Free Family Psychiatric & Mental Health Nurse Practitioner Test
1. The pathophysiology of major depressive disorder includes which of the following biochemical abnormalities?
a. Cortisol secretion following administration of 1 mg of dexamethasone will be suppressed after 12 hours in 75% of patients with clinical signs and symptoms sufficient to diagnose major depressive disorder.
b. Secretion of TSH following administration of TRH is suppressed in a significant proportion of patients with major depressive disorder relative to normal subjects.
c. CSF levels of 5HIAA are elevated in the majority of patients with major depressive disorder who commit suicide.
d. MHPG (3-methoxy-4-hydroxyphenylglycol), a metabolite of norepinephrine, is lower in the urine of patients with delusional depression than in patients with nondelusional depression.
2. A 25-year-old woman is brought by her family to the emergency room after complaining of having seizures again. She had been evaluated fairly recently for this same complaint, according to the family, but no medication was prescribed. The patient states that she doesn't like the neurologist and doesn't want him involved. You suspect that she is having pseudoseizures with a psychogenic etiology. What clinical observations or symptoms would help to confirm this possibility?
a. Her seizures involve bilateral tonic/clonic movements during which she remains conscious and verbal.
b. The patient holds her breath and becomes slightly cyanotic during an observed seizure in the ER.
c. She reports having the olfactory hallucination of burning rubber just before the seizures.
d. The patient and the family report that she is sometimes incontinent during the seizures.
3. You receive a notice from the pharmacy management service of your patient's insurance plan that he has been obtaining benzodiazepine medication from three other practitioners besides yourself, violating your agreement with him that you would prescribe these medications only if you were the sole provider. You decide that you will terminate treatment with this individual. You are concerned that he may become abusive, violent, or threatening if confronted with this directly. Your best course of action is which of the following?
a. Leave him a phone message telling him that you are canceling his next appointment, not refilling any more prescriptions for him, and terminating your services as his clinician.
b. At your next appointment, have a security guard or policeman present as you discuss the notice with him, give him a chance to respond to it, state that you believe that he is abusing these medications and may be dependent on them or addicted to them, suggest in-patient detoxification and substance abuse treatment, and inform him that you have decided that you can no longer treat him and will cease to be available as his clinician after 1 month, which will give him time to find another practitioner.
c. Send him a registered letter (return receipt requested), in which you inform him of your decision to terminate with him as his clinician, cancel his next appointment, and tell him that you will be available for emergencies only for the next month, during which time he can seek alternative sources of treatment.
d. Speak with him directly by phone to discuss the notice and its implications, give him a chance to respond to it, inform him of your decision to terminate with him as his clinician, suggest possibilities for in-patient detoxification and substance abuse treatment, and offer to be available by phone only for emergencies for 1 month while he seeks alternative treatment. Document the conversation fully in the medical record.
4. Your patient is a 70-year-old recently widowed woman who complains of initial insomnia as she works through her bereavement and requests something from you to help her with sleep. The best option of the following medications is:
5. You are meeting in your office with a 24-year-old man and his mother. His working diagnosis is schizophrenia, but he has become very depressed and is almost mute. His therapist and his mother agree that he should be hospitalized, but the mother would like him to be at the university hospital psychiatric unit, which will not have a bed available until the next day. The local community hospital psychiatric unit has a bed available immediately. Although he mumbles "no" to questions about suicidality, you feel that he should be hospitalized immediately because he is psychotic and unpredictable. Your supervisor is unavailable for consultation. What is the safest course of action?
a. Allow the mother to take him home until tomorrow because she has agreed to take responsibility for monitoring him.
b. Explain that you have no choice but to hospitalize him immediately, given your assessment, and instruct the mother to take him to the community hospital for admission.
c. Ask the patient and his mother to sit in the waiting area while you make arrangements and then call the police and the ambulance service, fill out an involuntary commitment form, and wait for the police to arrive.
d. Outline your recommendation that the patient be admitted immediately. State that you will arrange for him to be taken to the community hospital by ambulance and that you will assist with the transfer to the university hospital psychiatric unit the next day, if possible. Explain that you would prefer to avoid an involuntary commitment action but that you are willing to do so if the family does not agree to the plan.
Answers and Explanations
1. B: The response of TSH to TRH is blunted in a significant proportion of patients with major depressive disorder. The dexamethasone suppression test is positive (that is, cortisol is not suppressed) in only about 50% of patients with major depressive disorder. CSF levels of the serotonin metabolite 5HIAA are significantly reduced in patients who commit suicide. MHPG is elevated in the urine of patients with delusional depression compared with patients without delusional depression.
2. A: Patients may remain conscious during unilateral, partial motor seizures; however, the spread of the seizures to both cerebral hemispheres (indicated by bilateral tonic/clonic movements) is always associated with loss of consciousness. The other symptoms are frequently seen during seizure disorders.
3. D: You are not required to expose yourself to undue risk of injury or even abuse from a potentially violent patient. The compassionate and correct way to terminate your services is to speak with the patient directly, by telephone if an office visit will present too great a risk, and inform them of your decision and why you are making it, offering to help arrange additional treatment for substance abuse issues. Full documentation in the medical record and in a registered letter and the offer to be available on an emergency basis for 1 month will protect you against any accusation of abandonment. Offering to help arrange in-patient detoxification will protect you against any liability should the patient refuse and then have withdrawal complications.
4. C: Both flurazepam and diazepam have long elimination half-lives and are not recommended for use in patients over the age of 65 years. Eszopiclone is likely to be more expensive than the other agents listed, which are available in generic form. Temazepam has an intermediate half-life, is FDA-approved for insomnia, and is well-tolerated and inexpensive.
5. D: Although family members might be willing to "take responsibility," they are not trained mental health professionals and you will be liable for any adverse outcome resulting from delaying the admission overnight. Even expecting the mother to follow through on taking her son to the community hospital is risky, because she could decide to drive him home instead. An involuntary commitment without discussion with the family would be needlessly challenging to the therapeutic alliance, unless your assessment is that the patient would run away if he knew that he would be taken to the community hospital immediately, instead of waiting for a bed to become available at the university hospital. Sending the patient voluntarily by ambulance is the best route, if the family agrees, with involuntary commitment as the fall-back option.
Last Updated: 03/01/2017