the past month (2.8%). B. Generalized anxiety disorder is seen more frequently in girls than boys. D. Autism spectrum disorder is three to four times more common in boys than girls.

Answer 954

Correct Answer: B. Reinforcement This is an example of positive reinforcement. B.F. Skinner, who coined the term operant conditioning, described 4 quadrants relevant to this type of conditioning based on the desired outcome and whether a stimulus was added or removed (see table below). Although crying is perhaps most easily measured in the case described, the desired behavior is the child’s ability to self-soothe and cope with the pain and fear associated with blood draws and doctor’s visits. In positive reinforcement, a desirable stimulus is added (candy), prompting an increase in the desired behavior (self-soothing). Negative reinforcement involves removing a negative or undesirable stimulus to promote a behavior (e.g., allowing the child to remain in his mother’s arms rather than sitting on an exam table during doctor’s appointments). Increased Behavior Decreased Behavior Stimulus Added Positive reinforcement Positive punishment Stimulus Removed Negative reinforcement Negative punishment Incorrect Answers: A. Classical conditioning occurs when a neutral stimulus is paired with an unconditioned stimulus and results in a conditioned response. For instance, in this case, if the child began to cry whenever someone wearing a white coat entered his room, this would be a conditioned response (crying) to a conditioned stimulus (the white coat) due to an unconditioned stimulus (blood draws). C. Positive punishment uses a new negative stimulus to decrease an unwanted behavior. With negative punishment, a decrease in behavior is achieved by taking away a positive stimulus (e.g., eliminating the candy reward). D. Over time, if a classically conditioned stimulus is no longer reinforced by pairing with the unconditioned stimulus, extinction will occur (i.e., the stimulus no longer causes the conditioned response). Extinction also occurs in operant conditioning. Vital Concept: Classical and operant conditioning are methods of changing behavior. Classical conditioning pairs a neutral stimulus with an unconditioned response and results in an association between that neutral stimulus and the response. Operant conditioning uses reinforcement or punishment to increase or decrease a particular behavior.

Answer 955

Correct Answer: C. Contact Child Protective Services (CPS) or the appropriate local/state agency for child abuse reporting As a licensed health care provider, the NP is legally mandated to report suspected child abuse to child protective services. A spiral fracture of a long bone should be a red flag for abuse since these fractures are caused by twisting of the extremity. In addition, bruises on the torso in different stages of healing often indicate that the child is being abused. The story of the injuries does not match the physical evidence. Incorrect Answers: A. Children are not reliable reporters of abuse since they are often told that they will be taken away if they tell the truth about the abuse. Fear of abandonment is a strong deterrent to reporting by the child. B. Alerting the caregiver that child abuse is suspected may cause them to disappear with the child. D. Since the NP should suspect abuse in this case, providing education about playground supervision would be a non-productive intervention. Vital Concepts: A spiral fracture of a long bone should be a red flag for abuse since these fractures are caused by twisting of the extremity. In addition, bruises on the torso in different stages of healing often indicate that the child is being abused.

Answer 956

Correct Answer: C. CN V afferent, CN VII efferent This is known as the corneal reflex. The cornea is innervated by the nasociliary branch of the ophthalmic branch (V1) of the trigeminal nerve (CN V). V1 carries afferent (sensory) fibers, and passes the signal to the brainstem. There, the signal is transmitted to the motor fibers traveling within the facial nerve (CN VII), specifically the temporal and zygomatic branches. These two branches innervate the orbicularis oculi, the muscle responsible for closing the eyes. Incorrect Answers: A. CN II is the optic nerve, which is a purely sensory nerve that only carries fibers for vision and not tactile sensation. CN III is the oculomotor nerve, which innervates all of the extraocular muscles of the eyes except for the superior oblique (innervated by CN IV), and the lateral rectus (innervated by CN VI). Neither CN II can carry the tactile signal of the lens touching the cornea, nor can CN III close the eyes since it does not innervate muscles capable of doing so. This answer choice is wrong. B. CN II is explained in answer choice (A) (see above). While CN VII controls the efferent arm of the reflex arc, there needs to be an afferent signal coming through CN V first. D. While CN V can deliver the afferent, sensory signal, CN III does not innervate the orbicularis oculi, and, therefore, cannot close your eyes.

Answer 957

Correct Answer: B. Up to 15% of boys may have transient tics As many as 15% of boys (not girls) ages 8-12 may have transient tics. Incorrect Answers: A. Stress reduction and relaxation may reduce tics C. Adolescents treated with atypical neuroleptics need monitoring for mood disturbances; there's not an elevated risk of tics D. Both clonidine and guanfacine are effective in treating tics

Answer 958

Correct Answer: A. Cognitive behavioral therapy Cognitive-behavioral therapy helps patients with PTSD by equipping them with skills to control anxiety and to counter disruptive and unproductive thoughts. Incorrect Answers: B. Group therapy isn't as effective for PTSD patients. It's more often used for relationship problems, communication and social skill deficits, grief/loss, emotional trauma, and low self-esteem. C. Family therapy isn't indicated for this patient, as there's no indication he's experiencing problems with his family. D. While psychodynamic psychotherapy can be used for PTSD, it's more often used for personality-related disorders.

Answer 959

Correct Answer: D. Inpatient hospitalization Medicare Part A covers inpatient hospitalization, including inpatient psychiatric hospitalization, hospice care, home health care, and skilled nursing facilities. Incorrect Answers: A., B., C. These aren't covered by Medicare Part A Vital Concepts: Medicare Part A covers inpatient hospitalization, including inpatient psychiatric hospitalization, hospice care, home health care, and skilled nursing facilities.

Answer 960

Correct Answer: A. Chiropractors A collaborative agreement is a written agreement between a supervising physician and nurse practitioner that outlines the nurse practitioner’s role and responsibility to the clinical practice. This agreement is sometimes known as a “protocol.” Chiropractors are not considered physicians under the Nurse Practice Act. Incorrect Answers: B, and C. These practitioners can all sign collaborative agreements with an NP under the Nurse Practice Act. Vital Concepts: A collaborative agreement is a written agreement between a supervising physician and nurse practitioner that outlines the nurse practitioner’s role and responsibility to the clinical practice. This agreement is sometimes known as a “protocol.” Chiropractors are not considered physicians under the Nurse Practice Act.

Answer 961

Correct Answer: B. It is a process measure The measure used in this question is a process measure, a healthcare-related activity that is performed for, on behalf of, or by a patient. Process measures usually assess the activities of healthcare professionals to deliver services. Activities measured are frequently guided by evidence-based clinical guidelines. This particular measure is based on strong evidence that aspirin can prevent future cardiovascular events. Performance on some process measures may not reach 100 percent for reasons other than failure to follow clinical guidelines. These reasons may include patient refusal or contraindication to the treatment. Measure specifications should be reviewed for exclusions and exceptions when adapting use of a measure. Process measures are used to compare performance, for public reporting, and to set pay-for-performance incentives. They provide a detailed look at activities performed by professionals and staff. Incorrect Answers: A. Outcome measures are "what matters" to patients, for example, utilization or adverse events. This measure is a process measure, not an outcome measure. C. There will be reasons to fail to follow clinical guidelines, such as, refusals or contraindications; that does not make the measure poor quality. D. Process measures ARE used to compare performance, for public reporting, and to set pay-for-performance incentives. Vital Concept: A process measure is a healthcare-related activity that is performed for, on behalf of, or by a patient; usually used to assess the activities of healthcare professionals to deliver services.

Answer 962

Correct Answer: A. Deontology Deontology is a theory based on the works of Immanuel Kant and is the root of many religious traditions. Incorrect Answers: B. The theory of Ethical Relativism believes that one’s morality is directly linked to the “norm’s” of one’s culture. Moral right and wrong, according to this theory, varies from person to person and culture to culture. C. Feminist Theory evaluates the effects of an action on the person, the family and the community before drawing a moral conclusion. D. Utilitarianism theory values what is best for the majority. Its primary emphasis is on the outcome. Vital Concepts: Deontology is a theory based on the works of Immanuel Kant and is the root of many religious traditions.

Answer 963

Correct Answer: B. The claim will be covered if the NP purchased tail coverage at the time she changed jobs There are two types of malpractice insurance: claims-based and occurrence. Claims-based insurance only covers claims if the NP is still enrolled with the same insurance company at the time the claim is filed in court. If an NP changes jobs or retires, the claim will only be covered if the NP has purchased “tail coverage.” It does not matter if the NP was covered at the time of the incident. Tail coverage must be purchased before a lawsuit is filed. Occurrence coverage is unaffected by job changes or retirement and will cover an NP for claims in the future if the NP was covered by the occurrence policy at the time of the incident. Incorrect Answers: A. Tail coverage needs to be preexisting C. The claim will be covered if the NP purchased tail coverage when she changed jobs D. Claims-based insurance only covers claims if the NP is still enrolled with the same insurance company at the time the claim is filed in court, which isn't the case here Vital Concepts: There are two types of malpractice insurance: claims-based and occurrence. Claims-based insurance only covers claims if the NP is still enrolled with the same insurance company at the time the claim is filed in court. Occurrence coverage is unaffected by job changes or retirement and will cover an NP for claims in the future if the NP was covered by the occurrence policy at the time of the incident.

Answer 964

Correct Answer: B. The nurse practitioner is the defendant in the case Medical malpractice lawsuits are filed by patients or on behalf of the patient or other party claiming damage. This person is the plaintiff, and the healthcare provider is the defendant in the case. A plaintiff must prove all the following four elements: * A duty was owed to the plaintiff by the defendant (legal duty) * The duty was breached (standard of care was not met, etc.) * This breach of duty caused an injury (proximate cause) * Damage occurred. A lawsuit is filed in an appropriate court and the discovery phase begins with requests for medical records, expert opinions, and depositions. The plaintiff has the burden of proof. The case will either enter a trial phase or settle out of court. Lawsuits can be dismissed or damages can be awarded for physical, emotional, and mental harm. Incorrect Answers: A. The suing party is the plaintiff — that's the patient C. Medical records are requested in the discovery period D. Damages can be awarded for physical, emotional, and mental harm in addition to medical fees Vital Concept: Medical malpractice lawsuits are filed by patients or on behalf of the patient or other party claiming damage. This person is the plaintiff, and the healthcare provider is the defendant in the case. A plaintiff must prove all the following four elements: * A duty was owed to the plaintiff by the defendant (legal duty) * The duty was breached (standard of care was not met, etc.) * This breach of duty caused an injury (proximate cause) * Damage occurred.

Answer 965

Correct Answer: A. The patient asked for suggestions of a therapist since they are not able to get the time needed with the PMHNP. The PMHNP is resistant to the idea of others treating this patient. Signs that indicate countertransference are occurring are intense emotional reactions on first contact with client, recurrent anxiety while dealing with the client, difficulty emphasizing, preoccupation with or dreaming about client, running overtime with client or always cutting time short with client, depression or other strong emotions during or after interaction with client, feedback from others over-involvement with client, and uncharacteristic carelessness in interaction and follow-up with the client. Incorrect Answers: B. The PMHNP ending the appointment at the scheduled time is part of the PMHNP's responsibility to try to manage care. It isn't indicative of countertransference. C. The PMHNP expressing her concerns regarding the possibility of addiction to Klonopin is an important aspect of being a provider and does not indicate countertransference. D. Discussing disability options with a patient is appropriate for the PMHNP to do. It isn't indicative of countertransference.

Answer 966

Correct Answer: C. Standards of practice "Standards of practice" refers to the clinical practice aspects of patient care. A nurse practitioner should follow national standards of care appropriate for practice in a particular setting, such as ambulatory, acute, or long-term care facility. Incorrect Answers: A. A treatment plan is a plan that documents an individual’s healthcare problems and outlines goals and strategies to address those problems. B. Clinical guidelines are statements that include recommendations for optimization of patient care that result from a systematic review of evidence and assessment of the harms and benefits of alternative care options. D. Care plans provide direction for individualized care of a patient, resulting from the patient’s unique diagnoses and according to the individual’s specific needs. Vital Concepts: "Standards of practice" refers to the clinical practice aspects of patient care. A nurse practitioner should follow national standards of care appropriate for practice in a particular setting, such as ambulatory, acute, or long-term care facility.

Answer 967

Correct Answer: A. Contracted service system In a contracted service system, the NP signs a contract and agrees to provide care for a specific population. Incorrect Answers: B. A second-party system includes payments made through a legal guardian or guarantor. C. A third-party payment system includes payments made through Medicare, Medicaid, and private insurance. D. A fee for service system occurs when the patient pays the NP directly. Vital Concepts: In a contracted service system, the NP signs a contract and agrees to provide care for a specific population.

Answer 968

Correct Answer: B. 1 case per 100 The average prevalence of autism spectrum disorder globally is 1%. Recent data suggest that between 1/50 and 1/100 people in the US are affected by this disorder. Incorrect Answers: A, C, & D. These prevalences are too low

Answer 969

Correct Answer: A. Splitting This patient displays signs of borderline personality disorder, including impulsivity, emotional lability, and unstable interpersonal relationships. By lavishing exaggerated praise on the attending and insulting the resident, she is displaying splitting, an ego defense mechanism in which an individual can only be regarded as all good or all bad with no middle ground or opposing characteristics. Incorrect Answers: B. Projection is an ego defense in which an individual ascribes unconscious and unacceptable impulses to another person. For example, a bully who fears his own weakness may attack someone he perceives as weak. C. Idealization occurs when negative aspects of a person or situation are ignored and only positive aspects are acknowledged. Although this patient has idealized the attending, splitting is the more relevant ego defense mechanism in this case. D. Regression in children can lead to a loss of milestones like continence when faced with stress. In adults, it may involve child-like or immature behaviors. Vital Concept: Splitting, a common ego defense in borderline personality disorder, results in attributing either all negative or all positive attributes to others and ignoring suggestions or evidence to the contrary.

Answer 970

Correct Answer: D. Ego Integrity vs. Despair This patient is demonstrating ego integrity vs. despair. (See table below) Incorrect Answers: A. This applies to ages 6-12 (too young) and relates to confidence, competence, and social skills (not applicable). B. This applies to ages 12-28 (too young) and relates to the formation of identity and devotion (not applicable). C. This applies to ages 18-35 (too young) and relates to forming a relationship and commitment (not applicable).

Answer 971

Correct Answer: B. This syndrome can occur during selective serotonin reuptake inhibitor (SSRI) tapering or after missing an SSRI dose. Discontinuation syndrome can occur during tapering of selective serotonin reuptake inhibitors (SSRIs) or after missing an SSRI dose. Occurs when there is a sudden absence of increased serotonin, like when stopping SSRIs. When taking SSRIs there is a surge of serotonin so down regulate serotonin receptors in response to increased serotonin so after stopping get a short-term deficiency of serotonin activity. With discontinuation syndrome see fatigue, dizziness, headache and nausea. Incorrect Answers: A. This syndrome is primarily seen with atypical neuroleptics. Discontinuation syndrome is primarily seen with SSRIs, not atypical neuroleptics. C. Children tend to experience discontinuation syndrome with long-acting selective serotonin reuptake inhibitors (SSRIs). Children are more prone to discontinuation syndrome on short-acting SSRIs (e.g. paroxetine). In these cases, the SSRI may need to be restarted, or the patient may need to be started on a long-acting SSRI (e.g. fluoxetine). D. Cognitive symptoms include increased focus. Cognitive symptoms include confusion and memory problems. References:

Answer 972

Correct Answer: D. Care of this patient needs to be transferred to another physician. In a situation where any member of the patient's staff or patient's care is involved in a criminal case against the patient, alternative care must be sought for the patient. Factors such as confidentiality, trust, and empathy cannot fully exist in such a situation, and the therapeutic relationship is not adequate for optimal care of the patient. If the office staff member was independently pressing charges and the physician was in no way involved, then ongoing care with that physician would be possible if that member of the office staff was separated from interacting with the patient (e.g. seeing the patient on a day when that staff member was not working). It is the ethical duty of this physician to try to obtain adequate care for the patient with another physician. Incorrect Answers: A, B. The patient can't continue to be cared for by the current physician C. Banning from the practice and obtaining a restraining order are premature, and would also be unethical if they would interfere with the patient's ability to receive care References:

Answer 973

Correct Answer: A. Financial abuse/neglect Financial abuse and neglect are both occurring in this prompt. When a family member or other adults steal from a patient, convince them to invest in schemes, have the patient change their will, or move into their home without sharing household costs, the patient may be a victim of financial abuse. Neglect is a more passive form of abuse that includes providing suboptimal or no care for the elder. Not providing food, shelter, medications, etc. to a patient is considered neglect. Incorrect Answer: B. Psychological or emotional abuse includes threats or forced seclusion. C. Child abuse involves the maltreatment of a minor, and the patient in this scenario is an adult. D. Labor trafficking involves forcing an individual to work, under unfair or unsafe conditions, through the use of force or coercion. Vital Concept: Not providing food, shelter, or medications to a patient is considered neglect. Financial abuse occurs when the victim's access to their finances is limited. References:

Answer 974

Correct Answer: E. Offer to hold a meeting with the patient and his family members to discuss the decision to stop dialysis. A person with decision-making capacity has the absolute right to refuse medical intervention, even if it results in death. A patient should be considered to have capacity unless the clinician has reason to believe that the patient does not. The clinician will not take on any legal liability, and honoring a patient’s decision to withdraw or withhold life-sustaining treatment is not considered physician-assisted suicide. Although a family discussion may not change the patient’s course, it is always appropriate to treat patients and their families with respect. The best course of action is to facilitate a discussion with the patient and his family to give them the opportunity to express their concerns and motivations. Incorrect Answers: A and C. The clinician has no reason to think that this patient lacks capacity. These consults are unnecessary in this situation. B and D. A clinician cannot force treatment on a patient with capacity if the patient declines it. Vital Concept: A person with decision-making capacity has the absolute right to refuse any medical intervention. References:

Answer 975

Correct Answer: A. Deficits in intellectual function In the DSM-5-TR, intellectual disability: Typically includes deficits in intellect, social skills, and the ability to perform everyday tasks. Deficits in intellectual functioning must be obvious, including logical thinking, preparation, finding solutions, comprehension, discernment, and acquiring new knowledge through school or life lessons. Clinical assessment and intelligence testing confirm the lack of these skills. Deficits in adaptive functioning must hinder the individual's ability to perform the tasks required to have independence and life responsibilities. Without external support, these deficits affect the individual's ability to complete at least one activity of daily living, such as living independently, participating in social situations, and verbal communication with others in various settings. The disorder must develop during normal childhood development. Incorrect Answers: B. Deficits need to appear during normal childhood development, not in middle age C. An immediate family member with diagnosed intellectual disability isn't needed to diagnose a patient with intellectual disability D. There are no physical characteristics in the diagnostic criteria Vital Concept: Intellectual developmental disorder (intellectual disability) typically includes deficits in intellect, social skills, and the ability to perform everyday tasks.

Answer 976

Correct Answer: C. Present your findings to the peer-review committee and conclude the peer review in X’s favor. Professional peer review is necessary to ensure the fair assessment of healthcare provider performance. All healthcare providers have a duty to participate in peer review and to enjoy legal protection while participating in good faith. Although it is a professional's duty to disclose any well-formed suspicions of professional misconduct, incompetence, fraud, or patient abandonment by another healthcare provider, it is unethical for a healthcare provider to use the peer-review process to harm the practice of another provider or to limit or restrict clinical privileges. In this case, the healthcare provider should participate in good faith. If the outcome of the peer review is unjust or has been manipulated by the personal interests of another healthcare provider, report this suspicion to a higher local authority. Incorrect Answers: A. All health care providers have a duty to participate in peer review B. Only report to a higher local authority if the outcome of peer review is unjust or has been manipulated by another healthcare provider's interests D. All providers should act in good faith, so you shouldn't intervene by informing X of your suspicions Vital Concepts: Professional peer review is necessary to ensure the fair assessment of healthcare provider performance. All healthcare providers have a duty to participate in peer review and to enjoy legal protection while participating in good faith. Although it is a professional's duty to disclose any well-formed suspicions of professional misconduct, incompetence, fraud, or patient abandonment by another healthcare provider, it is unethical for a healthcare provider to use the peer-review process to harm the practice of another provider or to limit or restrict clinical privileges.

Answer 977

Correct Answer: B. Advocacy In this case, the nurse practitioner acted as the patient’s advocate, promoting the patient’s best interests and ensuring that the patient received appropriate healthcare. In some cases, a nurse practitioner may hesitate to act as an advocate due to a fear of retribution. In fact, there have been court cases and nursing board actions against nurses under similar circumstances. However, patient advocacy remains a fundamental nursing role. The ANA Code of Ethics proclaimed in 1978 that “the role of client advocate, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, or illegal practices by any member of the health care team or the health care system itself, or any action on the part of others that is prejudicial to the client’s best interest.” Incorrect Answers: A. Change agent. In the role of a change agent, an NP might work collaboratively to bring about evidence-based change in a clinical practice or might work to bring forth policy change at a governmental or organizational level. C. Independent practice. This is not independent practice; the nurse was being an advocate for the patient. D. Pioneer. A pioneer in nursing refers to those who have developed, maintained, and continue to advance the profession of nursing. Vital Concept: Acting as a patient advocate includes promoting the patient’s best interests and ensuring that the patient receives appropriate healthcare. References:

Answer 978

Correct Answer: C. Treat the patient without regard for the caregiver's wishes. If there is a clear and imminent danger to the life of a child with a risk of death as a result of a delay in treatment, the healthcare provider can proceed with treatment without judicial review against the wishes of the custodial parent. Incorrect Answers: A. In this situation, there is a clear and imminent danger to the life of the child, so attempting to obtain a court order prior to treatment would delay lifesaving treatment and would not be appropriate in this situation. B. Admitting the patient for observation and isolation without treatment would delay lifesaving treatment and would not be appropriate in this situation. D. After a divorce, only the parent with custody of the child can consent to treatment so attempting to obtain consent from the other caregiver would not solve the issue. Vital Concept: The NP is tasked with the protection of the patient and the NP’s decision should be based on the best interest of the patient. If treatment is required urgently, the NP can proceed without consent from the caregiver. References:

Answer 979

Correct Answer: B. His mother The patient's mother has the only legally signed document, so she is the one with the legal authority to make decisions for the patient. Unless the patient has rescinded the document, it does not make any difference that the patient did not live with his mother as a child and young adult. Incorrect Answers: A. The patient's father cannot make the decisions since his custody ended when his son turned 18. C. The patient's fiancé has no legal authority to make decisions for the patient since they were not legally married. D. Although this might be reviewed as an ethical dilemma, the Ethics Committee does not have the authority to make decisions for the patient. Vital Concept: The patient's mother has the only legally signed document, so she is the one with the legal authority to make decisions for the patient. Unless the patient has rescinded the document, it does not make any difference that the patient did not live with his mother as a child and young adult. References:

Answer 980

Correct Answer: A. Duty, deviation, damages, and direct involvement These are the four D’s that one must have to prove malpractice: a patient/ doctor relationship. Psychiatry makes judgment calls with particular treatments, even if a judgment call was wrong, it might not be a deviation from a standard of care. You also have to have damages that directly had affected the patient. Incorrect Answers: B. This question is about establishing malpractice, therefore it should not be part of the answer. If malpractice was determined, it must have directly involved the patient and not just the family. C. You do not have to have a patient die to determine malpractice. D. “Direct loss” is hard to measure and is not part of the malpractice determination process. References:

Answer 981

Correct Answer: B. Group A strep Group A strep (e.g. strep throat) in a small subgroup is associated with OCD and is also associated with neurological abnormalities and an abrupt prepubertal onset. PANDAS is an acronym for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections, a pediatric neurological disease in which a subset of children exhibit a rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorders with neuropsychiatric symptoms following group A beta-hemolytic streptococcal infections. Pediatric acute-onset neuropsychiatric syndrome (PANS) is a 2012 proposal describing another subset of acute-onset OCD cases, including disorders potentially associated with a preceding infection and acute-onset neuropsychiatric disorders without an apparent environmental precipitant or immune dysfunction. Incorrect Answers: A. Group B strep. Obsessive-compulsive disorder is not associated with this infection. C. Pneumococcus. Obsessive-compulsive disorder is not associated with this infection. D. Neisseria meningitidis. Obsessive-compulsive disorder is not associated with this infection. References:

Answer 982

Correct Answer: D. Combining several studies to minimize local and study-specific effects Meta-analyses are less influenced by local effects or study-specific idiosyncrasies and can yield more generalizable results. Incorrect Answers: A. Studies in a meta-analysis are chosen based on their characteristics (e.g. double-blind RCT) and the underlying science. Picking studies based on their results would corrupt the meta-analysis. B. While peer-review is an important component of the scientific publication process, reliance on only published data results in the well-known “file drawer problem,” which skews results and creates a base-rate fallacy that makes published results seem more significant due to the difficulty of publishing negative or insignificant results. C. A good meta-analysis cannot correct a poor study methodology and data. Some meta-analyses use corrections to reduce the power of weaker studies, but this process does not address the underlying poor data quality. References:

Answer 983

Correct Answer: D. Clinical decision support system (CDSS) The applications contain a database of medical knowledge. An evidence-based inference system provides patient-specific advice. Incorrect Answers: A. CPOE is a clinical software application that automates medications and treatment ordering. B. The computerized notification system provides alerts to abnormal lab results or imaging results. C. The EMR is a digital computerized patient record, which may be integrated with CPOE and CDSS. Vital Concepts: The applications contain a database of medical knowledge. An evidence-based inference system provides patient-specific advice. References:

Answer 984

Correct Answer: B. Open neural tube defects Valproate exposure prior to neural tube closure, during the fourth week of gestation, confers a 1-2% risk for open neural tube defects, which is 10-20x greater than the prevalence in the general population. Incorrect Answers: A. The cause of this is disputed, but not suspected to be related to valproate exposure C. This is an autosomal recessive genetic condition; so it's not related to valproate exposure D. This is a tumor made up of several tissue types; so it's not related to valproate exposure References:

Answer 985

Correct Answer: B. It is a broad-based measure of personality traits and psychopathology. The MMPI is the most widely used and studied standardized psychometric test of adult personality and psychopathology. The MMPI-A is used for adolescents and is designed for ages 14-18 years. Incorrect Answers: A. This describes the Stanford-Binet Intelligence Scale. C. This describes the MMSE. D. This describes the Rorschach test (also called the "inkblot" test). References:

Answer 986

Correct Answer: C. Sufficient evidence points to the lack of added benefit of this drug. Evidence-based medicine considers RCTs to provide a superior level of evidence in regards to therapeutic clinical research. A meta-analysis of RCTs, where the data from multiple RCTs are combined and analyzed, is considered even more superior than a single RCT. This is because combining RCTs increases the size of subjects and, therefore, the reliability of the conclusions. This method is considered, by far, to be the most trustworthy in terms of evidence. Therefore, a meta-analysis of 4 RCTs showing no added benefit can be relied on when making clinical decisions. Incorrect Answers: A. Cohort studies are observational studies where one cohort is exposed to a certain risk factor or treatment and the other one is not. The effect of that exposure is then assessed after a certain period. Cohort studies do not involve randomization, as clinicians simply observe patients. Therefore, it is very difficult to control for other confounding variables, making this type of study less reliable than RCTs. B. Expert opinions are simply statements from people who have extensively been involved in a certain field. However, they are neither observational nor experimental studies. Therefore, in evidence-based medicine, expert opinions provide the weakest type of evidence. A clinician must put more weight on any other available type of study over an expert’s opinion. D. The drug was evaluated by 4 randomized clinical trials and was not found to be more superior than the current options. Unless the aforementioned RCTs are flawed, there is no reason to believe that a clinician needs more evidence to interpret the efficacy of this drug. Vital Concepts: The hierarchy of evidence-based medicine is in the following order (from strongest to weakest evidence): Meta-analysis of RCTs > RCTs > Cohort studies > Case Control > Case Series > Expert opinion. References:

Answer 987

Correct Answer: D. Metabolite activity as well as inhibition of serotonin reuptake in presynaptic receptors Trazodone is metabolized to m-chlorophenylpiperazine (m-CPP), a major active metabolite that acts as a direct agonist of 5-HT. Those with CYP450 2D6 deficiency can experience CNS activation as m-CPP is metabolized by 2D6. In patients with normal CYP450 2D6 activity, plasma and CNS levels of mCPP compose <10% compared to trazodone itself. This suggests that trazodone blocks much of the effects of mCPP at 5HT-2A and 5-HT-2C receptors. In addition, trazodone inhibits the reuptake of serotonin in presynaptic receptors. Incorrect Answers: A, B, and C. These are not the means by which trazodone causes activation of the CNS. References:

Answer 988

Correct Answer: B. Adding hydrochlorothiazide Polyuria is caused by a reduced renal response to ADH. The severity can range from mild to severe nephrogenic diabetes insipidus. For mild cases can change to once-daily bedtime dosing of lithium. Check that fluid intake is sufficient and that the lithium is at the lowest doses needed. If these methods do not work then can add hydrochlorothiazide, thiazide diuretic. Would use hydrochlorothiazide 25 to 50 mg daily. However, the lithium dose will typically need to be decreased up to 50% because thiazides increase the reabsorption of lithium. Another option to treat lithium-induced polyuria is adding amiloride 5-10 mg twice a day. Amiloride is a potassium-sparing diuretic and does not affect lithium levels. Incorrect Answers: A. Changing dose of lithium from daily to 2-3x daily. To assist with polyuria the lithium can be switched to dosing once daily at bedtime. C. Adding potassium. Potassium replacement is only needed if the hydrochlorothiazide causes low potassium; it is not utilized to treat lithium-induced polyuria. D. Combining medication into a single morning dose. Combining mediation into a single bedtime, not morning, the dose has been effective in reducing polyuria associated with lithium. References:

Answer 989

Correct Answer: B. Administer benzodiazepine Benzodiazepines are the appropriate treatment for panic disorder. The young, healthy patient in this vignette has characteristic features of panic disorder, including recurrent episodes of shortness of breath, diaphoresis, chest pain, tachycardia, nausea, palpitations, and fear of dying. The classic symptoms of panic attack occur with a rapid onset and resolution of somatic symptoms, including cardiac, gastrointestinal, and neurologic symptoms, in addition to intense anxiety and fear. Benzodiazepine administration in the emergency department should bring rapid relief of symptoms. The diagnosis requires recurrent episodes that include at least four of the following symptoms: Trembling, diaphoresis, nausea Chest pain, palpitations, dyspnea, choking sensation Intense anxiety/fear of dying or losing control Derealization Depersonalization Dizziness Paresthesias Anxiety about additional attacks Avoidance behavior Incorrect Answers: A. Selective serotonin reuptake inhibitors are the first-line treatment of panic disorder, but emergency department treatment of an acute panic episode should begin with a benzodiazepine to relieve the patient's immediate symptoms. There are 3 SSRIs that are FDA-approved for the management of panic disorder. These are sertraline, fluoxetine, and paroxetine. Venlafaxine is an SNRI that is also approved for this condition. Escitalopram and citalopram are SSRIs that are indicated for other anxiety disorders. Selegiline is an MAO-B inhibitor with FDA indications for depression, Parkinson’s disease, and major depression. C. This patient's EKG and troponins are normal, so further cardiac workup for STEMI is not necessary. D. These studies would be indicated if pheochromocytoma was suspected as the cause of the patient's symptoms. Pheochromocytoma is a catecholamine secreting tumor that is less common than panic disorder. It is associated with episodes of tachycardia, headache, diaphoresis, and paroxysmal or sustained hypertension. Vital Concept: Panic disorder is characterized by episodes of intense anxiety, fear of dying, and somatic symptoms, including chest pain. Although SSRIs and SNRIs are first-line long-term treatment, benzodiazepines are indicated to relieve distress in an acute episode. References:

Answer 990

Correct Answer: A. Schizoaffective disorder The patient's symptoms are consistent with schizoaffective disorder. When symptoms of schizophrenia are present for greater than 6 months with symptoms alongside mood disorder symptoms such as depression or mania, schizoaffective disorder should be considered. The base prevalence may be less than 1% in the community, although the disorder is found at much higher rates in clinical settings. Schizoaffective disorder is a condition in which the patient has symptoms of both schizophrenia and a major mood disorder, and both sets of symptoms are prominent in the patient's course of illness. According to DSM-5-TR criteria, schizoaffective disorder includes the following: The patient must have two sets of symptoms simultaneously: Symptoms of a major depressive episode (MDE) or mania- the patient must meet the criteria, including poor or sad mood for the majority of the day most days At least two primary symptoms of schizophrenia: speaking incoherently without logical organization* a misconception, belief, or thought that is firmly held despite not being grounded in reality* illusions or perceived experiences that do not exist (e.g., sounds, voices, smells, visions, feelings, etc.)* actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) decreased display of emotion or a lack of motivation The symptoms of schizophrenia must be present for at least two weeks alone, without the mood symptoms listed above Mood symptoms are then present for the majority of the episode/illness The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition The disorder should be classified as Bipolar type if mania is present or Depressive type if ONLY depressive symptoms are present. This particular scenario would qualify as depressive type. Incorrect Answers: B. Bipolar disorder is mostly seen with affective symptoms by the absence of periods of psychosis. C. Schizoid personality disorder is not associated with psychotic symptoms. D. Major depressive disorder is ruled out as the patient has no history of low mood and crying spells without the psychotic symptoms. Vital Concept: Schizoaffective disorder consists of mood disorder symptoms, including depression or hypomania/mania, and schizophrenia symptoms. It is characterized by an uninterrupted period of illness during which there is a major mood episode concurrently with 2 or more symptoms of schizophrenia: hallucinations, delusions, disorganized or catatonic behavior, disorganized speech, or negative symptoms. References:

Answer 991

Correct Answer: D. 0.12 When calculating the risk that an individual will develop a disease, the number of new cases of the disease should be divided by the number of individuals at risk of developing the disease. In the second week of the outbreak, only 20 students remain at risk since 10 individuals have already contracted flu. In the third week of the outbreak, there are only 17 students at risk. As a result, the risk is 2/17 or 0.12. Incorrect Answers: A. 0.3 represents the risk of contracting flu during the first week of the outbreak. B. 0.06 represents the number of new cases in the third week divided by the total number of students in the original group, including those who had already contracted the flu. C. 3/20 represents the number of new cases in the second week divided by the total number of students. Vital Concepts: When calculating the risk that an individual will develop a disease, the number of new cases of the disease should be divided by the number of individuals at risk of developing the disease. References:

Answer 992

Correct Answer: B. Persecutory In amphetamine psychosis, persecutory delusions are the most common, followed by auditory and visual hallucinations. In most cases, these are self-limited and go away with discontinuation of the drug, but in some cases, symptoms can persist for several weeks. Persecutory delusions also rarely occur with high-dose cannabis use. Incorrect Answers: A. C. D. These are not delusions that tend to happen in amphetamine psychosis References:

Answer 993

Correct Answer: D. Lima beans Lima beans would be considered a safe food as it does not contain tyramine. Foods to be avoided include foods with tyramine. Strong aged cheeses, cured meats, smoked/ processed meats, pickeled foods, soybeans, yeast based, alcohol, and meat tenderizers are examples of foods to be avoided. Incorrect Answers: A. Pickled herring is a pickled food that is not safe while taking a MAOI antidepressant. B. Smoked salmon is a smoked food that is not safe while taking a MAOI antidepressant. C. Chianti wine is alcohol that is not safe while taking a MAOI antidepressant. References:

Answer 994

Correct Answer: A. Nephrolithiasis occurs in about 1% of patients. Nephrolithiasis is due to topiramate’s inhibition of carbonic anhydrase. Incorrect Answers: B. Topiramate is associated with acute myopia and with secondary closure glaucoma, causing ocular pain and blurred vision. Visual symptoms are due to increased intraocular pressure, which occurs most frequently in the first month of treatment and typically resolves with discontinuation of topiramate. C. Metabolic acidosis is associated with topiramate. Serum bicarbonate should be monitored during topiramate use. D. Decreased appetite, paresthesias, and cognitive slowing do not improve over time. Other initial neurological and GI side effects tend to decrease over time, and weight loss is a significant side effect. References:

Answer 995

Correct Answer: B. Case-control study A case-control study begins by identifying subjects with a disease or outcome and compares them with a group of subjects without the disease or outcome of interest. These studies are usually retrospective: researchers look back in time to investigate risk factors or exposures. A case-control study can result in confounding by other variables and errors due to recall bias and selection bias. A case-control study is used to get the association between risk factors and disease. Incorrect Answers: A. A retrospective cohort study identifies a risk factor or exposure in a population and looks back in time to identify patients with the exposure and a pre-determined outcome. These studies may have errors due to confounding bias. The odds ratio provides a measure of relative risk in cohort studies. Exposures are always identified before outcomes in cohort studies. C. Cohort studies yield true incidence rates and relative risk, but they require large numbers. Prospective cohort studies follow patients with a specified risk factor or variable to determine how it is associated with the development of a certain outcome. D. A cross-sectional study is an observational study that compares different population groups at a moment in time, sometimes allowing researchers to compare a variety of variables at once. A cross-sectional study is used to assess the prevalence, which is the presence of the disease at a point in time. It also only gathers information about a single group of people (those with the disease and the risk factors). A cross-sectional study does not include information on those without the disease since it only focuses on those with the disease out of the whole population to get the prevalence. Vital Concepts: A case-control study begins by identifying subjects with a disease or outcome and compares them with a group of subjects without the disease or outcome of interest. These studies are usually retrospective: researchers look back in time to investigate risk factors or exposures. A case-control study is used to get the association between risk factors and disease. References:

Answer 996

Correct Answer: D. Structural Minuchin proposed the structural school of family therapy. Incorrect Answers: A. Psychoeducational is associated with Carol Anderson and William McFarlane. B. Behavioral is associated with Robert Liberman and Lawrence Weathers. C. Narrative is associated with Michael White and David Epston. References:

Answer 997

Correct Answer: A. Bupropion Bupropion has a low incidence of sexual dysfunction. Isocarboxazid and phenelzine have a high incidence of sexual dysfunction. Incorrect Answers: B, C, D. These have a high incidence of sexual dysfunction. References:

Answer 998

Correct Answer: C. Glutamyltransferase (GGT) & carbohydrate deficient transferrin (CDT) GGT can be used to screen for chronic alcohol abuse (it will be elevated in about 75% of chronic drinkers) and to monitor for alcohol use in those who are receiving treatment for chronic alcohol use disorder or alcoholic hepatitis. CDT is a blood test to detect heavy alcohol use (five or more drinks a day) over the past two weeks. This alcohol biomarker can provide clinicians with an objective way to screen and monitor clients in treatment for alcohol use disorders. Using these two markers will provide a 90% sensitivity to alcohol use. Incorrect Answers: A. AST is a liver enzyme that is used to detect liver damage and is not directly related to the use of alcohol. AST is an indirect biomarker for alcohol use. Although GGT is use as a screen for chronic alcohol abuse, it and AST does not provide a 90% sensitivity to alcohol use/abuse. B. ALT is typically used to detect liver injury and is not directly related to the use of alcohol. . Although GGT is use as a screen for chronic alcohol abuse, it and ALT does not provide a 90% sensitivity to alcohol use/abuse. D. Mean Corpuscular Volume is the average amount of space occupied by each red blood cell. MCV is increased with excessive alcohol intake after 4 to 8 weeks, however the sensitivity of MCV is too low to justify it as a single maker. Although GGT is use as a screen for chronic alcohol abuse, GGT and MCV does not provide a 90% sensitivity to alcohol use/abuse. References:

Answer 999

Correct Answer: B. 50% The chance that an individual with a positive test has the disease refers to the positive predictive value. Prevalence of disease in the population has an effect on the predictive value of test results. Using Bayesian analysis, determine the likelihood that a person with a positive test result in a specific population has the disease by using the following steps (see image below for details): (1) There is an a priori probability of having the disease of 10% in this population and a 90% possibility of not having the disease. This refers to prevalence. (2) If a person has the disease, the probability of having a positive test result can be obtained from the sensitivity. A person with the disease has a 90% chance of having a positive test result. (3) The probability of having a positive test without the disease is 10%. This is obtained from the specificity of the test. (4) The joint probabilities are the products of multiplying values in rows B and C. (5) The final probability for each mutually exclusive state is obtained by dividing each value in row E by the sum of the 2 values in row D. In this case, the person with a positive test result has a 50% probability of having the disease and a 50% probability of normal cognition. The sensitivity and specificity are qualities of the test: sensitivity = 90% and specificity = 90%. Incorrect Answers: A. 9%. The positive predictive value is 50%, not 9%. This can be a distractor because the positive likelihood ratio of the test is 9.0 and can be calculated as follows: sensitivity/(100-specificity). C. 90%. If a person has the disease, the probability of having a positive test result can be obtained from the sensitivity. A person with the disease has a 90% chance of having a positive test result. The test can detect 90% of the population with mild cognitive impairment. However, 10% of people with MCI will be missed by the test. The test is 90% specific, which refers to the number of people with a positive test who actually have the disease. D. 98.90%. The negative predictive value of the test is 98.90%, which is the probability that a negative test is actually negative. Vital Concept: Positive predictive value (PPV) is the probability that patients with a positive screening test actually have the disease. PPV can be affected by prevalence of disease. Can use Bayesian analysis to determine the likelihood that a person with a positive test result in a specific population has the disease. References:

Answer 1000

Correct Answer: C. Lost to follow-up The validity of a study reflects bias. In this case, since researchers and patients are both blinded, the risk of ascertainment of outcome bias is reduced. Since the study is a large prospective study linked to treatment and outcomes, there is a risk that subjects may be lost to follow-up. Type I and II errors refer to statistical significance of a study and do not affect the internal validity of a study. The incidence of osteoporosis in the population will not affect the validity of the study, but if it is low, there may be an insufficient number of outcomes to reach statistical significance between the control group and treatment group. Incorrect Answers: A. and B. These refer to the statistical significance of a study and don't affect its internal validity. D. Because the researchers and patients are both blinded, the risk of ascertainment of outcome bias is reduced. Vital Concepts: The validity of a study reflects bias. Since researchers and patients are both blinded, the risk of ascertainment of outcome bias is reduced. Since the study is a large prospective study linked to treatment and outcomes, there is a risk that subjects may be lost to follow-up. Type I and II errors refer to the statistical significance of a study and do not affect the internal validity of a study. References:

Answer 1001

Correct Answer: A. Sertraline 50mg Sertraline has a wide range of effective doses, but therapy is often initiated at 50mg and increased every 2 weeks to a maximum of 200mg daily. Incorrect Answers: B. Fluoxetine is usually initiated at 10mg per day and maintained at that dose for 3 weeks due to the long half-life of the medication. The maximal benefit of fluoxetine is between 20-40mg, and doses of ≥60mg have more side effects and have not been effective. C. Paroxetine dosing is similar to fluoxetine, and a maximum of 50mg is recommended for initial treatment. D. Fluvoxamine has a wide dose range. Due to its short half-life, it generally requires doses of 100-200mg per day. References:

Answer 1002

Correct Answer: D. Haloperidol Haloperidol is least associated with sedation (see table below). Incorrect Answers: A. Mid association with sedation B, C. High association with sedation References:

Answer 1003

Correct Answer: C. Duloxetine Duloxetine selectively inhibits the uptake of both serotonin and norepinephrine. It is a serotonin-norepinephrine reuptake inhibitor (SNRI). Additional examples of SNRIs are venlafaxine and desvenlafaxine. Incorrect Answers: A. Fluoxetine is a selective serotonin reuptake inhibitor. B. Bupropion is a relatively weak reuptake inhibitor of dopamine and norepinephrine. D. Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) that acts by antagonizing the adrenergic alpha2-autoreceptors and alpha2-heteroreceptors, as well as by blocking 5-HT2 and 5-HT3 receptors. References:

Answer 1004

Correct Answer: B. Trans-Theoretical Model of Change Trans-Theoretical Model of Change states that there are six predictable stages in order for someone to change a behavior. The stages are pre-contemplation, contemplation, preparation, action, maintenance, and termination. The 33-year-old patient is just about to be in the action stage which is when they actually begin to make a change. Hierarchy of Needs, Theory of Adaption, and Interpersonal Theory do not include the stages discussed in this question. Incorrect Answers: A. This discusses humans' needs in ascending order. It doesn't describe steps towards change. C. This argues that adapting is central to the storytelling imagination and explores the development of creative thought. It doesn't describe steps towards change. D. This describes how relations between people affect their behavior. It doesn't describe steps towards change. References:

Answer 1005

Correct Answer: C. Serving as a role model The components of leadership for nurse practitioners can include acting as a change agent, a mentor, an advocate, and a pioneer. Mentorship includes acting as a role model and can also include more structured mentoring or participation in intra-disciplinary peer review. Nurse practitioners are role models for RNs who benefit from their ability to promote the development of the nursing profession. Incorrect Answers: A. Working collaboratively to produce a new evidence-based clinical practice represents the role of the NP as a change agent. Advocacy is closely related to being a change agent. NPs advocate for patients, health issues, and the progression of the nursing profession. B. Active membership and support of groups that advocate for change can be seen as evidence for leadership through advocacy. D. Pioneers are those NPs that establish, maintain, and build the role of nurse practitioners. Vital Concepts: Mentorship includes acting as a role model and can also include more structured mentoring or participation in intra-disciplinary peer review. Nurse practitioners are role models for RNs who benefit from their ability to promote the development of the nursing profession. References:

Answer 1006

Correct Answer: C. Acting as sponsor to patients A 12-step facilitator can be in recovery, but they cannot be a sponsor and a treatment provider at the same time. Incorrect Answers: A. 12-step facilitators can enhance utilization by reading the Big Book, attending AA meetings, and learning about AA traditions. B. 12-step facilitators can aid patients by monitoring AA attendance and discussing barriers to attendance. D. 12-step facilitation is generally about reinforcing the goals and principles in AA by reviewing lessons from AA in session. References:

Answer 1007

Correct Answer: B. When individuals do not have a good working relationship, substantive issues can lead to unresolved conflict Likert and Likert distinguished between two types of workplace conflict, substantive conflict and affective conflict. Substantive conflict may result from content issues or process issues. Affective conflict may result from clashing personal styles, even if individuals have good intentions. Other affective conflict may result from pathology. When individuals have a good working relationship that is based on mutual trust and respect, conflicts can easily be resolved. Without a good working relationship, issues can quickly lead to unresolved conflict over what to do and who should make the decision. Models of conflict resolution have been developed to demonstrate how the choice of an approach to conflict may lead to a certain outcome. A simple model of conflict resolution categorizes actions as active and passive. Active solutions tend to result in resolution of a conflict, but passive solutions result in poor outcomes. Emotional reactions to conflict that result in poor outcomes including avoidance and giving up, which are passive reactions; and competition, which is an active emotional reaction to conflict. Rational reactions more likely to resolve conflict include accommodation, compromise, and collaboration. Incorrect Answers: A. Substantive conflict results from content or process issues, not personalities C. Competition is an active emotional reaction to conflict D. Avoidance is an emotional reaction to conflict, and results in poor outcomes Vital Concepts: Without a good working relationship, issues can quickly lead to unresolved conflict over what to do and who should make the decision. Active solutions tend to result in resolution of a conflict. References:

Answer 1008

Correct Answer: D. Phenelzine Phenelzine is an MAOI. All MAOIs associated with sexual side effects and weight gain. Incorrect Answers: A. Bupropion-long term side effects are rare but include a lower incidence of sexual side effects and weight gain similar to placebo. B. Trazodone-sexual side effects and weight gain are rare. Priapism has been noted in 1 in 6,000 male patients. C. Nefazodone has low rates of long-term side effects, including sexual dysfunction and weight gain. References:

Answer 1009

Correct Answer: D. Gabapentin overdose is associated with sedation, ataxia, and diplopia. Gabapentin is generally safe in overdose. Hemodialysis can be used for treating an overdose. Incorrect Answers: A. Gabapentin has similar initial side effects to other anticonvulsants, including sedation, dizziness, nausea, ataxia, headache, tremor, and visual changes. B. Weight gain is more common with valproic acid than with gabapentin. C. Initial side effects are generally mild and transient. References:

Answer 1010

Correct Answer: C. Can be done concurrently or retrospectively The timing of the PI process will depend on when the issue is identified. Therefore, the initiative can be carried out concurrently or retrospectively. Incorrect Answers: A. The PI project should include all of the people involved in the process, including Quality, unit managers, and clinicians. It is important that all groups participate to ensure buy-in on the end product. B. Unless specific patients will be identified, IRB approval is NOT required. Since PI results are meant to improve internal processes, this is rarely required. D. Typically, there is no fixed endpoint. Instead, processes are implemented and tested, issues with the new process are identified, and new processes are put into place. This makes the PI process a continuous, cyclical process. Vital Concept: The timing of the PI process will depend on when the issue is identified. Therefore, the initiative can be carried out concurrently or retrospectively. References:

Answer 1011

Correct Answer: C. Accountability for patient outcomes is shared Working in a team is a collaborative effort in which health professionals share their expertise and also relinquish some autonomy to achieve better patient outcomes. Accountability, problem-solving, and decisions are shared elements in collaborative teamwork. Incorrect Answers: A. Team leadership is a potential source of conflict and status or leadership within the team should not be confused with authority based on professional expertise. If there is a conflict, remaining focused on the patient-centered goals while dealing with conflict constructively and openly will improve the ability of the team to work collaboratively. B. A characteristic of collaborative interprofessional care is relinquishment of some autonomy. D. Within the team, it is important to be clear about one’s own and others’ roles and responsibilities within the team. Vital Concepts: Accountability, problem-solving, and decisions are shared elements in collaborative teamwork. References:

Answer 1012

Correct Answer: C. Good The factors that imply good prognosis in this case are the patient's strong ability to function in professional or social environments prior to the incident and significant symptoms of psychosis within a month of the initial alteration in function or behavior. To confirm the diagnosis of schizophreniform disorder, at least two of the following symptoms must be present for a substantial period during a month or more timeframe: · speaking incoherently without logical organization* · a misconception, belief, or thought that is firmly held despite not being grounded in reality* · illusions or perceived experiences that do not actually exist (e.g., sounds, voices, smells, visions, feelings, etc.)* · actions that are chaotic or confused, repetitive, purposeless, or significantly reduced (or absent) movement and speech (with catatonia) · decreased display of emotion or a lack of motivation *at least one of the two symptoms displayed must be among the first three symptoms described above · An incidence of this disorder should persist for 1-6 months · There have been no (or minimal) concurrent periods of depressive or manic symptoms that would satisfy the requirements for schizoaffective DO, major depressive disorder, or bipolar disorder with psychotic features · The patient’s symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern and are not due to a more appropriate psychiatric condition · The prognosis is considered good if two or more of the following are true: o A healthy or strong ability to function in professional or social environments prior to the incident o A sense of bewilderment or puzzlement o A consistent, observable, and appropriate emotional reaction or response to external stimuli o Significant symptoms of psychosis within a month of the initial alteration in function or behavior Incorrect Answers: A. There is sufficient information given here to determine a good prognosis. B. This patient meets multiple factors that imply good prognosis for schizophrenia; their prognosis is good. D. This patient meets multiple factors that imply good prognosis for schizophrenia; their prognosis is good, not poor. Vital Concept: Schizophreniform disorder is characterized by psychotic symptoms like those seen in schizophrenia but for a shorter duration (under 6 months). The prognosis is based on the presence of at least two of four specified factors. References:

Answer 1013

Correct Answer: A. Overgeneralization: coming to generalized conclusions based on a single experience This CBT-definition pair is correct. Incorrect Answers: B. The correct definition is "taking points that are unrelated to oneself personally." C. The correct definition is "coming to an incorrect conclusion based on a previous experience." D. The correct definition is "taking a small detail out of context and making an experience negative". References:

Answer 1014

Correct Answer: D. Cohort study A cohort study follows a group of similar individuals (a cohort) without a disease over time to determine the risk of developing the disease. In this case, the study is a prospective cohort study because the cohort is followed from the onset of exposure. Incorrect Answers: A. Case-control studies analyze a known outcome by looking back in time to assess exposure. B. Cross-sectional studies analyze a population (or representative subset) at a single point in time (a cross-section) to assess disease incidence and prevalence. C. An RCT is an experiment/clinical trial that studies the effect of an intervention by comparing the treatment to a placebo in 2 equivalent groups separated by randomization. References:

Answer 1015

Correct Answer: A. Become a teacher or preceptor Becoming involved in education of new NPs is of great importance to political advocacy. Through teaching and preceptorship there are countless opportunities for serving on committees, writing for publications, and serving as a mentor to countless students and trainees. Incorrect Answers: B, C. These are more difficult than becoming a teacher or preceptor D. This isn't a political advocate action Vital Concepts: Through teaching and preceptorship, there are countless opportunities for serving on committees, writing for publications, and serving as a mentor to countless students and trainees. References:

Answer 1016

Correct Answer: C. Standard deviation The standard deviation refers to a measurement that quantifies the amount of variation or dispersion of a set of values in a distribution in reference to the mean, a measure of central tendency. It is the square root of the variance, mathematically. Incorrect Answers: A. and B. The mode and median are measures of central tendency. D. The frequency distribution refers to the frequency with which data values appear in a distribution. Vital Concepts: The standard deviation refers to a measurement that quantifies the amount of variation or dispersion of a set of values in a distribution in reference to the mean, a measure of central tendency. It is the square root of the variance, mathematically. References:

Answer 1017

Correct Answer: B. First-generation antipsychotics can be utilized in pregnancy. High-potency antipsychotics, unlike low-potency medications, are least likely to cause anticholinergic, antihistaminic, or hypotensive effects in neonates. Haloperidol has the most evidence supporting its use in bipolar disorder and schizophrenia in pregnant women. When considering maintenance therapy with a pregnant bipolar patient, it is important to discuss the severity of past symptoms and the possibility of relapse if medications are discontinued. Give ample time to discuss the potential side effects of mood stabilizers and antipsychotics if they are indicated during pregnancy. Coordination may be needed with the obstetrician to discuss fluid shifts and metabolic changes due to pregnancy. Incorrect Answers: A. Second-generation antipsychotics are used more commonly than first-generation antipsychotics in the U.S. during pregnancy. C. Typically, mood stabilizers, like lithium, are restarted in the second trimester to avoid the time of highest teratogenic risk. ECT is an effective and safe treatment for severe mania in pregnancy. The risk of anesthetic use with ECT is considered low in comparison with maintenance antipsychotic or mood-stabilizer treatment. D. Breastfeeding neonates may display extrapyramidal symptoms with mothers taking antipsychotics. Vital Concept: High-potency antipsychotics, unlike low-potency medications, are least likely to cause anticholinergic, antihistaminic, or hypotensive effects in neonates. Haloperidol has the most evidence supporting its use in bipolar disorder and schizophrenia in pregnant women References:

Answer 1018

Correct Answer: D. The numerator in an item-by-item measurement of a quality improvement measure is the number of patients for whom the item was performed Quality improvement measures can either be reported as an item-by-item measurement or as an all-or-none measurement. The item-by-item measurement measures performance of each item in a quality measure. The numerator is the number of people for whom the item was performed and the denominator is the total number of people eligible to receive the care. Incorrect Answers: A. The all-or-none measure is the most sensitive scale for assessment of improvement. B. All-or-none measurement is the most sensitive scale for assessment of quality improvement performance. C. Four of the measures for pneumonia performance set by JCAHO are discrete variables, including oxygenation assessment, pneumococcal vaccination, blood cultures, smoking-cessation counseling, and mean time of antibiotic initiation. Vital Concepts: The numerator is the number of people for whom the item was performed and the denominator is the total number of people eligible to receive the care. References:

Answer 1019

Correct Answer: C. Transference pattern is activated in important relationships. This is an assumption of the CCRT. Incorrect Answers: A. The CCRT assumes that the transference pattern appears in the therapeutic relationship B. The CCRT assumes that the transference pattern is based on early experience, not experiences throughout the patient's life D. The CCRT assumes that the transference pattern is constantly repeated through the patient's life References:

Answer 1020

Correct Answer: A. (5/50) - (5/500) Attributable risk (AR) is the risk of exposed group e.g. experimental event group) minus the non-exposed group (e.g. control group). In this scenario this is the risk of suicide attempts in people with borderline personality disorder (BPD) versus normal controls. Risk of suicide attempts in people with BPD is 5/50 and the risk of suicide attempts in control group is 5/500. AR= (5/50) - (5/500) Incorrect Answers: B. (5/50)/(5/500) (experimental event rate divided by control event rate) calculates relative risk. C. (5/45)/(5/495) calculates the odds ratio. D. (5/45) - (5/495) is not a valid formula. Vital Concept: Attributable risk (AR) is the risk of exposed group minus the non-exposed group. References:

Answer 1021

Correct Answer: C. Some patients have a different response to d-amphetamine vs l-amphetamine Some patients preferentially respond to one isomer over the other. Incorrect Answers: A. D-amphetamine and l-amphetamine have different pharmacodynamic properties. Some patients respond differently to each isomer. B. Lisdexamfetamine is an amphetamine prodrug, and d,l amphetamine is a pharmacologically active amphetamine. D. Lisdexamfetamine is composed of a covalent linkage of L-lysine to d-amphetamine. It has to be hydrolyzed to remove the l-lysine. References:

Answer 1022

Correct Answer: C. Behavioral therapy A fear of public speaking is a social phobia that can be disabling. Behavioral therapy refers to changing the behavior of a patient to reduce dysfunction and improve the quality of life. The principles that govern behavioral therapy are based on early studies of operant conditioning by Skinner and classical conditioning by Pavlov. Systematic desensitization, a technique based on the behavior principle of counter conditioning, This is a technique by which a person overcomes a maladaptive anxiety by approaching the anxiety-provoking situation gradually, in a psychosociological state that reduces the anxiety. The therapist typically guides the client through a series of steps meant to reduce the fear and/or anxiety. This technique is effective for eliminating phobias, obsessive compulsive disorder, and anxiety disorder. The technique consists of relaxation training, hierarchy construction of situations in order of increasing anxiety, and desensitization of the stimulus. Incorrect Answers: A. Interpersonal psychotherapy is a brief psychotherapy that focuses on resolving interpersonal problems. It is highly structured, and takes 12–16 weeks to complete. B. Psychoanalysis is a method of psychotherapy used for people who are struggling with longstanding difficulties in the way they think and feel about themselves, their environment, and other people. D. Family therapy is a type of psychotherapy for family members to improve communication and resolve family conflicts. Vital Concepts: Behavioral therapy refers to changing the behavior of a patient to reduce dysfunction and improve the quality of life. The principles that govern behavioral therapy are based on early studies of operant conditioning by Skinner and classical conditioning by Pavlov. References:

Answer 1023

Correct Answer: B. With partial seizures, 40% of patients have normal EEG. Partial seizures often derive from deep, limbic brain structures (commonly the temporal lobe); abnormal impulses do not transmit to the surface electrodes of the EEG in up to 40% of patients. A negative EEG is not sufficient evidence to rule out a seizure disorder. Incorrect Answers: A. Partial seizures are responsible for 60% of the nonconvulsive seizures and are under-diagnosed. C. Partial seizures often derive from limbic deep structures, most commonly the temporal lobe. D. Over 50% of epileptic patients experience depression. Higher rates occur in patients with complex partial seizures. References:

Answer 1024

Correct Answer: D. Negative punishment Negative punishment is the removal of a desirable stimulus to decrease a specific behavior. Taking away a child’s videogame system is negative (removal) and a punishment (designed to reduce unwanted behavior like tantrums). Traditionally, punishments are thought to be less powerful than reinforcements in creating lasting changes in behavior. Incorrect Answers: A. Positive reinforcement is the addition of a desirable stimulus to increase a specific behavior. B. Positive punishment is the addition of an undesirable stimulus to reduce a specific behavior. C. Negative reinforcement is the removal of an undesirable stimulus to increase a specific behavior. References:

Answer 1025

Correct Answer: A. Reducing excessive sleepiness in narcolepsy Sodium oxybate is the only FDA approved medication to treat cataplexy. Sodium oxybate is also FDA approved to reduce excessive daytime sleepiness in patients with narcolepsy. Sodium oxybate is the sodium salt of gamma hydroxybutyrate (GHB). Therefore it is a schedule 3 controlled substance and has restricted distribution through a REMS program. The dosing of the medication can be problematic because the patient has to take half the dose before bedtime and the other half 2.5-4 hours later, requiring the patient to wake up each night. Stimulants can improve wakefulness, and some antidepressants (including clomipramine, fluoxetine, duloxetine, and venlafaxine) can reduce cataplexy attacks. Incorrect Answers: B. Reducing excessive sleepiness in Parkinson's disease. Sodium oxybate is not utilized to reduce excessive sleepiness in Parkinson's disease, only in narcolepsy. C. Fatigue in multiple sclerosis. Modafinil, a dopamine reuptake inhibitor is utilized to treat fatigue in multiple sclerosis, not sodium oxybate. D. Fatigue. Sodium oxybate is not utilized to treat fatigue. Vital Concept: Sodium oxybate is FDA approved medication to treat cataplexy and to reduce excessive daytime sleepiness in patients with narcolepsy. References:

Answer 1026

Correct Answer: D. Fluoxetine Fluoxetine has a half-life of approximately 48 hours. The long half-life of the medication is the reason fluoxetine has minimal withdrawal symptoms. When discontinuing fluoxetine no taper is necessary due to long half-life. Incorrect Answers: A. Sertraline has a half-life of approximately 26 hours. B. Venlafaxine has a half-life of approximately 5 hours (parent drug) and 11 hours (active metabolite/desvenlafaxine). C. Citalopram has a half-life of approximately 24-48 hours. References:

Answer 1027

Correct Answer: D. Topiramate Topiramate is FDA approved for seizure disorders and migraine prophylaxis. Also FDA approved for chronic weight management in obese adults in a combination with phentermine (Qsymia). Topiramate is used off-label for alcohol dependence, bipolar disorder, PTSD and binge-eating disorder. The blockage of voltage-dependent sodium channels can lead to CNS side effects. Topiramte is referred to as Topamax "Dopamax" due to the cognitive side effects. Inhibition of the carbonic anhydrate enzyme can cause rare side effects from topiramate including kidney stones, paresthesias, and metabolic acidosis. Potentiating GABA-A receptors and antagonism of AMPA/kainate subtype of the glutamate receptor contributes to the effectiveness of the medication. Incorrect Answers: A. Trazodone blocks serotonin 2A receptors and serotonin reuptake pump. B. Bupropion is a norepinephrine dopamine reuptake inhibitor. C. Olanzapine is an atypical antipsychotic, a dopamine and serotonin receptor antagonist. Vital Concept: Topiramate mechanism of action includes blockage of voltage-dependent sodium channels, augmentation of gamma-aminobutyrate activity at GABA-A receptors, antagonism of AMPA/kainate subtype of the glutamate receptor, and inhibition of the carbonic anhydrate enzyme. References:

Answer 1028

Correct Answer: C. Lamotrigine and topiramate Lamotrigine and topiramate are least likely to cause weight gain. Lamictal is relatively weight-neutral, and significant weight gain is rare. Incorrect Answers: A. Clozapine and olanzapine cause some of the greatest weight gain of all antipsychotics and carry high rates of metabolic syndrome. B. Valproic acid and lithium cause significant weight gain, among other troublesome side effects. D. These drugs are all well known for causing significant weight gain. References:

Answer 1029

Correct Answer: D. Nicotina tabacum Nicotine is an active ingredient in tobacco, which is derived from the plant nicotina tabacum (see image below). Tobacco is the most common substance smoked in various ways. Active as well as passive smoking is associated with health hazards like asthma, emphysema, bronchitis, heart problems, lung cancer, and decreased lifespan. The prevalence is higher among men, teenagers, and the poor. Prevalence decreases with increasing educational levels. Incorrect Answers: A. Cocaine is derived from the leaves of the plant erythroxylon coca. B. Cannabis is derived from the plant cannabis sativa. C. Opium is extracted from poppy seeds. References:

Answer 1030

Correct Answer: D. Develop policies to recognize employees who do the right things in terms of safety Building a safety culture is a process that should tie all levels within an organization to the common goal. All employees should be valued. One of the recommendations given by OSHA is to find opportunities to provide recognition, rewards, and incentives to employees who participate, to encourage participation in ongoing activities. Incorrect Answers: A. Self-assessments should be encouraged. B. All employees should be aligned with the goal. It is important to establish a steering committee that is comprised of employees, management, safety staff, and any union that exists, in order to facilitate, support, and direct change. C. Roles and responsibilities for safety and health at all levels of the organization should be specifically defined, although safety and health should be viewed as everyone’s responsibility. Vital Concepts: One of the recommendations given by OSHA is to find opportunities to provide recognition, rewards, and incentives to employees who participate, to encourage participation in ongoing activities. References:

Answer 1031

Correct Answer: D. 190 The mode of a distribution is the most common value in a list of numbers. Since 17 patients have cholesterol levels of 190 mg/dL, this represents the mode. Incorrect Answers: A. 197.8. The mean is the mathematical average. In this distribution, the average cholesterol or mean = 3(220) + 10(210) +15(200) + 17(190) + 5(180)/50 = 197.8. B. 17. 190 mg/dL is the mode because it the most common value (17 patients in this category). 190 is the mode; 17 only represents the number of patients that fall into this category. C. 200. The median is the numerical value separating the higher half from the lower half. This would be the middle value in a list of number. In this distribution, the median number is 200, since half of the subjects have cholesterol levels less than or equal to 200 and half of them have cholesterol levels of 200 or greater. Vital Concept: The mode of a distribution is the most common value in a list of numbers. References:

Answer 1032

Correct Answer: B. Hyperparathyroidism Lithium has been associated with hyperplasia and adenomas of the parathyroid glands, leading to hyperparathyroidism and hypercalcemia. Incorrect Answers: A. Eosinophilic colitis is associated with clozapine. C. Neutropenia is associated with clozapine. D. Pancreatitis is a rare but potentially deadly side effect of valproic acid. References:

Answer 1033

Correct Answer: A. Notifying a physician of a patient’s need for home health visits An advocate is a person who pleads for on behalf of another, or an intercessor. Notifying a physician of a patient’s unmet needs is a basic form of advocacy. Incorrect Answers: B, C, D- In these examples, the NP is not speaking out on behalf a patient. Educating the patient on drug interactions is part of the NP role as educator. Joining an employee wellness group benefits the NP. The NP may be able to find a role as advocate within a professional organization, but simply becoming a member is not considered advocacy. Vital Concepts: Notifying a physician of a patient’s unmet needs is a basic form of advocacy for the patient. References:

Answer 1034

Correct Answer: A. Fluoxetine In an individual who is sensitive to weight gain, fluoxetine would be a good choice of SSRI as it tends to be weight neutral. Avoid paroxetine as it has the highest incidence of weight gain. Incorrect Answers: B. Fluvoxamine has a slight risk of weight gain C. Sertraline has a slight risk of weight gain D. Paroxetine has the highest list of weight gain out of the approved treatment options. References:

Answer 1035

Correct Answer: B. Paroxetine Optimal treatment of male sexual dysfunction, including erectile dysfunction, premature ejaculation, and decreased libido, varies depending upon the cause or causes of the dysfunction. Premature ejaculation (PE) is rapid or early ejaculation, defined by three criteria: brief ejaculatory latency loss of control psychological distress in the patient and/or partner. Ejaculatory latency time (ELT) of approximately one minute or less may qualify a man for the diagnosis. The patient's history should include a consistent inability to delay or control ejaculation, and marked distress about the condition. Selective serotonin reuptake inhibitors (SSRIs), such as escitalopram, sertraline, paroxetine, or fluoxetine, can be used to help delay ejaculation. A meta-analysis of trials showed paroxetine can delay ejaculation to an average of 9 minutes over baseline. Other options include clomipramine, tramadol, topical anesthetics, and, in men with coexisting erectile dysfunction, phosphodiesterase-5 inhibitors. Incorrect Answers: A. This is a benzodiazepine, not an SSRI; it won't help with premature ejaculation. C. Tramadol is a third-line agent for the treatment of premature ejaculation. It is used for the treatment of patients who do not tolerate SSRIs or clomipramine. D. Sildenafil is a phosphodiesterase-5 inhibitor and is typically used for the treatment of men with coexisting erectile dysfunction. Vital Concept: Selective serotonin reuptake inhibitors, clomipramine, topical anesthetics, tramadol, and phosphodiesterase-5 inhibitors can be used to delay premature ejaculation. Paroxetine is the first-line agent. References:

Answer 1036

Correct Answer: D. Graduated cessation of steroids as an outpatient Steroid use should be tapered and not stopped abruptly because it gives the adrenal glands time to return to normal secretion patterns. This also helps minimize steroid withdrawal symptoms, which includes mood swings, depression, decrease appetite, insomnia, fatigue and decreased sex drive. Counseling on body image issues may help relieve some of the pressure to use steroids in addition to counseling on the adverse long-term effects of steroids. Hospitalization with a tapering dose is not necessary unless suicidal ideation is present. Incorrect Answers: A. Admission to hospital isn't necessary unless suicidal ideation is present. B. Graduated, not immediate, cessation of steroids is needed. C. IV fluids, complete metabolic testing, and kidney ultrasound aren't needed in this case. Vital Concept: Graduated cessation of the anabolic steroids and counseling on body image issues and the adverse long-term effects of steroids is important. References:

Answer 1037

Correct Answer: D. Male sex, being single, living alone The possibility of suicidal behavior is a concern throughout any depressive episodes (unipolar or bipolar depression). Although a past history of suicide attempts is a risk factor for suicide, most people who die by suicide do not have a history of unsuccessful attempts. Other characteristics that have been associated with an increased risk for death by suicide include male sex, being single or living alone, and prominent feelings of hopelessness. Incorrect Answers: (A) Male sex, being married, living alone. Being married is a protective factor. Being single is assoicated with an increased risk for death by suicide. (B) Male sex, being single, living with family members. Living with family members is a protective factor. Living alone is assoicated with an increased risk for death by suicide. (C) Female sex, being married, living alone. Male sex is assoicated with an increased risk for death by suicide, not female sex. Also being married is a protective factor. Being single is assoicated with an increased risk for death by suicide. References:

Answer 1038

Correct Answer: D. Fetal risk is significant with valproate, so it should be avoided in pregnancy Valproate’s mechanism of action is the blockade of sodium-gated channels. This increases presynaptic GABA without affecting GABA receptors. Initial adult dosing is typically 10-15 mg/kg/day given three times daily (if using the immediate-relaease formulations). ER formulations may allow for less frequent dosing and more consistent blood levels. Doses can be increased weekly by 5-10 mg/kg/day. Trough serum levels can be checked 1-2 weeks after initial administration and 3-4 days after dose adjustments. The target serum levels are typically 50 to 125 mcg/mL. Common side effects include nausea, vomiting, hair loss, easy bruising, tremor, weight gain, obesity, insulin resistance, and metabolic syndrome. It is considered highly teratogenic. It is associated with major malformations and neurodevelopmental abnormalities. Unfortunately, oral contraceptives also tend to interact with valproate, reducing valproate levels as it increases clearance. Incorrect Answers: A. Valproate's MOA is the blockade of sodium-gated, not potassium-gated, channels. It increases GABA levels B. Valproate is generally the most effective medication for generalized tonic-clonic seizures such as in idiopathic generalized epilepsy. C. There is a black box warning for hepatotoxicity, and dose adjustments should be made in those with hepatic insufficiency. Vital Concept: While highly effective, valproate is also highly teratogenic. It is also associated with hepatotoxicity, pancreatitis, and hyperammonemic encephalopathy. References:

Answer 1039

Correct Answer: B. Construct a timeline Individual interpersonal psychotherapy involves the construction of an illness (depression) timeline reflecting major mood changes and significant interpersonal events. Incorrect Answers: A. Conducting an interview focusing on early childhood experiences is consistent with psychodynamic psychotherapy. C. Chain analysis is a technique employed in dialectical behavioral therapy. D. Thought-mood logs are used in cognitive-behavioral therapy. References:

Answer 1040

Correct Answer: C. Priapism Priapism is associated with trazodone. All males should be warned of this rare side effect, which can require surgical intervention to reverse. Incorrect Answers: A. B. Sedation and weight gain are common side effects of trazodone. While they are common, they are not serious. D. Increased serum cholesterol has not been associated with trazodone. Vital Concept: A potentially serious side effect of trazodone is priapism in males. References:

Answer 1041

Correct Answer: C. For this test, the sensitivity of 95% implies that 5% of the tests are false negatives while the specificity of 57% implies that 43% of the test results are false positives. Sensitivity is the likelihood of a positive result when the patient does have depression or the particular disease of interest. Specificity is the likelihood of a negative result when the patient does not in fact have depression or the disease of interest. Major depression usually has an onset before age 30. The lifetime prevalence is 10%. In twin studies, there is a 37% concordance of major depression. The criteria for diagnosis of major depressive episode include depressed mood or loss of pleasure or interest in things, plus 5 (including depressed mood and loss of interest) of the following nearly every day for at least 2 weeks: weight loss or gain or change in appetite, sleep problems, psychomotor agitation or slowing, fatigue, worthlessness, difficulty thinking/concentrating, and recurrent thoughts of death or suicide. This can be a single episode or recurrent in nature. Up to 50% of patients with a mood disorder also have an anxiety disorder at some point, usually before the depression. Borderline personality disorder is also common in depressed patients, and other cluster B personality disorders can be present as well. Depression occurs in up to 14% of adolescents and is likely to present as irritability rather than mood changes. Depression is also exceedingly common in the elderly; some studies suggest the condition presents in up to 25%, and suicides present in up to 15% of this population. Risk factors for developing depression include early childhood trauma, negative life events in adulthood, neuroticism, and family history of depression. Incorrect Answers: A. Specificity is the measurement of the probability of identifying individuals who truly do not have the disease and are frequently identified through the use of a screening test. B. This refers to the positive predictive value of the test (true positives/true positives + false positives), which is about 69%. D. These parameters are not defined. References:

Answer 1042

Correct Answer: A. Citalopram Citalopram Selective serotonin reuptake inhibitor (SSRI) FDA approved for depression only Off-label uses: Generalized anxiety disorder (GAD) Premenstrual dysphoric disorder Obsessive-compulsive disorder Panic disorder Posttraumatic stress disorder Social anxiety disorder. Increased QTc prolongation at doses >40 mg/day Side effects: Sexual dysfunction Gastrointestinal Headache Dose dependent sweating Rare side effects: Increased risk for bleeding Hyponatremia Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Dose range: 20mg to 40 mg daily Metabolized primarily by: 2C19 and 3A4 Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first line treatment for generalized anxiety disorder. Incorrect Answers: A. Lamotrigine is used as a mood stabilizer and is not utilized for generalized anxiety disorder. B. Aripriprazole is an atypical (second generation) antipsychotic that is not utilized for generalized anxiety disorder. It is FDA approved for schizophrenia, bipolar disorder, major depression adjunct, irritability in autism, and Tourette's disorder. C. Lorazepam is a benzodiazepine that can be utilized for short-term management of anxiety. It is not recommended to use benzodiazepines for long-term management of anxiety because of their potential for dependence and tolerance. It is FDA approved for anxiety (unspecified). Vital Concept: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first line treatment for generalized anxiety disorder. References:

Answer 1043

Correct Answer: B. Levetiracetam Most mood stabilizers mechanism of action is to increase GABA and decrease glutamate. This mechanism of action is why these medications are utilized as anticonvulsants and mood stabilizers. Lithium is one of the only mood stabilizers that is not an anticonvulsant. There are several anticonvulsants that are not utilized as mood stabilizers (e.g. levetiracetam). Levetiracetam is used predominantly in epilepsy and does not have other uses. mood stabilizers Incorrect Answers: A. Lithium is one of the only mood stabilizers that is a mood stabilizer but not an anticonvulsant. C. Lamotrigine is an anticonvulsant and a mood stabilizer. D. Valproate is an anticonvulsant and a mood stabilizer. Vital Concept: Lithium is one of the only mood stabilizers that is not an anticonvulsant. There are several anticonvulsants that are not utilized as mood stabilizers (e.g. levetiracetam). References:

Answer 1044

Correct Answer: C. Both stimulants increase levels of norepinephrine and dopamine. Both stimulants increase norepinephrine and dopamine. Incorrect Answers: A. Methylphenidate binds primarily to dopamine transporter proteins, blocking the reuptake of dopamine and increasing intrasynaptic dopamine. Amphetamine travels into dopaminergic neurons, promoting the release of dopamine from reserpine-sensitive vesicles in the presynaptic neuron. B. Amphetamines decrease presynaptic reuptake of dopamine by binding to dopamine transporter proteins. D. Both stimulants increase intrasynaptic levels of dopamine. Methylphenidate blocks the reuptake of both norepinephrine and dopamine. Serotonin is not increased. References:

Answer 1045

Correct Answer: C. Assertive community treatment Patients with a history of frequent hospitalizations benefit especially from assertive community treatment, resulting in reduced hospitalization and homelessness rates. Incorrect Answers: A. Family psychoeducation also improves family relationships. However, it doesn't show evidence for reducing hospitalization rates and/or homelessness in schizophrenia patients. B. Studies using cognitive remediation in conjunction with vocational rehabilitation yielded positive findings. However, it doesn't show evidence for reducing hospitalization rates and/or homelessness in schizophrenia patients. D. CBT is more appropriately used in patients in the stabilization phase and/or with residual symptoms. Additionally, it doesn't show evidence for reducing hospitalization rates and/or homelessness in schizophrenia patients. References:

Answer 1046

Correct Answer: B. Critical thinking Critical thinking is a process of reflective thinking that guides the nurse practitioner in the evaluation of a problem and generation and implementation of solutions, in patient care and other professional situations. Incorrect Answers: A. Diagnosis is the process of determining by examination the nature of a diseased condition. C. Inductive reasoning uses specific observations to make broad generalizations. D. Rote memorization is a form of non-reflective thinking. Vital Concepts: Critical thinking is a process of reflective thinking that guides the nurse practitioner in the evaluation of a problem and generation and implementation of solutions, in patient care and other professional situations. References:

Answer 1047

Correct Answer: C. Reducing physical symptoms Generalized anxiety disorder is characterized by excessive anxiety and worry that causes impairment of at least one realm of the patient’s life without panic disorder for at least 6 months. Patients with GAD often worry about small things and have significant fear while expecting the worst from most situations. They can also present with muscle tension, sleep problems, fatigue, or irritability. Prevalence of GAD is highest among women and the elderly as well as patients with low socioeconomic status. Major depression and other anxiety disorders are commonly comorbid with GAD (up to 59%). Treatment of GAD includes the use of SSRI and SNRI drugs as well as buspirone. Benzodiazepines may be effective in reducing physical symptoms of anxiety including muscle tension, headaches, panic attacks, sweating, insomnia and restlessness. Beta-blockers like propranolol may help with palpitations and tremors. Benzodiazepines are fast-acting and are effective immediately for GAD and panic disorder especially in the first few weeks of SSRI treatment while waiting for SSRI onset of therapeutic effect. Incorrect Answers: A. Reducing depression. Antidepressants are more effective than benzodiazepines at treating depression. B. Reducing worrying. Antidepressants are more effective than benzodiazepines at reducing worry long term. D. Reducing perceived stress levels. There is no difference between antidepressants and benzodiazepines in reducing perceived stress levels. Vital Concept: For generalized anxiety disorder, benzodiazepines are more effective than antidepressants in treating physical symptoms of anxiety. Benzodiazepines are fast-acting and are effective immediately for GAD and panic disorder especially in the first few weeks of SSRI treatment while waiting for SSRI onset of therapeutic effect. References:

Answer 1048

Correct Answer: D. If no real difference in results exists between the 2 groups studied, there is still a 5% chance that a difference would be observed. The p-value indicates the probability that the results of a study could reflect the same differences observed in the study (or greater differences between the groups) without any actual difference in the magnitude of change between the 2 groups. The p-value does not provide a direct measure of the real difference between 2 values. A p-value of 0.05 or less is used to indicate statistical significance. If the p-value is greater than 0.05, the null hypothesis (the assumption that any differences between 2 groups in this study are due to chance alone) cannot be rejected. The confidence interval refers to the chance that the difference of reduction in blood pressure reflects an actual difference between the 2 groups. Incorrect Answers: A. The results of the study are not due to chance. The confidence interval refers to the chance that the difference of reduction in blood pressure reflects an actual difference between the 2 groups. B. If the same experiment is performed multiple times, there is a 5% chance that the same results would occur. The 95% confidence interval, in this example, consists of the range of values in which a probability of means would fall if performed multiple times. C. There is a 5% probability that the study results are significant. The p-value itself does not represent the probability results are significant. Whether the mean difference between the two variables is significant is based upon the p-value being greater than 0.05 or equal to/less than 0.05. Vital Concept: The p-value indicates the probability that the results of a study could reflect the same differences observed in the study (or greater differences between the groups) without any actual difference in the magnitude of change between the 2 groups. References:

Answer 1049

Correct Answer: C. Anorexia nervosa The Maudsley model is a family-based therapy for the treatment of anorexia nervosa for patients up to 19 years of age. The family plays an active role in the treatment of the patient with the goal of weight restoration and the eventual return of control regarding eating habits to the patient. Incorrect Answers: A, C, and D. These conditions are not successfully treated using the Maudsley model. References:

Answer 1050

Correct Answer: B. The prevalence will increase The same number of people will contract the disease every year, so the incidence of disease will remain stable. However, because people with the disease will live longer, the prevalence of the disease will increase. In the case of short-term diseases such as influenza, the incidence may be higher than the prevalence. For chronic or long-term diseases, the prevalence is greater than the incidence. Incorrect Answers: A. Incidence won't be affected. C. As more people with the disease live longer, prevalence will increase. D. Prevalence is greater than the incidence for chronic or long-term diseases like prostate cancer, to begin with, and the treatment will only increase that trend. Vital Concepts: The same number of people will contract the disease every year, so the incidence of disease will remain stable. However, because people with the disease will live longer, the prevalence of the disease will increase. For chronic or long-term diseases, the prevalence is greater than the incidence. References:

Answer 1051

Correct Answer: C. Intimacy vs. Isolation This patient is experiencing intimacy vs. isolation. (See table below) Incorrect Answers: A. This applies to ages 6-12 (wrong age) and relates to confidence, competence, and social skills (wrong issues). B. This applies to ages 12-18 (wrong age) and relates to the formation of identify and devotion (wrong issues). D. This applies to ages 35-65 (wrong age) and relates to building a family and having a productive career (wrong issues). References:

Answer 1052

Correct Answer: D. Heart disease Heart disease is the cause of death in 26.3% of men and 25.8% of women in the United States. Incorrect Answers: A. and C. Cancer is the second leading cause of death and unintentional injuries are the fourth leading cause of death. Prostate and breast cancers are the most prevalent cancers in men and women, respectively. The leading cause of cancer mortality in the United States is lung cancer. B. Drug overdose was the most common cause of death by unintentional injury in 2013, and 51.8% of those deaths were attributable to prescription drugs. Vital Concept: Heart disease is the cause of death in 26.3% of men and 25.8% of women in the United States. References:

Answer 1053

Correct Answer: D. 487 In a sample population that has a normal distribution, 95% of observations should fall within two standard deviations of the mean. In this case, that is 475 subjects (500 x 0.95). The mean is the sum of the elements divided by the elements in the distribution. In this example, the mean is 130mmHg and the standard deviation is 5mmHg. A blood pressure of 140 mmHg is two standard deviations above the mean. When calculating the number of people with blood pressure <140 mmHg, the calculation should include the 2.5% of the population with blood pressures <120 mmHg who are not included within two standard deviations of the mean. Thus, 487 subjects represent 97.5% of the population who would be expected to have a blood pressure measurement <140 mmHg. So, 68% of the population, or 340 subjects, should fall within one standard deviation of the mean. As a result, 99.7% of the population, or 498 subjects, are expected to fall within three standard deviations of the mean. Incorrect Answers: A. 340. 340 subjects fall within one standard deviation of the mean. 500 x 0.68=340. 340 subjects have a blood pressure between 125 and 135 mmHg B. 498. 498 subjects fall within three standard deviations of the mean. 500 x 0.99.7=498. 498 subjects have a blood pressure between 115 and 145 mmHg. C. 475. 475 subjects fall within two standard deviations of the mean. 500 x 0.95=475. 475 subjects have a blood pressure between 120 and 140 mmHg. This does not include the 2.5% of the population with blood pressures <120 mmHg that the <140mmHg group includes; 487 subject total, not 475 subjects. Vital Concept: In a sample population that has a normal distribution, 68% of observations should fall within one standard deviation of the mean, 95% within two standard deviations of the mean, and 99.7% within three standard deviations of the mean. References:

Answer 1054

Correct Answer: C. Catatonic disorder Karl Kahlbaum believed that patients with catatonia passed through several phases of illness: a short stage of immobility (with waxy flexibility and posturing), a second stage of stupor or melancholy, a third stage of mania (with pressured speech, hyperactivity, and hyperthymic behavior), and finally, after repeated cycles of stupor and excitement, a stage of dementia. Incorrect Answers: A. While catatonia can be a symptom of schizophrenia, this male's symptoms alone don't meet DSM-V's four criteria for schizophrenia B. As the melancholy didn't last, major depressive disorder doesn't seem appropriate D. This is characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction; the male's symptom's don't meet these diagnostic criteria. References:

Answer 1055

Correct Answer: B. Standing in line at the store Agoraphobia diagnostic criteria: Terror or significant concern about at least two of the following conditions: entering public places that are not confined (e.g., parks/fields, vacant lots, etc.) entering indoor spaces (e.g., conference rooms, stores, etc.) entering an area with lots of people, or waiting in a queue public transportation utilization leaving their house without anyone else, such as a companion or partner The terror/concern is related to becoming trapped or unable to leave or get assistance if the patient becomes frightened, hurt, or otherwise uncomfortable (e.g., losing bowel or bladder control, getting injured/falling, etc.) The patient reports sudden terror or significant concern almost every time they are presented with the above conditions The terror/concern or active evasion of the condition leads to dysfunction (academic, professional, social, or otherwise) or substantial anguish The patient evades the condition(s) or requires an acquaintance/attendant The actual risk or threat posed by the condition is insignificant in comparison to the patient’s emotional response and concern The terror or concern is consistent for at least 6 months If there is a related comorbid diagnosis (e.g., irritable bowel syndrome, multiple sclerosis), the patient’s concern is disproportionate and extreme The symptoms are not due to a more appropriate psychiatric condition such as a specific phobia, past trauma (i.e., post-traumatic stress disorder), flaws in physical appearance (i.e., body dysmorphic disorder), social interactions (i.e., social anxiety disorder), separation from a loved one (i.e., separation anxiety disorder), or a recurrent thought (i.e., obsessive-compulsive disorder). If the patient also experiences panic attacks and meets the required characteristics of panic disorder, the patient may be diagnosed with both Incorrect Answers: (A) Sitting near a door is not a situation commonly triggering for a patient with agoraphobia. (C) Being in the bedroom is not a situation commonly triggering for a patient with agoraphobia. (D) Wearing sunglasses is not a situation commonly triggering for a patient with agoraphobia. Vital Concept: The list of potentially triggering situations for a patient with agoraphobia include entering public places that are not confined (e.g., parks/fields, vacant lots, etc.) entering indoor spaces (e.g., conference rooms, stores, etc.) entering an area with lots of people, or waiting in a queue public transportation utilization leaving their house without anyone else, such as a companion or partner References:

Answer 1056

Correct Answer: A. Oppositionality is common in children at age 2. Oppositionality is common in children at age 2, and its presence should not be used to diagnose a disorder. Incorrect Answers: B. Fit between adult caregiver and child is not a feature. C. Resistance to multiple authority figures (including parents) is a feature. D. Oppositionality symptoms often increase and persist in children; oppositionality around toilet training and dating is common. Vital Concept: Toddlers tend to be naturally noncompliant and argumentative. References:

Answer 1057

Correct Answer: A. The most appropriate measure of central tendency is the median. Asymmetric frequency distributions can be skewed positively (right) or negatively (left). Refer to the image below. The tail of the curve identifies the type of distribution. The study results depicted illustrate a positively skewed distribution. In a positively skewed distribution, the mean is greater than the median. Although the most commonly used measure of central tendency is the mean, the central tendency of a population with a skewed distribution is better represented by the median or the mode than the mean. The mean refers to the mathematical average. The median represents the figure that divides the frequency distribution in half when all the data is ranked. If the number of values is even, the median is the average of the 2 middle values. The mode is the observed value that occurs with the greatest frequency. In a normal curve, the 3 measures of central tendency are identical. With a positively skewed distribution, the mean is typically greater than the median, and the median is always greater than the mode. In a negatively skewed distribution, the mean is typically less than the median, and the median is always less than the mode. Incorrect Answers: B. Although the mean is the most commonly used measure of central tendency, the median or mode better represent the central tendency of a population with a skewed distribution, like this one. C. This distribution is right-skewed (positive skewness). In a positively skewed distribution, the mean is typically greater than the median. D. The distribution is right-skewed (positive skewness), as tail is on the right. If it were left-skewed, the tail would be on the left. Vital Concepts: In a normal curve, the 3 measures of central tendency are identical. With a positively skewed distribution, the mean is typically greater than the median, and the median is always greater than the mode. In a negatively skewed distribution, the mean is typically less than the median, and the median is always less than the mode. References:

Answer 1058

Correct Answer: C. 3 The DSM specifier with mixed features requires the presence of at least three manic/hypomanic symptoms that do not overlap with symptoms of major depression (in the case of a depressive episode) or the presence of at least three symptoms of depression in a manic/hypomanic episode. The presence of mixed features with a major depressive episode is a prominent risk factor for the development of bipolar disorder. Incorrect Answers: A. The patient must have one symptom of either lack of pleasure regarding all activities or only from activities that normally bring pleasure (in addition to 3 or more of the other melancholic features) to include the "with melancholic features" specifier in the diagnosis of an episode of major depression, hypomania, or mania. B. At least two anxiety symptoms must be present to include the "with anxious distress" specifier in the diagnosis of an episode of major depression, hypomania, or mania. D. At least five depressive symptoms must be present for 2 weeks to qualify for a major depressive episode. Vital Concept: Three non-overlapping symptoms must be present to include the "mixed-features" specifier in the diagnosis of MDE, hypomania, or mania. References:

Answer 1059

Correct Answer: D. Negative symptoms may be secondary to drugs. Dysphoria is an example of a negative symptom that can be secondary to drugs. Incorrect Answers: A. Thought disorder is classified as a disorganized symptom; other symptoms in this category include inattention and disorganized behavior. B. Negative symptoms can be primary as a central part of symptoms in schizophrenia or secondary to environmental deprivation, depression, psychosis, or medication. Symptoms include flat affect, alogia, anhedonia, and avolition. C. Disorganized symptoms were previously categorized with positive symptoms, which are delusions and hallucinations. References:

Answer 1060

Correct Answer: C. Latency The latency stage in Freud’s Psychosexual Stages of Development is when children 6 years of age to puberty work on developing peer relationships, learning, motor skills development, and socialization. The anal stage involves learning sphincter control, activities of expulsion and retention. The phallic stage is associated with exhibitionism, masturbation with focus on oedipal conflict, castration anxiety, and female fear of lost maternal love. The genital stage is the integration and synthesis of behaviors from early stages and primary genital-based sexuality. Incorrect Answers: A. This involves learning sphincter control and activities of expulsion and retention; it isn't the stage the child is in. B. This involves exhibitionism, masturbation with a focus on oedipal conflict, castration anxiety, and female fear of lost maternal love; it isn't the stage the child is in. D. This is the integration and synthesis of behaviors from early stages and primarily genital-based sexuality; it isn't the stage the child is in. References:

Answer 1061

Correct Answer: D. Marriage Schizophrenia is associated with major disturbances in thought, emotion, behavior, disordered thinking, faulty perception and attention, inappropriate or flat emotions, bizarre motor activity, and disrupted interpersonal relationships. Marriage is a good prognostic factor for schizophrenia. Other good prognostic factors are late onset with acute development of symptoms, female gender, presence of mood disorders, good functionality, social and family support, absence of family history of psychotic disorder, absence of organicity, absence of perinatal trauma, short duration of untreated psychosis, and absence of suicide and assault history. Incorrect Answers: A. Gradual onset of psychiatric illness is associated with a poor prognosis. B. Absence of a family history of mood disorder is a poor prognostic factor. However, absence of family history of psychotic disorder is a good prognostic factor. C. Male gender is a poor prognostic factor in the course of schizophrenia. Vital Concept: Being married is a good prognostic factor in schizophrenia. References:

Answer 1062

Correct Answer: D. Nurses can prevent or manage conflict by improving their communication skills. Conflict is neither good nor bad and cannot be avoided. It is a natural phenomenon and an inevitable aspect of life. Conflict is a disagreement between individuals who perceive a threat to their needs, concerns, or interests. If it is improperly managed, it can result in the inability of a nurse to provide quality care. Improperly handled conflict can also escalate into abuse or violence. Nurses can prevent or manage conflict by improving their communication skills. Cultural diversity, in combination with the stress of providing quality health care, often results in conflict. When unresolved, conflict can lead to barriers to organizational growth, productivity, and cohesion. It creates barriers for both employees and teams within an organization. The use of avoidance as a conflict resolution method results in ineffective and unproductive outcomes, since it only postpones the conflict. Incorrect Answers: A. Avoiding conflict is important for nurses to provide quality care. Unresolved conflict can result in the inability of a nurse to provide quality care and therefore should be addressed. B. Collaboration is difficult to utilize when resolving a conflict and is not the most desirable approach. Collaboration IS the most desirable approach in resolving a conflict. C. The use of avoidance as a conflict resolution method is effective and postpones the conflict. The use of avoidance as a conflict resolution method results in ineffective and unproductive outcomes, since it only postpones the conflict. Vital Concept: The use of avoidance as a conflict resolution method results in ineffective and unproductive outcomes, since it only postpones the conflict. Nurses can prevent or manage conflict by improving their communication skills. References:

Answer 1063

Correct Answer: D. Amoxicillin Amoxicillin is safe to use with an MAOI. Although the interactions are not well understood, meperidine, epinephrine, local anesthetics (containing sympathomimetics), and decongestants can induce a hypertensive crisis. Patients on an MAOI should check with their physician before adding medications to prevent a possibly life-threatening event. Incorrect Answers: A, B, and C. These medications all carry the potential to induce a hypertensive crisis in patients taking MAOIs References:

Answer 1064

Correct Answer: C. Schizophrenia with catatonia Echolalia is when someone unsolicitedly repeats words, sounds, or phrases they hear. Schizophrenia with catatonia (DSM-5-TR) can feature echolalia. Other clinical features include echopraxia, motoric immobility, catalepsy, extreme negativism, posturing, and stereotyped movements or grimacing. Schizophrenia is characterized by positive symptoms (hallucinations, delusions, and disorganized speech and behavior) and negative symptoms (flattened affect and alogia), as well as other symptoms including inattentiveness. There is usually significant impairment in their social, occupational, and interpersonal lives. Echolalia can also be present in dementia, head injuries, children with autism or other developmental disorders. A diagnosis of catatonia requires at least three of the symptoms below: · catalepsy (i.e., a posture maintained due to muscular contractions, often against gravity and without intention, after being placed in that position by examiner) · mutism (i.e., minimal or absent speech, not applicable if patient has a history of aphasia) · posturing (i.e., a posture maintained due to muscular contractions, often against gravity and without intention, after spontaneously assuming that position) · stereotypy (i.e., recurring actions or movements that are quickly performed without purpose) · facial expressions that communicate pain or anguish · echopraxia (i.e., to copy someone else’s actions) · echolalia (i.e., to copy someone else’s sounds when talking) · stupor (i.e., a lack of responsiveness) · waxy flexibility (i.e., a consistent yet minimal muscular opposition to being placed in a position by the examiner) · negativism (i.e., doing the opposite or not reacting to external directions or requests) · mannerism (i.e., strange or affected display of normal motions) · irritability not affected by surrounding environment Incorrect Answers: A. Tourette's disorder is a type of tic disorder where one experiences involuntary vocal tics. These vocal tics can be echolalia, but it is not common. B. In selective mutism, there is failure to speak in particular social situations when expected to speak. The patient is able to speak in other situations. There is no association between echolalia and selective mutism. D. It is not common to have echolalia with depression. Vital Concept: Echolalia is when someone unsolicitedly repeats words, sounds, or phrases they hear. Echolalia is a feature of schizophrenia with catatonia. References:

Answer 1065

Correct Answer: A. SSRIs may increase risk of bleeding due to interactions with serotonergic receptors on platelets. SSRIs cause decreased platelet activation and aggregation on platelet serotonin receptors. They involve a risk of bleeding that is similar to nonsteroidal anti-inflammatory agents. Incorrect Answers: B. Gastrointestinal side effects (e.g. nausea, diarrhea, and heartburn) are the most common. SSRI side effects affect H-T3 receptors, which line the gut; these occur most commonly with sertraline and fluvoxamine. C. CNS activation (e.g. anxiety, restlessness, tremor, and insomnia) occurs most commonly with fluoxetine. Sedation occurs most commonly with paroxetine. D. SIADH commonly occurs with fluoxetine. References:

Answer 1066

Correct Answer: C. Borderline personality disorder DBT is a structured individual and group treatment designed for patients with borderline personality disorder that has 4 goals: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. Duration of the treatment is at least 1 year and follows a manualized format. Research has indicated that DBT is effective in decreasing self-injurious behavior and hospitalizations. Incorrect Answers: A, B, and D. DBT isn't used to treat these disorders. References:

Answer 1067

Correct Answer: C. Interviews and observations When performing a needs assessment, primary and secondary data sources are both useful. Primary data can be collected by interviews, observation of the population under study, self-assessment tools, community forums, and questionnaires. Sources of secondary data for a needs assessment include the Centers for Disease Control and Prevention, the United States Census Bureau, state or local agencies with vital records or statistics; and nongovernmental agencies. Non-governmental agencies such as hospitals can provide information on discharges or admission. Scientific studies and peer-reviewed journals are also sources of secondary data acquisition. Incorrect Answers: (A) Scientific studies and peer-reviewed journals are also sources of secondary data acquisition. (B)(D) Sources of secondary data for a needs assessment include the Centers for Disease Control and Prevention, the United States Census Bureau, and state or local agencies with vital records or statistics Vital Concept: Primary data can be collected by interviews, observation of the population under study, self-assessment tools, community forums, and questionnaires. References:

Answer 1068

Correct Answer: D. Extinction Extinction is the loss of a previously learned operant response after it is no longer reinforced by a stimulus. Good grades are the operant response (learned behavior) that has been stimulated by a monetary reward. Without the reward, the conditioned behavior is no longer reinforced and can fade over time. Incorrect Answers: A. Positive reinforcement is the addition of a desirable stimulus to increase a specific behavior. B. Positive punishment is the addition of an undesirable stimulus to reduce a specific behavior. C. Negative reinforcement is the removal of an undesirable stimulus to increase a specific behavior. References:

Answer 1069

Correct Answer: C. Phencyclidine (PCP) Acute phencyclidine (PCP) intoxication can present with behavioral changes like impulsiveness, unpredictability, psychomotor agitation, impaired judgment, and assaultiveness. Physical findings include hypertension, tachycardia, diminished pain sensation, ataxia, dysarthria, muscle rigidity, and seizures. PCP is the only drug that causes vertical nystagmus, although it can also cause horizontal or rotatory nystagmus. Onset of symptoms of PCP intoxication occurs within 1-2 hours, peaks in 2-4 hours, and lasts for 8-12 hours. Results from the Monitoring the Future Survey revealed that in 2005, 2.4% of high-school seniors reported a lifetime use of PCP, and annual use was reported by 1.3% of seniors. Management of acute intoxication with PCP includes providing a calm environment with minimal stimuli. Diazepam or haloperidol may be useful for the management of PCP-induced agitation. Incorrect Answers: A. Cannabis intoxication is not associated with vertical nystagmus. B. Amphetamine overdose is associated with euphoric rush, restlessness, irritability, hallucinations, paranoid delusions, loss of appetite, and insomnia. D. Lysergic acid diethylamide (LSD) causes sensory disturbances, tremors, mydriasis, insomnia, blurry vision, elated mood, visual and tactile hallucinations, grandiose themes, and delusions. Vital Concept Phencyclidine (PCP) is the only drug that causes vertical nystagmus, although it can also cause horizontal or rotatory nystagmus. References:

Answer 1070

Correct Answer: D. Initiative vs. Guilt This child is demonstrating initiative vs. guilt. This stage revolves around interacting socially through play and developing a sense of leadership and decision-making skills. Incorrect Answers: A. This applies to children ages birth to 18 months (too young) and basic trust (wrong concept). B. This applies to children ages 18 months to three years (too young) and control and independence (wrong concept). C. This applies to children ages 6-12 (too old) and confidence, competence, and accomplishment (wrong concept). Vital Concept: Erikson's stage of Initiative versus Guilt, which typically occurs between the ages of 3 and 6, involves interacting socially through play and developing interpersonal skills. References:

Answer 1071

Correct Answer: C. Consultative This is a consultative relationship- best described as two providers occasionally sharing information about a patient on an informal basis. Incorrect Answers: A. This is not a formal relationship. B. The new practitioner is not transferring her patient to the experienced practitioner. D. A collaborative relationship is a more formal process. It involves sharing responsibility for a patient’s treatment. Vital Concepts: A consultative relationship is best described as two providers occasionally sharing information about a patient on an informal basis. References:

Answer 1072

Correct Answer: D. Changing the dose of medication or starting immediate-release medication may be required. Obesity can be a comorbidity of depression. Often causing decreased energy, this leads to poor adherence to an exercise regimen and diet. Weight gain can also define a subgroup of depressed patients like atypical depression. Following gastric bypass and jejunoileal bypass, changes in the medication dose or release methodology may be required. This will also be affected by the lipo/hydrophilic properties of the medication and the fat content of the patient's diet. Incorrect Answers: A. Antidepressants with the greatest weight gain are mirtazapine, TCAs (especially tertiary), and MAOIs. Weight gain is less problematic with SNRIs and SSRIs. Mirtazapine is less likely to cause common side effects of other SSRIs, including nausea, diarrhea, and sexual dysfunction. The most common side effects of mirtazapine are increased appetite, weight gain, dry mouth, and somnolence. B. In patients who have had bariatric surgery, studies indicate an improvement in mood as well as a decrease in medical comorbidities. However, bariatric patients with premorbid chronic depression or illness that has required hospitalization have a less robust decrease in weight and less robust improvement in mood. C. As body weight increases, medications might need to be adjusted to compensate for the possibility of decreased efficacy or increased absorption (if lipophilic). Conversely, hydrophilic medications may need to be increased with weight loss or the use of a low-fat diet, while lipophilic medications may require the reverse. Vital Concept: Following a surgery that alters the absorption and/or metabolism of medications, dose changes or a transition in release methodology (e.g., extended to immediate release) may be required. References:

Answer 1073

Correct Answer: C. National guidelines close the gap between research outcomes and practice Evidence-based practice is characterized by the use of current research evidence in combination with clinical expertise and patient values to formulate sound clinical interventions. The movement was founded in 1972 by Professor Archibald Leman Cochrane, an epidemiologist in Britain, who developed the Cochrane Review to rigorously evaluate current research and synthesize the available evidence, to facilitate care based on reliable and current information. National guidelines have been developed to close the gap between research outcomes and practice in some areas. Incorrect Answers: A. Some reports suggest that it may take up to 17 years for research to be incorporated into practice, and some research is never incorporated into the clinical setting. Integration of research results into clinical practice rarely occurs in a timely manner. B. Evidence-based practice takes current research, clinical expertise, and patient values into account when interventions are formulated for patient care. D. Although there has been some resistance to evidence-based practice, claiming the approach is “cookie-cutter,” in reality the patient’s clinical state, setting, circumstances, and preference should be taken into account. Vital Concepts: Evidence-based practice is characterized by the use of current research evidence in combination with clinical expertise and patient values to formulate sound clinical interventions. National guidelines have been developed to close the gap between research outcomes and practice in some areas. References:

Answer 1074

Correct Answer: B. A highly sensitive test will have minimal false negatives. A highly sensitive test effectively identifies those who have the disease or condition, or the true positive rate. It will have minimal false negatives. This statement is true regarding sensitivity. Incorrect Answers: A. A sensitive test helps rule in disease. C. A highly sensitive test will have false positives. D. Negative predictive value is the probability that subjects with a negative screening test truly do not have the disease. Vital Concepts: A highly sensitive test effectively identifies those who have the disease or condition, the true positive rate. It will have minimal false negatives. This statement is true regarding sensitivity. References:

Answer 1075

Correct Answer: D. Fluvoxamine Fluvoxamine has been associated with an increase in Clozaril levels through its inhibition of the cytochrome p450 1A2 enzyme. Clozaril is metabolized primarily by CYP450 1A2. Is also weakly metabolized by CYP 450 2D6 and 3A4. Clozaril is a substrate of the CYP1A2, 2D6, and 3A4 isoenzymes. About 2-3% of the population are “slow metabolizers” of Clozaril and may develop higher than expected levels of the medication when standard dosing is used. A similar effect is noted with TCAs and SSRIs, as most of them inhibit the 2D6 isoenzyme and cause an increase in the blood level of the TCA. A screening ECG as well as repeat blood levels should be performed when a SSRI is added to a TCA. Fluvoxamine also inhibits the 3A3/4 enzyme, which can increase alprazolam, triazolam, and trazodone. This may result in greater than expected sedation. Incorrect Answers: A. Sertraline. Sertraline inhibits CYP450 2D6 and 3A4. Clozaril is metabolized primarily by CYP450 1A2, which Fluvoxamineinhibits. Clozaril is only weakly metabolized by CYP450 2D6 and 3A4. B. Fluoxetine. Fluoxetine inhibits CYP450 2D6 and 3A4. Clozaril is metabolized primarily by CYP450 1A2, which Fluvoxamineinhibits. Clozaril is only weakly metabolized by CYP450 2D6 and 3A4. C. Paroxetine. Paroxetine inhibits CYP450 2D6 only. Clozaril is metabolized primarily by CYP450 1A2, which Fluvoxamineinhibits. Clozaril is only weakly metabolized by CYP450 2D6. References:

Answer 1076

Correct Answer: D. Major depressive disorder Major depressive disorder has been described in up to 50% of patients (both male and female) with PTSD. Alcohol use disorders are seen in nearly 50% of males and 27% of females, simple phobias and social phobia in about 30% of males and females, and persistent depressive disorder (previously dysthymia) in about 20% of males and females. The presence of PTSD in schizophrenia is associated with increased secondary negative symptoms. The rate of attempted suicide in patients who have PTSD is estimated at 20% overall. These diagnoses can come before, during, or after the diagnosis of PTSD. Incorrect Answers: A. Simple and social phobias have about a 30% prevalence in female PTSD sufferers. B, C. Bipolar disorder's and OCD's prevalence in PTSD isn't listed, but can be assumed to be below that of major depressive disorder. References:

Answer 1077

Correct Answer: D. Flooding: exposing patients to anxiety-provoking or feared situations all at once until anxiety and fears subside Flooding exposes patients to anxiety-provoking or feared situations all at once until anxiety and fears subside Incorrect Answers: A. Behavioral therapy is based on modifying stimulus-response relationships and is rooted in Pavlovian theory (conditioning). Psychodynamic therapy is different in that its goal is to help patients identify and understand unconscious drives that influence emotion and behavior. Behavioral therapy has been shown to ameliorate signs related to eating disorders, phobias, OCD/OCPD, and mood disorders. B. Exposure involves gradually exposing patients to situations that they would ordinarily consider uncomfortable or anxiety-provoking. This approach is often used in agoraphobia and is introduced through “imagined exposure.” In imagined exposure, patients first imagine themselves in target situations to begin altering their conditioned fear response. C. Relaxation training involves teaching skills to patients and empowering them to reduce distress and anxiety on their own. A common form of relaxation training is "progressive muscle relaxation." In this modality, the patient tenses and then relaxes each muscle group progressively. This approach has been helpful for patients with anxiety disorders, pain disorders, or other pain-related problems. References:

Answer 1078

Correct Answer: C. Belief that her thoughts are controlled by secret radio station messages Psychosis is identified by the presence of delusions, hallucinations, or disorganized behavior or speech. A delusion is a patently false belief (e.g. the belief that one’s thoughts are being controlled by secret radio station messages). Suspiciousness, hyper-religiosity, and philosophical rumination or perseveration are not necessarily delusions. Depending on the context, these characteristics can present in both emotionally healthy and psychologically disturbed individuals. Disorientation to time and place suggests a cognitive disorder that affects short-term memory. Incorrect Answers: A, B, D. These aren't necessarily a delusion (which would be suggestive of psychosis). Depending on context, these could all present in both emotional health and psychologically disturbed individuals. References:

Answer 1079

Correct Answer: B. Flumazenil Flumazenil has been used as an antidote in the treatment of benzodiazepine overdoses. It reverses the effects of benzodiazepines by competitive inhibition at the benzodiazepine binding site on the GABA-A receptor. Flumazenil's short half-life requires multiple doses and careful patient monitoring to prevent recurrence of overdose symptoms. Incorrect Answers: A. This is used to treat muscle spasticity caused by conditions such as a spinal cord injury, stroke, cerebral palsy, or multiple sclerosis, not to reverse benzodiazepine overdoses. C. This is used to prevent relapses into alcohol or drug abuse, not to reverse benzodiazepine overdoses. D. This is used to prevent and control high blood pressure during surgery, not to reverse benzodiazepine overdoses. References:

Answer 1080

Correct Answer: C. Disulfiram Disulfiram blocks aldehyde dehydrogenase, leading to the accumulation of acetaldehyde at toxic levels and causing many unpleasant, hangover-like side effects. Incorrect Answers: A. Acamprosate, an NMDA receptor blocker, exerts its action by mimicking alcohol’s increase in GABA activity. B. Naltrexone and nalmefene block the activation of the reward system associated with alcohol and opiates. D. Chlordiazepoxide is a benzodiazepine that is used for acute detox rather than treatment of alcohol dependence. References:

Answer 1081

Correct Answer: C. Early adulthood (25-35) The median age of onset is 30. The lifetime prevalence is 5.7%, and 32% of patients are classified as “severe.” Generalized anxiety disorder is characterized by extraordinary concern on most days for 6 months or more regarding various things (school, work, family). This is accompanied by at least three of the following: feeling tired, agitated, uneasy/fidgety, tense/clenched with poor sleep, and an inability to sustain focus. The individual must find it difficult to control the worry. The lifetime prevalence rate of GAD is 5%, and the course fluctuates but is worse during stressful periods. GAD is most prevalent among women, older adults, and patients with low socioeconomic status. Major depression and other anxiety disorders are commonly comorbid with GAD (up to 59%). Incorrect Answers: A. The median age of onset of GAD is 30, not in childhood. B. The median age of onset of GAD is 30, not in pre-adolescence. D. The median age of onset of GAD is 30, not middle age. Vital Concept: The median age of onset of GAD is 30. References:

Answer 1082

Correct Answer: D. Gambling when emotionally unsettled If the gambling occurs in the context of a manic episode, it is considered a symptom of bipolar disorder. To meet the criteria for pathological gambling, patients must have at least four of following nine symptoms throughout a one-year period: · becomes agitated or uncomfortable when trying to decrease the betting behaviors · seems consistently distracting by betting (thinking about or discussing the next betting trip/excursion, discussing or remembering past betting trips/excursions, or devising methods to obtain additional capital with which to bet again) · after not winning a bet, bets again on a subsequent day to earn the lost money back · betting has resulted in the loss of a substantial employment, relationship, or job/learning prospect · has developed a tolerance, requiring bets of a larger amount to obtain the same psychological thrill · has tried multiple times to reduce the habit of betting without success · tends to place bets when emotionally unsettled (low mood, nervous, etc.) · is untruthful regarding how much/often they place bets · often requires external financial support from family/friends due to betting Incorrect Answers: A. Fixation on regaining losses is a criterion of pathological gambling; willingness to accept losses is not. B. Going to casinos on a set schedule is not a criterion of pathological gambling. C. When gambling occurs during a manic episode, it is considered a symptom of bipolar disorder, not a criterion for gambling disorder. Vital Concept: Gambling disorder is defined in the DSM as the observation of at least four of the nine potential problemtaic gambling traits over the course of a year. References:

Answer 1083

Correct Answer: B. Acne Lithium has been associated with acne. Incorrect Answers: A. C. Neutropenia, myocarditis, and eosinophilic colitis are associated with clozapine. D. Pancreatitis is a rare but potentially deadly side effect of valproic acid. References:

Answer 1084

Correct Answer: A. Non-weight-bearing fixtures and curtain rods Methods of reducing suicide in the inpatient setting include: Non-weight-bearing fixtures and curtain rods, short cords on adjustable beds, confiscating belts/shoelaces, jump-proof windows, cordless telephones and using barricade-proof doors. Incorrect Answers: B. Cord telephones. Cordlesstelephones are used as a method of reducing inpatient suicide. C. Locked patient rooms. Patients' roomsshould not be able to lockedby the patients or the staff. If staff was to lock a room a patient was in that would be considered a restrictive seclusion. Patient should not be able to lock their room doors due to safety concerns. D. Only 1 patient per room. The number of patients/room is not a verified method of reducing suicide in the inpatient population. References:

Answer 1085

Correct Answer: D. Experiencing childhood trauma Childhood trauma has been associated with increased risk for both panic disorder and dissociative symptoms in adulthood. Smoking is also a risk factor for panic disorders and panic attacks. Panic disorders criteria include both (1) and (2) of the following: 1) recurrent unexpected panic attacks 2) at least 1 of the attacks is followed by ≥1 month of (a) persistent concern about having additional attacks, (b) worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, "going crazy"), and/or (c) a significant change in behavior related to the attacks Incorrect Answers: (A) Having controlling parents. Having controlling parents is not assoicated with an increased risk for panic disorder. (B) Having a parent with phobias. Having a parent with phobias is not assoicated with an increased risk for panic disorder. (C) Being sheltered/homeschooled. Being sheltered/homeschooled is not assoicated with an increased risk for panic disorder. References:

Answer 1086

Correct Answer: C. Abreaction: process that occurs when repressed memory and associated effect is brought into consciousness This concept/definition pair is correct. Incorrect Answers: A. Neurosis is correctly defined as "unconscious conflict between opposing wishes or between wishes and prohibitions." The incorrect definition defines the defense mechanism. B. Defense mechanism is correctly defined as "unconscious intrapsychic process that regulates basic biological drives and maintains psychological homeostasis." The incorrect definition defines neurosis. D. Pleasure principle is correctly defined as "the concept that people seek to avoid pain and discomfort and strive for gratification and pleasure." The incorrect definition describes the reality principle. References:

Answer 1087

Correct Answer: B. Residential Facility A residential facility provides care for patients over a 24 hour period. Services in typical residential treatment facilities include psycho-education around symptom management and medications, assistance with vocational training, and, in the case of severely and persistently mentally ill, may include training for activities of daily living. Rehabilitation is often a goal for residential treatment facilities. Incorrect Answers: A. A Crisis intervention unit may be found in the emergency department of a general or psychiatric hospital or within centers in the community. Patients in crisis demonstrate severe symptoms and require a high intensity of nursing services. C. Community-Based Care refers to care delivered in partnership with patients in their homes, work sites, mental health clinics and programs, health maintenance organizations, shelters and clinics for the homeless, crisis centers, senior centers, group homes, and other community settings. D. Assertive Community Treatment Model is an interdisciplinary team approach to the care of people with severe mental illness; it provides services in the individual’s natural setting, including homeless shelters. The goals of ACT are to help patients meet the requirements of community living after discharge from another more restricted form of care, and to reduce recurrences of hospitalization. References:

Answer 1088

Correct Answer: A. Internal, global, and fixed The patient's statement make be broken down as follows: “I'm the cause of all my problems (internal), all of the time (global), and nothing will ever change (fixed).” Incorrect Answers: B. The patient blames herself for all of her problems. In addition, she does not expect things to change or vary in the future. C. Local and intermittent are not terms used to describe attributions. D. The patient does not make a specific attribution. She feels her problems are ubiquitous in her life. References:

Answer 1089

Correct Answer: C. Expression of understanding Expression of understanding helps to assure the patient that the therapist is listening (e.g. seeking clarification when a patient’s statement is unclear). Incorrect Answers: A. Expression of interest, such as accurately recalling details from previous sessions, helps to build trust B. Expression of empathy, which could involve agreeing with the patient's feelings, is a way to assure the patient that the patient is listening D. Maximization is a cognitive error where a part of a situation is picked out and exaggerated; it's not a technique for building a therapeutic alliance References:

Answer 1090

Correct Answer: D. Long-term inpatient care usually involves a minimum of three months Long-term care facilities provide treatment and rehabilitation for patients who are at chronic risk of self- harm or causing harm to others as a result of psychiatric illness. Long-term inpatient care usually involves a minimum of three months and can be provided by a public or private psychiatric facility. Incorrect Answers: A. Acute symptom stabilization with safe housing options or employment is provided by partial hospitalization or outpatient treatment. B. Residential facilities provide care over a twenty-four-hour period. C. Acute inpatient care offers the most intensive care, and it is reserved for acutely ill patients at high risk for harming themselves or others or who are unable to care for their basic needs. Vital Concepts: Long-term inpatient care usually involves a minimum of three months and can be provided by a public or private psychiatric facility. References:

Answer 1091

Correct Answer: C. Understand the organizational culture to align with the goals of the organization Leadership requires good interpersonal skills, empathy, and adaptability. A leader should never stop soliciting feedback to remain self-aware. It’s important to understand the organizational culture and how decisions are made, but to build trust, the nurse practitioner should not become too political. A leader should show empathy by listening without judgment, remaining aware of the balance of power and its effect on interactions with employees, and keeping confidences private when requested. It’s important to listen, support the staff, and act as a mentor. Leaders should look for opportunities to motivate people by recognition of their worth or contribution to the work of the team. Incorrect Answers: A. Flexible communication is needed to work well with different types of people B. Building trust is important, and negative feedback destroys that trust D. A leader should never stop soliciting feedback Vital Concepts: It’s important to listen, support the staff, and act as a mentor. Leaders should look for opportunities to motivate people by recognition of their worth or contribution to the work of the team. References:

Answer 1092

Correct Answer: D. There is a 5% chance of a similar result occurring by chance alone. A p-value of 0.05 implies that there is a 5% chance of the experimental result occurring by chance if the null hypothesis is true (i.e. no significant difference). Incorrect Answers: A. The type I or false-positive error rate is equal to the p-value. However, the p-value is not the probability of falsely rejecting the null hypothesis. B. The type II error or false-negative rate is denoted by and related to the power of the study. C. The p-value should never be changed to produce significant results. References:

Answer 1093

Correct Answer: C. High-demand jobs with low decision-making control Jobs that are the most demanding (long hours, rushing to meet deadlines) with low decision-making control (no say in pace of work, time off, breaks) are linked to both emotional and cardiovascular disease. Incorrect Answers: A. High-demand jobs with low decision-making control are linked to emotional disability and cardiovascular disease; this is high decision-making control B, D. Low-demand jobs aren't linked to emotional disability and cardiovascular disease References:

Answer 1094

Correct Answer: D. 20 The number needed to treat (NNT) is the number of patients who need to receive an intervention to prevent one additional bad outcome. Absolute risk reduction (ARR) represents the amount by which an intervention reduces the rate of a bad outcome. ARR is calculated as the difference in the absolute risk (AR) between a treatment group and a control group. In this case, patients receiving Breathewell have an AR of 15% for an asthma exacerbation at one year, while patients who do not receive Breathewell have an AR of 20% for an asthma exacerbation at one year. ARR can therefore be calculated as follows: ARR NNT is calculated as the inverse of the ARR. With an ARR of 0.05, the NNT would be calculated as follows: NNT The relative risk for an asthma exacerbation in one year in the group treated with Breathewell is 0.15/0.20 = 0.75. The relative risk reduction or the amount by which the number of asthma exacerbations is reduced in the Breathewell group compared to the control group is 100 - y/x = 100 - 75% = 25%. Incorrect Answers: A. The ARR, in this case, is 5% B and C. These are not accurate statistical calculations for this case. Vital Concept: The number needed to treat is the total interventions necessary to prevent one outcome. This can be calculated by taking the inverse of the absolute risk reduction, which in turn can be calculated from the relative risk if the likelihoods of an outcome with and without the intervention are known. References:

Answer 1095

Correct Answer: B. 12-step facilitation can be used by medical or mental health professionals to support and enhance patients' attendance of 12-step programs. 12-step facilitation does not interfere with the 12-step meeting, it is another layer outside of the 12-steps designed to help people start in a 12-step program. Incorrect Answers: A. There are many 12-step programs including Adult Children of Alcoholics, Al-Anon or Alateen, Food Addicts Anonymous, Gamblers Anonymous, Narcotics Anonymous, Nicotine Anonymous, Overeaters Anonymous, and Sex Addicts Anonymous. C. 12-step programs are focused on the indivudual, and family are not required to be involved. D. 12-step facilitation can be used at any stage (including active issues), not only recovery. References:

Answer 1096

Correct Answer: B. The nursing profession articulates the scope of professional nursing practice and defines its boundaries The nursing profession defines the boundaries of professional nursing practice by developing and articulating the scope and standards of practice and informing society about the parameters of nursing practice. This guides the development of rules and regulations that govern nurse practice and state-level nurse practice acts. Incorrect Answers: A. Each state develops its own laws regulating nursing, so the designated limits, functions, and titles for nurses may differ from state to state, particularly at the Advanced Practice level. C. Although new trends like telehealth require nurses to move seamlessly between states, nursing practice is still governed by the nursing practice act within the state of practice. D. Individual nurse practitioners are responsible for ensuring that they practice within the limits of their own competency, professional code of ethics, and professional practice standards, and must ensure that their practice remains within the boundaries of the state practice act. Vital Concepts: The nursing profession defines the boundaries of professional nursing practice by developing and articulating the scope and standards of practice and informing society about the parameters of nursing practice. This guides the development of rules and regulations that govern nurse practice and state-level nurse practice acts. References:

Answer 1097

Correct Answer: B. The patient is at risk of developing carpal tunnel syndrome. This patient has hypothyroidism, which carries a greater risk of developing carpal tunnel syndrome. Incorrect Answers: A. Depressive symptoms persist after hormone replacement in about 10% of patients. C. Myxedema madness, a syndrome of hallucinations and paranoia, is a manifestation of late disease. D. Physical findings (e.g. thin dry hair, dry skin, constipation, carpal tunnel syndrome, lateral eyebrow loss, hearing loss) aid the diagnosis of prolonged disease. References:

Answer 1098

Correct Answer: C. Stimulus reduction This describes stimulus reduction. Incorrect Answers: A. Acting out is where the patient does something reckless or impractical. B. Projection/disowning/externalization is where the patient blames someone or something other than himself or herself. D. Compliance occurs when the patient goes along with directives from authority figures. References:

Answer 1099

Correct Answer: D. Generativity vs. stagnation This woman is likely at the stage of generativity vs. stagnation (see table below). The existential question is this stage is "can I make my life count?" She is contributing to society and helping to guide future generations (generativity), in comparison to a person who is unable or unwilling to help society move forward and who develops a feeling of stagnation. Incorrect Answers: A. Industry vs. inferiority is incorrect. This is the 4th stage occurs in childhood between ages 5-12 yrs. B. Initiative vs. guilt is incorrect, This is the 3rd stage that occurs in childhood where children begin to learn to assert themselves. Occurs at ages 4-5 years. C. Identity vs. role confusion is incorrect. This is the fifth stage that occurs in adolescent years. References:

Answer 1100

Correct Answer: C. Qualitative A qualitative study is used to promote understanding of the human experience. These studies are usually conducted in natural settings. Incorrect Answers: A. and B. An experimental or quasi-experimental study is a study of an intervention and its effect on a group compared to a group that did not experience the same intervention. D. Although a quantitative study would be possible if a valid scale for the experience of grief is utilized, a qualitative study is more suitable to describe human experience. Vital Concepts: A qualitative study is used to promote understanding of the human experience. These studies are usually conducted in natural settings. References:

Answer 1101

Correct Answer: A. Review depressive symptoms, relate them to death of significant other, reconstruct lost relationship, construct narrative of relationship, explore negative and positive feelings, and consider options for increasing social support IPT focuses on resolving problems and symptomatic recovery in a structured format, with or without medications. The therapist helps the patient review depressive symptoms, relate them to the death of his or her significant other, reconstruct the lost relationship, construct a narrative of the relationship, explore negative and positive feelings, and consider options for increasing social support. Incorrect Answers: B. This explains a technique for patients with interpersonal disputes that cause depression. C. This explains a technique for patients with role transitions. D. This explains a technique for patients with interpersonal deficits that lead to depression. References:

Answer 1102

Correct Answer: A. Acute alcohol ingestion may be the culprit Acute alcohol ingestion is known to inhibit CYP450 activity, which leads to substrate accumulation and an increase in the incidence of the adverse effect profile of CYP450-dependent drugs. Topiramate is one such drug, and one of its side effects is kidney stone formation. It is likely that the patient may have acutely increased his alcohol intake, leading to CYP450 inhibiting and topiramate accumulation. Consequently, the patient developed kidney stones. Incorrect Answers: B. St. John’s wort induces CYP450 activity, thus leading to increased clearance of Topiramate, and decreases the chance of developing kidney stones. This is not the case with our patient in this clinical vignette. C. D. Phenytoin, Phenobarbital, and Carbamazepine are all anti-epileptics that induce CYP450 activity. Initiating either one would have caused an increase in Topiramate clearance, thus decreasing its concentration in the blood and decreasing the adverse effect profile. This patient developed kidney stones due to a sudden increase in Topiramate concentration. References:

Answer 1103

Correct Answer: B. Control term infants Confidence intervals represent the boundary of values within which the true parameter actually lies. Wide confidence intervals indicate a greater degree of uncertainty and usually result from a smaller sample size. Large sample sizes increase the precision of a study. This results in a decrease in the width of the confidence intervals (CI). A confidence interval of 95% indicates statistical significance of the values demonstrated within the CI. As the sample size diminishes, the confidence interval will increase and the study will be less likely to demonstrate a statistical difference between two groups, as a result of “low power.” When the confidence interval of means in the control group and the studied group overlap, this suggests there may be no statistical difference between the groups. Incorrect Answers: A. Control preterm infants. This group has a narrower confidence interval than the control term infants indicating a larger sample size than the control term infant group. C. High-risk term infants. This group has the narrowest confidence interval indicating a lower degree of uncertainty and usually results from a larger sample size. D. High-risk pre-term infants. This group has a narrower confidence interval than the control term infants indicating a larger sample size than the control term infant group. Vital Concept: Wide confidence intervals indicate more uncertainty and usually result from a smaller sample size. Narrow confidence intervals indicate less uncertainty and usually result from a larger sample size. References:

Answer 1104

Correct Answer: B. Valproate Valproate causes hepatotoxicity in rare cases, requiring liver function tests every 6–12 months at most. Incorrect Answers: A. Side effects of carbamazepine include sedation, dizziness, fatigue, nausea, ataxia, agranulocytosis, and aplastic anemia. C. Side effects of lithium include tremor, polyuria, polydipsia, weight gain, cognitive slowing, hypothyroidism, and decreased creatinine clearance. D. Side effects of lamotrigine include benign rash in about 10% of people and Stevens-Johnson syndrome (a potentially fatal rash) in <1%. References:

Answer 1105

Correct Answer: D. Abnormally elevated, irritable, and labile mood is required to diagnose mania in Bipolar disorder. In order to be diagnosed with mania in bipolar disorder there must be a noted change in abnormally elevated, irritable, and labile mood. Incorrect Answers: A. Substance use, eating disorders, PTSD, and anxiety are commonly comorbid. B. Patients may have psychotic symptoms during manic episodes but not hypomanic episodes. C. Suicide rates are simuilar to the general population with patients diagnosed with Bipolar disorder is incorrect. It is estimated to be 10-15% higher in clients diagnosed with Bipolar disorder. References:

Answer 1106

Correct Answer: C. The patient has Medicare Part A, a terminal diagnosis, and a phsyician who can certify that the patient has less than six months to live if the illness runs its typical course. Incorrect Answers: A. Hospice eligibility does not depend on the patient's request for that level of care; however, it is important that the patient wants hospice care once they become eligible. B. A terminal diagnosis by itself is not sufficient to qualify for hospice care. The patient must also have two physicians who are willing to certify in writing that the patient has less than six months to live. D. The ACA did not limit the ability of Medicare patients to receive hospice care. Vital Concepts: Hospice eligibility for a Medicare patient is determined when that patient has Part A coverage AND certification by a primary care phsyician and/or a hospice physician that the patient has a terminal illness that will result in death within 6 months if the disease runs its typical course. References:

Answer 1107

Correct Answer: D. Case-control study This is a retrospective case-control study. In this observational study design, subjects are selected based on an outcome, and their prior exposures are assessed and compared to subjects who do not have the particular outcome. The result of the study is expressed as an odds ratio: OR = (# exposed with disease / # exposed without disease) / (# not exposed with disease / # not exposed without disease). A retrospective case-control study does not prove causation but demonstrates an association. Incorrect Answers: A. A cross-sectional study is used to assess disease status and risk factors at 1 point in time. B. A randomized controlled trial refers to a study where a group is given a treatment and outcomes are compared against a control group given a placebo or treated with the standard of care. C. A meta-analysis provides a statistical analysis of the results of multiple studies. Vital Concepts: In an observational study design, subjects are selected based on an outcome, and their prior exposures are assessed and compared to subjects who do not have a particular outcome. The result of the study is expressed as an odds ratio: OR = (# exposed with disease / # exposed without disease) / (# not exposed with disease / # not exposed without disease). A retrospective case-control study does not prove causation but demonstrates an association. References:

Answer 1108

Correct Answer: C. Venlafaxine Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that is FDA indicted for MDD, social anxiety disorder, GAD, and panic disorder. It is used off-label for PTSD and PMDD. Side effects that make it second line to SSRIs for depression include hypertension and discontinuation syndrome. Venlafaxine is approximately 5% excreted unchanged in urine. Incorrect Answers: A. Desvenlafaxine is excreted 45% unchanged in urine. B. Milnacipran is excreted 55% unchanged in urine. D. With fluoxetine, a negligible amount is excreted unchanged in urine. Vital Concept: Venlafaxine is approximately 5% excreted unchanged in urine. References:

Answer 1109

Correct Answer: B. Lorazepam Lorazepam is metabolized in the liver by the process of glucuronidation. This metabolism does not involve hepatic oxidation by the cytochrome P450 enzymes and is relatively unaffected by liver injury. Lorazepam has no active metabolites. There are three benzodiazepines that can be used with patients with liver injury: lorazepam, oxazepam, and temazepam. Can remember this with the acronym Out The Liver (OTL). These three benzodiazepines are all metabolized in the liver by the process of glucuronidation. Incorrect Answers: A. Chlordiazepoxide is a long acting benzodiazepine that is commonly utilized in alcohol withdrawal. However, its active metabolite is from hepatic conjugation and therefore is not recommended in patients with liver impairment. C. Alprazolam is metabolized through the liver. Due to the short half-life of alprazolam it is not typically used for alcohol withdrawal even in patients without liver impairment. D. Diazepam is a long acting benzodiazepine that is commonly utilized in alcohol withdrawal. However, its active metabolite is from hepatic conjugation and therefore is not recommended in patients with liver impairment. Vital Concept: Can use the benzodiazepines lorazepam, oxazepam, and temazepam in patients with liver injury because they are metabolized by glucuronidation. Can remember this with the acronym Out The Liver (OTL). References:

Answer 1110

Correct Answer: D. Constipation Constipation can be managed by bulk-forming laxatives and hydration. The other options are contraindications for the use of antidepressant medications with significant anticholinergic side effects, especially TCAs. The most common side effects of TCAs are dry mouth, constipation, urinary retention, weight gain, sedation, orthostasis, tachycardia, and conduction abnormalities. In patients with cognitive impairment, these medications will worsen concentration and memory and can contribute to delirium. Pilocarpine drops can improve impaired visual accommodation. Medications like TCAs will also worsen urinary hesitancy and exacerbate urinary symptoms. Medically compromised patients are likely to have an unstable fluid balance and may become toxic secondary to any of these side effects. Incorrect Answers: A. This is a contraindication for antidepressant medications with significant anticholinergic side effects, especially TCAs, because these medications will worsen concentration and could contribute to delirium B. This is an adverse effect of TCAs; if it already exists, TCA use should be discontinued. C. This is a contraindication for antidepressant medications with significant anticholinergic side effects, especially TCAs, because medications like TCAs will worsen urinary hesitancy and exacerbate urinary symptoms. References:

Answer 1111

Correct Answer: B. Assertive community treatment The Assertive Community Treatment model is an interdisciplinary team approach to providing services in an individual’s natural setting. It is used in settings that include homeless shelters. The approach offers a comprehensive range of treatments to help patients meet the requirements of community living after they have been discharged from a more restricted form of care. An important goal of the ACT approach is the reduction of recurrences of hospitalization. Incorrect Answers: A. Partial hospitalization is a structured program of outpatient psychiatric services that are provided to patients as an alternative to inpatient care. C. Medicaid is a government program to fund healthcare for the poor. D. Intensive outpatient programs are treatment and support programs that typically require patients to meet at a predefined location for several mornings or evenings each week for two to three hours. They are usually used to treat eating disorders, self-harm, and substance use disorders that do not require detoxification. Vital Concepts: The Assertive Community Treatment model is an interdisciplinary team approach to providing services in an individual’s natural setting. It is used in settings that include homeless shelters. The approach offers a comprehensive range of treatments to help patients meet the requirements of community living after they have been discharged from a more restricted form of care. An important goal of the ACT approach is the reduction of recurrences of hospitalization. References:

Answer 1112

Correct Answer: C. Nefazodone Nefazodone can cause fatal liver failure in rare cases, but overall it is considered a safe drug and is not associated with death (even in overdose). It inhibits CYP450 3A4, which can cause interactions with carbamazepine, alprazolam, and other drugs. Incorrect Answers: A, B, and D. These drugs don't carry the risk of fatal liver failure. References:

Answer 1113

Correct Answer: D. Anabolic steroid abuse Anabolic steroid abusers seldom present for medical help and rarely seek treatment. These substances can produce a mania or hypomania, which may look like bipolar disease at first. However, closer examination and careful history will help the cautious physician know when to suspect that another pathology is in play. Incorrect Answers: A. It would be very unusual for marijuana intoxication to cause aggression, irritability, and extreme mood swings. B. Nitrites usually present with symptoms akin to alcohol intoxication. C. A viral encephalopathy would present with possible confusion, focal neurological deficits, seizures, and decreased consciousness. References:

Answer 1114

Correct Answer: B. Increases levels of gamma-aminobutyric acid (GABA) The anticonvulsant effects of valproate have been attributed to the blockade of voltage-dependent sodium channels and increased levels of gamma-aminobutyric acid (GABA) in the brain. It both inhibits GABA metabolism and increases its synthesis. Incorrect Answers: A. Valproic acid blocks voltage-dependent sodium channels; it doesn’t stabilize them in an inactivated state C. Valproic acid blocks voltage-dependent sodium channels; it doesn't facilitate sodium channel opening D. This is unrelated to valproic acid's MOA

Answer 1115

Correct Answer: C. Potential chronic alcohol use disorder Chronic alcohol use disorder can lead to an increase in CYP450 enzyme activity. In this case, it is possible that the stressful life events that happened eight months may have triggered a maladaptive behavior where the patient started drinking heavily. Interestingly, an acute increase in alcohol consumption inhibits CYP450, but chronic use leads to CYP450 induction. If the CYP450 enzymes are induced, they break down substrates faster, thus leading to subtherapeutic levels of the drugs that are CYP450 substrates. Anti-epileptics, such as topiramate, are such substrates. If the patient has been heavily consuming alcohol for the past eight months, then it is likely that he experienced CYP450 induction, causing subtherapeutic levels of topiramate, and eventually led to seizure recurrence. Incorrect Answers: A. Increasing the dose of the anti-epileptic, topiramate, is unlikely to cause seizure relapse. However it can increase the incidence of the adverse effects associated with it, such as fatigue, drowsiness, headache, and neuropsychiatric symptoms (such as personality changes). B. As mentioned above, acute chronic alcohol use disorder causes CYP450 inhibition, rather than induction. If CYP450 enzymes are inhibited, then substrates will accumulate, leading to supra-therapeutic levels of those substrates. In this case, topiramate would accumulate, possibly causing the adverse effects mentioned above. However, it shouldn’t cause seizure relapse. D. Valproate is a known CYP450 inhibitor, and adding it to the regimen would cause a similar profile to acute chronic alcohol use disorder.

Answer 1116

Correct Answer: A. Depression Depression is the most common psychiatric comorbid condition in epilepsy. Depression prevalence is estimated at 23.1%. In intractable patients is as high as 50%. Incidence of depression is significantly elevated before and after an epilepsy diagnosis (bidirectional relationship). There is an increased risk of depression in temporal lobe epilepsy. Incorrect Answers: (B) Anxiety. Anxiety is the second most common psychiatric comorbid condition in epilepsy. Anxiety lifetime prevalence is estimated at 22.8%, just shy of depression. However, depression is the most common because the prevalence increases when accounting for intractable patients. (C) Psychosis. Estimates are 5.2% for interictal psychosis and 2% for postictal psychosis. (D) Mania. Estimates are 12.2% for manic symptoms in patients with epilepsy.

Answer 1117

Correct Answer: A. 5-HT1A Buspirone acts as a serotonin 5-HT1A receptor partial agonist. It also functions as a presynaptic dopamine antagonist at the D2, D3, and D4 receptors and as a partial α1 receptor agonist. Incorrect Answers: B, C, and D. Buspirone does not act at these receptors

Answer 1118

Correct Answer: B. X mg y drug administered to patient. No adverse effects noted. This is the most factual note; the writer does not give blame or assume liability. Incorrect Answers: A, C, and D. These notes would be “red flags” for a chart reviewer. The mention of an incident report makes it virtually impossible to protect these documents from disclosure, especially in the jurisdictions that afford protection of these internal “early warning” documents that seek to alert risk management personnel to a potential claim. Vital Concepts: X mg y drug administered to patient. No adverse effects noted. This is the most appropriate way to document.

Answer 1119

Correct Answer: D. Patients desiring to achieve or sustain abstinence are best treated by a combination of medication and behavior intervention strategies. Research shows that patients with schizophrenia and substance abuse disorders are best managed by a combination of pharmacotherapy and pscyhosocial interventions. Incorrect Answers: A. Nicotine abuse/dependence exceeds 50% prevalence in patients with schizophrenia. The prevalence of other substance use disorders in patients with schizophrenia is nearly 50%. B. Patients with schizophrenia and comorbid substance use disorders are best served in a comprehensive treatment program where the same clinicians address both issues. If this is not possible, both clinicians should work closely together. C. Harm reduction, abstinence, relapse prevention, and rehabilitation are all parts of the treatment plan. Goals are established according to where the patient is along this spectrum of intervention.

Answer 1120

Correct Answer: C. Elderly patients with low cardiac output have increased problems with hypotension and cardiac arrhythmia. Elderly patients with low cardiac output have increased problems with hypotension and cardiac arrhythmia. Orthostatic hypotension is also associated with second-generation agents. Incorrect Answers: A. Recommended starting doses in elderly patients are 25-50% of regular adult starting dose. This is due to physiological changes, including decreased cardiac output, reduced liver and kidney blood flow, decreased liver metabolism, and age-related changes in receptor site activity. B. Elderly patients have a 6x higher incidence of tardive dyskinesia and extrapyramidal symptoms. This is especially true for patients with dementia, Parkinson’s disease, or intellectual disability (formerly mental retardation). D. Age-related decreased cholinergic function and anticholinergic side effects of antipsychotic drugs can exacerbate fecal impaction, constipation, confusion, and urinary retention.

Answer 1121

Correct Answer: D. TEOSS study examined pediatric patients with early onset schizophrenia and schizoaffective disorder and showed no significant difference in response likelihood between molindone, olanzapine, or risperidone. The TEOSS study that examined pediatric patients with early-onset schizophrenia and schizoaffective disorder showed no significant difference in response likelihood between groups on molindone, olanzapine, or risperidone. Although response likelihood was the same for all groups, patients with molindone had a higher rate of akathisia. Risperidone and olanzapine were associated with significant metabolic side effects and weight gain. Incorrect Answers: A. There is little clinical utility in making a distinction between first- and second-generation agents. B. This is supported by no significant difference in clinical outcomes in CATIE, CUtLASS, and TEOSS studies. C. There was no significant difference in clinical outcomes in the CUtLASS study.

Answer 1122

Correct Answer: D. Depression is a number one psychiatric cause of disability in the world. Mental illness poses a significant burden throughout the world. Depression was the number one cause of psychiatric disability in the world, reported by the World Health Organization. The WHO study also determined that mental disorders are the second most disabling cause of illness in the world. Incorrect Answers: A. An estimated 20% of adults in the United States have a mental illness in a given year, with an estimated 5% experiencing serious mental illness. B. The World Health Organization conducted a study of the global burden of disease that revealed mental disorders are the second most disabling category of illness around the world. C. Most individuals with mental illness do not receive treatment.

Answer 1123

Correct Answer: A. Normal behavior Going to great lengths to make sure one does not take part in something against their strict religious beliefs is a normal behavior. It is imperative to be aware of cultures and their differences in order to accurately diagnosis. The provider must be certain they do not instill their own beliefs (countertransference) into the diagnosis and treatment. Incorrect Answers: B. This patient does not have any signs of depression. C. A personality disorder does not apply here as well. D. A religious fanaticism would mean that his thoughts and feelings are obsessed by religion and holding a job would be difficult, especially for 15 years.

Answer 1124

Correct Answer: A. Bupropion Bupropion is used to help people quit smoking; however, it is contraindicated in this patient, given his seizure history. Bupropion lowers the seizure threshold. Incorrect Answers: B. Varenicline can help people quit smoking and is rarely associated with an increased seizure risk, making this the best option for this patient. It may be combined with Nicotine patches to increase the efficacy. C. D. These medications are not used for tobacco cessation.

Answer 1125

Correct Answer: B. Ramelteon Ramelteon is a melatonin agonist that can help patients fall asleep more easily. It has not been demonstrated to carry abuse or addiction potential. Although the other medications can all be used to treat insomnia, they carry a risk of abuse or addiction, especially in patients with a history of a substance use disorder. Incorrect Answers: A, C, and D. While these medications can be used to treat insomnia, they carry a risk of abuse or addiction, especially in patients with a history of substance use disorder like this patient.

Answer 1126

Correct Answer: D. Duloxetine should not be given to patients who consume large amounts of alcohol or have chronic liver disease. Duloxetine increases hepatic transaminases and may further increase levels in patients with chronic liver disease, cirrhosis, or heavy drinking. Incorrect Answers: A. Duloxetine is an SNRI and has a longer half-life than venlafaxine. Discontinuation syndrome is less likely. B. Duloxetine has fewer sexual side effects than paroxetine. It also does not have significant effects on blood pressure or the cardiovascular system. C. Duloxetine does not have an affinity for histaminic or cholinergic receptors. Sedation, weight gain, and anticholinergic effects are uncommon.

Answer 1127

Correct Answer: D. Hypersalivation/drooling Sialorrhea (or drooling/hypersalivation) is seen in 10-40% of clozapine users. The most common side effect is sedation (seen in 20-50%). Grand mal seizures are seen in 1-10%, and agranulocytosis occurs in about 0.3% of treated patients. Other common side effects include hypotension, tachycardia, and weight gain. Incorrect Answers: A. These are only seen in 1-10% of patients B. This is only seen in .01-.2% of patients C. This is only seen in 0.3% of patients

Answer 1128

Correct Answer: D. Hallucinations may subside with treatment. This B12 deficiency is due to the patient's chronic alcohol use and subsequent poor dietary intake. Vitamin treatment can improve this patient's clinical condition. If untreated, a more prolonged disease may manifest as delirium syndrome (i.e., megaloblastic madness) or prominent hallucinations, paranoia, and worsening cognition. Incorrect Answers: A. Megaloblastic macrocytic anemia, the hallmark of vitamin B12 (cobalamin) deficiency, is associated with neurodegenerative changes of the central and peripheral nervous systems, which manifest as decreased position and vibratory sensation. B. Initial nonspecific symptoms may be psychiatric (e.g., apathy, irritability, depression, or labile mood) rather than neurological or hematological. C. Vitamin B12 deficiency is a cause of macrocytosis. Because DNA synthesis requires cyanocobalamin (vitamin B12) as a cofactor, a vitamin deficiency leads to decreased DNA synthesis in the erythrocyte, resulting in macrocytosis. Dietary deficiency of vitamin B12 is rare. However, deficiency can result from the following lack of intrinsic factor in patients who have undergone a gastrectomy, pernicious anemia, or malabsorption of vitamin B12 secondary to small bowel bacterial overgrowth, tapeworm, familial factors, drugs, ileal bypass, ileal enteritis, or sprue. Nutrient Clinical Features Causes Thiamine, or vitamin B1 "Beriberi": neuropathy, weakness, muscle wasting, cardiomegaly, ophthalmoplegia, confabulation Alcoholism Niacin, or vitamin B3 Pigmented rash of sun-exposed areas, disorientation, and problems with memory, diarrhea, memory problems, bright red tongue b6 deficiency, alcoholism, riboflavin deficiency, tryptophan deficiency Vitamin B6, or pyridoxine Seborrhoeic dermatitis, inflamed tongue, neuropathy, confusion, depressed mood, microcytic anemia Alcoholism, INH Folate, or vitamin B9 Shrunken and inflamed tongue, megaloblastic anemia, high homocysteine Alcoholism, sulfasalazine, pyrimethamine, triamterene Vitamin B12, or cobalamin Dorsal column loss of vibratory and position sense, ataxic gait, dementia, loss of control of bowels, erectile dysfunction, megaloblastic anemia Gastric atrophy, disease of the ilium, vegan diet, gastric bypass surgery Vital Concept: The hallucinations described by this patient may improve with vitamin supplementation to correct the deficiency described.

Answer 1129

Correct Answer: A. Wernicke’s syndrome To avoid the emergence of Wernicke’s encephalopathy (i.e. ataxia, ophthalmoplegia, disorientation, and paresis of the lateral rectus muscle), thiamine, 100mg, should be administered by the IM or IV route before giving any fluids or food with caloric value. A deficiency in the essential nutrient thiamine resulting from chronic alcohol consumption is one factor underlying alcohol-induced brain damage. Thiamine is a helper molecule required by three enzymes involved in carbohydrate metabolism. A reduction in thiamine can interfere with numerous cellular functions, leading to a serious brain disorder including Wernicke’s syndrome. Incorrect Answers: B. Wolf-Hirschhorn syndrome is caused by the deletion of the distal short arm of chromosome 4. The disorder’s major features include a characteristic facial appearance, delayed growth and development, intellectual disability and seizures. C. Jacobsen Syndrome, also known as 11q deletion disorder, results from a loss of genetic material from the end of the long arm of chromosome 11. Signs and symptoms of this condition vary, but most individuals experience delayed development in motor skills and speech, cognitive impairments, learning difficulties, and some behavioral problems. D. Edwards syndrome or Trisomy 18 occurs when a person has a third copy of material from chromosome 18. Some symptoms include clenched hands, feet with rounded bottom, mental deficiency, underdeveloped fingernails and an unusual shaped chest.

Answer 1130

Correct Answer: C. Summarize key themes in the discussion When facilitating conflict resolution, the NP should protect the self-respect of each party by focusing on the issue or issues, and not on individual personalities of the involved parties. The facilitator should not place blame, which discourages open discussion of issues. Both positive and negative feelings should be discussed freely to allow a better opportunity for both parties to express all of their concerns. The facilitator should allow equal time for all parties to express opinions, then summarize key themes in the discussion and assist to develop alternative solutions to the problem. The facilitator should also give positive feedback to both parties at a later date and should follow up on the progress of the conflict resolution. Incorrect Answers: A. A focus on the personalities of the parties involved in a conflict should be avoided, to allow parties to retain self-respect and remain open to discussion. B. A facilitator should not assign blame to parties in a conflict resolution. D. The facilitator should encourage parties to share both positive and negative feelings to increase the chance of open and honest discussion of all concerns. Vital Concepts: When facilitating conflict resolution, the NP should protect the self-respect of each party by focusing on the issue or issues, and not on individual personalities of the involved parties. The facilitator should not place blame, which discourages open discussion of issues. Both positive and negative feelings should be discussed freely to allow a better opportunity for both parties to express all of their concerns.

Answer 1131

Correct Answer: B. Autonomy vs. Shame and Doubt This child is experiencing autonomy vs. shame and doubt. Incorrect Answers: A. This applies to birth to 18-month-olds (wrong age) and involves basic trust (wrong task). C. This applies to 3-6-year-olds (wrong age) and involves taking control of the environment and purpose (wrong task). D. This applies to ages 12-28 and involves confidence, competence, and social skills (wrong task).

Answer 1132

Correct Answer: D. Duloxetine Duloxetine has been shown in some trials to reduce stress incontinence in women significantly. Trials are ongoing, and use of the medication for this purpose is not FDA-indicated. Imipramine at doses of 10-25mg is used in children with enuresis. It has not been well studied in urinary incontinence in women, nor has it been proven highly effective, but some clinicians believe it may be worth a trial if other therapies fail. In addition to lack of evidence of efficacy, there are a number of significant side effects. The other medications listed have no significant effects on incontinence. Incorrect Answers: A, B, and C. These medications have no significant effect on incontinence.

Answer 1133

Correct Answer: C. Process Clinical quality measures used to assess the performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees include process measurements, which generally consist of a measure of patients eligible for a particular service in the denominator and the number of patients who do or do not receive the service in the numerator. Process measures are supported by evidence that the clinical process has led to improved outcomes. Incorrect Answers: A. Access measures refer to the measure of attainment of timely and appropriate health care by patients or enrollees of a healthcare organization or clinician. B. Use of service measures can assess provision of service to patients or enrollees through encounters, tests, or interventions that are not supported by evidence for appropriateness of the service for the specified individuals. D. Population outcomes are measures of the health of a population as a result of a public health intervention. Vital Concepts: Process measures are supported by evidence that the clinical process has led to improved outcomes. References:

Answer 1134

Correct Answer: B. Tremor 6% of patients on clozapine will experience tremors. Incorrect Answers: A. This is not caused by clozapine C. Clozapine may produce this, but at a 3% incidence rate, which is less than the 6% incidence rate for tremors D. There is no evidence that clozapine causes rigidity References:

Answer 1135

Correct Answer: C. 20% About 20% of bereaved people meet the criteria for major depressive disorder. Normal bereavement can be highly disruptive and trigger severe dysphoria. Normal bereavement is treated with support and psychoeducation. With acute grief, recurrent sadness, longing, and thoughts and memories of the deceased person are common. This acute period typically lasts no more than 6 months. Complicated grief represents ongoing dysphoria, persistent yearning and longing for the dead person, and guilty or angry ruminations. To review, patients with major depressive disorder must exhibit five or more symptoms for the same 2-week period and represent a change from previous functioning. At least one of the symptoms must be either a depressed mood or loss of interest or pleasure. Other symptoms include psychomotor agitation or delay, significant weight change or appetite change, sleep disturbances, fatigue or loss of energy, feelings of worthlessness/guilt, decreased mental clarity, and recurrent thoughts of death/suicidal ideation, intention, plan. In contrast, uncomplicated bereavement is described as a normal reaction to the death of a loved one. Patients experiencing uncomplicated bereavement can have some symptoms of major depression, such as sadness with associated insomnia, poor appetite, etc. Patients typically describe their mood as normal despite the associated symptoms which line up with those of depression. Changes in the level of functioning are not seen, not as severe, or not as long-standing with uncomplicated bereavement. Lastly, prolonged grief disorder is defined by an individual experiencing extreme and substantial symptoms of grief beyond a typical or expected timeline leading to anguish and dysfunction. Incorrect Answers: A. About 20% of bereaved people meet the criteria for major depressive disorder, not 5%. B. About 20% of bereaved people meet the criteria for major depressive disorder, not 10%. D. About 20% of bereaved people meet the criteria for major depressive disorder, not 30%. E. About 20% of bereaved people meet the criteria for major depressive disorder, not 40%. Vital Concept: About 20% of bereaved people meet the criteria for major depressive disorder. References:

Answer 1136

Correct Answer: D. Feelings of inferiority Feelings of inferiority are developed if the developmental task of industry vs. inferiority is not accomplished. Industry vs. inferiority is the developmental task for school-age children ranging in ages 6-12 and mastery creates the ability to work and sense of competency and achievement. Failure in the developmental task of trust vs. mistrust creates poor relationships and autonomy vs. shame and doubt results in poor self-control and self-doubt. Incorrect Answers: A. This is attributed to failure in the developmental task of trust vs. mistrust. B. C. These are both attributed to failure in the developmental task of autonomy vs. shame and doubt. References:

Answer 1137

Correct Answer: B. Working This PMHNP is demonstrating countertransference with this patient. This happens in the working phase of The Phases of a Therapeutic Nurse-Client Relationship. These phases were developed by Hildegard Peplau in the first significant psychiatric nursing theory. Incorrect Answers: A. This brief stage involves information-gathering about the patient on the nurse's part. They display courtesy and respect at all times. Countertransference doesn't happen in this stage. C. This stage involves discharge planning. Countertransference doesn't happen in this stage. D. This isn't a phase of Peplau's three-stage nurse-client relationship. References:

Answer 1138

Correct Answer: B. Feelings of worthlessness Major depressive disorder can lead to suicide. It is the leading cause of morbidity and mortality in individuals over the age of 15 worldwide. Signs and symptoms include the following: significantly reduced interest or enjoyment in most activities for the majority of the day, practically every day, self-reported or observed* poor or sad mood for the majority of the day most days; may include self-reports of unhappiness, unfulfillment, or despondency or tearfulness observed by others* psychomotor excitement or delay most days; must be obvious to others, not solely a self-report of symptoms reduced mental clarity, focus, or decision-making almost every day feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic substantial (at least 5% of total body weight) unintentional decrease or increase in weight in a month the inability to sleep at night or stay awake during the day despite getting an adequate amount of sleep the night before most days feeling lethargic, weary, or exhausted most days a preoccupation with death, consistent suicidal ideations with or without a specific plan, or an attempted suicide * To qualify for a diagnosis of MDE, at least one of the first two symptoms listed here must be present Symptoms cause substantial anguish or dysfunction in at least one environment (work, home, social settings) The symptoms are unrelated to the effects of a physical illness or substance use. Incorrect Answers: A. Nightmares are an intrusive symptom of posttraumatic stress disorder (PTSD), if the distressing dreams are related to trauma. C. Apraxia refers to a motor disorder caused by brain damage. This is not associated with depression. D. Difficulty controlling worries is a symptom of generalized anxiety disorder. Vital Concept: Signs and symptoms of depression include the following: depressed mood, psychomotor retardation or agitation, loss of pleasure (anhedonia), weight change, appetite disturbance, sleep disturbance, fatigue or loss of energy, feelings of worthlessness, inability to concentrate, and recurrent thoughts of death, with or without a plan for committing suicide. References:

Answer 1139

Correct Answer: A. Open-ended questions, affirmations, reflective listening, and summaries OARS stands for Open-ended questions, Affirmations, Reflective listening, and Summaries. Incorrect Answers: B. A in OARS stands for "Affirmations," not answers. The other skills are correct. C. S in OARS stands for "Summaries," not sharing. The other skills are correct. D. R in OARS stands for "Reflective listening," not reflection. The other skills are correct. References:

Answer 1140

Correct Answer: A. Regression Regression will happen first, followed by focusing on self-management strategies, then reviewing the client's progress toward objectives. The three phases in the Therapeutic Nurse-Client Relationship that was developed by Hildegard Peplau are the introduction, working, and termination phases. Countertransference occurs in the working phase. Regression, focusing on self-management strategies, and reviewing client’s progress toward objectives are all aspects of the termination phase. Incorrect Answers: B. This isn't expected to happen at all. C. This happens after regression. D. This happens after regression and focusing on self-management strategies. References:

Answer 1141

Correct Answer: D. GHB (Xyrem) GHB (Xyrem, also known as sodium oxybate) is a schedule III drug and has been approved by the FDA for the treatment of cataplexy in patients with narcolepsy. Incorrect Answers: A. Although methamphetamine is approved for ADHD and exogenous obesity, it is a schedule II drug and is only used off-label for the treatment of narcolepsy. B. MDMA is in clinical trials for use in PTSD and anxiety in cancer patients. C. Ketamine is used frequently in anesthesia. References:

Answer 1142

Correct Answer: D. Mirtazapine Selective serotonin reuptake inhibitors (SSRIs)are considered the first-line treatment for depression in older adults due to their effectiveness, safety, and side effect profile. Mirtazapine is an appropriate second-line therapy if SSRIs are not effective. Mirtazapine is a tetracyclic antidepressant that is well-tolerated by older patients. It has noradrenergic and serotonergic properties. It is less anticholinergic than older tricyclic antidepressants. Mirtazapine is a relatively safe antidepressant for seniors. It also has sedating properties and is associated with increased appetite and weight gain. Due to its sedating effects, it is typically taken at bedtime. Since this patient has trouble sleeping and eating, mirtazapine would be the best choice. Incorrect Answers: A. Olanzapine is an atypical antipsychotic drug that can treat schizophrenia and bipolar disorder. It would not be indicated in this case. B. Amitriptyline is a tricyclic antidepressant; common side effects include drowsiness, dry mouth, and dizziness. Tricyclic antidepressants are not considered first-line medications for older patients due to their anticholinergic and other side effects. C. Doxepin is a psychotropic drug is a tricyclic antidepressant with anxiolytic properties. Tricyclic antidepressants can cause postural hypotension, leading to falls and fractures, cardiac conduction problems, and delirium. Dry mouth and constipation are also common. Vital Concept: Mirtazapine is a safe tetracyclic antidepressant in the elderly and can help those with poor sleep. Tricyclic medications are no longer the first-line treatment for depression due to anticholinergic properties that can cause many side effects, including postural hypotension, delirium, and falls. References:

Answer 1143

Correct Answer: B. In AA, you must have a “higher power” but not necessarily believe in God. To work the AA program, one must accept a "higher power" since the program of recovery involves a spiritual experience and awakening. Incorrect Answers: A. AA is not a Christian organization, and there are AA chapters for other world religions, atheists, and agnostics. C. Agnostic and atheist AA groups exist. D. Spirituality and requisite hope for recovery can be achieved without a formal religious affiliation. References:

Answer 1144

Correct Answer: C. 6-8% Mood switching occurs in 6-8% of patients being treated for major depressive disorder with an antidepressant in an average of 2 years of treatment. The risk of mood switching increased up to 2 years of antidepressant treatment. The rates of mood switching in juveniles were 4.3 times greater than in adults. Of note, the DSM-5 and DSM-5-TR consider mood elevation with antidepressant use as justification for a diagnosis of bipolar disorder (it was previously considered a "drug-induced reaction"). Incorrect answers: (A) <1%. Mood switching occurs in 6-8% of patients being treated with an antidepressant for major depressive disorder, not <1%. (B) 3-4%. Mood switching occurs in 6-8% of patients being treated with an antidepressant for major depressive disorder, not 3-4%. (D) 20%. Mood switching occurs in 6-8% of patients being treated with an antidepressant for major depressive disorder, not 20%. Vital Concept Of those patients with MDD being treated with an antidepressant, 6-8% may experience mood switching, displaying symptoms of mania. References:

Answer 1145

Correct Answer: C. State-dependent learning State-dependent learning assumes that both learning and memory recall occur most effectively under the same circumstances. This well-known phenomenon applies both to external states (the learning environment) and internal environments (intoxication). Incorrect Answers: A. A placebo effect is a perceived or tangible improvement after administration with an inert medication (a "placebo"). In this case, marijuana is not a placebo, and the effect on memory recall is a known phenomenon. B. Habituation is a form of non-associative learning whereby repetitive stimuli elicit weakening behavioral responses if the stimuli do not reinforce or punish the behavior. D. While some may feel that intoxication with various substances may allow users to reach a state of higher consciousness, this phenomenon has no relationship with learning and memory recall. References:

Answer 1146

Correct Answer: A. Rash The risk of serious skin reactions, including Stevens-Johnson syndrome, may be fatal. Patients should be given a list of physical signs that require evaluation by a physician. They should be advised to avoid excessive sun exposure early in treatment. Also, anyone with a rash accompanied by systemic symptoms such as fever or discomfort in the mouth, eye, or bladder should discontinue the lamotrigine and go to the emergency room for evaluation immediately. The risk of rash is highest with rapid titration and around dose increases. Incorrect Answers: B, C, and D. These are not characteristic side effects of lamotrigine. References:

Answer 1147

Correct Answer: D. MRI scan shows areas involved in Korsakoff’s syndrome, including midbrain, pons, hypothalamus, thalamus, and cerebellum. On MRI scan, the areas involved in Korsakoff’s syndrome include the midbrain, pons, hypothalamus, thalamus, and cerebellum, as well as the mammillary bodies, which are part of the diencephalon. Incorrect Answers: A. B. Bariatric surgery and 5-fluorouracil decrease thiamine absorption, resulting in an increased risk for the development of Wernicke’s encephalopathy and Korsakoff’s syndrome in certain patients (ethanol abusers). C. Vitamin B1 (not B6) is deficient in Wernicke’s encephalopathy and in Korsakoff’s syndrome. References:

Answer 1148

Correct Answer: D. Generativity vs. Stagnation This patient is experiencing generativity vs. stagnation. (See table below) Incorrect Answers: A. This describes infants' to 18-month-year-olds' development of basic trust. B. This describes 18-month-year-olds' to three-year-olds' development of control and independence C. This describes three-year-olds' through six-year-olds' development purpose and taking control of their environments References:

Answer 1149

Correct Answer: C. Bupropion The patient suffered head trauma, and his medical status is an important consideration in choosing the appropriate antidepressant. Patients with a history of a seizure disorder, stroke, or head trauma are more safely treated with an SSRI or venlafaxine than with a TCA or bupropion. Incorrect Answers: A, B, and D. These are all more appropriate than bupropion for a patient with a history of head trauma, as such patients are more safely treated with an SSRI or venlafaxine versus a TCA or bupropion. References:

Answer 1150

Correct Answer: B. Mentorship A supportive leadership style includes the core values of mentorship, coaching, and supervision. Mentorship can foster ongoing role development and should be based on the acquisition and mastery of new skills. The goal of mentorship is to create a stable and supportive environment that encourages professional growth through effective role modeling. Incorrect Answers: A. C. and D. These aren't leadership values. Vital Concepts: The goal of mentorship is to create a stable and supportive environment that encourages professional growth through effective role modeling. References:

Answer 1151

Correct Answer: B. <1% is excreted unchanged in feces and urine. Less than 1% of the drug is excreted unchanged in feces and urine. Incorrect Answers: A. Trazodone is about 89-95% protein-bound, and its peak plasma level occurs after 1 hour when taken on an empty stomach and after 2 hours when taken on a full stomach. C. CYP3A inhibitors (ritonavir, indinavir, and ketoconazole) inhibit trazodone’s clearance. D. Clinical trials have shown that the therapeutic efficacy of trazodone is equivalent to that of TCAs. References:

Answer 1152

Correct Answer: B. Davanloo Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo. Incorrect Answers: A. In Sifneo’s method, the therapist serves as a detached, didactic figure who holds focus and challenges the patient to relinquish both dependency and intellectualization, while confronting anxiety-producing conflicts. C. In Malan’s method, the therapist discerns and holds focus without explicitly defining it for the patient. D. Ferenczi's work has strongly influenced theory and praxis of the interpersonal-relational theory of American psychoanalysis, as typified by psychoanalysts at the William Alanson White Institute. References:

Answer 1153

Correct Answer: B. Start sedative antihistamine Although acutely apparent with shorter-acting benzodiazepine compounds, rebound insomnia may occur 5–7 days after discontinuation of benzodiazepines with longer half-lives and may be misinterpreted as a reemergence of underlying insomnia. When rebound insomnia occurs, avoid resuming the drug. Reassurance and the prescription of antihistamine sedatives (e.g. 50mg of diphenhydramine), sedating antidepressants (e.g. 50–100mg of trazodone), or gabapentin (100 or 300mg hs) for a few days may prove beneficial. When this does not work, reinstituting the benzodiazepine and gradually tapering the dose is an alternative strategy. Incorrect Answers: A. Re-prescribing benzodiazepine is a secondary strategy if sedative histamine doesn't work, and it should be gradually tapered C. Re-prescribing benzodiazepine is a secondary strategy if sedative histamine doesn't work; and as it should be gradually tapered, it prescribing at a higher dose isn't recommended, as it will need a longer taper D. This is not recommended as a treatment for rebound insomnia References:

Answer 1154

Correct Answer: B. Alcoholic liver disease The AST:ALT ratio in Non Alcoholic Fatty Liver Disease is usually <0.8 and is >1.5 in alcoholic liver disease. Long-term chronic alcohol use disorder results in damage to the liver, leading to cirrhosis and death. Esophageal varices from the long-term abuse of alcohol can also be life-threatening because they can rupture, leading to rapid, profuse bleeding. Heavy alcohol consumption results in serious health sequelae over time, and many cases ultimately result in death. It elevates blood pressure and increases the risk of myocardial infarction. There is an increased risk of cancer, particularly esophageal, head, neck, liver, stomach, colon, and lung. Incorrect Answers: A. Liver cirrhosis reveals fibrosis, necrosis of liver cells, and nodule formation on liver biopsy. C. Wernicke-Korsakoff syndrome is an acute condition with symptoms of confusion, ophthalmoplegia, ataxia, and nystagmus. D. Alcoholic hepatitis is an unlikely diagnosis since his bilirubin levels are normal. References:

Answer 1155

Correct Answer: A. Inhibits voltage-dependent sodium channels and presynaptic sodium channels Carbamazepine inhibits voltage-dependent sodium channels and presynaptic sodium channels. It also causes inhibition of glutamate. Incorrect Answers: B. Depakote increases GABA in the brain. C. Carbamazepine inhibits glutamate releases. D. Topiramate inhibits sodium channels, enhances GABA-a receptors, and antagonizes kainate at AMPA receptors. References:

Answer 1156

Correct Answer: A. Clinical Decision Support Systems (CDSS) A CDSS is an interactive software solution that the NP can use to help make clinical health care decisions by entering patient data into a database that then offers specific patient treatment advice. All of these systems can be integrated to improve care and documentation and prevent mistakes. Incorrect Answers: B. A computerized notification system sends alerts to the clinician based on pre-set abnormal radiology or laboratory values. C. A CPOE system automates provider ordering. This kind of system helps to minimize errors due to illegibility or human error. D. The EMR is a computerized patient medical record. Vital Concepts: A CDSS is an interactive software solution that the NP can use to help make clinical health care decisions by entering patient data into a database that then offers specific patient treatment advice. References:

Answer 1157

Correct Answer: A. Promotes "both and" rather than "either or" outlook Dialectics is a cognitive behavioral treatment that aims to help patients with personality disorders manage their intense emotions. These patients often have intense conflict in their relationships. This therapy teaches the patient to balance two opposite perspectives at once and avoid black-and-white thinking. Incorrect Answers: B. Dialectics is a philosophy, not a theory. It is not psychoeducational. C. Dialectics works to eliminate linear, black-and-white thinking in patients. D. Dialectics is a philosophy (a theory that pertains to boundaries is ego psychology) and does not address resistance. References:

Answer 1158

Correct Answer: C. Akathisia may be seen when medications are stopped. Akathisia is a movement disorder associated with anxiety and an inability to sit still. It occurs as a withdrawal side effect of antipsychotics in children. Incorrect Answers: A. Clozapine is associated with severe side effects, including cardiovascular symptoms, hyperlipidemia, seizure, and nocturnal enuresis. Currently, other second-generation antipsychotics are first-line agents in treating psychosis. Clozapine is typically used after at least 2 adequate trials of other antipsychotics fail to resolve psychotic symptoms. B. Olanzapine and quetiapine are more sedating than risperidone. Sedation can be managed by lowering the dosage. D. Extrapyramidal signs occur in up to 75% of pediatric patients on first-generation antipsychotics. Acute episodes can be treated with anticholinergic agents, antihistamines, or amantadine. References:

Answer 1159

Correct Answer: A. First line treatment is typically lithium, olanzapine, quetiapine, and/or valproate during manic episodes. These medications are generally first line treatment in elderly in manic/hypomanic episodes. Incorrect Answers: B. Antipsychotics can cause orthostatic hypotension which can increase risk for falls however often antipsychotics are used to help treat mania in the elderly and are used frequently with caution. C. Lithium is metabolized through the kidney and is not the best choice for a client with kidney disease. D. Medications used to treat bipolar can cause confusion and ataxia, resulting in increased falls and injuries. References:

Answer 1160

Correct Answer: B. Substance-related disorders In 2011, over 125 million visits were made to 24-hour EDs in general-purpose, non-federal hospitals in the United States. It is estimated that over 5 million of these visits, or about 1,626 ED visits per 100,000, were related to drugs, a 100% increase since 2004. Among emergency mental-health visits, substance-related disorders (30%), mood disorders (23%), anxiety disorders (21%), psychosis (10%), and suicide attempts (7%) are the most common. Incorrect Answers: A. Mood disorders accounted for 23% of psychiatric ER visits in 2011; this is slightly less than the 30% that were related to substance-related disorders. C. Suicide attempts accounted for 7% of psychiatric ER visits in 2011; this is far less than the 30% that were related to substance-related disorders. D. Psychosis accounted for 10% of psychiatric ER visits in 2011; this is far less than the 30% that were related to substance-related disorders. Vital Concepts: Substance-related disorders are the most common psychiatric reason for an ED visit. References:

Answer 1161

Correct Answer: C. Intubate the patient and discuss this situation with family members compassionately, allowing them to express their feelings and desires. Competent and informed adults have a legal and ethical right to refuse any medical intervention, including ventilation, artificial nutrition or hydration, defibrillation, or resuscitation. This right is based on respect for patient autonomy. Healthcare providers should particularly encourage patients who face serious illness or who are of advanced age to discuss resuscitation preferences in advance of cardiopulmonary arrest. Especially when death is expected or imminent, healthcare providers should be committed to assisting family members and loved ones as they deal with their fear and grief. Quality end-of-life care is marked by an ongoing commitment to serve the patient and family with physical, psychological, and spiritual support. Treatment should conform to what the patient would want on the basis of written or oral advanced planning or expressed preferences. If this information is not available, care decisions should be based on the patient’s best interest and evidence of what the patient would have chosen based on his or her values, previous choices, and beliefs. Incorrect Answers: A. Healthcare providers should be committed to providing compassionate and competent care to the dying patient and effectively communicating with the family. B. Although family members and healthcare providers should not project their own preferences about care onto an incapacitated patient, it is never appropriate to dismiss the concerns of family members, particularly when they are faced with the death of a loved one. D. A DNR order does not preclude other potentially life-saving measures, including intubation. Vital Concepts: Competent and informed adults have a legal and ethical right to refuse any medical intervention, including ventilation, artificial nutrition or hydration, defibrillation, or resuscitation. This right is based on respect for patient autonomy. Healthcare providers should particularly encourage patients who face serious illness or who are of advanced age to discuss resuscitation preferences in advance of cardiopulmonary arrest. Especially when death is expected or imminent, healthcare providers should be committed to assisting family members and loved ones as they deal with their fear and grief. References:

Answer 1162

Correct Answer: A. Give carbamazepine and consider increasing the theophylline dose in the future Theophylline is a bronchodilator with a very narrow therapeutic index, thus making its use somewhat problematic. Theophylline toxicity includes neurotoxic and cardiotoxic effects. This bronchodilator is metabolized by CYP450. Therefore, any medication that induces or inhibits this class of enzymes can easily affect the theophylline levels. The key to answering this question is figuring out what induces CYP450, increasing theophylline clearance, and potentially prompting a dosage increase. On the other hand, in the case of CYP450 inhibition, the effect would be decreased theophylline clearance and theophylline accumulation, prompting a dosage reduction. Carbamazepine induces CYP450, increasing theophylline metabolism and decreasing theophylline’s plasma concentration. Therefore, it is plausible to anticipate a potential future increase in theophylline’s dose to achieve a therapeutic level. Incorrect Answers: B. Valproate inhibits CYP450, causing theophylline to accumulate, and if anything, you should anticipate decreasing the theophylline dose in the future to avoid its toxicity. Therefore, this answer choice is incorrect. C. Phenobarbital induces CYP450, causing theophylline to be cleared faster, and if anything, you can anticipate increasing theophylline’s dose in the future to achieve a therapeutic level. D. Phenytoin, much like phenobarbital and carbamazepine, decreases theophylline’s serum levels by upregulating CYP450’s metabolic function. Therefore, it is more plausible to anticipate increasing the theophylline dose in the future than to keep it at the same level. References:

Answer 1163

Correct Answer: B. Theory of Adaptation The Theory of Adaptation created by Sister Callista Roy believes that behavior represents the individual trying to adapt to internal or environmental forces. Jesse is unable to adapt to his internal and external forces and thus keeps getting fired. The Theory of Self-Care, Health Promotion Theory, and the Caring Theory are not applicable in this situation. Incorrect Answers: A. This is related to taking care of oneself in daily life; it doesn't apply here. C. This is related to promoting healthy behaviors; it doesn't apply here. D. This is related to viewing nursing as both art and science; it doesn't apply here. References:

Answer 1164

Correct Answer: D. Clozapine Two significant studies in 2001 and 2003 showed clozapine to be effective in reducing suicide attempts and suicide completion in schizophrenia and schizoaffective disorder. Antipsychotics are the mainstay of treatment for schizophrenia. First-generation antipsychotics, such as haloperidol, bind dopamine-2 receptors with high affinity and antagonize them, blocking dopamine release. In general, blockade of 80% or more of the receptors is associated with increased extrapyramidal effects, while lower blockade (60-70%) is safer and still clinically effective. Second-generation antipsychotics also block dopamine-2 receptors, but each of the second-generation drugs has a different binding affinity (e.g. risperidone is high, and clozapine and quetiapine are lower). Both first- and second-generation antipsychotics bind with muscarinic, histaminergic, and adrenergic receptors as well, and this may also contribute to their clinical effects. Second-generation drugs are more effective for treating negative symptoms. First-generation antipsychotics are also used to treat acute psychosis (and at higher than maintenance dosage for this use). Beta-blockers and lithium can be used for aggression and impulsivity in schizophrenics, and antidepressants can be used to treat their depression or anxiety disorders. ECT can also be used in schizophrenia, most often for catatonia. Early studies also suggest that TMS might be useful in treating hallucinations. Case management, vocational rehab, family therapy, social work, and CBT can also be very important in the treatment success of schizophrenia. Incorrect Answers: A. Lithium is the treatment of choice for suicidal behavior in patients with bipolar disorder. B. C. These options are not FDA-approved for this use specifically. References:

Answer 1165

Correct Answer: A. He may display symptoms of chronic stimulant abuse (e.g. dental caries) and muscle cramping related to dehydration and depletion of magnesium and potassium. It's correct that this patient may display symptoms of chronic stimulant abuse, such as dental caries, as well as muscle cramping related to dehydration and depletion of magnesium and potassium. Incorrect Answers: B. Benzodiazepines may aid in sedating the patient, and can be used. C. Methamphetamine can be withdrawn abruptly. D. As suicide risk often rises after withdrawal from methamphetamines, the patient may require psychiatric admission. References:

Answer 1166

Correct Answer: B. Sleep quality The dependent variable refers to the variable that changes as a result of the manipulation of the independent variable. The dependent variable here is sleep quality. Incorrect Answers: A. In this hypothesis, the independent variable is daily exercise. C. and D. The frequency of exercise does not vary in this hypothesis and the age is a characteristic of the population studied that also does not vary. Vital Concepts: The dependent variable refers to the variable that changes as a result of the manipulation of the independent variable. References:

Answer 1167

Correct Answer: D. Reduce symptoms and improve self-esteem and functioning Individual supportive therapy seeks to reduce symptoms while improving self-esteem and functioning. Incorrect Answers: A. Cognitive-behavioral therapy seeks to modify dysfunctional thoughts and behaviors. B. While individual supportive therapy focuses on bolstering ego functioning, psychodynamic therapy seeks to discover unconscious sexual or aggressive impulses. C. Motivational interviewing seeks to increase motivation to change behavior. References:

Answer 1168

Correct Answer: C. Unconsciousness due to nitrite intoxication Nitrites (present in liquid incense) would not show on the toxicology screen, and are drugs of abuse, particularly in this population. They are used to heighten sexual pleasure. In nitrite poisoning can see nausea, vomiting, dizziness, cyanosis, hypotension, tachycardia and loss of consciousness. The nitrites cause methemoglobinemia and can use methylene blue as treatment to reverse the methemoglobinemia and restore hemoglobin. Incorrect Answers: A. Onanism with subsequent deep sleep. The child is engaging in onanism (masturbation), but key parts of the history are ignored, and this child's apparent unconscious period is alarming. Further investigation is required. B. Normal experimentation with self-stimulation. Self-stimulation alone does not lead to being unconscious. Nitrite poisoning is the better option with the history of several empty incense bottles. D. Likely seizure with short post-ictal state. The history does not indicate a seizure and nitrite poisoning is the better option with the history of several empty incense bottles. References: