psych Flashcards
A 22-year-old male patient is brought to the primary care clinic by his brother. The patient has been experiencing auditory hallucinations and delusional beliefs for the past year. He often hears voices criticizing his actions. His brother reports that the patient has been reluctant to take medication for his symptoms due to a concern about side effects. Which of the following medications is most appropriate to initiate as a first-line treatment for this patient, especially considering his concern about side effects?
A.Clozapine (Clozaril)
B.Risperidone (Risperdal)
C.Haloperidol (Haldol)
D.Chlorpromazine (Thorazine)
Answer: B. Risperidone (Risperdal)
Risperidone (Risperdal) is an atypical antipsychotic that is often used as a first-line treatment for schizophrenia. It has a more favorable side effect profile than typical antipsychotics, especially in terms of extrapyramidal symptoms (like tremors or rigidity). Given the patient’s concern about side effects, starting with risperidone (Risperdal) would be a suitable first step.
The nurse practitioner (NP) is seeing a 15-year-old patient who has been showing declining school performance and social withdrawal. They appear anxious and have lost weight. The patient is vague about their symptoms, but the NP notes pronounced eye redness and behaviors that suggest intoxication. Based on these observations, what would be the most appropriate next step in assessing this patient’s condition?
A.Conduct a physical examination focusing on signs of substance use
B.Refer for psychiatric evaluation
C.Use a validated adolescent substance use screening tool, such as the CRAFFT
D.Obtain a detailed family history focusing on substance use
Answer: C. Use a validated adolescent substance use screening tool, such as the CRAFFT
The use of a validated adolescent substance use screening tool, such as the CRAFFT, is recommended for assessing possible substance use disorder in adolescent patients. It is a more respectful and less invasive first step than other measures, and it can help to open a dialogue about the topic. Conducting a physical examination focusing on signs of substance use could potentially provide additional clues to substance use but may not give a clear indication of a substance use disorder. Referral for psychiatric evaluation might be beneficial once a substance use disorder has been identified and if concurrent mental health issues are suspected. However, a substance use disorder should first be established. Obtaining a detailed family history focusing on substance use can provide additional context but may not be directly useful in assessing the patient’s immediate situation without other concurrent assessment strategies.
A male patient’s history indicates that they are prescribed phenelzine (Nardil) for depression and anxiety. What information revealed during the patient interview would be the most urgent for the nurse practitioner to address with the patient?
A.Drinks one to two beers each week
B.Smokes three to four cigarettes daily
C.Has occasional difficulty sleeping
D.Reports poor appetite recently
Answer: A. Drinks one to two beers each week
Patients who are prescribed a monoamine oxidase inhibitor (MAOI) such as phenelzine (Nardil) should be advised to avoid alcohol because it contains tyramine. The consumption of tyramine while taking an MAOI can result in severely elevated blood pressure and increased risk for stroke. While the nurse practitioner should discuss smoking cessation, this is less urgent than explaining the dangerous food–drug interaction. Insomnia and anorexia are common side effects of selective serotonin reuptake inhibitors, but reports of occasional difficulty sleeping and recent poor appetite do not suggest any imminent risk for this patient.
Which of the following is part of the female athlete triad?
A.Lanugo
B.Premature osteoporosis
C.Self-absorbed behavior
D.Insulin resistance
Answer: B. Premature osteoporosis
The female athlete triad consists of amenorrhea, premature osteopenia/osteoporosis, and disordered eating. Lanugo and self-absorbed behavior, like the female athlete triad, are often seen with anorexia nervosa, but they are not part of the triad. Insulin resistance is part of metabolic syndrome.
The nurse practitioner is seeing a 58-year-old patient in the clinic who presents with unexplained weight loss, restlessness, and rapid speech. The patient’s spouse, who accompanies them, shares concerns about the patient’s mood swings and frequent nosebleeds. The patient appears fidgety and mentions recent financial difficulties. Given these findings, which screening tool would be most appropriate to further evaluate this patient’s condition?
A.Geriatric Depression Scale (GDS)
B.Drug Abuse Screening Test (DAST)
C.Hamilton Anxiety Rating Scale (HAM-A)
D.Mini-Cog
Answer: B. Drug Abuse Screening Test (DAST)
The patient presents with signs that may be indicative of substance use, including unexplained weight loss, restlessness, mood swings, frequent nosebleeds, and financial difficulties. Therefore, the DAST, which is designed to identify possible substance use disorders, would be the most appropriate tool to further evaluate this patient’s condition. The GDS is primarily used to screen for depression in older adults. While mood swings can be a symptom of depression, the other symptoms presented by the patient are not typically associated with depression. The HAM-A is a tool used to screen for anxiety. However, while restlessness and rapid speech can be associated with anxiety, the complete symptom picture is more suggestive of potential substance use. The Mini-Cog is a quick tool used to screen for cognitive impairment. While restlessness and rapid speech can be seen in cognitive impairment, the patient’s other symptoms suggest a different condition.
Which statement about nicotine gum is true?
A.The patient chews each piece continuously until the nicotine is depleted.
B.The gum is most effective when used to supplement the nicotine patch.
C.Patients with depressive symptoms should avoid the product.
D.Users will likely require several pieces each day.
Answer: D. Users will likely require several pieces each day.
Nicotine gum aids in smoking cessation by providing an alternative source of nicotine. Each piece provides nicotine for approximately 30 minutes, and users will likely require several pieces each day early in their cessation effort. The patient chews each piece briefly to release the nicotine but then “parks” the gum next to the buccal mucosa until it is depleted. To avoid the risk of nicotine overdose, patients should be cautioned against combining nicotine gum with other sources of nicotine, such as the patch. Patients with depressive symptoms or recent suicidal thoughts should avoid some medications used in cessation—specifically buproprion and varenicline—but no such caution exists for nicotine gum.
A 32-year-old male patient presents with complaints of recurrent abdominal pain and diarrhea. He has been to several providers over the last year and has undergone numerous tests, all of which have come back normal. Despite receiving medical clearance multiple times, he insists that his symptoms are real and severe. He has an extensive medical history with frequent hospitalizations, but no clear diagnosis has been established. The assessment finding that would most strongly support the nurse practitioner’s suspicion of factitious disorder imposed on self (Munchausen syndrome) is that the patient:
A.Has a consistent history of symptom presentation across multiple healthcare providers
B.Has symptoms that improve under consistent surveillance
C.Expresses a desire to undergo surgery to address his abdominal pain
D.Becomes defensive and demands more tests when asked about inconsistencies in his history
Answer: D. Becomes defensive and demands more tests when asked about inconsistencies in his history
Patients with factitious disorder imposed on self (Munchausen syndrome) often become defensive or evasive when confronted with inconsistencies or when their narrative is questioned. They are driven by a need to assume the sick role and might go to great lengths to maintain the facade, including demanding more tests or procedures. Assessing factitious disorder requires careful clinical judgment, as there are many potential mimics, and it is crucial not to mislabel genuinely ill patients. A consistent history of symptom presentation across multiple healthcare providers suggests that the patient has genuine symptoms. While symptom improvement under observation can suggest factitious disorder imposed on self, it is more commonly associated with malingering or with factitious disorder imposed on another (Munchausen syndrome by proxy). In factitious disorder imposed on self, individuals might continue to feign symptoms even under surveillance. Although the patient expressing a desire to undergo surgery to address his abdominal pain may raise suspicion, especially if there is no clear indication for surgery, a patient’s willingness to undergo surgery can be present in various conditions, not only in factitious disorder imposed on self.
A 26-year-old patient in the second trimester of pregnancy presents with complaints of feeling “down” for the past month. The patient states that they have difficulty sleeping and sometimes wake up in the middle of the night with anxious thoughts. They feel constantly fatigued, have diminished appetite, and express guilt over not feeling as connected to their unborn fetus as they believe they should be. The patient denies any thoughts of self-harm or harm to the fetus. They have no history of depression, and their pregnancy has been uneventful so far. What is the most appropriate initial step in the management of this patient?
A.Reassure the patient that it is common to feel emotional during pregnancy and that they will likely feel better after delivery
B.Conduct a thorough review of the patient’s medical history and any current medications to rule out organic causes of their symptoms
C.Refer the patient to a counselor for weekly cognitive behavioral therapy (CBT) sessions
D.Administer the Edinburgh Postnatal Depression Scale (EPDS) to better assess the severity of the patient’s symptoms
Answer: D. Administer the Edinburgh Postnatal Depression Scale (EPDS) to better assess the severity of the patient’s symptoms
The symptoms described by the patient—feelings of guilt, disturbed sleep, fatigue, and decreased appetite—can be suggestive of depression in pregnancy. Proper assessment is essential in determining the severity and the appropriate intervention. In spite of its name, the EPDS is a validated tool to screen for depression during pregnancy, not just postnatally, making it the most appropriate initial assessment step. Emotional changes commonly occur during pregnancy, but it is vital not to dismiss symptoms suggestive of depression. Proper assessment and prompt intervention can lead to improved outcomes for both the patient and the fetus. Assessing medical history and medications can help rule out other potential causes for the symptoms, but given the patient’s expressed feelings, a focused assessment on possible depression is a priority. While counseling and CBT can be beneficial for individuals with depression, it is crucial to first assess the severity of the depression to determine subsequent treatment decisions.
A 45-year-old patient visits the clinic and shares concerns about their smoking habit. They have been smoking a pack of cigarettes a day for the past 20 years. The patient states, “I never mean to smoke a whole pack, but sometimes I lose track.” The patient expresses a strong desire to reduce their smoking and indicates that they have failed in three previous attempts to quit. How many diagnostic criteria does this patient meet for a diagnosis of tobacco use disorder?
A.1
B.2
C.3
D 4
Answer: C. 3
Tobacco use disorder is diagnosed based on 11 criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. These criteria are (1) taking the substance in larger amounts or for longer than intended; (2) persistent desire or unsuccessful efforts to cut down or control use; (3) spending a great deal of time obtaining or using the substance; (4) craving or strong desire or urge to use tobacco; (5) recurrent tobacco use resulting in failure to fulfill major role obligations; (6) continued use despite social or interpersonal problems caused by or exacerbated by the effects of tobacco; (7) giving up or reducing important social, occupational, or recreational activities because of tobacco; (8) recurrent tobacco use in situations where it is physically hazardous; (9) continued use of tobacco despite knowing it is causing or worsening a physical or psychological problem; (10) tolerance, as defined by a need for markedly increased amounts of tobacco to achieve the desired effect or a markedly diminished effect with continued use of the same amount of tobacco; and (11) withdrawal, as manifested by either the characteristic withdrawal syndrome for tobacco or tobacco being taken to relieve or avoid withdrawal symptoms. This patient’s symptoms align with three of these criteria: smoking more than intended, several failed attempts to quit, and a persistent desire to reduce smoking.
A patient who has been dealing with chronic pain for several years due to a back injury presents in the clinic. The patient was initially prescribed opioids, and over time, they’ve reported needing to take more to manage their pain. Additionally, they’re experiencing restlessness, mood swings, and discomfort when they try to reduce their opioid use. The patient acknowledges their concern about their increasing reliance on the medication. In discussing a treatment plan for this patient, which of the following options would be the most appropriate first step?
A.Begin a tapering regimen of the patient’s current opioid medication
B.Initiate medication-assisted treatment (MAT) with buprenorphine
C.Introduce non-drug pain management strategies like cognitive behavioral therapy (CBT)
D.Prescribe an over-the-counter (OTC) pain reliever to manage the patient’s pain symptoms
Answer: B. Initiate medication-assisted treatment (MAT) with buprenorphine
Given the patient’s increasing reliance on opioids and the presence of withdrawal symptoms, the patient is most likely experiencing opioid use disorder. The initiation of MAT with buprenorphine is typically the first-line treatment. Buprenorphine is a partial opioid agonist that can help reduce cravings and withdrawal symptoms, allowing for more effective engagement in treatment. Beginning a tapering regimen of the patient’s current opioid medication is not likely to be as effective as initiating MAT, given the severity of the patient’s symptoms. Introducing non-drug pain management strategies, such as CBT, can be a component of the overall treatment plan for opioid use disorder, but it is usually not sufficient as a first-line treatment given the physical dependence and withdrawal symptoms that the patient is experiencing. An OTC pain reliever to manage the patient’s pain symptoms may be part of a multimodal pain management plan but would not address the patient’s opioid tolerance and withdrawal symptoms. It is crucial to treat the opioid use disorder, given its significant potential for morbidity and mortality.
An older adult male with alcohol use disorder is scheduled for a physical exam and laboratory testing. The patient’s laboratory blood test results may show:
A.Increased serum creatinine levels and estimated glomerular filtration rate (eGFR)
B.Decreased number of platelets and increased mean corpuscular volume (MCV)
C.Increased serum potassium and increased triglycerides
D.Decreased aspartate transaminase (AST) and alanine transaminase (ALT) levels
Answer: B. Decreased number of platelets and increased mean corpuscular volume (MCV)
Chronic alcohol use affects the MCV because of reduction of folate levels from dietary deficiency and/or impaired absorption due to excessive use of alcohol. Alcohol also interferes with the production and function of white blood cells. Alcohol interferes with platelet production, with diminished fibrinolysis resulting in thrombocytopenia. Patients with alcoholism are at higher risk for bleeding. Alcoholism can increase AST and ALT because of liver inflammation. Alcohol affects lipid metabolism in the liver, resulting in hypertriglyceridemia.
Aripiprazole
is a second-generation antipsychotic medication that has a lower risk of causing weight gain and metabolic side effects compared with other atypical antipsychotics.
A 24-year-old patient presents with a 2-day history of high fever, muscle stiffness, and confusion. They were recently diagnosed with schizophrenia and started taking oral haloperidol 1 week ago. Laboratory tests show an increased creatine kinase level. What is the nurse practitioner’s primary diagnosis?
A.Serotonin syndrome
B.Malignant neuroleptic syndrome
C.Extrapyramidal side effects
D.Tardive dyskinesia
Answer: B. Malignant neuroleptic syndrome
Malignant neuroleptic syndrome is a rare but life-threatening reaction to antipsychotic drugs. It may occur when a patient is newly exposed to a drug or has recently had a dose increase. Malignant neuroleptic syndrome is characterized by hyperthermia (high fever), muscle rigidity (“lead pipe” rigidity is common), altered mental status (like confusion), and autonomic dysregulation. Increased creatine kinase level is also a common finding due to rhabdomyolysis from sustained muscle rigidity. Serotonin syndrome is generally associated with the use of serotonergic medications. Although it can present with some similar symptoms such as altered mental status and autonomic dysregulation, it typically includes symptoms of restlessness, myoclonus (jerky movements), and diarrhea. Extrapyramidal side effects can occur with antipsychotic use, but they generally manifest as acute dystonic reactions, akathisia (restlessness), parkinsonism, and tardive dyskinesia. Tardive dyskinesia is a side effect of long-term antipsychotic use and typically presents as involuntary, repetitive body movements, such as grimacing, sticking out the tongue, or smacking the lips.
