PMHNP Certification Q & A – Details, episodes & analysis

A 32-year-old female patient with diagnoses of bipolar I disorder and borderline personality disorder was recently transferred to your care. She was managed on desvenlafaxine ER 150 mg daily and olanzapine 10 mg daily but experiencing increasingly elevated mood. In an attempt to wean off desvenlafaxine you reduce her from 150 mg to 100 mg daily. She experiences profound discontinuation syndrome symptoms. What is the most appropriate approach?

A. Resume desvenlafaxine ER 150 mg daily

B. Add valproic acid 750 mg daily

C. Increase olanzapine to 15 mg daily

D. Begin fluoxetine 20 mg daily
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YouTube: https://www.youtube.com/watch?v=6Z6t5IAVPpc&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=32

You are evaluating a 71-year-old female patient and have made a diagnosis of major depressive episode, moderate. The patient is agreeable to pharmacotherapy. When considering pharmacologic treatment options, you review her existing medication list for potential interactions and contraindications. Which of the following classes of medication might increase the patient’s risk of cognitive impairment with the addition of an SSRI?

A. A calcium channel blocker

B. An antiepileptic

C. A diuretic

D. A proton pump inhibitor
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YouTube: https://www.youtube.com/watch?v=HkgHo5uf0D8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=31

Anthony is a 41-year-old male patient who presents for evaluation. His wife made the appointment because she is worried about him, and she says he would never seek care on his own. Reportedly, Anthony has become progressively withdrawn over the last few months, and actually is in danger of losing his job because he misses so many days. He has been evaluated by his primary care provider and has no apparent medical conditions. His wife reports that he has been diagnosed with depression in the past and has even taken medication that seemed to help. This time he just refused to pursue care. After a comprehensive assessment the PMHNP diagnoses the patient with major depressive episode with psychotic features. Which of the following options would be the best choice of initial medication therapy for Anthony?

A. Venlafaxine and clozapine

B. Fluoxetine and olanzapine

C. Amitriptyline and haloperidol

D. Paroxetine and buspirone
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YouTube: https://www.youtube.com/watch?v=-5Hkph0iX4s&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=22

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

A. CBC and BMP 

B. TSH and serum Na+ 

C. CMP and ECG 

D.  LFTs and EEG 
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YouTube: https://www.youtube.com/watch?v=nZY82DoTVCw&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=21

A 22-year-old male patient is started on sertraline 50 mg p.o. daily after presenting with a major depressive episode. After tolerating it without difficulty for two weeks his dose was increased to 100 mg p.o. daily. Approximately 4 weeks later he reported 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:

A. When symptoms are preceded by antidepressant therapy a diagnosis of bipolar does not apply 

B. His symptoms may be consistent with bipolar disorder if they persist for at least two weeks 

C. A formal assessment of the social and occupational implications of his symptom should be performed 

D. The symptoms are most likely a physiologic adaptation to the sertraline and most often normalize 
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YouTube: https://www.youtube.com/watch?v=AGbD2hqR3K8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=20

Jeffrey 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 vocal that his driving was not impaired and that he can function normally even after drinking what others might consider excess amounts of alcohol. His wife confirms this; they both admit 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: 

A. Dependence

B. Abuse

C. Adaptation

D. Addiction
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YouTube: https://www.youtube.com/watch?v=stFQXo4XV6Y&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=19

Fletcher 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 victims. An interview with his wife reveals that for the last few years he has lied about almost everything; 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: 

A. History and symptoms are most consistent with antisocial personality disorder

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

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

D. It is likely that substance abuse is the underlying cause of symptoms and should be explored further
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YouTube: https://www.youtube.com/watch?v=GINQB976rx4&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=18

Mrs. 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.” With respect to considering Mrs. Bowen’s medication history, the PMHNP knows that: 

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

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

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

D. Some forms of recurrent depression are best managed with nonpharmacologic strategies
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YouTube: https://www.youtube.com/watch?v=tkuR-oLi0S8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=17

Chantel is a 19-year-old female who presents for care because she thinks she is bipolar. During her initial interview, she admits that she has a long history of feeling like she was the person in the family of whom there were always high expectations, and she was never able to express her feelings of inadequacy. When asked why she thinks she is bipolar, she says she gets very moody. She was at the grocery store last week and slipped and fell; while waiting for help she could not control her anger and reached up to swipe all the food off of the shelves. She has been fired from jobs because of her uncontrollable temper; she sometimes “just can’t be around certain people.” Chantel also reports that at times she will go two full days and nights without sleep, and that her mind keeps racing and she can’t “shut it down.” When this happens she gets up and does things around the house. Finally, Chantel reports that she cannot hold onto money at all. Whenever she gets a paycheck she immediately spends it on things that she acknowledges she doesn’t even need. When considering a diagnosis of bipolar disorder the PMHNP specifically assesses for: 

A. Any history of suicidal attempts of suicidal ideation 
B. History and current patterns of substance abuse 
C. Concomitant psychotic features such as hallucination or delusion 
D. Manic symptoms are sustained most of the day for at least two weeks 
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YouTube: https://www.youtube.com/watch?v=X-x8g9wflPg&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=16

Renee is a 27-year-old female who has come to group therapy while incarcerated in the city jail. She was arrested for vagrancy because she was sleeping in her car. She could not post bail and was 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 for 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? 

A. Histrionic
B. Narcissistic
C. Borderline
D. Schizoid
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YouTube: https://www.youtube.com/watch?v=qDhZKym5gn8&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=15