A 78-year-old man presents for a follow-up visit. Two months ago he was started on sertraline for major depressive disorder and has been titrated up to 100 mg daily. Today his daughter reports that she cannot really evaluate if his mood has improved because he seems to have become confused. The patient’s daughter reports a distinct new onset confusion and forgetfulness.

The PMHNP considers the most likely cause of his confusion to be:

A. Urinary tract infection.

B. Hyponatremia

C. Alzheimer’s disease

D. Depression

Cognitive assessment in children characterizes stages of development consistent with Piaget’s developmental theory. One of the cognitive principles typically developed during the sensorimotor stage is:

A. Object permanence

B. Animalistic thinking

C. Phenomenalistic causality

D. Learning without reasoning.

A 12-year-old patient is being seen today in follow-up after being started on fluoxetine 1 month ago for a diagnosis of generalized anxiety disorder. The patient and her father both report that while there does appear to be a mild improvement in anxiety, some adverse effects have developed about which they are concerned.

Which of the following is not an expected adverse effect and is a cause for concern?

A. Vivid nightmares

B. Diaphoresis

C. Restless legs

D. Impulsivity

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YouTube: https://www.youtube.com/watch?v=6onROBl73UE&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=93

The PMHNP is evaluating a patient who presents complaining of panic attacks that occur for no identifiable reason. The patients has been treated for these previously with a variety of pharmacotherapies that did not provide any meaningful improvement. Upon further conversation, the NP learns that the patient experienced a near-fatal bicycle accident 4 years ago after being hit by a car.

When considering a diagnosis of PTSD, the NP explores his history for all of the following diagnostic criteria except:

A. Intrusion symptoms.

B. Angry outbursts.

C. Negative cognition

D. Avoidance symptoms.

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YouTube: https://www.youtube.com/watch?v=QQ-KgQYOuSg&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=92

J.B. is a 41-year-old female patient who is being managed for obsessive compulsive disorder. She has been in exposure response therapy (ERT) for several months with marginal improvement, but she has never approached true remission. At one time she was on fluvoxamine with notable improvement, but after a few months it ceased to produce any notable impact and after conferring with her therapist she was converted to fluoxetine 20 mg qd. After two months she was still struggling with symptoms, so two months ago her dose was increased to 40 mg qd. Today she presents for follow-up, reporting no notable improvement with pharmacotherapy. She continues to engage in psychotherapy but at this point is becoming very frustrated.

The appropriate approach at this point would be to:

A. Continue fluoxetine 40 mg daily for one more month and reassess

B. Convert the patient to therapy with a tricyclic antidepressant

C. Continue fluoxetine at 40 mg daily and consider a change in therapy.

D. Increase the fluoxetine to 60 mg daily and reassess in four to eight weeks

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YouTube: https://www.youtube.com/watch?v=GHa21K_Zprc&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=91

The PMHNP is evaluating a patient with significant anxiety and depressive symptoms. In the course of the evaluation the NP further appreciates that the patient is having hypnopompic hallucinations, and that the patient is very concerned about this because his uncle has schizophrenia.

The PMHNP advises the patient that:

A. There are a variety of pharmacologic options that can be helpful.

B. The hallucinations are benign and not a cause for concern.

C. There is no need for intervention unless they are accompanied by sleep paralysis.

D. The sensory systems involved will dictate the need for further evaluation and treatment.

A.J. is an 8-year-old male who is under the care of the PMHNP for ADHD. His symptoms are profound, and the recommendation is to begin psychostimulant therapy along with behavioral therapy. The parents are concerned because they have read that psychostimulant therapy can impact growth and final adult height if the child starts taking it before the growth spurt of adolescence.

The most appropriate response to the parents is to say that:

A. The impact on growth can be minimized by taking breaks from the medication on weekends and over the summer

B. This concern is not supported by the evidence and that there is no impact on growth when appropriately prescribed

C. The impact on growth can be significant and the best management for this patient is likely a non-stimulant option

D. The cardiovascular consequences are actually the bigger concern.

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YouTube:

A 14-year-old patient has been managed for the last year with fluoxetine 40 mg daily for a diagnosis of generalized anxiety disorder. She had been doing well, but today her mother reports that ever since returning to school after the summer break she has been distant, sullen, argumentative and defiant. She has been spending time with new friends from school and is always out somewhere with them.

The PMHNP recognizes that today’s appointment should include use of which of the following objective tools?

A. The AIMS tool

B. The BPRS

C. The MDQ

D. The CRAFFT tool

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YouTube: https://www.youtube.com/watch?v=jQmzYmvXL-o&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=88