Walden NURS6670 midterm exam

Question 1 Sally is a 54-year-old female who presents for care at the urging of her employer. She says that she doesn’t think she needs to be there, but the manager of her division at work strongly suggested that she make an appointment. She is the evening shift manager in the accounting department of a major online sales organization. Her role requires meticulous accountability of a complex system of production statistics, and she has done this exceedingly well for years. She has been a valued employee, and her work is above reproach. A few months ago, the company adopted a new software program that required a complete revamping of Sally’s department. She has not adapted well, and her resulting anxiety is almost prohibitive of functioning in her role. During her interview, Sally is very somber and serious, and is clearly having difficulty with this change. She is distraught over the potential of not being able to do her job well and meet her immediate supervisor’s expectations. Recognizing the likely diagnosis, the PMHNP knows that Sally is likely to respond best to:

Pharmacotherapy with

clonazepam

 Free-association, nondirective therapy

Interpersonal therapy Serotonergic agents

Question 2Becci is a 31-year-old female who presents to the PMHNP for evaluation after being referred by her friend who is a patient of the practice. She describes a relatively acute, recent onset of panic attacks. Becci says that “out of the blue” her heart starts to race, her mouth gets dry, she gets shaky, and feels like she cannot get her breath. She is afraid because her friend has panic disorder and Becci knows that before her friend got treatment, she basically would not leavethe house in case an attack happened. The PMHNP recognizes that the immediate priority in assessment for Becci is:

 A thorough physical examination

A family history of mental health disease

A urine drug screen

An assessment for phobic disorder

Question 3Mrs. Bowen is a 33-year-old female who presents as a new patient requesting medication for depression. She reports a long history of mood disorders on and off going back to adolescence. She is very articulate in describing her history and reports that neither sertraline nor fluoxetine “worked for her.” She was unable to remember the dose or how long she took the medication. With respect to considering Mrs. Bowen’s medication history, the PMHNP knows that:

An SNRI will likely be the most appropriate choice if pharmacotherapy is indicated for this episode

 This may be an inaccurate characterization, as depressed patients tend to overemphasize negatives

In some circumstances patients will purposefully mischaracterize the efficacy of medications they feel were ineffective

Some forms of recurrent depression are best managed with nonpharmacologic strategies

Question 4 Danielle is a 31-year-old female who is having a psychiatric evaluation at the insistence of her husband. They have been married for 4 years, and her husband has finally become so frustrated by her jealous behavior that he threatened to leave her if she didn’t “get help.” Her husband insists that he has never been unfaithful, but Danielle repeatedly accuses him of having an affair. If he is even a few minutes late getting home from work, she demands an explanation and then does not believe anything he says. She does not have any real friends—her sister is her closest social contact, but Danielle has been angry with her for several weeks and won’t answer phone calls. Reportedly she does this often, and according to her husband can “hold a grudge forever.” During the interview, Danielle is calm, responsive, but distant. She says she really doesn’t understand why she is there—there is not a problem. The PMHNP considers the most likely diagnosis and discusses with Danielle that the treatment of choice is:

Diazepam Pimozide

 Psychother apy

Group therapy

Question 5A 22-year-old male patient is started on sertraline 50 mg p.o. daily afterpresenting with a major depressive episode. After tolerating without difficulty for 2 weeks, his dose is increased to 100 mg p.o. daily. Approximately 4 weeks later he reports an unusual set of new symptoms for the last week and a half. He says he feels “amped up” and just very generally agitated and nervous. He was short- tempered at work and home and was snapping at people for no good reason. He also reports difficulty concentrating at work. Last week he expressed disproportionate anger at his work and his boss told him that he was bipolar and should be put on medication. The PMHNP discusses with the patient that:

When symptoms are preceded by antidepressant therapy, a

 diagnosis of bipolar does not apply

His symptoms may be consistent with bipolar disorder if they persist for at least 2 weeks

A formal assessment of the social and occupational implications of his symptoms should be performed

The symptoms are most likely a physiologic adaptation to the sertraline and most often normalize

Question 6Darius is a 26-year-old male who presents for care as part of couple therapy with his wife, who is being seen for dependency issues. Darius himself seems very anxious to “do the right thing” and appears to want to please the therapist. During the evaluation, Darius is impeccably dressed, very formal in his presentation and interaction, and is watchful of time because he has an appointment after the interview and states several times that he cannot be late. The PMHNP considers that Darius may have obsessive compulsive personality disorder (OCPD). In differentiating this from obsessive compulsive disorder (OCD), she explores his history further for:

A history of racing thoughts

Difficulty interacting with others

Extremely high expectations of self

 Significant impairment at work

Question 7 In documenting a mental status exam (MSE) for Janet, a 54-year-old female, the PMHNP notes that she is bradykinesic, has poverty of speech, is depressed, and appears flat. This includes all the following elements of physical examination except:

Appearanc e

Motor activity Mood Affect

Question 8 When performing a psychiatric assessment of an elderly patient with Alzheimer’s dementia, the PMHNP recognizes that:

An important part of the history will come from the caregiver

The patient must also be interviewed alone to preserve privacy of the relationship

A sexual history is not necessary in patients who are not sexually active

 All of the above.

Question 9When differentiating a major depressive episode from dysthymic disorder, the PMHNP considers that:

The cognitive theory of depression does not apply to dysthymia

Hospitalization is typically indicated early in the course of dysthymia

 Dysthymia is more subjective in its presentation than depression

Insight-oriented therapy is the most effective treatment for dysthymia

Question 10During the interview of Kevin, a 42-year-old male who presents for treatment because of marital problems, the PMHNP responds to his tears by gently moving a box of tissues toward him. This is a facilitating intervention of interview known as:

Reinforcement

Reassurance

Encouragemen t

 Acknowledgem ent

Question 11The psychological sciences have contributed theoretical foundations to the

etiology and management of anxiety disorders from both conceptual and practical perspectives. The concept that anxiety develops in persons who feel as though they are living in a world devoid of meaning is an example of which theoretical foundation?

Psychoanal ytic Behavioral

 Existential Cognitive

Response Feedback

Question 12 Which of the following is a true statement with respect to the treatment of narcissistic personality disorder?

Psychoanalytic psychotherapy has strong empiric support

 Both serotonergic drugs and lithium are useful Group therapy is rarely helpful

Immobilized patients (hospitalized or incarcerated) have the best outcomes

Question 13Fletcher is a 29-year-old male referred for court-ordered counseling. He has a long history of repeated offenses including DUI, domestic violence, battery, and other violent acts that fortunately have not yet caused any serious injury or death to the recipients. An interview with his wife reveals that he has lied about almost everything for the last few years; he is able to get hired for jobs because he is very engaging and likeable, and then invariably he gets fired because he misses work and doesn’t do his job properly when he is there. According to the wife, they have known each other since high school, where Fletcher was very happy and well-adjusted. He was on the soccer team, liked by teachers, and never demonstrated the tendencies he does now. Apparently in college he got involved with a fraternity that was notorious for alcohol and drug abuse, and he started drinking heavily; it was “all downhill from there.” The PMHNP considers that:

History and symptoms are most consistent with antisocial personality disorder

Fletcher needs a neurological workup to include an EEG and assessment for neurological soft signs

Consistent with his symptoms, Fletcher will likely respond well to a stress interview

 It is likely that substance abuse is the underlying cause of symptoms and should be explored further

Question 14Anne is a 32-year-old female who presented to care after a random drug screening at work was positive for cocaine. She was initially resistant to therapy, maintaining that her use is not a problem and she could stop at any time. Upon further discussion in session, it appears that she uses cocaine every day at work, sometimes 2–3 times, other days more. She also uses it occasionally at home and most weekends. During her third session, she admitted that it is a financial burden, and she basically cannot afford any other form of recreation. Sheunderstands that if she uses again she will lose her job, and she admits that she loves her job and that cocaine is not worth losing it. When counseling her about cessation strategies, the PMHNP advises all the following except:

The physiologic symptoms of withdrawal may require a short-term hospitalization

Unlike other substances of abuse, there are no medications to help reduce the intensity of withdrawal

She will need to be monitored for depression

Overcoming the intense craving for cocaine is the biggest issue

Question 15Which of the following personality disorders is associated with females with fragile X syndrome?

Borderlin e Narcissis tic

Depende nt

 Schizoty pal

Question 16Alexa is a 27-year-old female who has come to group therapy while she is in the city jail. She was arrested for vagrancy because she was sleeping in her car in aparking lot at a local shopping center. She could not post bail, so she is sentenced to 14 days in jail. During group, she contributes that none of this is her fault. Her mother is totally evil because she would not let Alexa stay in the family home. She has some other family. but they are all jerks because they won’t help her. Alexa’s friend Melanie is the absolute best person in the world, but she can’t help because her boss fired her for no reason. Alexa has a history of arrests for buying illegal drugs and prostitution. The last time she was in jail, her sentence was extended for 30 days because she got into a fight with another inmate and beat her up so badly she had to be admitted to the hospital for 6 days. The PMHNP considers which of the following personality disorders?

Histrioni c

Narcissis tic

 Borderlin e Schizoid

Question 17The professional relationship between therapist and patient with schizoid personality disorder is a challenge because these patients do not typically seek care independently. However, once a trusting relationship develops, this type of patient may:

Reveal a very strong desire for an intimate relationship

Become very engaged in group therapy

 Describe an active fantasy life with imaginary friends

Demonstrate psychotic or delusional features

Question 18The major defensive mechanisms employed by patients with histrionic personality disorder include:

Repression and dissociation

Projective identification

Fantasy and isolation

 Splitting

Question 19Jen is a 31-year-old female who presents for care complaining of depressed mood. During the interview, it becomes apparent that she has a long history of depressive symptoms, as well as a long history of being socially isolated and feeling generally inadequate. When considering a diagnosis of dysthymia, the PMHNP considers that the core concept of dysthymia refers to sub-affective or subclinical depressive disorder with all of the following except:

Low-grade chronicity for at least 2 years Insidious onset, usually in childhood or adolescence

Strong family history of depression and bipolar disorder

 Long asymptomatic periods between episodes

Question 20Cory is a 23-year-old male recently incarcerated in the county correction facility for a 9-month sentence following his third conviction for battery. As part of anearly release program, he is required to participate in the therapy program. During his initial interview, he is very pleasant and engaged, expressing no anxiety or distress with his current circumstances. His psychiatric history is significant for numerous adolescent episodes of running away, truancy, and substance abuse. As a young adult, he reportedly has not held a steady job but rather is constantly coming up with money-making schemes. According to family reports is a personality disorder are very likely to:

Have a family history of the same disorder

Respond well to dialectical behavioral therapy

Have impaired emotional defense mechanisms

Come from smaller nuclear families

Question 21Assessment of the manic state in a patient with bipolar disorder is likely to include all the following except:

Mood-congruent delusions of

grandeur

 Suicidal or homicidal ideation

 Impaired judgment with no insight

Unrestrained flow of ideas

Question 22From a biological perspective, all of the following neurotransmitters are implicit in the anxiety response except:

Gamma-aminobutyric

acid Norepinephrine Serotonin

 Dopamine

Question 23The International Study of Expert Judgment on Therapeutic Use of Benzodiazepines and Other Psychotherapeutic Medications was designed to gather systematic data on the opinions of leading clinicians concerning the benefits and risks of benzodiazepines and alternative anxiety treatments. Which of the following best characterizes the majority opinion of this group?

Patients who require long-term benzodiazepine management should be maintained on long-acting agents

 The use of benzodiazepines long term for anxiety does not pose a high risk of dependence and abuse

The panel supports increased federal and/or state restrictions on benzodiazepine prescribing

When detoxifying from therapeutic dosages, daily intake should be decreased by 10–25%

Question 24Which of the following is a true statement with regard to the etiology of substance abuse?

Neurotransmitters or receptors have been identified with most substances of abuse except for alcohol

Twin and sibling studies do not support a genetic component with respect to the etiology of substance abuse

Substances of abuse decrease activity in the amygdala and anterior cingulate

The WHO schematic of drug use and dependence identifies immediate antecedents as the central element of abuse

Question 25Marlene is a 35-year-old female who is in therapy primarily to develop coping mechanisms for living with her husband, who has narcissistic personality disorder. She is committed to the marriage and loves her husband, but finds his inflated sense of self-importance and complete lack of empathy to be especially difficult. She believes he has a good side, but most of her friends have only ever seen extreme arrogance, and she is embarrassed by that. While counseling Marlene, the PMHNP advises her that patients with narcissistic personality disorder have extremely fragile:

Sense of self- importance

Defense mechanisms

 Self-esteem Interpersonal relationships

Question 26Cory J. is a 23-year-old male being seen by the PMHNP today for an initial evaluation. He says that he does not think anything is wrong, but his family, including his mother, grandmother, and aunt, have all told him that he must be“mentally ill.” He has been unable to hold a job and has worked as a cook at more than five chain restaurants in the last 6 months. He has no real friends—he says his “friends” only call him when they need something but never help him. He is currently staying with his grandmother but reportedly will soon be homeless “unless things change.” While he is telling his story, the PMHNP appreciates that Cory repeatedly includes details that make it hard to understand his point. When asked why he thinks he will be homeless, he responds by talking about how many hours he has worked and how everything was going well but then his car broke down and he couldn’t afford to fix it because his tax return was held by the IRS. The PMHNP recognizes that this represents an abnormal:

Affect Cognition

 Thought process Abstract reasoning

Question 27A variety of pharmacologic agents have demonstrated effectiveness in the treatment of post-traumatic stress disorder. Which of the following does not have any evidenced-based support in the literature?

SSRIs TCAs

Antiadrener gics

Antipsychoti cs

Response Feedback

Question 28The PMHNP is on call at the local county correctional facility. He is asked toevaluate M.S., a 21-year-old male who was just arrested following an altercation at a local bar. M.S. has never been incarcerated before and apparently has no psychiatric or medical history available. His toxicology screen was negative for alcohol or any drugs of abuse. His mother says that he has in the past had some occasions when he got kind of agitated, but this is the first time it’s been a problem. Reportedly some people from his office were at the bar celebrating a birthday, and before anyone knew what happened an argument escalated into

M.S. getting very loud, yelling, and acting “crazy” before he punched a coworker and started breaking bottles. When considering a manic or hypomanic episode, the PMHNP expects that his speech would most likely be:

Stutter ed

Increas ed Childlik e Confus ed

Question 29The PMHNP is considering pharmacotherapeutic options for Ana, a 28-year-old female with generalized anxiety disorder. Ana is very concerned about becoming“addicted” to medication, but she is open to pharmacotherapy because there are a lot of things going on in her life and she worries all the time. Her husband is deployed overseas, she has just started a new job, and her only child has just started kindergarten. Ana denies any panic-type symptoms; her primary concern is that she is worried about everything and it is making it hard to sleep and concentrate on learning the skills for her new job. Ana may best benefit from:

Lorazepa m Venlafaxi ne Propranol ol

 Buspiron e

Question 30The PMHNP is evaluating Jared, a 47-year-old male who is brought to care by hiswife because “he’s not the man I married 20 years ago.” According to his wife, she and Jared have been married for 20 years, have two children, and have lived a “normal” life. Jared owns a local construction company and their marriage has been a solid one, characterized by the typical day-to-day issues that occur in most marriages, but otherwise happy. For the last 2–3 months, she says Jared has completely changed. He will get angry for no apparent reason and even broke a lamp once. He tells stupid and offensive jokes that no one else thinks are funny, and even had someone call the police when he continued to make inappropriate remarks to a woman in a restaurant. Jared seems unsure what to say, but his wife is adamant that this is a totally different man from the one she has known. The PMHNP knows that Jared should be evaluated for:

Borderline personality disorder

 Structural brain damage Substance abuse disorder Cognitive impairment

Question 31Tim is a 20-year-old male who has been referred for care by his college counselor. The counselor has noted that Tim engages in virtually no social activities in college, and for that matter avoids day-to-day activities that require social interaction. By his own admission, Tim never participates in class discussions, even in online discussion boards. Tim is so afraid of rejection that he confines himself to his room and his studies. When differentiating schizoid personality from avoidant personality, the PMHNP knows that a primary difference is that:

 

Avoidant personalities have a strong desire for personal relationships

Avoidant personalities may have an active fantasy life Schizoid personalities are perceived as distant and aloof Schizoid personalities may be very attached to animals

Question 32Clare’s history of personal relationships is characterized by complete intolerance of being alone. Whether it is an intimate-partner relationship or a close friend, Clare appears to always need someone in her life. She had a live-in boyfriend of 3 years, and while they were together, he took care of everything. The PMHNP expects all of the following to be additional features of Clare’s history except:

Has difficulty disagreeing with others

Needs reassurance to support even mundane decisions

Volunteers to do unpleasant tasks to obtain nurturance

 Has disproportionate anger toward an abusive spouse

Question 33The PMHNP is conducting an initial interview with a patient whose history isconsistent with avoidant personality disorder. The PMHNP understands that one of the most striking features of this interview is likely to be centered upon the patient’s:

Clothing Speech pattern Anger

 Anxiety

Question 34Patients on lithium carbonate for management of bipolar disorder should be subject to routine assessment of:

CBC and BMP

TSH and serum Na+

CMP and ECG LFTs and EEG

Question 35Mr. Henderson is a 69-year-old man who presents for evaluation and care for depression. His wife died 6 months ago following a difficult 2 years with breast cancer. His primary complaint is that he just does not look forward to anything anymore. He cannot get interested in his children and grandchildren, he no longer enjoys any of his hobbies because he and his wife used to do them together. He does not sleep well, and wakes up frequently during the night. He also admits to thinking more and more about dying himself, although he expressly denies suicidal ideation. His medical history is significant for coronary artery disease, osteoarthritis, hypothyroidism, hypertension, and dyslipidemia. He also has atrial fibrillation and is on warfarin for emboli prophylaxis, but he does not remember the names of all of his other medications. When considering pharmacotherapy for Mr. Henderson, the PMHNP considers that which of the following SSRIs is safest with respect for potential drug interactions?

Fluoxetine Paroxetine

 Escitalopr am Sertraline

Question 36The PMHNP is asked to evaluate the parent of one of her existing patients, a 49-year-old woman named Sheri. Sheri reports that her father, a 78-year-old man who lives alone, has always been in good health. However, when Sheri went to have breakfast with him this past Sunday, she found her father overtly confused and he did not even seem to recognize her at first. Sheri is concerned that he has Alzheimer’s disease, and she is amazed because two days prior he was “completely fine.” The PMHNP knows that the most likely cause of this presentation is:

 

Urinary tract infection Mild cognitive impairment Normal pressure hydrocephalus Depression

Question 37 Differentiating post-traumatic stress disorder (PTSD) from panic disorder and generalized anxiety disorder can be challenging. Which of the following provides the strongest support for PTSD vs the other two differential diagnoses?

The time course of

symptoms

Presence of physiologic arousal

 Reexperiencing the event Response to pharmacotherapy

Question 38The PMHNP is seeing a patient who has been referred by primary care. The patient was diagnosed with major depressive disorder and trialed on both an SSRI and SNRI by the primary care provider. The patient appears refractory to therapy and has not had any appreciable clinical response. A more detailed psychiatric history is significant for indicators of bipolar disease, as well as a family history of bipolar disease in both the patient’s father and paternal aunt. This patient will most likely benefit from:

Lithium Answers:            

Lamotrigin e

Valproic acid Lithium Amitriptyli ne

Question 39John is a 41-year-old male who presents for management of heroin addiction. He has a long history of opiate abuse spanning decades and has had several unsuccessful attempts at recovery. Because of his lifestyle, he has developed avariety of chronic health problems, including cardiomyopathy and stage 2 chronic kidney disease. He currently takes several psychiatric medications for mood disorder. When considering methadone maintenance as a mechanism of treating his opiate addiction, the PMHNP knows that if he requires more than 100 mg of methadone at the start of therapy he should have a baseline:

Urine drug screen Hepatic function test

Pulmonary function test

 12-lead ECG

Question 40Karen is a 19-year-old female who has been referred to care after being seen in the emergency department following a violent sexual assault. She was workinglate one evening at the shopping mall and walked alone to her car after dark. She was assaulted, beaten, and thankfully a passerby saw her lying in some bushes and called 911. Initially she was resistant to mental health care, but now, 2 months later, she feels as though she needs help because she is experiencing a collection of symptoms including flashbacks, dreams of the assault, palpitations, anxiety, and a sense that she is watching the assault happen to her This sense of watching the assault as if she was an observer is characteristic of which diagnostic domain of PTSD?

Intrusion symptoms

 Avoiding stimuli Autonomic arousal

Clinical significance

Question 41Validated and reliable instruments are an important part of assessment for both clinical practice and research in psychiatrics. Which of the following tools is currently considered the standard for assessing clinical outcomes in treatment studies of schizophrenia?

SCID

BPRS

PANS S HAM- D

Question 42 The PMHNP is working on a graduate program in which he is hoping to develop a new personality assessment tool. After an exhaustive review of the literature andmany months of work, he developed a tool to use in a research study and needs to establish its psychometric properties. He distributes the tool to four different professionals in the field and asks that they assess whether the questions appear to measure what they are purported to measure. This is an assessment of:

Internal consistency

reliability

Parallel form reliability Construct validity

 Face validity

Question 43The difference between a manic and hypomanic episode is best characterized by all the following except:

The duration of symptoms is shorter for hypomanic episodes

Hypomanic episodes do not cause marked impairment in function

There are no psychotic features with hypomanic episodes

Hypomanic episodes may occur as a response to antidepressants

Question 44Which among the following neurotransmitters is decreased in depression and increased in mania?

Dopamine Norepinephri ne

Serotonin Glutamate

Response Feedback

Question 45Dependence is a common feature of many psychiatric disorders. One of theprimary distinguishing features that differentiates dependent personality disorder from histrionic and borderline personalities is that:

The treatment of dependent personality is rarely successful Occupational dysfunction is rarely impaired

 Dependent personalities tend to have long-term relationships with one person

This disorder tends to be more common in men

Question 46Trudy L. is a 29-year-old female patient who initiated care because she feels like she has no energy. She just had her annual wellness exam and her primary care provider told her that she is in excellent health. Because she complained about this excessive fatigue, her PCP performed a CBC, CMP, UA and thyroid function tests and was told, along with her physical examination, that everything looks normal. Further discussion reveals that Trudy is having some relationship challenges with her boyfriend of 2 years and this seems to be “spilling over” at work, where she is having persistent conflict with her supervisor. Ultimately thePMHNP diagnoses Trudy with major depressive disorder, mild, single episode. The PMHNP and Trudy discuss treatment options, and Trudy would really like to try nonpharmacologic interventions. Which of the following represents the best approach for Trudy?

Family therapy Behavior therapy Psychoanalytic therapy

 Interpersonal therapy

Question 47The PMHNP is considering a diagnosis of paranoid personality disorder in a new patient. When reviewing the history and physical examination, which of the following findings would be most consistent with this diagnosis?

The presence of fixed delusional

thought

 Disdain for weak or sickly people A history of antisocial behavior Extreme “drama” in most personal relationships

Question 48The PMHNP is called to the acute care unit to evaluate a patient who is admitted after being brought in by his friends. They were at a party where there werenumerous drugs of abuse as well as alcohol. The patient cannot provide a history, and his friends are unclear as to which drugs he used. Physical examination reveals a patient who is diaphoretic, tremulous, has a pulse of 130 bpm, dilated pupils, and cannot perform fine motor tasks. These physical findings are most consistent with which type of intoxication?

Alcohol Cannabis Opiate

 Hallucinog en

Question 49Jeffrey T. is a 27-year-old man who has presented for care after being required to do so by the county court. He was involved in a car accident, and while he was not at fault for the accident, routine blood alcohol screening revealed that he was driving while intoxicated. He is a bit resentful at being required to attend therapy; he is very vocal that his driving was not impaired and that he is able to function normally even after drinking what others might consider excess amounts of alcohol. His wife confirms this; they both admit that what began as one or two beers after work a few years ago has evolved to where he now drinks at least a 12 pack of beer nightly. Regardless, they both confirm that he never “seems drunk,” and this does not interfere with his job or fulfilling his family functions. Jeffrey’s ability to function normally despite high blood alcohol is likely a result of:

Depende nce Abuse

Adaptatio n Addiction

Respons e Feedback

Question 50Sarah is a 23-year-old patient who presents for a follow-up of her major depressive episode. She was titrated up to maximal dose fluoxetine 6 weeks ago after demonstrating tolerance without side effects at lower doses. Today in follow-up, she rep

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