PMHNP certification Exam KM Deck Flashcards
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<div><b>Which patient is at highest risk for SI</b></div>
<div><b>A. 30y/o married AA female with previous SI attempt *1 risk factor</b></div>
<div><b>B. 35 y/o single Asian male with previous SI attempt *3 risk factors</b></div>
<div><b>C. 38 y/o single AA male who is a manager of a bank *2 risk factors</b></div>
<div><b>D. 68 y/o single white male with depression *5 risk factors (age, male, white, depression)</b></div>
<div><b>D. 68 y/o single white male with depression *5 risk factors (age, male, white, depression)</b></div>
<div></div>
<div>Count the risk factors</div>
When interview teenagers (16 y/o) that arrive with their parents what should you do?
interview them separately from parents. <br></br>-This helps Build therapeutic rapport with teens by telling them the info is confidential. Parents may be upset but remember you are advocating for the child.
Which Ethnic group has the highest rate of suicide?
Native Americans
Example A patient is being treated for schizophrenia with olanzapine. Which of the following is the most common side effect of olanzapine?<br></br>A. Increased waist circumference<br></br>B. EPS (not as common in atypical antipsychotics d/t 5HT2A)-receptor antagonism<br></br>C. Increased Lipids<br></br>D. Metabolic Syndrome
<div><b>D. Metabolic Syndrome</b> (UMBRELLA ANSWER)</div>
Which antipsychotics have the least weight gain?
<div><b>Latuda, Abilify, (also least sedating), Geodon-if patient has metabolic syndrome consider switching to one of the medications above. Or if the patient is overly sedated try switching to ABILIFY</b></div>
Which mood stabilizer have the least weight gain?
Lamictal <br></br>-But remember all mood stabilizers cause some weight gain
When presented with a question about typical vs atypical antipsychotic the answer is usually to start of a
atypical
<div><b>A client presents with complains of changes in appetite, feeling fatigued, problems with sleep-rest cycle, and changes in libido. What is the neuroanatomical area of the brain that is responsible for the normal regulation of these functions?</b></div>
<div><b>A. </b>Thalamus</div>
<div><b>B.</b> Hypothalamus</div>
<div><b>C. </b>Limbic System</div>
<div><b>D. </b>Hippocampus</div>
Hypothalamus<br></br>A, B, & D are all part of the limbic system so you can rule that out
When a patient is hesitant to participate in treatment you should encourage?
Bring a support person like a husband
Thyroid-Stimulating hormone normal level
0.5-5.0 Mu/L
When T4 and T3 are high and TSH is low what is the diagnosis
HYPERTHYROIDISM, TSH secretion decreases: TSH LOW à key symptoms HEAT INTOLERANCE
Key symptoms of Heat Intolerance
Hyperthyroidism
When T4 and T3 are Low and TSH is high what is the diagnosis
(HYPOTHYROIDISM) TSH secretion increased: TSH HIGH à COLD INTERANCE
Key symptoms of Cold Intolerance
Hypothyroidism
Hyperthyroid can mimic
Mania
Hypothyroid can mimic
Depression
A patient on depakote complains of RUQ pain and has reddish/brown urine
Hepatoxicity<br></br>-Check LFTs
Signs of Depakote toxicity
Disorientation, confusion, lethargy
You suspect depakote toxicity what do you do?
Check <br></br>-LFT<br></br>-Ammonia<br></br>-Depakote Level
What herbal supplement can cause hepatoxicity?
Kava Kava
When taking Kava Kava in combinations with other medications you should caution about
Risk of Hepatoxicity and Sedation
TCAs carry a risk of
Hepatotoxicity
Signs of Stevens-Johnson Syndrome
NAME?
two psychotropics known to cause steven johnson syndrome
lamictal and tegretol
What nationality is most suseptible of getting steven johnson?
Asians
When treating asians with tegretal screen for?
HLAB-1502 Allele
What two medications cause agranulocytosis?
Clozaril & Tegretal
Agranulocytosis when to discontinue medication
Less than 1000
When monitoring for agranulocytosis in patients look for s/s of what?
Infection<br></br>-Fever, sore throat, fatigue, chills
Before starting any mood stabilizer in a female of childbearing age be sure to check?
HCG
Which two medications may decrease the risk of suicide?
clozaril and lithium
Medications that increase lithium level
NSAID-ibuprofen, INDOCIN<br></br>THIAZIDES-hydrochlorithiazide ACE INHIBITORS-lisinopril
Ace inhibitors are treatment of choice for?
Heart Failure
Certain medications are known to increase lithium level, but HOW?
by reducing renal clearance
When educating a patient about lithium teach them about
Hyponatremia<br></br>Dehydration-hot days, exercise
Normal Lithium Level
0.6-1.2
Lithium Toxicity
1.5 or above<br></br>Discontinue and re-order lithium level
Lithium level of 1.4
Monitor for toxicity
Labs before starting lithium
<div><b>TSH, BUN, CREATININE, HCG, U/A to check for presence of protein in the urine (4+ protein is concerning for renal impairment)à4+ protein in urine=MONITOR FOR TOXICITY</b></div>
4+ protein in the urine of a patient on lithium
<div><b>4+ protein is concerning for renal impairment</b></div>
<div><b>4+ protein in urine=MONITOR FOR TOXICITY</b></div>
Lithium side effects
<div><b>hypothyroid, leukocytosis, maculopapular rash, t-wave inversion, Coarse Hand Tremor, GI upset (nausea, vomiting, anorexia) </b></div>
<div></div>
<div>-Some of these are also signs of toxicity</div>
Signs of lithium toxicity
confusion, ataxia, GI upset, palpitation, tremor
NMS
<div><b>muscle rigidity, mutism (because of muscle rigidity), increased CPK (caused by muscle contraction and muscle destruction), increase WBC, increased WBC, myoglobinuria (also from muscle destruction)</b></div>
Cherry colored urine in a patient that exercises a lot
test for myoglobinuria may be a sign of rhabdo
Serotonin Syndrome
With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures. <br></br>-Treatment: cyproheptadine (5-HT2 receptor antagonist).
Treatment for NMS
<div><b>Stop Offending Medication</b></div>
<div><b>-Dantrolene (muscle relaxer)</b></div>
<div><b>-Bromocriptine (Dopamine D2 agonist). </b></div>
<div><b>*In question focus on what they are asking for….dopamine agonist vs muscle relaxer</b></div>
Treatment for Serotonin Syndrome
<div><b>Stop Med (1 or more SSRI, SSNRI, TCA, MOAI)</b></div>
<div><b>-Cyproheptadine</b></div>
Triptans
<div><b>Used for MIGRAINES</b></div>
<div><span><b>-These meds increase serotonin</b></span><b> </b></div>
<div><b>example SUMATRIPTAN </b></div>
<div><b>patient taking Prozac and started on sumatriptan</b></div>
<div><b>-call PCP to ask them to switch the migraine med if patient already on SUMATRIPTAN do not start antidepressant without talking to PCP</b></div>
How long do you wait when switching between an SSRI to an MAOI?
2 weeks
How long do you wait when switching between Prozac and MAOI?
5-6 weeks wash out period
What is the first line treatment for depression and why?
<div><b>SSRI-First line treatment for depression due to less risk of injury from OVERDOSE</b></div>
If a cancer patient has depression what should you consider?
Treating with a medication with minimal drug/drug side effects like Lexapro
Patient with depression worries about sexual dysfunction what would be the medication of choice?
Wellbutrin
Primary symptoms of depression include fatigue and low energy what med would you chose?
Wellbutrin
Wellbutrin is contraindicated in patients with
Seizures and anorexia
Which medications are best for neuropathic pain?
SNRI<br></br>Gabapentin<br></br>TCA
Secondary to the black box warning providers caring for patients on antidepressants should assess for?
Suicidality, frequency, and severity at EVERY appointment
Which meds have the worse serotonin discontinuation syndrome
Those with short half lives<br></br>such as zoloft
Symptoms of serotonin withdrawal syndrome
<div><b>Fever, achiness, soreness, lethargy, fatigue, impaired memory, decreased concentration, GI UPSET</b></div>
<div></div>
<div><span>Shits and Shivers</span></div>
Ages of onset for schizophrenia in males vs females
<div><b>-MALES 18-25 years</b></div>
<div></div>
<div><b>-FEMALE 25-35 years</b></div>
Schizophrenia increases the risk for
<div>SUICIDE</div>
<div><span><b>*HIGH RISK OF SI in SCHIZOPHRENIA*</b></span><b> </b></div>
<div><b>Just having schizophrenia increases your risk of suicide. </b></div>
<div><b>MUST ASK ABOUT SI, EVERYTIME (frequency, severity of thoughts)</b></div>
What increases the causes or increases the risk or schizophrenia
<div><b>excessive pruning of synapses</b></div>
<div><b>-inadequate synapse formation, </b></div>
<div><b>-intrauterine insults such as maternal exposure to toxins, viral agents, maternal substance use, maternal illness, maternal malnutrition, fetal oxygen deprivation, </b></div>
<div><b>-first order relative (mom/dad)</b></div>
MRI or PET scan what is seen in schizophrenia
<div><b>EVERYTHING DECREASES EXCEPT </b><u><b>VENTRICLES</b></u></div>
<div></div>
<div><span><u><b>-You will see VENTRICULAR ENLARGEMENT</b></u></span></div>
Stimulants can potentiate the release of what neurotransmitter?
Dopamine which can worsen symptoms of schizophrenia
Assertive Community Treatment (ACT)
<div><b>a form of rehabilitation post hospitalization, in home treatment</b></div>
What level of prevention is ACT?
Tertiary
What adjunctive treatment is important in schizophrenia
NAME?
Exercise for mental health patients can promote
Cognition<br></br>Quality of Life<br></br>Long-term health
ACT is ideal for patients with a history of
Treatment non-compliance<br></br><br></br>-Think about making the treatment convenient for them–>bringing it to their home
What diagnosis has the highest risk of Homicidality
Antisocial
In the MMSE how do you test for abstraction?
<div><b>proverb interpretation (everyone that lives in glass houses shouldn’t throw stones) Are they able to think abstractly</b></div>
Thought Process-Tangential
<div><b>means that their response has nothing to do with the question</b></div>
Circumstantial
<div><b>means that their response goes in circles instead of getting to the point of the question</b></div>
Mental Status-Thought Content includes
<div><b>SI/HI/AH/VH</b></div>
Another name for MMSE
Folstein Scale
How to assess concentration on MMSE
Serial 7s or perform an activity backwards i.e list the days of the week backwards
Assess ability to learn new material
repeat 3 words after me
Assess ability to recall
repeat 3 words after 5 minutes
Assess fund of knowledge
Who is the president
What is a quick and easy way to assess for neurological issues
Clock drawing test
If patient is unable to draw a clock this indicates
Problem with the right hemisphere, cerebrum, or parietal lobe
mesolimbic pathway
<div><b>Hyperactivity of dopamine in the this pathway mediates positive psychotic symptoms</b></div>
<div></div>
<div><b>-Antagonism of D2 receptors in this pathway treats positive psychotic symptoms</b></div>
mesocortical pathway
<div><b>-Decreased dopamine in the this projection to the dorsolateral prefrontal cortex is postulated to be responsible for negative and depressive symptoms of schizophrenia</b></div>
Nigrostriatal Pathway
<div><b>-This pathway mediates motor movements</b></div>
<div><b>-Dopamine blockade in this pathway can lead to </b><u><b>increase acetylcholine levels</b></u></div>
<div></div>
<div><b>-Blockade of dopamine (D2) receptors in this pathway can lead to EPS, i.e dystonia, parkinsonian symptoms and akathisia</b></div>
<div></div>
Low Dopamine in the nigrostriatal pathway increases which neurotransmitter
<div><b>-Dopamine has a reciprocal relationship with acetylcholine (Ach) (LOW DOPAMINE INCREASE Ach)</b></div>
<div><b>Long-standing D2 blockade in the nigrostriatal pathway can lead to </b></div>
<div><b>tardrive dyskinesia</b></div>
Tuberoinfundibular pathway
<div><b>-Blockade of D2 receptors in this pathway can lead to increase prolactin levels leading to hyperprolactinemia which clinically manifests as amenorrhea, galactorrhea, and sexual dysfunction, gynecomastia</b></div>
<div></div>
<div><b>-DECREASE DOPAMINE INCREASED PROLACTIN</b></div>
<div><b>Long-term hyperprolactinemia can be associated with what condition</b></div>
<div><b>osteoporosis</b></div>
Normal Prolactin Level in Men
<div><b>level less than 20ng/ml</b></div>
Normal Prolactin Level in Women
<div><b>less than 25ng/ml</b></div>
Which medication is the highest offender for increasing prolactin
Risperdal
Acute Dystonia + Treatment
<div><b>neck stiffness, muscle spasm of upper body especially neck/face/tongue</b></div>
<div></div>
<div><b>-Treatment is IM COGENTIN + continue PO COGENTIN for several days</b></div>
Akathisia + Treatment
<div><b>may mimic anxiety, restlessness, can’t sit still, rocking, pacing</b></div>
<div></div>
<div><b>-</b><span><b>First line Treatment</b></span><b> is BETA-BLOCKERS like PROPANOLOL (Inderal)</b></div>
<div><b>-</b><span><b>Second line treatment</b></span><b> is COGENTIN</b></div>
<div><span><b>-Third line treatment</b></span><b> is benzos</b></div>
Beta-Blockers such as Inderal are contraindicated with what type of asthma medication
<div><b>-DO NOT GIVE WITH BROCHODIALATOR such as ALBUTERAL this combination can cause bronchospasm</b></div>
akinesia/bradykinesia + treatment
A. difficulty initiating movement; slowness of movement<br></br>-Treatment Cogentin
PSEUDOPARKINSON or PARKINSONIAN + Treatment
<div><b>caused by dopamine blockade, results in muscle rigidity, mask like facial expression, may look blunted, pill rolling tremors in fingers, shuffling gait, motor slowing</b></div>
<div><b>-Treatment COGENTIN</b></div>
tardive dyskinesia + Treatment
<div><b>abnormal facial movements, grinding teeth, lip smacking, protruding tongue</b></div>
<div></div>
<div><b>-Treatment DECREASE DOSE OF MED, DISCONTINUE MED, Switch to CLOZARIL, Switch to different med, VINPAT</b></div>
Does Cogentin Treat TD
<div><b>COGENTIN MAKES TD WORSE</b></div>
Typical onset of TD
<div><b>OCCURS 1-2 years TYPICALLY, but can be </b><u><b>ACUTE ONSET ALSO</b></u></div>
What non-psych med can cause TD?
<div><b>REGLAN (Metoclopramide) can CAUSE Tardive Dyskinesia must educate patient that this med or the combination of this PLUS antipsychotic can increase risk of TD*** encourage them to discontinue reglan if TD develops</b></div>
<div>In<u><b>D</b></u>ucers CYP450</div>
<div>DECREASE</div>
<div></div>
<div><b>C</b>arbamazepine</div>
<div><b>R</b>ifampin</div>
<div><b>A</b>lcoholics (chronic)</div>
<div><b>P</b>henytoin</div>
<div></div>
<div><b>G</b>risiofulvin</div>
<div><b>P</b>henobarb</div>
<div><b>S</b>ulphonylureas </div>
<div></div>
<div>Crap GPS Induces me to Madness! </div>
<div>Inh<u><b>I</b></u>bitors of CYP450 </div>
INCREASE<br></br><br></br>Ciprofloxacin<br></br>Ritonavir<br></br>Amiodarone<br></br>Cimetidine<br></br>Ketoconazole <br></br><br></br>Acute Etoh<br></br>Macrolides<br></br>INH<br></br>Grapefruit Juice<br></br>Omeprazole<br></br><br></br>Crack Amigos
Erythromycin and Clarithromycin can cause
Increased tegretol levels
<div><b>Patient started on Clozaril or Zyprexa and two months later starts smoking</b></div>
<div><b>as a provider you know that the smoking can decrease the medication effectiveness</b></div>
<div><b>-Increase medication dose</b></div>
Patient has been a chronic smoker and has been stable on Zyrexa but tells you that he recently quit smoking cold turkey
<div><b>as a provider you know that you must now decrease the dose of the antipyshcotic</b></div>
Medications that cause mania
<div><b>Steroids, Disulfiram (Antabuse), Isoniazid (INH), Antidepressants in persons with bipolar</b></div>
<div></div>
<div>-If a patient must take steroids, the provider should <u>increase</u> the mood stabilizer</div>
Medications that cause depression
<div><b>steroids, beta blockers, interferon, Accutane (isotrentinoin), some retroviral drugs, antineoplastic drugs, benzodiazepines, progesterone</b></div>
<div></div>
<div><b>-may need to increase antidepressant</b></div>
Accutane (isotretinoin)
Can cause depression and birth defects
Flonase
As a provider you know that flonase is a STEROID so it may exacerbate mood symptoms<br></br><br></br>Increase mood stabilizer to maintain stability, steroids can also trigger depression
Flonase can trigger mood instability but it can also cause an increase in
<div>Psychosis</div>
<div><b>patient is taking flonase while on antipsychotic but you find that the antipsychotic is ineffective it is likely because the flonase is exacerbating psychosis</b></div>
<div><b>-increase the dose of antipsychotic</b></div>
Neurotransmitters involved in Addiction
Dopamine and GABA
Symptoms of Stimulant Abuse
- agitation/aggression<br></br>2. impaired judgment<br></br>3. euphoria<br></br>4. elevated BP<br></br>5. tachycardia<br></br>6. dilated pupils<br></br>7. hallucinations<br></br>8. TREMORS<br></br>9. IMSOMNIA
If an anorexic patient complains of pain or bloating after eating this may indicate
delayed gastric emptying
Medications that delay gastric emptying
<div><b>Omeprazole, ranitidine, famotidine</b></div>
Proton Pump Inhibitors (omeprazole & Protonix)
Decrease absorption of antipsychotics & SSRI<br></br><br></br>-MUST WAIT TWO HOURS BEFORE TAKING ANTIPSYCHOTIC OR SSRI
When initiating an SSRI on an elderly patient you should advise about
increased anxiety
Paradoxical effect
when meds cause the opposite effect than expected
Apoptosis
programmed cell death/neuronal loss
<div><b>At age 45 and above the patient displays mania for first time what should be ruled out </b></div>
MEDICAL CONDITION
<div><b>Patient with bipolar disorder presents with depressed mood & emotional lability</b></div>
Give Depakote
Hallmark sx of Borderline Personality
Recurrent self harm
Treatment for Borderline Personality
DBT
Creator of DBT
Marsha Linehan
What activity is helpful in making a diagnosis of borderline personality
Journaling or diary keeping
Conversion Disorder
<div><b>STRESS leads to neurological symptoms such as seizures, paresthesia, blindness, mutism</b></div>
Adjustment Disorder
<div><b>adjusting to a situation resulting in depression or anxiety or both or mixed disturbance of emotions and conduct (this type is more common in children: insomnia, peer conflict, verbal altercations, truancy, crying)</b></div>
<div></div>
<div><span><b>-Symptoms occur within 3 months of the stressor</b></span></div>
<div><b>If question states recently moved, recent death….THINK ADJUSTMENT</b></div>
factitious disorder
<div><b>when patients introduce foreign substances into their body or contaminate their food</b></div>
<div><b>-Faking illness but NO MOTIVE BEHIND IT</b></div>
Malingering
<div><b>Faking illness for financial gain</b></div>
Reactive Attachment
<div><b>common in children in foster care, abuse from parents</b></div>
<div><b>-Withdrawn and shows no emotion towards caregiver</b></div>
ODD
<div><b>They deliberately annoy others, no aggression, defiance of authority</b></div>
<div>-Family Therapy is mainstay</div>
<div>-Child management /Parent management skills is the focus in therapy</div>
<div>-Positive reinforcement</div>
<div>-Boundary Setting</div>
Conduct Disorder
<div><b>violence, criminal, fire setting, killing animals, gang activity, +AGGRESSION, NO REMORSE</b></div>
<div><b>-May need meds and therapy</b></div>
<div><b>-Goal of therapy is to target MOOD & AGGRESSSION (mood stabilizers, antipsychotics, alpha agonists/alpha 2 adrenergic receptor blockers such as guanfacine and clonidine)</b></div>
<div><b>-Monitor BP with guanfacine and clonidine</b></div>
Acute Stress Disorder
<div><b>similar to PTSD but the timeline differs</b></div>
<div><b>-heightened arousal, nightmares, flashbacks</b></div>
<div><b>-LESS THAN ONE MONTH</b></div>
PTSD
<div><b>-OVER ONE MONTH</b></div>
<div><b>-3 HALLMARK SXS: intrusive re-experiencing of trauma, increased arousal, avoidance</b></div>
<div><b>-May also have NIGHTMARESà GIVE PRAZOSIN</b></div>
<div><b>-Non-pharm tx of PTSD- EMDR, CBT</b></div>
Panic attack vs Panic disorder (treatment)
Panic attack = BZ<br></br>Panic disorder = SSRI<br></br><br></br>Panic Attack is ACUTE<br></br>Panic Disorder is CHRONIC <br></br><br></br>Feels like impending doom
Tourette’s Syndrome
<div>Criteria for diagnosis</div>
<div>-TWO moto tics and ONE vocal tics</div>
<div>-LASTS more than ONE YEAR</div>
<div>-By age 18</div>
<div><b>**CHILDREN MAY NORMALLY HAVE TICS so if they have one tic only THIS IS NORMAL**</b></div>
Child presents with one tic and the parent is worried
<div><b>**CHILDREN MAY NORMALLY HAVE TICS so if they have one tic only THIS IS NORMAL**</b></div>
Neurotransmitters involved in Tourettes
DNS: Dopamine, Norepinephrine, Serotonin
Treatment for tourettes
<div><b>Treatment: Haldol, Pimozide, Abilify, Guanfacine, clonidine</b></div>
What type of medication can cause tics or exacerbate them
Stimulants
Neurotransmitters involved in mood disorders
DNS: Dopamine, Norepinephrine, Serotonin + GABA
Neurotransmitters involved in ADHD
DNS: Dopamine, Norepinephrine, Serotonin
part of brain implicated in ADHD
prefrontal cortex<br></br>basal ganglia <br></br>reticular activating system
ADHD inattentive type is caused in what part of the brain
Prefrontal Cortex which is known to regulate ATTENTION and EXECUTIVE FUNCTION
dorsolateral prefrontal cortex
Attention<br></br>Executive Function<br></br>Cognition<br></br>Processing<br></br>Working Memory<br></br>Problem Solving
Deficit in the _____ can lead to ADHD inattentive type
Prefrontal Cortex
<div><b>Teacher reports that the stimulant only works for first few hours of class</b></div>
<div><b>medication has worn off too fast. Order multiple dosing throughout the day</b></div>
When does the aftercare plan start
on admission
If parents become anxious while you are educating about a new diagnosis what should you do
<div>-Provide patient and parents information immediately don’t wait till discharge</div>
<div>-Parents may become anxious after a diagnosis of mental illness such as ADHD, <b>stop teaching</b> offer support because they will not absorb the education. <b>Provide supportive therapy</b></div>
Neurotransmitters involved in OCD
serotonin, dopamine, glutamate & GABA
A tic may also be a ___
Compulsion
Facts about OCD
<div>Obsession/Compulsion</div>
<div>-A tic may be a compulsion</div>
<div>-If first order relative has OCD the child’s risk of developing OCD is increased</div>
<div>-Streptococcal infections increase risk of OCD</div>
<div><b>-Treatment SSRI-prozac, Zoloft, if adult you may also use TCA such as clomipramine</b></div>
DMDD
<div><b>6-17 years ONLY</b></div>
<div><b>-Irritability for no reason, sad, depressed mood, tantrums, crying, moody, always mad</b></div>
If patient presents with irritability or labile mood and you need help further delineating symptoms
Administer MOOD QUESTIONAIRE<br></br>7/13 Bipolar Diagnosis Likely
Sleep Disorders are often _____ <br></br>So what should you assess if a parent reports that a child is having nightmares
<div>GENETIC </div>
<div><b>ask if someone in the family has a similar issue with sleep…look for family patterns of sleep problems</b></div>
GAD
<div><b>Worry, apprehension, fear must LAST ATLEAST 6 MONTHS</b></div>
Delirium
<div><b>-ACUTE (within hours to days) onset of disturbance of LOC, COGNITION, </b></div>
<div><b>inattention</b></div>
<div><b>-Urinary Tract Infections are common cause for DELIRIUM always check UA</b></div>
<div><b>-Treatment is antipsychotics like HALDOL</b></div>
Dementia
<div><b>-Chronic and slow onset (months to years to develop)</b></div>
<div><b>-Mental decline in cognition, irritability, personality changes</b></div>
<div>-<b>When asked questions they may try to answer or MAKE UP ANSWERS (confabulate)</b></div>
Low levels of what labs may mimic dementia
Vit B12 and Folic Acid
Cortical Dementia
Language and memory (aphasia and amnesia)
Subcortical Dementia
Motor abnormalities/Mood issues like apathy, depression, irritability<br></br><br></br>HIV Dementia is a type of subcortical dementia
Early signs of HIV dementia
<div>subcortical form of dementia</div>
<div><b>COGNITIVE, MOTOR, BEHEAVIOR for example a patient with lack of coordination, unsteady gait</b></div>
Treatment for HIV dementia
Antivirals
Pseudo Dementia
<div><b>Depression causes the memory issues, common in older adults</b></div>
<div></div>
<div><b>-Also assess onset of symptoms, pseudo dementia is more acute onset</b></div>
<div><b>-When asked questions they often say “I DON’T KNOW”</b></div>
<div></div>
Instruments to use to differentiate between dementia and pseudo dementia
<div><b>-Use instrument to further screen out cognitive issues such as SLUMS, MOCHA, MMSE</b></div>
hallmark of lewy body dementia
visual hallucinations
Frontotemporal lobe Dementia
<div>PICKs Disease </div>
<div><span><b>-Hallmark is personality changes, language difficulties, poor impulse control, and behavioral changes</b></span></div>
<div>-May see slurred speech or difficulty getting words out </div>
What lobe is associated with ability to understand what others are saying (comprehending speech)
Temporal Lobe
Neurotransmitters involved in Autism
GABA, Glutamate, Serotonin
Autism
<div>a disorder that appears in childhood and is marked by deficient communication, social interaction, Poor eye contact, May not respond when you call their name, Stereotypical movement</div>
<div><b>When play they often like to line up their toys, stack them in tidy rows</b></div>
Broken Mirror Theory of Autism
<div><b>Explains that the child’s presentation is caused by the mirror neuron i.e dysfunction in the mirror neuron</b></div>
Risk Factors for Autism
Male gender, genetic loading, intellectual disability, parents ages, preterm
Screening tools for Autism
ADOS-G (autism diagnostic observation schedule-genetic)<br></br>ASQ (ages and stages questionnaire) <br></br>M-CHAT (modified-checklist for autism-toddler)
Where is Norepinephrine produced?
locus coeruleus and medullary reticular formation
Where is serotonin produced?
raphe nuclei
Where is dopamine produced?
substantia nigra, ventral tegmental area, nucleaus accumbens
Where is acetylcholine synthesized?
Basal nucleus of Meynert
Hippocampus
a neural center located in the limbic system; helps process memory and manage stress
Limbic System
The limbic system is the part of the brain involved in our behavioral and emotional responses, especially when it comes to behaviors we need for survival: feeding, reproduction and caring for our young, and fight or flight responses.<br></br>-Hippocampus<br></br>-Amygdala <br></br>-Hypothalamus<br></br>-Thalamus
Amygdala function
Responsible for the response and memory of emotions, especially fear
Thalamus function
relay station for sensory impulses, pain
hypothalamus function
<div>homeostasis, temperature, thirst, appetite, sex drive, sleep cycle, emotions</div>
<div><b>* believed to serve a regulatory role in aggression</b></div>
anterior cingulate cortex
brain region that regulates cognitive function, decision making, empathy, impulse control, and emotions
Cerebellum
Balance and coordination
signs of lead toxicity
<div><b>developmental delay, learning diff., irritability, loss of appetite, weight loss, sluggishness, fatigue, abdominal pain, vomiting, constipation, hearing loss, seizures, eating non-food items PICA</b></div>
<div><b>Hint home built before 1970’s</b></div>
<div><b>TEST FOR LEAD</b></div>
When caring for an infant that is about to die?
<div><b>GIVE THE BABY TO THE PARENTS and allow them to grieve</b></div>
Risk factors for osteoporosis
Age<br></br>smoking <br></br>caffeine<br></br>lack of exercise<br></br>diet lacking calcium and vit D<br></br><br></br>Provide Education
<div><b>Assume you are doing group therapy and there is a patient that is not comfortable sharing but you are trying to promote interpersonal learning. What should you do? </b></div>
<div><b>Provide </b><u><b>adjunctive individual session </b></u><b>that will help facilitate group participation</b></div>
Cognitive Therapy
<div>-Aaron Beck</div>
<div><b>Replacing irrational or distortive thoughts with positive thoughts</b></div>
Behavioral Therapy
NAME?
Humanistic Therapy
NAME?
Existential Therapy
Victor Frankl -an insight therapy that focuses on the elemental problems of existence, such as death, meaning, choice, and responsibility, emphasized making courageous life choices. <br></br>-Emphasizes accepting freedom and making responsible choices<br></br>-Focus on the present<br></br><br></br>Why am I here, What is my purpose
Interpersonal Therapy
<div>Gerald Kierman & Myrna Weissman </div>
<div>-<b>-Used for people who have trouble interacting with others, relationship distress</b></div>
<div><b>-Marital conflict</b></div>
<div><b>-12-16 weeks (3-4 months)</b></div>
EMDR Phases
Desensitization Phase: visualize the trauma, verbalize negative thoughts but remain attentive to physical sensations <br></br><br></br>Installation Phase: Installs and increases strength of the positive thoughts that the patient has declared as a replacement<br></br><br></br>Body Scan: Visualize the trauma along with the positive thought and then scan ones body mentally to identify any tension within
Group therapy: Installation of hope
participants develop hope for creating a different life; they gain hope from others
Group therapy: Universality
people have similar problems, thoughts, and feelings and they are NOT ALONE
Group Therapy: Altruism
sharing of oneself with another and helping another
Group Therapy: Imitative Behavior
Patients can increase their skills by imitating the bx of others
Group Therapy: Interpersonal learning
interacting with others increases adaptive interpersonal relationships
Group Therapy: Group Cohesiveness
Patients develop an attraction to the group and other members as well as a sense of belonging
Group Therapy: Catharsis
Patients openly express their feelings which were previously suppressed
Group Therapy: Existential Factors
Groups enable participants to deal with the mean of their own existance
Group Therapy: Corrective Refocusing
Participants reexperience family conflicts in the group, which allows them to recognize and change behaviors that may be problematic
Group Phases
forming, storming, norming, performing, adjourning
Family Systems Therapy
<div>Murray Bowen</div>
<div>-a person's problematic bx may serve a function for the family or be a symptoms of dysfunctional patterns</div>
<div><span><b>KEY WORDS* </b></span></div>
<div><span><b>Self-Differentiation, Triangulation, </b></span></div>
<div><span><b>Triangles</b></span></div>
Structural Family Therapy
<div>Salvador Minuchin</div>
<div>-How, when, and who whom family members relate </div>
<div><span><b>KEY WORDS*</b></span></div>
<div><span><b>Mapping</b></span></div>
<div><span><b>Hierarchies</b></span></div>
<div><span><b>Boundaries</b></span> </div>
Strategic Therapy
<div>Jay Haley</div>
<div>-Symptoms are a way to communicate metaphorically in a family</div>
<div><b>-Symptom focused</b></div>
<div><span><b>KEY WORDS* </b></span></div>
<div><span><b>Straightforward directive</b></span></div>
<div><span><b>Paradoxical directive</b></span><span> (reverse psychology)</span></div>
<div><span><b>Reframing</b></span><span> (you are not jealous of your sister you just care for her so much)</span> </div>
Solution Focused Therapy
<div><span><b>-MIRACLE QUESTIONS</b></span></div>
<div><span><b>-EXCEPTION-BASED FINDING -SCALING QUESTIONS</b></span></div>
Meditation
<div><b>if teaching about meditation must tell them about MUSCLE RELAXATION</b></div>
PICOT
P: Population<br></br>I: Intervention<br></br>C: Comparison<br></br>O: Outcome<br></br>T: Time
If a patient has rheumatoid arthritis check
ESR
<div><b>Therapy session with husband and wife & only one shows up</b></div>
Reschedule
<div><b>A patient’s mother calls and tells you that her son has been sodomized by their 15 year old brother</b></div>
<div><b>tell mother DO NOT LEAVE THE CHILD ALONE WITH THE BROTHER</b></div>
<div><b>-Provider calls CPS</b></div>
<div><b>-Arrange crisis therapy for family</b></div>
<div><b>Patient is moving out of state</b></div>
<div><b>if there is no imminent danger then provide enough medication for them to establish a new provider</b></div>
Level 1 evidence
systematic reviews of random control trials (RCTs) or Meta-analysis or RCT-highest internal validity due to randomizations<br></br>At least (2)
Level 2 Evidence
systematic reviews of cohort studies <br></br>-little bias because the subjects are identified prior to outcome - randomization is lost
Shrill Cry
Intracranial pressure
Child between the ages of 3-6 masterbating
<div><b>Normal to play with genitals (PHALLIC STAGE) NORMAL do not assume they have been abused*</b></div>
Mom is concerned that her son age 10 has swelling in his chest and she is concerned he is developing breasts
<div><b>Young boys ages 9-16 years old often have NORMAL BREAST ENLARGEMENT which disappears within 6 months</b></div>
<div><b> *reassure them that this is normal</b></div>
Elderly female presents with decreased sex drive
<div>Check Testosterone level</div>
<div><b>Sex Hormone-Testosterone is involved in sex drive</b></div>
<div><b>-MUST KNOW THAT WOMAN have TESTOSTERONE TOO</b></div>
alcohol dehydrogenase
<div>an enzyme active in the stomach and the liver that metabolizes alcohol </div>
<div><b>-WOMAN HAVE LOWER ALCOHOL DEHYDROGENASE (metabolizes alcohol)</b></div>
<div><b>-This is why woman get drunk faster</b></div>
<div><b>-Lower levels of this enzyme may also cause a higher propensity to develop LIVER DISEASE</b></div>
<div></div>
<div><b>When OB wants to hire psych providers</b></div>
<div><b>they want to increase mental health access to those that need it the most</b></div>
<div></div>
<div><b>Normalizing grief and loss in children</b></div>
<div><b>Don’t tell them what to do because grief responses vary</b></div>
<div><b>-i.e Don’t tell them to stop working that is prescriptive advise</b></div>
<div><b>-With children the most important thing is to </b><span><u><b>reinforce FAMILY support an supportive therapy such as group therapy</b></u></span><b> so they can learn from other children who have experienced similar events</b></div>
palmar grasp reflex
normal up to 5-6 months<br></br>If older baby still has this reflex->refer to specialist
Moro (startle) reflex
Normal till 5-6 months<br></br>If present past normal range->refer to specialist<br></br>If not present within the normal age->Xray may be a sign of a broken bone, nerve injury, or spinal injury
Babinski reflex
Normal up to 2 years <br></br>If present past normal range->refer to specialist
PDE-5 inhibitors
<div>Sildenafil (Viagra)</div>
<div>Vardenafil (Levitra)</div>
<div>Tadalafil (Cialis)</div>
<div></div>
<div><b>RAPIDLY ABSORBED</b></div>
<div>Used for erectile disfunction </div>
Difference between BMI in anorexia vs Bulemia
Anorexia-Low BMI<br></br>Bulemia-Normal BMI
<div><b>Parent brings in 16-year-old with BMI 12, Pulse LOW, BP LOW and you determine the patient needs to be sent for medical evaluation but the parents refuse</b></div>
Contact CPS
<div></div>
<div><b>You read and article that says that most children with ADHD abuse substances…</b></div>
<div><b>-To translate this information into practice what should you do?</b></div>
<div><b>-Screen ALL children for ADHD for SUBSTANCE USE</b></div>
<div><b>-OR Screen ALL children with SUBSTANCE USE for ADHD</b></div>
accupuncture
used for pain and depression
<div><b>Habeas Corpus</b></div>
<div><b>legal concept that protects patients from unlawful hospitalization</b></div>
<div><b>-May be a reason to leave AMA</b></div>
<div><b>Disseminated Encephalomyelitis</b></div>
<div><b>inflammation of nervous system</b></div>
<div><b>-MUST DO NEURO EXAM</b></div>
<div><b>-EXAM: May present with ASSYMETRICAL BODY MOVEMENTS</b></div>
<div><b>Assume you are interviewing a patient and you want them to provide information in a specific timeline, but they are unable</b></div>
<div><b>TO help ask them specific questions which helps to ANCHOR their memory</b></div>
<div><b>Before you administer a medication, you must educate them about the medication but first you should assess</b></div>
<div><b>BUT FIRST ASSESS WHAT THEY KNOW ALREADY or WHAT THERE BELIEVES ARE ABOUT THE MEDICATION</b></div>
Patient presents with iatrogenic effect
<div><b>assess ALL the medications that the patient is taking</b></div>
<div><b>-Don’t assume that it is from the medication you prescribed</b></div>
When trying to pass a policy and your co-workers are against it what should you do
<div><b>educate them on how the policy will benefit patient care</b></div>
To promote a policy how do you get the word out there
Think most FEASIBLE option with WIDE net or audiance
<div><b>Working in outpatient setting and you want to ensure continuous improvement in quality of care.</b></div>
<div><b>-Create an instrument to monitor clinical outcomes (this helps to identify what you are doing right or wrong)</b></div>
Autoimmune disease can lead to increased
Cytokine level
If a child is urinating the bed
<div><b>-Teach parents to use alarm clock to wake up to urinate (NON PHARM FIRST)</b></div>
<div><b>-If that doesn’t work try </b><span><b>DESMOSPRESSIN</b></span><b> (decreased enuresis)</b></div>
Are you allowed to look up a patient on social media?
No it violates their trust
<div><b>Assume you started a patient on a medication and they go home and find out that there is a black box warning on the medication that you were unaware of. They call with concerns…</b></div>
<div><b>-First, go online and do your own research</b></div>
<div><b>-Research the RISK vs BENEFIT before you tell the patient to stop the medication</b></div>
Risk factors for sleep apnea
<div><b>excessive weight, obesity, diabetes, smoking</b></div>
Tolerance
<div><b>you need higher doses of the medication in order for the medication to be effective</b></div>
PHQ-9
> 5 mild depression<br></br>> 10 moderate<br></br>> 15 moderately severe<br></br>> 20 severe<br></br><br></br>Max score 27
HAM-D
> 10 Mild<br></br>>14 Moderate<br></br>>17 Severe
HAM-A
> 8 Mild<br></br>>15 Moderate<br></br>>24 Severe
Beck Depression Inventory (BDI)
0-13 Subclinical <br></br>>14 Mild <br></br>>20 Moderate <br></br>>29 Severe <br></br>>40 EXTREME<br></br><br></br>Max score 63
GAD-7 Scoring
0-4: Minimal Anxiety<br></br>>5 Mild Anxiety<br></br>>10 Moderate Anxiety<br></br>>15 Severe Anxiety<br></br><br></br>Max score 21
COWS
<div>Medicate with PRNS at score of <b>7</b> or above</div>
<div></div>
<div>Consider Subutex or Suboxone at <b>13</b> or above</div>
<div></div>
<div>Remember Methadone is the LEAST safe option due to cardiac issues </div>
<div></div>
<div></div>
CIWA
<div>Begin PRN medication at <b>8</b> or above </div>
<div></div>
<div>Scores of <b>15</b> or above consider scheduled medications</div>
Patient in alcohol withdrawal and you are choosing medication for CIWA, check what?
<div>LFT</div>
<div><b>if liver disease use ATIVAN because of short half life over VALIUM</b></div>
Idealization
Seeing someone else as perfect, ideal, or more worthy than everyone else<br></br><br></br>This is often seen in grieving before acceptance of the loss
Appreciative Inquiry
<div><b>is an approach to organizational change which focuses on strengths rather than on weakness</b></div>
<div><b>Example do not focus on what the employee does wrong focus on what they do well</b></div>
Reflective Practice
<div>Links theory to practice with a goal of correcting practices that are incorrect.<b> Example Debriefing after a restraint to find out what went wrong or what went right </b><span><b>DEBFRIEFING MAY BE A KEY WORD</b></span></div>
<div><b>-After an incident--> Debrief</b></div>
<div><b>Assume you started the patient on an antidepressant and now they complain of insomnia</b></div>
<div><b>1. Before changing medication, CHANGE THE TIME OF DAY THEY ARE TAKING THE MED</b></div>
<div><b>Conflict of interest between pharmaceutical companies and Nurse Practitioners i.e promises to sponsor NP loan forgiveness. You want to create a policy to address this. First you must examine...</b></div>
<div> <span><b>study the relationship between the industry provided samples and industry sponsored education</b></span></div>
If a patient is involuntarily admitted can they still refuse medications?
<div><b>they can still refuse medications, UNLESS it is an emergency or if the court determines they must take medications</b></div>
Scope of practice is determined by
State board of Nursing
Scope of practice defines
NP roles and actions <br></br>-Varies broadly state to state
If you would like to perform ECT as an NP what should you review
The state scope of practice standards to see if it is allowed and what certification is needed
Standard of practice is determined by
<div>ANA </div>
<div>-Provides a way to judge nature of the care provided </div>
<div><b>The PMHNP is required by law to carry out care in accordance with what other reasonably prudent nurses would do in the same or similar circumstances. Thus, provision of high-quality care consistent with established standards is critical</b></div>
Exceptions to Confidentiality
<div><span>-Answering court orders, subpoenas, or summonses *high yield (if you don’t release or lie about knowing this is PERJURY)</span></div>
<div>-Insurance companies</div>
<div>-Giving information to attorneys involved in litigation</div>
<div>-Intent to harm self or others</div>
<div>-Meeting state of federal requirements for reporting disease states</div>
<div>-When the need for information outweighs the principle of confidentiality i.e unconscious patient and their life is at stake</div>
Tarasoff principle
<div>1976 - duty to warn victims of potential harm from client</div>
<div><b>may vary by state so you must check with your state board of nursing first…it may not be your responsibility to notify</b></div>
<div><b>If you are taking care of a patient and during the process of interview she tells you that her husband just texted her that her husband is going to kill self</b></div>
<div><b>-Call the police, provide the address</b></div>
informed consent
<div>-Communication process between the provider and client that results in client’s acceptance or rejection of proposed treatment</div>
<div><span><b>-Ensure they understand the risks vs benefits</b></span></div>
<div></div>
<div><b>If patient is able to reiterate the risks vs benefits of procedure or treatment, they are able to give consent*</b></div>
<div><b>Example patient comes to the hospital, and they are unable to give consent i.e to sick to agree to treatment you must </b></div>
<div><b>assess need for involuntary treatment</b></div>
Justice
<div><b>doing what is fair, fairness in all aspects of care</b></div>
Nonmaleficence
do no harm
Beneficence
doing good/promoting well-being
Fidelity
being true and loyal
Veracity
telling the truth, patients have the right to know the truth about their treatment
Autonomy
doing for self (right to self-determination)
<div><b>New male patient has a 10 year history of substance abuse, depression, and anxiety. He is requesting Xanax. Which principle should the PMHNP employ moving forward?</b></div>
<div><b>A. Beneficence</b></div>
<div><b>B. Fidelity</b></div>
<div><b>C. Non-Maleficence</b></div>
<div><b>D. Veracity</b></div>
<div><b>C. Non-Maleficence</b></div>
<div></div>
<div>*Do no harm, giving Xanax would endanger him secondary to the high abuse potential and imminent danger if he were to overdose on Xanax*</div>
<div></div>
<div><i><b>If no history of substance use</b></i>, then beneficence would be appropriate because the Xanax would help the anxiety</div>
Acute agitation and anxiety vs acute agitation and psychosis <br></br><br></br>IM ordered
IM ativan for agit/anx<br></br><br></br>IM antipsychotic for agit/psychosis
Patients have the right to be treated in the Least
Restrictive Setting
The PMHNP is asked to consult with a local inpatient psychiatric facility to provide nursing staff development. After meeting with the administrator to identify the nature of the problem requiring the consultation, the PMHNP’s next step is to:<br></br>A. Create interdisciplinary teaching team<br></br>B. Develop Outcome measures<br></br>C. Market the educational plan<br></br>D. Utilize a survey to assess the educational needs of the staff
<div>D. Utilize a survey to assess the educational needs of the staff</div>
<div></div>
<div><b>*3 Interventions vs 1 Assessment* FIRST YOU NEED TO ASSESS FIRST</b></div>
What is the best way to reduce stigma
<div><b>THROUGH EDUCATION</b></div>
<div><b>*THINK WIDEST AUDIENCE</b></div>
<div></div>
Just Culture
<div><b>individuals are continually learning, designing safety systems, and managing behavioral choices</b></div>
The PMHNP is concerned about access-to-care issues in the local community and wants to help develop health care policy to help patients access care more effectively.<br></br>A. Asking the clinical manager to explore options for access<br></br>B. Organizing a political protest<br></br>C. Working with the local chapter of the nurses professional association<br></br>D. Writing letters to the editor of the local newspaper
<div>C. Working with the local chapter of the nurses professional association</div>
<div></div>
<div><b>*Remember strength in numbers but STAY INVOLVED i.e asking the manager just passes off*</b></div>
<div><b>If a patient from a specific culture is refusing to accept any diagnosis of mental health disorders because of shame what could be done to address this barrier?</b></div>
<div><b>A. Educate the family</b></div>
<div><b>B. Political advocacy</b></div>
<div><b>C. Public Health Concern</b></div>
<div><b>D. Community education programs</b></div>
<div><b>D. Community education programs</b></div>
<div></div>
<div><b>*Narrow down to education A/D…then think WIDE NET =Community EDUCATION</b></div>
A client with Biolar I disorder presents to your PMHNP office for a follow-up visit. During the visit the client informs you he no longer wants to be treated with medication. , and he does not have bipolar disorder, that was a misdiagnosis, He further informs you he stopped all his medications 2 months ago and is here to thank you for your care and tell you he no longer needs appointments. Understanding ethical conflict, you use which of the following ethical principles?<br></br>A. Autonomy<br></br>B. Nonmaleficence<br></br>C. Justice<br></br>D. Beneficence
<div><b>A. Autonomy</b></div>
<div></div>
<div><b>*Patient’s have the right to self-determination*</b></div>
<div><b>Recovery Model * RELAPSE IS A LEARNING OPPORTUNITY</b></div>
<div>-Treatment approach that does not focus on full symptom resolution but emphasizes on resilience and control over problems in life</div>
<div></div>
<div>-Self-Direction (do not tell them what to do)</div>
<div></div>
<div>-Individualized and Person-Centered</div>
<div></div>
<div><span><b>-Non-Linear, Recovery is not a step-by-step process, but one based on continual growth, occasional setbacks, and learning from experience</b></span></div>
In counseling a 23 y/o married Hispanic mother who brought her 4 year old son to the clinic for “mal de ojo” with symptoms of fitful sleep, diarrhea, vomiting, and fever the PMHNO;<br></br>A. Identifies what steps the mother has already tried in caring for the child<br></br>B. Explain that the symptoms are viral infection<br></br>C. Educates about importance of fluid electrolyte imbalance<br></br>D. Respects the mother’s understanding of the child’s illness
<div><b>A. Respects the mother’s understanding of the child’s illness</b></div>
<div></div>
<div><span><b>*In cultural questions remember RESPECT FIRST! Even before assessment</b></span></div>
<div><b>Quality Improvement</b></div>
<div><b>Projects designed to improve systems, decrease cost, and improve productivity</b></div>
What is an example of a quality improvement process?
Plan, Do, Study, Act
<div><b>The NP is responsible for initiating quality improvement at a community clinic. The effective strategy for evaluating the clients services is to</b></div>
<div><b>A. Chart review analysis</b></div>
<div><b>B. A root cause analysis</b></div>
<div><b>C. Plan DO Study Act</b></div>
<div><b>D. Failure effect mode analysis</b></div>
<div><b>C. Plan Do Study Act</b></div>
SBIRT
Screening, Brief Intervention, and Referral to Treatment<br></br>* Use to screen substance use disorders
Erikson’s stages of psychosocial development
- trust vs. mistrust<br></br>2. autonomy vs. shame and doubt<br></br>3. initiative vs. guilt<br></br>4. industry vs. inferiority<br></br>5. identity vs. role confusion<br></br>6. intimacy vs. isolation<br></br>7. generativity vs. stagnation<br></br>8. integrity vs. despair
Piaget’s stages of cognitive development
- sensorimotor<br></br>2. preoperational<br></br>3. concrete operational<br></br>4. formal operational
Preoperational Stage includes
<div><b>2-7 y.o- MAGICAL THINKING IS NORMAL, if they believe that monsters can fly this is NORMAL</b></div>
<div>Egocentric</div>
<div>Understand language </div>
formal operational stage
<div>12+ y/o during which people begin to think logically about abstract concepts</div>
<div><b>KEY WORD is </b><span><b>LOGIC</b></span><b> think like a scientist or do a science project you must be able to use logic </b><span><b>ABSTRACT THINKING</b></span><b> such as doing algebra</b></div>
sensorimotor stage
in Piaget’s theory, the stage (from birth to about 2 years of age) during which infants know the world mostly in terms of their sensory impressions and motor activities<br></br>Object permanance
concrete operational stage
in Piaget’s theory, the stage of cognitive development (from about 6 or 7 to 11 years of age) during which children gain the mental operations that enable them to think logically about concrete events<br></br>i.e finding similarities in objects, grouping things
Risk factors for suicide
Sex (Male), <br></br>Age (Teenager or Elderly), <br></br>Depression, <br></br>Previous Attempt, Ethanol or Drug Use, Loss of rational thinking, Sickness (medical illness), <br></br>3 or more prescription medications, <br></br>Organized plan, <br></br>No spouse (divorced, widowed, or single especially if childless). Social support lacking.<br></br>WHITE<br></br><br></br>Women try more often. Men succeed more often.
<div></div>
<div><b>A 72 year old female brought in by her husband with increasing forgetfulness, decreased activity, and decreased appetite for 2 months. She has a history of HTN and is being treated with Lisinopril. The exam is normal and the MMSE provides a score of 24 but she declines to answer some questions and needs to be urged to participate in the assessment. What is the likely diagnosis?</b></div>
<div><b>A. Alzheimer</b></div>
<div><b>B. Vascular Dementia</b></div>
<div><b>C. Depression</b></div>
<div><b>D. Medication Toxicity</b></div>
<div>C. Depression </div>
<div></div>
<div><b>*2 months=too soon for Alzheimer’s, 24 is mild MMSE, HTN is not enough info to diagnose vascular dementia HALLMARKS FOR VASCULAR DEMENTIA are carotid bruits fundoscopic abnormalities and enlarged cardiac chambers, remember PSEUDO dementia is DEPRESSION</b></div>
<div><b>HALLMARKS FOR VASCULAR DEMENTIA</b></div>
<div><b> carotid bruits fundoscopic abnormalities and enlarged cardiac chambers,</b></div>
<div><b>Patient comes to the office, and you score them on HAM-D a 23 and you start an antidepressant on dose Xmg, 2 weeks later they score a 16 on the HAM-D. What would you do?</b></div>
Leave the dose where it is
<div><b>Patient is taking Zoloft 200mg and on the GAD 7 they score a 2, what do you do</b></div>
Leave the dose where it is
Zung Depression Scale Scoring
> 50 Mild<br></br>>60 Moderate<br></br>>70 Severe <br></br><br></br>25-49 is NORMAL RANGE <br></br>100 is max score
MMSE scoring
<div>0-10 severe </div>
<div>>10 moderate</div>
<div>>20 mild</div>
<div>>25 Normal </div>
<div></div>
<div>Kids under 10 years old are severely challenging to teach</div>
<div></div>
<div><span><b>HIGHER THE BETTER! </b></span></div>
<div></div>
Teratogenic Effects <br></br>1. Lithium<br></br>2. Carbamazepine<br></br>3. Depakote<br></br>4. Benzo
- Epstein Anomaly <br></br>2. Neural Tube<br></br>3. Neural Tube (specifically spina bifida, atrial septal defect, cleft palate)<br></br>4. Floppy Baby
Primary prevention
Efforts to prevent an injury or illness from ever occurring.<br></br>-Education<br></br>-Safety Initiatives<br></br>-Modifying environment
Secondary Prevention
Efforts to limit the effects of an injury or illness that you cannot completely prevent.<br></br>-Early findings<br></br>-Screening<br></br>-Prompt and effective treatment<br></br>Example: Crisis hotline, disaster response
Tertiary Prevention
NAME?
Pharmacokinetics
what the body does to the drug
Pharmacodynamics
what the drug does to the body
messenger RNA codes for
amino acids
Poor relationships, lack of future hope, suspicious of others indicates developmental failure of what stage
infancy, trust vs mistrust
Poor self-esteem, low self control, self-doubt, lack of independence indicates failure of what stage
early childhood 1-3, autonomy vs shame and doubt
Lack of self-initiative, lack of goal orientation indicates failure of what stage
Late childhood 3-6 y/o initiative vs guilt
sense of inferiority, difficulty with working/learning indicates a failure of what stage
school age 6-12 y/o industry vs inferiority
identity confusion, poor self-identification in groups indicates failure of what stage
adolescence 12-20 y/o identity vs inferiority
emotional isolation, egocentrism indicates a failure of what stage
early adulthood 20-35 y/o intimacy vs isolation
self-absorption, inability to grow and change as a person, inability to care for others indicates a failure at what stage
middle adulthood 35-65 y/o generativity vs stagnation
bitterness, sense of dissatisfaction with life, despair over impending death indicates failure of what stage
> 65 y/o integrity vs despair
agonist effect
Drug binds to receptors and activates a biological response
Inverse agonist effect
Drug causes the opposite effect of agonist
partial agonist effect
Drug does not fully activate the receptors
Antagonist effect
Drug binds to the receptor but does not activate a biological response
Herbals that interact with warfarin
Vitamin E<br></br>Omega-3
Black Cohosh
herbal used for menopause
Bellandonna
herbal used for anxiety
chamomile
herbal used for sedation and anxiety
Ginko
Herbal used to treat memory, dementia, & sexual dysfunction from SSRIs
Ginseng
Herbal product used for stress reduction, fatigue, and depression
Valerian
herbal used for sedation
Hypertensive crisis can occur when MAOI are taken with
Meperidine<br></br>Decongestants<br></br>TCAs<br></br>Atypical Antipsychotics<br></br>St.Johns wart<br></br>L-Tryptophan<br></br>Stimulants<br></br>Asthma meds
Microcytic anemia
iron deficiency
macrocytic anemia
due to folate or vitamin B12 deficiency<br></br><br></br>Labs: Folic Acid, B12, ESR/CRP, HGB, MCV
14 y/o with no axillary hair and no period
Normal tanner stage, start by 16
Two classes of cardiac meds that should not be used together
ACES and ARBS (angiotensin receptor blocker) <br></br>Together can cause renal dysfunction
Abnormal Trendelenburg Test
Hip disease, refer child out, assessed during head to toe
too little acetylcholine<br></br>too much acetylcholine
Alzheimer’s<br></br>Parkinson’s and EPS
4 D’s Discover, Dream, Design, Destiny
Appreciative Inquiry
Cranial Nerve V
Trigeminal<br></br>Clenched Teeth
WBC 1500-2000
Biweekly labs<br></br>Less than 1000 Stop
How can you assess cranial nerve XII?
Ask patient to stick out their tongue
First sign of metabolic syndrome
large waist circumference
Grade 2/5 hoarse systolic heart murmur
aortic stenosis
Ibuprofen + lithium
increases the serum level of lithium up to double
Kleinfelter’s Syndrome
male with more than one X chromosome (XXY)<br></br>-Decreased sperm, fertility issues
Mental Health Parity Act
forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits
what does nuchal rigidity indicate?
meningitis
Patient is on interferon and lexapro, as a provider you understand that
interferon can increase depression therefore you may have to increase the lexapro
Patient complains of neuropathic pain and neurontin is not working
Try Lyrica (pregabalin) its absorbed quickly and the maximum rate of absorption is 3x of Neurontin
Patient is in hospital with no family and is failing cognitive test what should you do?
MRI<br></br>Tox Screen
Phases of policy making
formulation, implementation, evaluation
Rhett Syndrome
a rare disorder found virtually exclusively in girls, is a neurodevelopmental disorder in which the child usually develops normally until about 6 to 18 months of age at which characteristics of the syndrome emerge; characteristics include: hypotonia (loss of muscle tone), reduced eye contact, decelerated head growth, and disinterest in play activities
Signs of fetal alcohol syndrome
small head, smooth palpebral fissure, inner epicanthal folds, thin upper lip
Tegretol side effects
Aplastic anemia, agranulocytosis, steven johnsons, hyponatremia. Watch with cipro and erythro
Telemedicine legal question?
Licensing Jurisdiction for the NP must be considered
A person is seen wandering the streets for 2 days
Delirium
Medication used for serotonin syndrome
Cyproheptadine<br></br><br></br>Why? it is an H1 blocker but is also has serotonin receptor blocking activity. Specifically, it acts to block 5-HT1A and 5-HT2A receptors which are the ones responsible for serotonin syndrome
When to assess a patient in restraints?
initially within 1 hour; then 8 hours
Why would you be concerned with immature reticulocytes?
Reticulocytes are involved in conditions affecting RBCs such as anemia. <br></br>-Low reticulocytes may be seen is iron def. anemia, pernicious anemia, folic acid deficiency, and aplastic anemia
pharm treatment for agoraphobia
short term benzo, SSRI, SNRI, TCA, or beta-blocker off label
Anorexia admission Criteria for hospitalization includes:
weight loss over 30% over 6 months<br></br>severe hypothermia temp less than 96.8 <br></br>HR less than 40<br></br>BP less than 70<br></br>Hypokalemia less than 3mEq/L<br></br>BMI<16
ANOVA
ANalysis Of VAriance - btwn means of 3 or more groups<br></br>An inferential statistical test for comparing the means of three or more groups
precontemplation stage
stage of change in which people are unwilling to change their behavior
Contemplation stage
person is considering making a change, aware that there is a problem but is not quite committed to changing
Preparation Stage
Person has made the decision to change, is ready for action
Action Stage
Person is engaging in specific, overt actions to change
Maintanence stage
The person is engaging in behaviors to prevent relapse
These 3 meds cause BIG FREAKING PROBLEMS
Strong inhibitors of 2D6<br></br>Bupropion, Fluoxetine, Paxil
Boy tells you he wishes to be a girl and asks you not to tell the parents
Don’t tell
BRUISE on the padded part of his arms
Say I see you have bruises on your arm <br></br>may I Ask what happened
Can an advanced directive be revoked? How?
Yes<br></br>at any time
Can you take Buspar during pregnancy?
Category B - ok if really needed.
Carb and barb + Coumadin
Strong Inducers of 3A4 can decrease INR
Who is in charge of the DEA?
State and Federal
Common comorbidities of bipolar
anxiety, alcohol, substance use
Conjunctival injection, munchies, psychomotor slowness?
Marijuana intoxication
Diary Log
CBT
Depakote and Disulfiram
increases INR
What 3 atypicals can be used with teens?
Zyprexa, Abilify, Seroquel - low doses<br></br><br></br>* also Risperdal
Np wants to implement a certain policy in nursing.
start with nurse manager
Phenycyclidine (PCP) can cause?
Nystagmus
Hildegard Peplau
Theory of Interpersonal Relations<br></br>Nurse as therapeutic tool<br></br>-Care for the person as well as the illness<br></br>-Patients are PEOPLE not DIAGNOSES
Patient acting out due to missing session what do you do?
You relate to childhood abandonment and talk about it with the patient
Patient on antidepressants for 3 weeks and attempted Suicide
stop the medication immediately
Patient shows symptoms of dizziness, tremors, sweating, What Medical Diagnosis
hypoglycemia
Pearson’s r
a statistic that measures the direction and strength of the linear relation between two variables that have been measured on an interval or ratio scale
pincer grasp
9 months
Problems in the parietal lobe can lead
Sensory-perceptual disturbances and agnosia(inability to perceive objects)<br></br>R-L confusion <br></br>Difficulty writing (agraphia)<br></br>Aphasia(difficulty of language)
To promote resilience in a patient with schizophrenia that lives alone consider referral to
NAME?
Patient on Lithium and Depakote and has temp, right flank pain, brown urine. What do you do FIRST?
Check LFT<br></br>If fine then check creatinine
Pt states “god did this to me.”
Assess spiritual needs first
Patient taking breathing treatment Albuterol/Proventil
Do not take MAOI or TCA
p-value
The probability of results of the experiment being attributed to chance.
Reliability
consistency of measurement
Stereogenesis
identify an object without sight<br></br>i.e dice in hand
Tagamet (cimetidine)
H2 receptor antagonist (antacid) <br></br>Increases benzo<br></br>Increases coumadin
Trazadone concerns
EKG-QT prolongation<br></br>Priapism<br></br>Glaucoma
Turner Syndrome
A chromosomal disorder in females in which either an X chromosome is missing, making the person XO instead of XX, or part of one X chromosome is deleted.<br></br>-Delayed puberty<br></br>-Amenorrhea<br></br>-Web neck, osteoporosis, lymphedema<br></br>-poor social skills
To start your own firm as an NP and need to examine economic viability
Show Revenue and expenses
3 CK muscle enzyme tests?
CKMM, CKBB, CKMB (normal 0.3 mmcg/L)
What are the legal ramifications of treating someone without informed consent?
The same as they are with informed consent<br></br>-Respect<br></br>-Beneficence<br></br>-Justice
Two important things to measure when prescribing Zyprexa
Waist circumference <br></br>Lipids
What schedule of controlled substances are NPs allowed to prescribe?
II-V
What crania nerve is affected when you ask the patient to shrug their shoulders?
XI (11) Spinal Accessory
These medications are renally metabolized
Gabapentin<br></br>Campral <br></br>Lithium
grapefruit juice
inhibitor that can reduce the absorption of the drug by 47% therefore the drug blood levels will be increased<br></br>-Decrease dose of drug
How do Asians see HC providers?
As in a position of authority.<br></br>Expect to give instructions and help make decisions
How do you protect from the evil eye?
Red ribbon on an infant<br></br>Amulet for adults
T-test
assesses whether the means of two groups are statistically different from each other
Treatment for children with panic disorder
clonidine <br></br>guanfacine
What do BCP’s do to Lamictal?
Inducer - will lower dose of Lamictal
What does an increased retic count indicate
Bone marrow disorder or Vitamin Deficiency<br></br>Normal Range 0.5-1.5
What do you see in Labs with HIV dementia
CD4 <200<br></br>Viral Load is high<br></br><20% get it with antiretroviral treatment
What is occuring in the adolescent brain?
Dendritic pruning<br></br>Emotions are controlled by amygdala<br></br>Prefrontal Cortex is still not fully developed (may be why young boys are risk takers)
Indomethacin is a
NSAID- WATCH WITH LITHIUM
Tramadol
Highly serotonergic
Dissemination
the act of spreading widely<br></br>-publication-highest level<br></br>-Presenting at national conference <br></br>-Journal club
Sensitivity vs. Specificity
sensitivity - how well a test identifies truly ill people (True positive)<br></br>specificity - how well a test identifies truly well people (True negative)<br></br><br></br>*In medical diagnosis, testing sensitivity is the ability of a test to correctly identify those with the disease (true positive) whereas test specificity is the ability of the test to correctly identify those without the disease (true negative)
What is the purpose of HIPAA?
National standards for electronic HC transactions<br></br>-National ID for providers, health plans and employers.<br></br>-Not SIMPLY Confidentiality.
DETROL interactions
Topamax<br></br>KCL<br></br>Zonegran
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
OCD<br></br>0-7 subclinical <br></br>8-15 Mild <br></br>16-23 Moderate <br></br>24-31 Severe <br></br>32-40 Extreme
If you want to decrease the use of seclusion who would be considered the primary change agent
Unit staff
Rennie vs Klein
• right to refuse any treatment <br></br>Until court orders it <br></br>“due process”
Roger vs. Oken
<div>determined that patients have an absolute right to refuse treatment, but a guardian may authorize their treatment.</div>
<div><span><b>ROGERS GUARDIAN</b></span></div>
Donalson vs O’Connor
Confinement<br></br>-It is unconstitutional to commit a person involuntarily who is not imminently dangerous to self or others<br></br><br></br>Donalson was a patient hospitalized for 15 years
Dusty vs United States
incompetent to stand trial
Durham vs King
Insanity defense
Riese vs St. Mary’s Hospital
7/8 8B ruling says that there should be court determination of incompetence for involuntary committed mental persons to receive antipsychotic medications
Stark Law
Prohibits physicians or their family members who own health care facilities from referring patients to those entities if the federal government, under Medicare or Medicaid, will pay for treatment.
