pharmacology Final Exam with Answers ACED

  Question 1 1 out of 1 points The PMHNP is formulating a diagnosis for Peter, a 24-year-old man who was admitted for management of acute psychoses. He believed that he was the Holy Ghost of the Christian Trinity ...

  Question 1 1 out of 1 points The PMHNP is formulating a diagnosis for Peter, a 24-year-old man who was admitted for management of acute psychoses. He believed that he was the Holy Ghost of the Christian Trinity. According to his mother and father, he did not have any psychiatric symptoms or history throughout childhood and adolescence, but after college, he began to develop “issues” characterized by extremes of mood in which he would be too depressed to attend classes for weeks at a time followed by a rebound in which he would go partying, stay awake for days at a time, and go on ridiculous shopping sprees. When considering a diagnosis of schizoaffective disorder, the PMHNP attempts to establish that: Selected Answer: The delusions at some point have occurred for 2 weeks absent a major mood episode Answers: His religious delusions are of at least 4 weeks’ duration and have produced social or occupational impairment The delusions at some point have occurred for 2 weeks absent a major mood episode Symptoms respond favorably to a combination of antipsychotic medications and mood stabilizers There is evidence of premorbid or prodromal symptoms prior to the psychotic episode Response Feedback : (b) is the correct answer. The history supports bipolar disorder, which is now characterized by delusions; if the delusions occur for at least a 2-week period absent a mood episode, this supports a schizoaffective diagnosis. Symptoms of 4-week’s duration and coincident occupational or social impairment may be due to a manic episode and do not necessarily constitute the schizophrenic component. While schizoaffective disorder does respond best to combination therapies, this is not a criterion for diagnosis. Premorbid or prodromal symptoms support schizophrenia but are not necessarily evident in schizoaffective disorder.  Question 2 1 out of 1 points Mr. Vasquez is a 76-year-old man who is presented to care by his daughter for management of his Parkinson’s dementia. He was initially diagnosed with Parkinson’s disease 5 years ago and has been managed with good results on carbidopa-levodopa (Sinemet). Approximately 18 months ago he began to develop symptoms of dementia that led to a diagnosis Parkinson’s dementia. Today the daughter reports that he has been acting “different” for over a week. He suddenly seems to be hallucinating and trouble sleeping, and has overall been acting acutely confused. There have been a few spells where he was hard to rouse. She took him to the primary care provider, but they could not identify any acute cause of hissymptoms; they even lowered his Parkinson’s medication, but it didn’t help. After ensuring that the appropriate metabolic causes of delirium have been rule out, the PMHNP considers: Selected Answer: Clozapin e Answers: Ziprasido ne Clozapin e Lorazepa m ECT Response Feedback : (b) is the correct answer. Antiparkinson agents are frequently implicated in dementia, and patients with preexisting dementia are twice as likely to develop delirium. Once treatable causes of delirium have been ruled out, the appropriate modality is to consider reducing the antiparkinson’s drugs. If this is not possible, or doesn’t help, clozapine is recommended, assuming the patient can tolerate it and present for appropriate monitoring. Ziprasidone may be activating and is not recommended for delirium. Benzodiazepines may be appropriate for the insomnia of delirium but not the acute confusional state. ECT is not routinely advised.  Question 3 1 out of 1 points Mr. and Mrs. Comstock are both patients of your practice; Mr. Comstock is treated for depression, which is largely secondary to his wife’s progressive dementia. He is trying to take care of her but fnds it very emotionally difcult. Previously very active, they have become socially isolated as their friends are not comfortable around Mrs. Comstock’s progressively obvious dementia symptoms. Mr. Comstock’s brother and his wife were visiting yesterday, and it became very uncomfortable. Mr. Comstock said they were having a conversation about a recent election and his wife suddenly became extremely agitated and started acting out inappropriately; she was yelling and broke a fgurine from the table; she fnally left the room. He said this has not happened before—that usually she participates in conversations, even if sometimes she jokes too much or changes the subject. The PMHNP discusses with Mr. Comstock that it sounds as though his wife: Selected Answer: Had a catastrophic reaction Answers: Is depressed Is demonstrating deteriorationHad a catastrophic reaction Has an infection Response Feedback : (c) is the correct answer. This history and event is most consistent with a catastrophic reaction, described by Goldstein as marked agitation secondary to intellectual defcits under stressful circumstances. Patients with dementia will typically compensate by joking or diverting the subject, but under stress may have a meltdown. While mood disorders can cause agitation in demented patients, there is no discussion of other depressive symptoms here. Deteriorating dementia is not typically so marked in its progress. While infection may produce delirium in an older patient, there are no other indices of delirium in this scenario.  Question 4 1 out of 1 points Which of the following is a true statement with respect to obsessive-compulsive disorder? Selected Answer: Most clinical drug trials support the hypothesis that dysregulation of the serotonergic system is involved in symptom formation Answers: Most clinical drug trials support the hypothesis that dysregulation of the serotonergic system is involved in symptom formation Between 50 and 75% of patients with obsessive-compulsive disorder (OCD) had premorbid obsessive-compulsive personality disorder (OCPD) Behavioral theory suggests that development of obsessive thoughts and compulsive behaviors are a result of respondent conditioning Most affected individuals are diagnosed between the ages of 25 and 40 Response Feedback : (a) is the correct answer. Drug trials provide appreciably more support for serotonergic etiology as compared to the noradrenergic system, which is implicit in other mental health disorders. Most people with OCD do not have premorbid OCPD, with estimates at 15–35%. Behavioral theory attributes respondent conditioning as the cause of obsessive symptoms, but compulsions are established differently based on avoidance strategies. Finally, 2/3 of patients with OCD are diagnosed before age 25.  Question 5 0 out of 1 points Maryanne is a 26-year-old female who is in therapy for obsessive compulsive disorder. She was trialed on SSRI therapy without remission and was changed to clomipramine, 25 mg q.h.s. titrated up to 100 mg q.h.s. 2 weeks ago. She presents today for follow up. The PMHNP assesses for which of the following adverse effects?Selected Answer: Diarrhea Answers: Diarrhea Bradycardia Sedation Urinary incontinence Response Feedback: (c) is the correct answer. As a tricyclic antidepressant, clomipramine should be assessed for anticholinergic adverse effects such as sedation, constipation, urine retention, and tachycardia.  Question 6 0 out of 1 points Gerry is a 24-year-old male who is being evaluated for obsessive-compulsive disorder (OCD). He has a long history of both obsessive thoughts and compulsive behaviors going back into mid-adolescence. When evaluating his history, the PMHNP knows that all of the following are more common in patients with OCD except: Selected Answer: [None Given] Answers: Celibacy Tourette’s disorder Marital discord Obsessive-compulsive personality disorder Response Feedback : (d) is the correct answer. There is not a correlation between OCPD and OCD. However, celibacy occurs in a higher than average incidence, especially in men. Marital discord occurs in a higher frequency than the general population. About 2/3 of people with Tourette’s disorder meet diagnostic criteria for OCD, and 90% of people with Tourette’s have compulsive symptoms.  Question 7 0 out of 1 points Steve is a 31-year-old male who presents for care on his own initiative. He has a new girlfriend for whom he really cares, but he is concerned that his lack of sex drive may be a problem as the relationship progresses. He says he just is not interested in sex. He doesn’t think about it, and while he really enjoys the company of this lady and doing things with her, he is not interested in sexual relations. When considering a diagnosis of male hypoactive sexual desire disorder, the PMHNP must consider all of the following except: Selected Answer: [None Given] Answers: The absent or defcient desire within the patient’ssociocultural context Whether or not the symptom is a source of distress to the patient The patient’s age and gender represent the population most affected The symptoms have been present for at least 6 months Response Feedback : (c) is the correct answer. While this disorder is only diagnosable in males, only 2% of men between age 16 and 44 are affected; the highest percentage is among men > 66 years old. The absent or defcient desire must be assessed in the context of the patient’s general and sociocultural context, symptoms must be present for at least 6 months, and they must be a source of distress to the patient.  Question 8 0 out of 1 points Johanne is a 22-year-old female who is being treated for narcolepsy. She is attempting to implement a regimen of forced daytime naps in an effort to manage her condition without pharmacotherapy as she is generally averse to taking medications. While following Johanne, the PMHNP should be alert to signs and symptoms of: Selected Answer: [None Given] Answers: Suicidality Depression Hyperphagia Disinhibition Response Feedback : (b) is the correct answer. Patients with narcolepsy are at increased risk of depression, especially if therapy is not producing optimal results. The social isolation resulting from difculty with academics or employment, as well as fear of driving, conspire to segregate the patient and contribute to depressed mood. Suicidality is not a common consequence of narcolepsy (although one should always be alert to it in depressed patients). Hyperphagia and disinhibition are characteristic of the Kleine-Levin syndrome of hypersomnia, but not narcolepsy.  Question 9 0 out of 1 points Joyce is a 30-year-old female patient who was recently diagnosed with schizophrenia after being referred for mental health eval uation by the police. She demonstrated paranoid delusions that ultimately led to such disruptive behavior at her place of work that the police were called. Her husband was able to provide a history consistent with prodromal symptoms, and in retrospect her disorganized thought and poor insight were evident over the last few months. She was initially stabilized on IM Zyprexa (olanzapine) and has been maintained on oral Zyprexa for the last 2 weeks, and has been on 10 mg daily for 1 week. Today at follow-up she demonstrates mild improvement. Her hygiene andappearance are much improved. She is still hearing voices and has delusions that communists are trying to infltrate the company for which she works. She is open to the idea that these are delusions but still seems hesitant to accept that premise. At this point her medication management should include: Selected Answer: [None Given] Answers: Obtaining an olanzapine level Increasing the dose of Zyprexa Cross titrate another antipsychotic Add a mood stabilizer Response Feedback : (b) is the correct answer. She has only been on this dose for one week; typically, best control is 10–15 mg daily, not to exceed 20. It is reasonable to either continue 10 mg for a few more weeks since she is evidencing improvement or increase the dose within the standard titration schedule; in either event, an appropriate dose should be trialed for 4–6 weeks before making the judgment that the patient is not optimally responding. Olanzapine levels are not monitored, although the patient will require metabolic monitoring. For reasons already stated, it is inappropriate to change to another drug as she has not been adequately trialed on this one. A mood stabilizer is not indicated unless there is a concomitant mood disorder or clear treatment failure with the SGA alone.  Question 10 0 out of 1 points John is a 20-year-old male who is referred to treatment by his father. The two of them live together following the murder of John’s mother 6 weeks ago. It was a tragic occurrence; John’s mother was a nurse at an inner-city hospital and was killed as an innocent bystander in a drive-by shooting. John was very close to his mother, and in the last 3 weeks he has been increasingly distraught. His dad says he did not cope well from the beginning, but for the last 2 weeks he has been agitated, combative, and is hearing voices telling him that he could have saved his mother. He has become so agitated that his father brought him to the emergency room. The PMHNP knows that immediate treatment for John should include: Selected Answer: [None Given] Answers: Electroconvulsive therapy IM antipsychotics Benzodiazepines Antidepressants Response (c) is the correct answer. John’s history and symptoms are most consistent withFeedback : brief psychotic disorder. Benzodiazepines are very helpful in the short term, particularly for the agitation. ECT is not indicated. Antipsychotics may be appropriate in the short term, but IM forms are long acting and not indicated here, as long-term antipsychotic therapy is not appropriate. There is no evidence of a mood disorder, so antidepressants are not indicated. John appears to be reacting to the death of his mother. Benzodiazepines will stabilize him in the short term, and then a decision can be made about psychotherapy or oral antipsychotics.  Question 11 0 out of 1 points In addition to the diagnostic criteria observed in patients with schizophrenia, physical examination of these patients is frequently characterized by: Selected Answer: [None Given] Answers: Hyperreflexia Saccadic movement Rheumatoid arthritis Type 1 diabetes mellitus Response Feedback : (b) is the correct answer. Saccadic movement (disorder of smooth ocular pursuit) and elevated blink rate are often found in patients with schizophrenia and may be due to increased dopaminergic activity. Hyperreflexia is not among the neurological symptoms often found; conversely, dysiadochokinesis, primitive reflexes, and diminished dexterity are associated fndings. Rheumatoid arthritis has an inverse correlation to schizophrenia, with only 1/3 of patient with schizophrenia affected as compared to the general population. While type 2 diabetes is more frequent, probably due to increased obesity as well as medication-mediated insulin resistance, type 1 does not correlate with this disease.  Question 12 0 out of 1 points Korsakoff’s syndrome is an amnestic disorder frequently associated with a long history of alcohol abuse, although it may occur in the setting of gastric carcinoma, prolonged total parenteral administration therapy, and hyperemesis gravidarum. Treatment centers around: Selected Answer: [None Given] Answers: Aggressive control of vascular disease Cholinesterase inhibitors Psychodynamic therapyThiamine administration Response Feedback : (d) is the correct answer. This disorder is a consequence of thiamine defciency, and although only 1/3 of patients recover completely, treatment centers around the administration of thiamine. Vascular management is most aggressive with vascular dementia, cholinesterase inhibitors are effective only in Alzheimer’s dementia, and psychodynamic therapy has no primary role in most dementing and amnestic disorders, although it may be of considerable value for patients with amnestic disorders due to brain insult.  Question 13 0 out of 1 points Jamal is a 31-year-old male who is being evaluated by the PMHNP as part of required care following a suicide attempt. He has never had mental health care before, but his history reveals a signifcant history of substance abuse. Upon further assessment, Jamal reveals that the reason he uses drugs and alcohol is that he becomes most aroused sexually when he dresses in women’s clothing. He is distressed by this. He says he is attracted to women, he is not gay, but he is just most aroused in this way. He admits that even when he was little, he was always drawn to his mother’s and sister’s clothing and underwear. Jamal’s condition is best characterized as: Selected Answer: [None Given] Answers: Gender dysphoria Intersex condition Sexual identity disorder Paraphilia Response Feedback : (d) is the correct answer. Jamal is a transvestite, and this is considered a paraphilic disorder. An intersex condition is a physiologic condition in which a person is born with a body that does not correspond to traditional male or female bodies. Sexual identity refers to a person’s sexual preference; heterosexual, gay, lesbian, or bisexual. Gender dysphoria is an incongruence between a person’s physiologic gender and the gender with which they identify. There is no apparent incongruence between Jamal’s sexual or gender identity—he has a paraphilic disorder, which refers to the fact that he requires deviations from traditional sexual stimuli to become aroused.  Question 14 0 out of 1 points Trayvon is a 28-year-old male who was recently discharged from the military as a result of some behavioral issues leading to early termination. He was never in a combat situation, and his behavior and anger seem to predate his military enlistment. He is only in care because the military offers this as a transitional service, and Trayvon thinks it will help him be successful with future job applications. During a comprehensive evaluation of Trayvon, the PMHNP realizes that, among other things, he is experiencing postcoital dysphoria. Predictably this is causing some problems with his girlfriend, and he asks if there is anything he cantake to help. The PMHNP advises that: Selected Answer: [None Given] Answers: Antianxiety agents have been successful in some patients This is most often due to issues in the relationship and dual-sex therapy is indicated Insight-oriented psychotherapy is necessary to help him identify unconscious antecedents to his behavior This is probably one symptom of an underlying personality disorder and requires treatment of the primary problem Response Feedback : (c) is the correct answer. Trayvon may or may not have other diagnoses, but postcoital dysphoria is typically related to the patient’s attitude toward sex in general and the partner. He needs insight-oriented therapy. There is no role for antianxiety agents in this disorder, and while there may be a relationship issue, dual-sex therapy is not likely to be helpful in this circumstance. Trayvon does need to be evaluated for any underlying disorders, but this symptom warrants insightoriented therapy.  Question 15 0 out of 1 points The PMHNP is preparing a community-based presentation for both the staff and residents of a local life-care facility. The facility offers a continuum of care from independent apartment living to assisted living to nursing home care. In an effort to increase awareness of signs and symptoms of dementia as compared to pseudodementia, the management has contracted with the PMHNP to prepare these informative educational programs. When comparing and contrasting these two conditions, the PMHNP emphasizes that in pseudodementia the patient is usually: Selected Answer: [None Given] Answers: Very aware of the dysfunction Aficted by poor attention and concentration Good at concealing disability Joyful at accomplishing tasks Response Feedback : (a) is the correct answer. In pseudodementia, patients are typically very aware of their dysfunction and its severity, whereas in dementing disorders they often are not. However, patients with pseudodementia usually have well-preserved concentration and attention spans, unlike patients with true dementia. Patients with pseudodementia emphasize their failures and complain about cognitive dysfunction, whereas those with true dementia are often quite skilled at concealing their disability. Patients with true dementia are often very happy to accomplish even trivial tasks, whereas those with pseudodementia are more likely to emphasize failures. Question 16 0 out of 1 points The PMHNP is preparing a presentation for a primary care conference. The topic is “Recognizing Schizophrenia: Common Signs and Symptoms Encountered by the Primary Care Provider.” A critical point to stress to primary care clinicians is that: Selected Answer: [None Given] Answers: Olfactory and gustatory hallucinations are unusual and should prompt evaluation for a neurological disorder A precox feeling as correlated with a diagnosis of schizophrenia has a demonstrated sensitivity of 83% Disorders of thought content are pathognomonic for schizophrenia and are an indication to begin antipsychotics Premorbid and prodromal signs and symptoms have a high predictive validity and should prompt a psychiatric referral Response Feedback : (a) is the correct answer. While auditory hallucinations are most common and visual hallucinations are also common, tactile, olfactory, and gustatory hallucinations are uncommon in schizophrenia and should prompt a thorough neurological evaluation. A precox feeling, the intuitive experience of the inability to establish emotional rapport, is often reported by clinicians, but there is no objective reliable or valid criterion to support diagnosis. There is no fnding of pathognomonic for schizophrenia; every fnding consistent with this disorder may present in other psychiatric diagnoses, so a thorough history is important. Premorbid and prodromal fndings are often recalled historically after diagnosis, but there are no studies to support predictive value.  Question 17 0 out of 1 points Jake and Laurie are a young married couple who have been referred to mental health counseling because Jake is having disturbing sleep events. Laurie reports that on more than one occasion she has awakened to fnd Jake having what appears to be a panic attack, but he doesn’t seem to realize it. When he fnally wakes up, he is confused and doesn’t really understand what happened, although he does have a sense of intense fear. This has happened twice in the last 2 weeks, and the last time Laurie heard him screaming. Jake is now a bit afraid to go to sleep and as a result does not feel well the next day. The PMHNP recognizes that sleep terrors in adults: Selected Answer: [None Given] Answers: Are often associated with trauma or psychiatric problems Represent a disorder of REM sleep May be a symptom of temporal lobe epilepsy Is treated with a cycle of sleep deprivationResponse Feedback : (a) is the correct answer. Unlike night terrors of childhood, sleep terrors in adults are frequently associated with trauma or a frank psychiatric disorder. Sleep terrors are a disorder of NREM stage 3 and 4 sleep and are not a symptom of temporal lobe epilepsy; in fact, epilepsy should be ruled out. Sleep deprivation can exacerbate night terrors, as can fever and withdrawal of CNS depressants.  Question 18 0 out of 1 points Several medical disorders can produce symptoms of obsessive-compulsive disorder (OCD). Which of the following fndings in a patient with new onset OCD should prompt an evaluation for a neurologic cause of symptoms? Selected Answer: [None Given] Answers: Family history of neurological disease Poorly controlled hypertension Age 40 at presentation Lack of response to SSRIs Response Feedback : (c) is the correct answer. OCD almost always develops under the age of 30. If symptoms present at age 40, the patient should be evaluated for neurologic conditions that can produce similar symptoms. Family history is always considered, but age is more telling. Poorly controlled hypertension can lead to a variety of neurological vascular conditions, but there is no correlation to OCD. While the SSRIs are often effective, lack of response is not in itself indicative of a neurologic origin.  Question 19 0 out of 1 points Collette is a 23-year-old female who presented for emergency care with her mother because her behavior has become increasingly erratic and caused her to lose her job. Her mother reports that she had never done anything like this in the past, but about 3 months ago, her boyfriend of 3 years broke up with her, and Collette began to express unrealistic beliefs that her boyfriend wanted to drive her crazy and hurt her. A gentleman trying to hail a taxi accidentally bumped into her this morning, and she started screaming that her ex-boyfriend had hired the man to throw her into the street under a car. Collette is on a 2-week suspension from her job as a restaurant server because she was combative to a customer—she accused him of colluding with her ex-boyfriend to get her fred. After this morning’s incident, her mother was so worried she brought her to the emergency room. Her appearance is disheveled, she is clearly hyperalert and is crying that her boyfriend must have converted her mother to work against her. Head imaging, screening lab, and a toxicology screen are negative. A leading differential for Collette is: Selected Answer: [None Given] Answers: Bipolar disorder Acute psychoticepisode Schizophreniform disorder Post-traumatic stress disorder Response Feedback : (c) is the correct answer. Collette’s symptoms are consistent with the schizotype spectrum. There is no history of mood disorder or symptoms, so schizoaffective disorder is unlikely. There is no reported insidious or prodromal history, and symptoms are only within the last 3 months so schizophrenia is not an appropriate diagnosis. The collective report suggests schizophreniform disorder. The absence of mood history rules out bipolar disorder, acute psychotic episodes are < 1-month duration, and there is neither a traumatic stressor or any other criteria for PTSD.  Question 20 0 out of 1 points Kasey is a 26-year-old male who is referred for emergency psychiatric evaluation in the local community emergency room. His girlfriend came home from work unexpectedly and found him in the bathtub with multiple longitudinal cuts on both wrists. She called 911 and he was stabilized in the ED; the injuries were not serious, and now he is pending psychiatric evaluation. When the PMHNP came into the room, he noticed that Kasey unbuttoned and rebuttoned his shirt four times before settling down to the interview. He presented as depressed and tearful, and admitted to feelings of hopelessness and worthlessness. He admits that he doesn’t really feel connected to anyone; he has always been a loner, and last night he tried to kill himself because life just was not worth living. In addition to his suicidal ideation, the PMHNP recognizes that he needs to be further evaluated for: Selected Answer: [None Given] Answers: Major depressive episode and obsessivecompulsive disorder Bipolar disorder with psychotic features Dysthymia and borderline personality disorder Obsessive compulsive disorder and schizoid personality disorder Response Feedback : (a) is the correct answer. The patient has demonstrated compulsive behaviors and has several features of major depressive disorder. Both are correlated with suicidal ideation and need to be further explored. He does not demonstrate the extremes of mood consistent with bipolar and there is no evidence of psychosis. He has no extremes consistent with borderline personality, and while he admits to some social isolation, this needs to be further explored with respect to many differentials.  Question 21 0 out of 1 pointsR.J. is a 77-year-old man who has been referred for care for refractory depression. His wife died of cancer 2 years ago, and through the course of her illness and death, his family recognized that he seemed depressed. After his wife’s death, his primary care provider tried two different antidepressant medications, and while his mood has improved a bit, his family says he is increasingly “forgetful.” It started out as relatively innocuous things like forgetting where his keys are or forgetting to return a phone call or mail in his monthly bills. His daughter became worried when she went to visit him last weekend and found that he had forgotten how to write a check. He considers himself an otherwise healthy man with a medical history signifcant only for hypertension, dyslipidemia, and type 2 diabetes. He takes medications for these and feels physically fne. The PMHNP recognizes that R.J. is exhibiting signs and symptoms consistent with: Selected Answer: [None Given] Answers: Major depressive disorder Mild cognitive impairment Vascular dementia Delirium Response Feedback : (c) is the correct answer. R.J.’s clinical presentation is most consistent with vascular dementia, the second leading cause of dementia. While depression can cause forgetfulness and pseudodementia, he is being treated for depression and his mood reportedly has improved; it is unlikely his dementia-like symptoms would deteriorate while mood improves. Mild cognitive impairment does not cause clinically signifcant defcits, and delirium is acute and global. R.J. has numerous risk factors for vascular disease and is demonstrating identifable, stepwise deterioration in cognitive tasks.  Question 22 0 out of 1 points Mrs. Swenson is a 71-year-old patient who has been referred to mental health services for evaluation and management of dementia. She recognized her own cognitive defcits and discussed them with her primary care provider, who advised that she seek specialty care. After performing a comprehensive assessment, the PMHNP diagnoses the patient with vascular dementia. While reviewing her medication list from the PCP, the PMHNP recognizes that which of the following medications may be contributing to Mrs. Swenson’s cognitive impairment? Selected Answer: [None Given] Answers: Metformin (Glucophage) Clopidogrel (Plavix) Metoprolol(Lopressor) Lisinopril (Lotensin) Response Feedback : (c) is the correct answer. Beta adrenergic antagonists may be characterized by cognitive depression and can exacerbate symptoms of cognitive impairment. Conversely, metformin and clopidogrel are often used to treat diabetes and coronary artery disease, and can help prevent deterioration of cognitive impairment by controlling vascular deterioration. Lisinopril, an angiotensin converting enzyme inhibitor, will lower blood pressure without affecting vascular flow and is a better choice in patients with vascular dementia.  Question 23 0 out of 1 points Which of the following infectious diseases associated with psychiatric symptoms is most likely to present with olfactory and gustatory hallucinations, psychosis, personality changes, and partial seizures? Selected Answer: [None Given] Answers: Rabies encephalitis Neurosyphilis Lyme disease Herpes simplex encephalitis Response Feedback : (d) is the correct answer. This symptom complex is most consistent with herpes simplex. Rabies encephalitis, usually fatal in a matter of days or weeks, is most characterized by hydrophobia. Neurosyphilis may demonstrate a variety of changes to include personality changes, poor judgment, and decreased self-care. Lyme disease, when neurological symptoms are present, more often presents with subtle symptoms such as memory lapse, irritability, depression, and difculty concentrating.  Question 24 0 out of 1 points Coryn has been referred to the PMHNP because she has a signifcant sleep disorder that has not been responsive to typical primary care strategies. She has tried sedative hypnotics, improving sleep hygiene, avoiding daytime naps, melatonin, and almost anything else suggested. She has always had trouble sleeping “like normal people,” but she is newly married and her sporadic sleep patterns are beginning to cause stress in the marriage. Her history suggests a circadian rhythm sleep disorder. When counseling Coryn, the PMHNP advises her that all the following strategies have demonstrated success except: Selected Answer: [None Given] Answers: Chronothera pyPhototherap y Tasimelteon Zaleplon Response Feedback : (d) is the correct answer. A variety of circadian rhythm disorders exist, and they do not customarily respond to sedative-hypnotics such as zaleplon. Chronotherapy, a technique to reset the biological clock, takes some time but has demonstrated successes. Phototherapy > 10,000 lux can also help reset the biological clock. Tasimelteon, a melatonin-receptor agonist, is the only drug with FDA approval for non-24 sleep-wake disorder.  Question 25 0 out of 1 points With respect to the negative symptoms of schizophrenia, all of the following statements are true except: Selected Answer: [None Given] Answers: Negative symptoms are a more important determinant of long-term function Conventional antipsychotics are more effective in controlling them as compared to atypicals They are a result of decreased dopamine in the mesocortical pathway A prodrome of negative symptoms often precedes psychotic episodes Response Feedback : (b) is the correct answer. Due to their dopamine-blocking activities, conventional antipsychotics more often exacerbate negative symptoms. Negative symptoms are a more important determinant of long-term function and outcomes. Negative symptoms are a function of decreased dopaminergic activity in the mesocortical pathways, which is why the dopamine-blocking activity of D2 receptors exacerbates them. While it is the positive symptoms that typically bring the disease to the attention of the health care system and produce a diagnosis, patient history usually demonstrates a prodrome of negative symptoms.  Question 26 0 out of 1 points John is a 19-year-old male who is self-referred for care after being prematurely discharged from the military. He is vague as to the details of his discharge, but it appears he had difculty with performance evaluations and was apparently arrested for several incidences of illegal substance abuse. Comprehensive evaluation of John reveals that he thinks he “is really a woman,” but he cannot accept this and joined the Army to try and “be a real man.” John indicates that he has always felt like he was really a girl, and he says that he “hates that he has a penis.” When considering a diagnosis of gender dysphoria, the PMHNP knows that which of the following would be most consistent with John’s history?Selected Answer: [None Given] Answers: He is only sexually attracted to men He has a desire for gender reassignment surgery Cross-gender behavior was evident before puberty John is unable to obtain an erection with partners of either gender Response Feedback : (c) is the correct answer. Most adults with gender dysphoria report having felt different from other children of the same sex, and parents in retrospect report that cross-gender behaviors were apparent as early as 3 years old. Many gender dysphoric patients do not want reassignment surgery. Cross-gender patients may be attracted to either gender, or be bisexual. Gender dysphoric anatomical males are capable of erection, although those who take estrogen may have a diminished response as a function of the estrogen.  Question 27 0 out of 1 points Nava is a 47-year-old female who has been in care for the last 9 months for a major depressive episode. She has struggled with depression intermittently since her 20s, but at this point she is on combination therapy with sertraline and bupropion and has achieved an excellent remission. However, she is asking for some help with her sleep. She says she has always had insomnia to some degree, mostly trouble falling asleep, but she thought that once she felt better from her depression it would improve. A review of Nava’s sleep hygiene habits reveals that there are numerous areas that could beneft from improvement. Nava’s sleep hygiene habits should ultimately be improved to include all the following except: Selected Answer: [None Given] Answers: Maintaining a regular exercise schedule Reading a book in bed with no distractors Having a light snack at bedtime if hungry Ensuring that the bedroom is cool Response Feedback : (b) is the correct answer. Universal sleep hygiene suggests that a cool, dry, dark, and quiet room is best. While exercise right before bed is not advised, a daily schedule of exercise is. Similarly, while a heavy meal at bedtime is not advised, a light snack at bedtime (if hungry) is suggested. Nothing should be done in bed except for sleep and sex; reading, eating, talking on the phone, or any other activities are not advised as they create an association between bed and activities other than sleep.  Question 280 out of 1 points Luz is a 24-year-old female who is being evaluated at the strong urging or her mother and the family primary care provider. According to the mother, Luz has been progressively demonstrating obsessive thoughts and compulsive behaviors centering on religion. She is preoccupied with the concept of heaven and hell, and she often becomes very distressed that she is going to go to hell when she dies. The mother also reports that Luz appears to be compulsive about reading her Bible and performing prayers and other rituals several times a day. The PMHNP must perform a detailed history and examination to differentiate obsessive-compulsive disorder (OCD) from: Selected Answer: [None Given] Answers: Obsessive compulsive personality disorder Psychosis Depression Schizoid personality disorder Response Feedback : (b) is the correct answer. Psychotic symptoms can often lead to obsessive thoughts and compulsive behaviors that are not easy to distinguish from OCD with poor insight; this circumstance raises a flag to make the distinction because psychotic delusions frequently have religious overtones. The clinician needs to assess for other symptoms of psychosis, including complete lack of insight into the unreasonableness of the behavior. Obsessive compulsive personality disorder is more about perfectionism and detail, easily distinguished by most clinicians from true obsessive-compulsive behavior. In depression, the symptoms occur only during depressive episodes and are more about obsessive thoughts than compulsive behaviors. Schizoid personality disorder is not characterized by repetitive thoughts or actions but rather just a disinterest in personal relationships.  Question 29 0 out of 1 points What is the primary difference between sexual interest and arousal disorders in men and women? Selected Answer: [None Given] Answers: Unlike men, women may not feel interest or desire until after arousal The disorder rarely occurs in older men but is common in older women Symptoms occur more commonly due to hormone defciencies in men Duration of symptoms to support diagnosis is longer in womenResponse Feedback : (a) is the correct answer. For women, it is not uncommon for desire to not occur until after physical arousal, so in women the diagnosis of interest/arousal disorder is combined. Older men and women are most commonly affected, although this can occur any time in the lifespan. There are numerous causes in both genders, and hormonal defciencies and variations should be considered in both genders. Duration of symptoms in both genders is > 6 months.  Question 30 0 out of 1 points The primary differentiating feature between mild cognitive impairment (MCI) and Alzheimer’s dementia is: Selected Answer: [None Given] Answers: The presence of the apolipoprotein E4 gene Performance on objective neuropsychiatric testing Presence or absence of functional impairment Atrophy of the hippocampal volume Response Feedback : (c) is the correct answer. There is no consensus among experts for diagnostic criteria for MCI; the primary difference between it and dementia is that patients with MCI have preserved functional status. ApoE4 carrier status is implicated in Alzheimer’s, but it is not a differentiating feature. Experts have not defned a cutoff on neuropsychiatric testing to support a diagnosis of MCI. Atrophy of the hippocampal volume has been described in MCI, but it is not a diagnostic criterion.  Question 31 0 out of 1 points Which of the following is a true statement with respect to psychoanalytic therapy for patients with paraphilias? Selected Answer: [None Given] Answers: Best psychotherapeutic approaches remain consistent with Sigmund Freud’s theory Paraphilia as a conditioned response is the more contemporary conceptual framework of causation Cognitive-behavioral therapy has not demonstrated any success as a treatment modality Psychoanalytic therapy typically requires coincident external control to maximize success Response Feedback (b) is the correct answer. Although the target of psychoanalytic therapy has evolved from the classic Freudian Oedipal theory to the treatment of defense: mechanisms, psychoanalytic therapy itself remains important. There are several theories with respect to the etiology of paraphilias, and while early life experiences are important, classic conditioning does not feature prominently. CBT is among the most successful therapeutic approaches to disrupt learned patterns. While external controls are one mechanism to inhibit paraphilic behavior, the success of psychoanalytic therapy does not require them.  Question 32 0 out of 1 points A wide variety of sleep-wake disorders are referred to the PMHNP for assessment and management. A contemporary approach to managing insomnia centers around: Selected Answer: [None Given] Answers: Diagnosing and managing underlying causation Providing relief and managing symptoms Focusing on nonpharmacologic therapies Differentiating “tiredness” from “sleepiness” Response Feedback : (b) is the correct answer. Historically clinicians were encouraged to diagnose and manage underlying disorders leading to insomnia, e.g., depression or anxiety, and controlling those; the presumption was then that the insomnia would resolve. A more contemporary approach favors symptom relief. Both pharmacologic and psychotherapies are appropriate depending on the collection of symptoms, and there is no emphasis on one over the other. While tiredness vs. sleepiness is an important distinction in some sleep-wake disorders, it is not a foundation for the management of insomnia.  Question 33 0 out of 1 points The PMHNP is asked to evaluate the elderly father of one of her patients. The father is a 72-year-old male who is demonstrating some difcult personality changes. His memory and ability to function ADLs seem intact, but the daughter reports that he seems very impulsive, and he doesn’t seem to appreciate that some actions or behaviors are inappropriate. He has been making inappropriate sexual remarks to some of her daughter’s friends and doesn’t understand that it is a problem. When considering various causes of dementia, the PMHNP evaluates for additional symptoms including: Selected Answer: [None Given] Answers: Hyperorality and declining hygiene Abnormal focus on a single taskor topic Psychosis and rapid mood changes Reduplicative paramnesia Response Feedback : (a) is the correct answer. This description is most consistent with Pick’s disease (frontotemporal dementia), and the PMHNP expects to see hyperorality, declining hygiene, and easy distractibility. Psychoses is not a common feature of this type of dementia. Reduplicative paramnesia is more consistent with Lewy body dementia.  Question 34 0 out of 1 points Valerie is a 27-year-old woman who has been referred by her primary care provider. She was initially diagnosed with major depressive episode following a breakup with her boyfriend of 7 years. They moved into a house together 1 year ago, but within a few months the boyfriend moved out. Valerie was unresponsive to medication for depression and was referred to the mental health clinic. During this initial psychiatric evaluation, the PMHNP learns that a primary reason for the breakup was that Valerie had an extensive routine every night of repeatedly checking every door and window in the home to ensure that they were locked. Valerie’s nighttime routine is exhaustive and involves checking every door and window at least four times. She has a remote history of being attacked in her home while alone and states that she is unable to go to bed until she is certain that every door and window is locked. When considering diagnostic criteria for OCD, the PMHNP needs further assessment to ascertain which diagnostic criteria? Selected Answer: [None Given] Answers: The patient has tried unsuccessfully to suppress the urge to repeatedly check locks The compulsive activities are time-consuming to the extent that at least 1 hour daily is spent on them The disturbance is not better explained as the symptoms of another mental disorder The patient has good or fair insight with respect to the appropriateness of her behaviors Response Feedback : (c) is the correct answer. The diagnosis of OCD is not appropriate if the obsessions or compulsions are better explained as the symptoms of another mental health disorder or substance abuse. An attempt to suppress obsessive thoughts is one of the two requirements of obsessive thought, but not compulsive action. According to DSM-5 criteria, symptoms need to be either time consuming or causing clinically signifcant dysfunction; as she has lost her boyfriend over this, the time requirement is not essential. Insight is not required for diagnosis—OCD can be specifed with any level of absent or present insight.  Question 35 0 out of 1 pointsShireen is a 21-year-old transgender female who has been through an exhaustive counseling program and is ready to start hormone therapy with estrogen, progesterone, and testosterone-blocking agents. When counseling her specifcally about the risks, benefts, and required monitoring of hormonal therapy, the PMHNP advises Shireen that: Selected Answer: [None Given] Answers: Her ability to conceive will not be adversely impacted There is a signifcant risk of developing benign prolactinomas Smoking cigarettes while on estrogen therapy increases risk of thrombosis If breast augmentation is planned, it should be performed prior to hormone therapy Response Feedback : (c) is the correct answer. Smoking and estrogen does increase risk of thrombotic disorders. With respect to conception, Shireen should be counseled that these hormones will very likely result in sterility. While prolactin levels are monitored, the risk of prolactinoma is rare. If breast augmentation is planned, the patient should be on hormones for 18–24 months prior to allow the natural development of breast tissue prior to augmentation.  Question 36 0 out of 1 points Schizophrenia, schizoaffective disorder, and schizophreniform disorder are all among the continuum of psychiatric illnesses characterized by psychotic episodes. Which of the following clusters of features best distinguishes schizophreniform disorder? Selected Answer: [None Given] Answers: Prodrome of negative symptoms, duration > 1 month, early age of onset Absence of mood disorder, two or more psychotic symptoms, duration > 6 months Progressive decline in social and occupational function, insidious onset, complete resolution of symptoms Rapid and acute onset, return to baseline in < 6 months, occurs in adolescents and young adults Response Feedback : (d) is the correct answer. Schizophreniform disorder, unlike the other two, is not generally characterized by a prodrome or progressive insidious decline in social or occupational function; it’s onset is relatively acute. There is no mood component— that would be more consistent with schizoaffective disorder. If symptoms collectively occur > 6 months, the diagnosis is schizophrenia whereas schizophreniform symptoms are > 1 month and < 6 months, at which point there is return to baseline. In many cases, these patients do progress to schizophrenia, but that includes a collective time frame of > 6 months of symptom presentation. Question 37 0 out of 1 points Amnestic disorders have a wide variety of potential causes, including vitamin and mineral defciencies, infectious diseases, substance-related causes, and structural damage. The shared feature is that many of these causes tend to affect the: Selected Answer: [None Given] Answers: Cerebellum Prefrontal cortex Temporal lobe Amygdala Response Feedback: (c) is the correct answer. Many of these etiologies affect the temporal lobe, resulting in amnestic disorders. The cerebellum is primarily implicated in ataxic disorders, the prefrontal cortex in schizophrenia, and the amygdala in fear.  Question 38 0 out of 1 points Jeremy is a 21-year-old male who is referred by his primary care provider. He has persistent erythema of both hands, which was initially thought to be eczema but eventually was diagnosed as a result of chronic, excessive handwashing. Further evaluation of Jeremy revealed fndings consistent with obsessive compulsive disorder. The PMHNP considers that the most appropriate initial therapy for Jeremy would be: Selected Answer: [None Given] Answers: Clomipramine 25 mg daily Fluoxetine 40–80 mg daily Psychodynamic therapy Behavioral therapy Response Feedback : (b) is the correct answer. The biologic origins of OCD are substantiated by the best response to pharmacotherapy. The most successful outcomes are with fluoxetine. Clomipramine is an alternative to SSRIs, but SSRIs are preferred due to the lesser adverse profle. Among the nonpharmacologic therapies, behavioral therapy is preferred and is highly successful with pharmacotherapy; pharmacotherapy, however, is the mainstay of care and should be the frst approach.  Question 390 out of 1 points Jack is a 19-year-old male who is being treated for obsessive-compulsive behavior. He has just begun his mission as a member of the Church of Jesus Christ of Latter Day Saints, and his partner has encouraged him to come to care due to his compulsive cleaning behaviors. Jack has had a very difcult time with treatment; after several sessions, it is apparent that he is having obsessive sexual thoughts with which he is not comfortable. Jack would like to avoid pharmacotherapy if he can, and is interested in exploring psychotherapeutic interventions. The PMHNP refers Jack to therapy and discusses with him that the psychodynamic theories of OCD include: Selected Answer: [None Given] Answers: Intolerance of the nuclear family to compulsive rituals The drive to seek secondary gain because of compulsive behavior Abnormalities related to the anal-sadistic phase of development A disproportionate ratio of concomitant personality disorders Response Feedback : (c) is the correct answer. Many patients with OCD are preoccupied with aggression and cleanliness, which leads to the theory that it may have its origins in the anal stage of development. The nuclear family tends to try and accommodate the compulsive behavior, thus reinforcing it. Secondary gains may reinforce compulsive behavior but are not identifed as an etiology. While some patients may have concomitant personality disorders, this does not occur disproportionately in the population and is not related to causation.  Question 40 0 out of 1 points Hypersomnia has a variety of etiologies, and treatments are varied based upon underlying cause. Which of the following types of hypersomnolence disorder is best managed with wake-promoting substances or psychostimulants? Selected Answer: [None Given] Answers: Hypersomnia due to substance abuse Menstrual-related hypersomnia Hypersomnia due to medical condition Idiopathic hypersomnia Response (d) is the correct answer. Hypersomnia due to substance abuse is best treatedFeedback : by discontinuing the substance and managing withdrawal as needed. Menstrualrelated hypersomnia is best managed with hormonal contraceptives, and hypersomnia due to medical conditions requires management of the underlying condition. Idiopathic hypersomnia is the form best treated with wake-promoting drugs or psychostimulants.  Question 41 0 out of 1 points All of the following strategies are used successfully to manage paradoxical insomnia except: Selected Answer: [None Given] Answers: Cognitive relabeling Diffusing sleep worry Anxiolytics Changing environment Response Feedback : (d) is the correct answer. While it may be useful for psychophysiological insomnia, changing the environment is not a strategy employed for paradoxical insomnia because the problem isn’t actually going to sleep—it is the patient’s perception. For this reason, cognitive relabeling and diffusing sleep worry may be very effective. Similarly, anxiolytics often help although they do not change the physiology of the patient’s sleep; they change the perception.  Question 42 0 out of 1 points A couple in their late thirties presents for care. They have been married for eight years, and the wife is becoming increasingly frustrated by their sex life. As their marriage has progressed she has become increasingly disturbed by the fact that her husband cannot ejaculate during intercourse. It is more of an issue lately because she really wants to have a baby. She admits that their sex life has never been “ideal,” but that she has been able to reach orgasm, often using a sex toy during sex with her husband. Her husband has ejaculated with manual stimulation, but never during intercourse. The husband is rather quiet during the whole evaluation, but he says he does not ejaculate during intercourse and he is “OK with that.” The PMHNP considers that: Selected Answer: [None Given] Answers: This probably represents difculties in the relationship An underlying medical condition may be the cause The patient may respond well topharmacotherapy A severe underlying psychopathology is likely Response Feedback : (d) is the correct answer. Lifelong delayed ejaculation likely indicates a severe underlying pathology related to a rigid, puritanical childhood. The patient likely has trouble with close relationships outside of sex. Acquired delayed ejaculation is more likely to be due to an interpersonal problem in a relationship. While medical causes should be ruled out, the fact that this is a lifelong problem makes that less likely. Pharmacotherapy is not an effective primary strategy in this disorder.  Question 43 0 out of 1 points Camille is a PMHNP student preparing a presentation for a group of primary care providers on common signs and symptoms of psychiatric disorders often frst seen in primary care ofces. The goal is to increase awareness of early indicators for mental health referral. When discussing obsessive-compulsive disorder, Camille discusses that the most common pattern of obsession is: Selected Answer: [None Given] Answers: Contamination Pathological doubt Intrusive thoughts Symmetry Response Feedback : (a) is the correct answer. In order of commonality, items (a) through (d) are the four most common patterns of obsessive thought. Contamination is most common, e.g., germs, dust. Pathologic doubt is second most common, often manifest as repeatedly checking that doors are locked, the stovetop is turned off, or being concerned about being followed or stalked. Intrusive thoughts, such as sexual thoughts, is third most common, and symmetry is fourth most common.  Question 44 0 out of 1 points The primary difference between sleepwalking and rapid eye movement behavior disorder (RBD) is that: Selected Answer: [None Given] Answers: Sleepwalkers do not have REM-mediated paralysis Sleepwalkers are acting on the dream imagery RBD patients do not respond topharmacotherapy RBD may be due to a variety of brain abnormalities Response Feedback : (d) is the correct answer. RBD may be produced by hemispheric lesions, bilateral thalamic abnormalities, or brainstem lesions; this is not the case with sleepwalking. Sleepwalkers are not in REM sleep, but RBD patients (who should have paralysis) do not have typical REM-mediated paralysis. Sleepwalkers are not acting on dream imagery, but RBD patients are. RBD is responsive to clonazepam.  Question 45 0 out of 1 points The clinical evaluation of neurocognitive disease includes a detailed assessment of cognition. Which of the following aspects of cognitive testing may result in false positives due to poor education or low intelligence? Selected Answer: [None Given] Answers: Memory Visuospatial ability Reading and writing ability Abstraction Response Feedback : (d) is the correct answer. The ability to interpret a proverb or phrase may be affected by education or intelligence and not be reflective of cognitive impairment. Conversely, memory, visuospatial ability, and reading and writing (which are performed at very simple levels) are usually accurate and not insidiously affected by intelligence or education.  Question 46 0 out of 1 points Jack is a 27-year-old male who has a history of paranoid schizophrenia that frst became apparent approximately 10 years ago. He developed paranoid delusions and eventually decompensated to the point that he required inpatient stabilization. At the time, he was started on conventional antipsychotics, but due to intolerable adverse effects he was switched to haloperidol. It worked well, but whenever he stopped taking it, symptoms would recur. After several hospitalizations, he was stabilized. The neurophysiologic theory of schizophrenia suggests that Jack’s symptoms were a result of: Selected Answer: [None Given] Answers: Increased dopamine activity in the mesolimbic pathwayIncreased dopamine activity in the mesocortical pathway Increased glutamate in the prefrontal cortex Increased glutamate in the hippocampus Response Feedback : (a) Is the correct answer. Current neural circuit theory suggests increased dopaminergic activity in the mesolimbic pathway and decreased dopaminergic activity in the mesocortical pathway. Glutamate is implicated in the etiology of positive symptoms as use of the glutamate antagonist can produce psychotic symptoms, but the relationship, while currently an area of investigation, is not clear. Glutamate is also implicit in a downstream increase in mesolimbic activity. Altered hippocampal blood flow is among proposed etiologies of memory symptoms.  Question 47 0 out of 1 points Trudy is a 49-year-old woman recently diagnosed with schizophrenia. While she has a strong family history of mood disorders, and has herself evidenced some depressive symptoms by history, her delusions and diagnosis of schizophrenia were a big surprise to herself and her family. She has been married for 25 years and by all accounts has had a successful marriage and family life until the last few months when she became increasingly concerned that her best friend was trying to seduce her husband. Further history suggests that she has paranoid delusions and that her memos from work carried messages that her coworkers were trying to destroy her family. Trudy was fnally referred for care when she tried to attack a coworker. There is no apparent precipitating factor, and her family cannot understand why she is just now demonstrating symptoms of schizophrenia. Now that she is in treatment, which elements of her history support a good prognosis? Selected Answer: [None Given] Answers: Lack of precipitating factors Neurological signs Physical assault Age of onset Response Feedback: (d) is the correct answer. Late age of onset is a good prognostic sign. Lack of precipitating factors and her assaultive behavior are poor prognostic indicators. There are no neurological signs reported in this history, but when present they are also a poor prognostic sign.  Question 48 0 out of 1 points D.M. is a 21-year-old male who presents for admission with his mother. He reports that he “cannot get himself together.” He is disoriented x 3 and his thought processes are chaotic. His speech is disorganized, he is easily distracted, and he appears to be rather agitated. He admits to both visual and auditory hallucinations over the last few weeks, and says he can “hear through the walls.” He was unable to sit still during the evaluation, often getting up and pacing the room, looking out ofthe windows, and then appearing to listen to something no one else could hear. According to his mother, his behavior has been bizarre for weeks; he has been wandering the neighborhood aimlessly, and reports that he was raped by a male neighbor. His mother fnally brought him to the hospital. He appears unaware of his circumstances. D.M. is a poor historian, but does admit to drug and alcohol use on and off for several years. According to his mother, he had a scholarship to college, but it was withdrawn last semester when he stopped going to classes. A screening laboratory assessment is within normal limits, and the PMHNP considers a diagnosis of schizophrenia. D.M.’s presentation is most consistent with which type? Selected Answer: [None Given] Answers: Paranoid Disorganized Undifferentia ted Catatonic Response Feedback : (b) is the correct answer. Disorganized is characterized by more unorganized behavior, often onsets before the age of 25, and the patient presents as aimless and unconstructive. The thought disorder is pronounced and contact with reality is poor. Paranoid type typically onsets in late 20s or 30s, but more importantly it is characterized by preoccupation and hallucinations related to persecution, showing less regression of mental faculties than other types; their intelligence in areas not invaded by paranoia remains intact. Undifferentiated schizophrenics do not ft into any individual type, and catatonic types, very rare now in the U.S., demonstrate disorders of motor function.  Question 49 0 out of 1 points Jaime is a 19-year-old woman who is in psychiatric care as a condition of probation. She frst came to the attention of the juvenile detention system when she was 15 years old. She was babysitting for a neighbor, and the parents came home early and found that she was exposing her breasts to the 9-year-old child in her care. Since then she has had several similar episodes, and since turning 18, she has been arrested several times for exposing herself to children and teenagers. During her evaluation, she admits that the only way she can experience arousal and orgasm is to engage in this behavior and then masturbate afterward. She has had more conventional sexual experiences but does not enjoy them. When considering a diagnosis of paraphilic disorder, the PMHNP recognizes that which of the following features is inconsistent with the typical paraphilic disorder patient? Selected Answer: [None Given] Answers: The subtype; exhibitionism is a very uncommon form of paraphilia The fact that Jaime is female; almost all patients with paraphilia are maleThe inability to experience arousal or orgasm any other way The onset before age 18 Response Feedback : (b) is the correct answer. Paraphilias are much more common in males, and almost 100% of cases of exhibitionism are men exposing themselves to women. It is unusual for a woman to come to the attention of the legal system for engaging in this behavior. Exhibitionism is the second most common form of paraphilia for which patients seek treatment. Characteristic of paraphilia is the inability to experience arousal and orgasm in a more conventional way. Peak age of onset is 15–25, so Jaime is very consistent with that statistic.  Question 50 0 out of 1 points Danny is a 19-year-old male who presents to the college mental health center at the insistence of his roommate. Danny has developed what his roommate calls an obsession with cleanliness. He showers several times a day and changes his clothes easily four or fve times. He also brushes his teeth every couple of hours, convinced that he has bad breath. During the interview, it does not appear that these are anxiety-reducing rituals but rather he is certain that he has unpleasant body odors and needs to keep showering and brushing his teeth to get rid of them. While considering a diagnosis of obsessive-compulsive disorder, the PMHNP considers that differential diagnoses for Danny include all the following except: Selected Answer: [None Given] Answers: Olfactory reference syndrome Obsessive compulsive personality disorder Temporal lobe epilepsy Sinus inflammation Response Feedback : (b) is the correct answer. OCPD is not a disorder of behaviors but rather a tendency to neatness and precision. This patient appears convinced that he has body odors that apparently his roommate does not perceive. Olfactory reference syndrome is a disorder characterized by the false belief that the patient has foul body odors that others cannot perceive. Somatic causes of false olfactory perception, such as temporal lobe epilepsy and inflammation of the frontal, sphenoid, and ethmoid sinuses should be ruled out. Delusional disorder may also be considered.  Question 51 0 out of 1 points Michael is an 18-year-old male who is presented to care at the urging of his parents. He has never had any signifcant medical or psychiatric problems in the past, but during his frst semester at college he has developed a very alarming pattern of excess sleep. He is missing classes and is in danger of losing a scholarship. He is sleeping normally at night but apparently is having these very long episodes of napping and sleeping during the day. When he is awake, he tends to be rather withdrawn. His parents have taken him to their family practitioner as they thought he might be using drugs. A full exam, laboratory assessment, and toxicology screenare all normal, and there is no apparent cause for this sleepiness. While very rare, the PMHNP considers Kleine-Levin syndrome and further assesses for coincident onset of: Selected Answer: [None Given] Answers: Narcolepsy Mood disorder Hypersexuali ty Alcohol abuse Respons e Feedback : (c) is the correct answer. In its classic form, this disorder is characterized by voracious eating and hypersexuality/disinhibition along with excess episodes of daytime sleeping on top of normal nighttime sleep patterns. Narcolepsy is a distinctly separate disorder; there is no coincident mood disorder classically noted; and alcohol abuse, while it may occur, is not a linked cause or fnding.  Question 52 0 out of 1 points R.M. is an 81-year-old male who was evaluated at his own request because of his failing memory. He is an active older adult and has enjoyed a comfortable retirement lifestyle, but over the last year he has become increasingly troubled by his forgetfulness. His wife agrees that it has extended beyond the occasional memory lapse; he forgets names of things he should know and has forgotten commitments to friends and family. After a thorough evaluation, the PMHNP diagnoses mild cognitive impairment (MCI). R.M. asks if this is really Alzheimer’s disease, if it is going to get worse, and what can he do about it? The most appropriate response would be to tell R.M. that: Selected Answer: [None Given] Answers: His cognitive function will likely decrease 10–15% per year The diagnosis is not stable and he may revert to normal function Cholinesterase inhibitors, such as donepezil, will improve memory but not cure the condition There is no identifed link between mild cognitive impairment and Alzheimer’s dementia Response Feedback : (b) is the correct answer. Several studies have indicated that MCI is not a stable condition, and the patient may either revert to normal function or progress to a dementing disorder such as Alzheimer’s. If the patient progresses to Alzheimer’s dementia, it is at a rate of 10–15% per year and associated with progressive loss of function. While cholinesterase inhibitors demonstrate improvement in Alzheimer’s dementia, there is no evidence that they improve MCI. MCI isconsidered a prodrome to several forms of dementia, including Alzheimer’s; however, as previously stated some patients do not progress and indeed return to a normal state.  Question 53 0 out of 1 points With respect to the treatment of obsessive compulsive disorder, which of the following statements best characterizes the role of psychotherapy? Selected Answer: [None Given] Answers: Best treatment outcomes occur when patients combine psychotherapy with pharmacotherapy Psychotherapy is superior to behavior therapy as a nonpharmacologic adjunct to medications Psychodynamic exploration of a patient’s resistance to treatment may improve compliance to therapy There is no apparent beneft to psychotherapy in the management of obsessive compulsive disorder Response Feedback : (a.) is the correct answer. Psychoanalysis and psychotherapy are not preferred treatments, as the biological basis of OCD has been supported by best response to drug therapy. However, psychodynamic therapy may be very helpful in understanding what precipiatates exacerbations and in managing resistance to treatment. Best treatment outcomes however are evident with pharmacotherapy and behavior therapy.  Question 54 0 out of 1 points Mr. T. is a 24-year-old man who presented himself to care for management of compulsions that have become so consuming that it is interfering with his job. He is a truck driver for a local branch of a ational delivery company. Several months ago, he rather abruptly developed a very strong compulsion to ensure that every door in the vehicle was in the unlocked position before he could drive. At this point he is unable to drive unless he checks every door seven times, and as he frequently gets in and out of the vehicle during the day, this has become prohibitive of making his stops on time. He has been on sertraline 200 mg daily for 4 weeks now without any meaningful improvement. The PMHP considers that the next step in his care might reasonably include all of the following except: Selected Answer: [None Given] Answers: A mood stabilizer An antipsychotic Behaviortherapy Psychotherap y Response Feedback : (b) is the correct answer. An antipsychotic would not be the next appropriate drug class for OCD refractory to an SSRI. If initial pharmacotherapy with an SSRI or clomipramine is unsuccessful, the next appropriate class of medication includes a mood stabilizer such as valproate, carbamazepine, or lithium. Other agents used include SNRIs, noncardioselective beta adrenergic antagonists such as pindolol, or MAO inhibitors. Antipsychotics have helped some patients after other medications noted have been unsuccessful. In addition to pharmacotherapy, behavior therapy is considered the nonpharmacologic intervention of choice and in some studies, has been as effective as SSRIs. Psychotherapy has also demonstrated utility when patients achieve insight into the origins of their behaviors.  Question 55 0 out of 1 points Recurrent isolated sleep paralysis is characterized by the awareness of normal REMmediated paralysis in the partially conscious state. It is a feature of normal REM sleep, and lifetime occurrence is estimated to be as high as 50%. While counseling patients about this condition, the PMHNP correctly states all the following except: Selected Answer: [None Given] Answers: First-line therapy includes ensuring adequate sleep Shift work can increase the likelihood that this occurs People experience this should not be touched It is among the tetrad of narcolepsy symptoms Response Feedback : (c) is the correct answer. Being touched by another person may terminate the episode. First-line management includes ensuring adequate sleep and good sleep hygiene. Shift work, stress, and sleep deprivation can all increase the risk of this occurring. While by itself it is a normal fnding, it is among the tetrad of narcolepsy symptoms, and patients exhibiting recurrent isolated sleep paralysis should be evaluated for narcolepsy.  Question 56 0 out of 1 points When evaluating the patient with dementia, the PMHNP recognizes that one of the clinical differences between cortical and subcortical dementias is that in subcortical dementia an early fnding will typically not include which of the following? Selected Answer: [None Given]Answers: Impaired visuospatial skills Depressed mood Dysarthria Aphasia Response Feedback: (d) is the correct answer. Aphasia is an early fnding in cortical dementia but not subcortical forms. Conversely, depressed mood and aphasia are found in early subcortical dementia, and impaired visuospatial skills are found early in both forms.  Question 57 0 out of 1 points Alex J. is a 31-year-old male who is being seen in the emergency room after having a car accident. There were no serious injuries. Alex insists that he was following the speed limit and trafc signs, that he was not doing any drugs or alcohol, but he just fell asleep at the wheel. A head CT and toxicology screen are negative, and other screening laboratory studies do not support any organic cause of sudden sleepiness. The PMHNP considers hypersomnolence disorder vs. narcolepsy. When reviewing his sleep history questionnaire, which of the following historical fndings would support a diagnosis of hypersomnolence? Selected Answer: [None Given] Answers: A sleep defcit of 1–2 hours nightly for the last week Lack of symptoms related to attention, memory, or concentration Auxiliary symptoms of REM intrusion into the waking state History of sleep symptoms prior to this episode Response Feedback : (a) is the correct answer. Hypersomnolence disorder is a consequence of neurologic disorder relative to brain-regulating sleep systems, insufcient sleep, disrupted sleep, or dysfuncation of circadian rhythm. Sleep defcits of 1–2 hours per night over 1 week can produce this dangerous, unavoidable sleepiness. There usually are coincident symptoms related to problems with memory, attention, or higher level cognitive function. Intrusion of REM sleep into the waking state is consistent with narcolepsy. Narcolepsy is more likely to present with a history of daytime sleep symptoms prior to age 30.  Question 58 0 out of 1 points A secondary prevention strategy to reduce the incidence of pedophilia includes: Selected Answer: [None Given]Answers: Participating in community awareness programs and promoting identifcation of sexual offenders in the neighborhood Designing a screening tool to identify children 13 years of age and younger at high risk for being targeted by pedophiles Volunteering one afternoon a week to counsel in a comprehensive center for children who have been victimized Researching strategies to promote best long-term success treatment modalities Response Feedback : (b) is the correct answer. Primary prevention promotes health and keeps any deviation from occurring. Participating in community awareness programs is a primary preventive strategy. Screening any high-risk population is a secondary strategy. Treating a patient after the event has occurred, such as counseling victimized children, is a tertiary prevention strategy. Similarly, best treatment strategies would be a tertiary-level intervention.  Question 59 0 out of 1 points Donna is a 41-year-old woman who is being evaluated at the request of her primary care provider for obsessive compulsive disorder. Which of the following aspects of Donna’s family medical history should prompt an immediate referral to a neurologist? Selected Answer: [None Given] Answers: Father committed suicide at age 38 Mother died from Huntington’s chorea Sister has temporal lobe epilepsy Brother has profound eczema Response Feedback : (b) is the correct answer. Donna is well past the typical age of onset of OCD, and given that her mother had a disorder of the basal ganglia, she needs immediate evaluation by a neurologist. A father who committed suicide may indicate greater psychiatric surveillance, but it is not an indication for a neurological evaluation. Similarly, temporal lobe epilepsy may produce olfactory delusions, but this does not impact Donna. Sometimes compulsive handwashing will be misdiagnosed as eczema, but this also does not indicate a neurological evaluation for Donna.  Question 60 0 out of 1 points Maureen is a 23-year-old female who self-refers to mental health because she is struggling with a recent diagnosis. She recently had appendicitis, but during the diagnostic CT scan she learned that she had cryptorchid testes, and now she is distressed over not knowing if she “is a man or a woman.” She says that she hasalways been a bit of a tomboy, but that she has never thought of herself as a man, or as wanting to be a man. She has had a boyfriend for 2 years, and she is terrifed that if he fnds out he will break up with her. She admits that she has never menstruated, but her mother took her to the doctor when she was 16 and “no one seemed worried about it.” The PMHNP recognizes that Maureen’s diagnosis is likely: Selected Answer: [None Given] Answers: Androgen insensitivity syndrome Turner’s syndrome Fragile X syndrome Klinefelter’s syndrome Response Feedback : (a) is the correct answer. Maureen was likely insensitive to androgen as a fetus, and did not develop typical male secondary sex characteristics. Therefore, she developed physically and emotionally as a female, but absent female reproductive organs, she would not menstruate or be incapable of reproduction. Turner’s syndrome is characterized by the absence of an X chromosome, and while these patients are also infertile, there are unmistakable physical fndings in young childhood and the absence of secondary female sex characteristics. Fragile X syndrome is more symptomatic in boys, and Klinefelter’s syndrome only occurs in males, as it is characterized by XXY aneuploidy.  Question 61 0 out of 1 points Obsessive compulsive disorder is characterized by variable success to treatment, presenting on a bell-curve continuum. Twenty to 30% of patients have signifcant improvement, 40–50% have moderate improvement, and 20–40% remain ill or even develop worsening symptoms. Which of the following is best correlated with the most optimistic treatment outcomes? Selected Answer: [None Given] Answers: Childhood onset Yielding to compulsions Precipitating event Some acceptance of symptoms Response Feedback : (c) is the correct answer. Those patients with the best prognosis are those with good social and occupational adjustment, a precipitating event to symptoms, and an episodic nature to the symptoms. Conversely, childhood onset, bizarre compulsions, yielding to compulsions, delusional beliefs, and overvalued ideas (some acceptance of obsessions and/or compulsions) are all associated with a poorer prognosis. Question 62 0 out of 1 points Dual-sex therapy is a therapeutic approach to sexual dysfunction in a marital dyad or relationship that is believed to result from disharmony or misunderstanding in the relationship. This is most effective in couples when: Selected Answer: [None Given] Answers: The therapeutic team takes the lead in directing activities There is no other psychopathology in either partner Individual therapy for the partner with the dysfunction is unsuccessful Each partner comes to therapy with an open mind to sexual play Response Feedback : (b) is the correct answer. This form of treatment is best when there is not signifcant psychopathology in either partner. However, it is not a form in which the treatment dyad takes the lead; the patients must be active and interactive with the treating therapists. Individual therapy is not a prelude; the premise is that the couple must be the treatment target even if one partner demonstrates most of the issues. While an open mind is helpful, it is not requisite; indeed, many times the problem is related to lack of information, misinformation, and fear, and the therapists’ job is to help manage that.  Question 63 0 out of 1 points Due to the adverse effect profle of second generation antipsychotics, patients taking them should have all the following monitored regularly except: Selected Answer: [None Given] Answers: Fasting blood sugar Body mass index Fractionated lipid panel Complete blood count Response Feedback: (d) is the correct answer. These medications can exacerbate insulin resistance, cause weight gain, and increase lipid profles. A CBC may be indicated for other medications due to the risk of agranulocytosis but are not indicated in routine monitoring of second generation antipsychotics.  Question 64 0 out of 1 pointsMr. Levinson is a 41-year-old man who is under care of the PMHNP for mood disorder and insomnia. His mood disorder is currently well managed, but he continues to complain about trouble sleeping. He says the primary issue is that he cannot seem to get comfortable because he has a recurrent sensation of ants or bugs crawling all over his legs. He cannot relax and sleep because he is constantly moving his legs trying to get comfortable. The PMHNP recognizes that: Selected Answer: [None Given] Answers: This may be tactile hallucination due to his mood disorder He needs laboratory assessment of iron, folic acid, and ferritin Alcohol, hot baths, and leg massage should be avoided before bedtime A polysomnography study should be obtained Response Feedback : (b) is the correct answer. These symptoms are consistent with restless leg syndrome, and the patient should be evaluated for uremia and mineral defciencies knows to cause secondary RLS. Tactile hallucinations are unusual and not likely given that his mood disorder is well controlled. While alcohol should be avoided before bedtime, hot baths and massage may help alleviate symptoms. A polysomnogram is helpful in many sleep disorders, but not so much in this sleeprelated movement disorder.  Question 65 0 out of 1 points Mrs. Johnson is a 79-year-old lady who has been managed for Alzheimer’s dementia with a variety of nonpharmacologic management strategies such as promoting a clear household routine, timed toileting, pet therapy, and other strategies to provide structure. However, she was fnally started on donepezil 10 mg daily at bedtime to try and maximize cognitive function and memory. When following up for medication tolerance and adverse effects, the PMHNP recognizes that the most common patient complaints include: Selected Answer: [None Given] Answers: Constipation and dry mouth Nausea and diarrhea Palpitations and anxiety Nocturnal awakenings and blurred vision Response Feedback : (b) is the correct answer. This is a cholinesterase inhibitor, and the most common adverse effects are those related to parasympathetic or cholinergic activation: salivation, bradycardia and fatigue, urinary incontinence or urgency, nausea, vomiting, and diarrhea. Constipation and dry mouth are the opposite—these are anticholinergic. Palpitations and anxiety are more a consequence of sympathetic activation and not expected with parasympathetic medications. Nocturnal awakening is not associated with this drug, and blurred vision may occur because of pupillary constriction but is much less likely. Nausea and diarrhea are very common.  Question 66 0 out of 1 points Stephen is a 19-year-old male who is having a court-mandated psychiatric assessment after causing a car accident that resulted in a serious, nonfatal injury to a passenger in his car. Stephen is adamant that he just “fell asleep” and he was not doing anything wrong. A review of his sleep history does not suggest a sleep defcit, although his mother says that he always “stays up late.” A careful history suggests that Stephen might be subject to narcolepsy attacks. Which of the following confrms a diagnosis of narcolepsy? Selected Answer: [None Given] Answers: Sleep-onset REM Excessive daytime sleepiness Cataplexy Hypnagogic hallucinations Response Feedback : (a) is the correct answer. Sleep onset REM, defned as REM within 15 minutes of falling asleep, is considered diagnostic of narcolepsy. While excessive daytime sleepiness, cataplexy, and hypnagogic hallucinations are all part of the classic presenting tetrad, each of them may occur absent a diagnosis of narcolepsy.  Question 67 0 out of 1 points Catatonia is an uncommon fnding most often related to: Selected Answer: [None Given] Answers: Schizophrenia Major depressive episode General medical condition Parkinsonism Response Feedback: (b) is the correct answer. Of the known causes of catatonia, 25–50% are related to mood disorder. Only 10% are related to schizophrenia. The incidence in general medical condition is unknown, and while neuroleptic-induced Parkinsonism is a potential cause, it is relatively rare. Question 68 0 out of 1 points The PMHNP student is working on a community outreach project as part of a larger primary prevention program designed to protect children from pedophiles. When considering target audiences and program design, the PMHNP student recognizes that most pedophile offenders report: Selected Answer: [None Given] Answers: Exhibitionism toward boys Fondling the genitals of boys Vaginal penetration of girls Anal penetration of girls Response Feedback : (b) is the correct answer. While most victims referred to the medicolegal system are girls, most offenders (60%) report that when they touch, it is a boy victim. Conversely, 99% of exhibitionism is toward girls. Penetration of either form toward either gender is an infrequent occurrence; most pedophiles report contact that is either manual or oral.  Question 69 0 out of 1 points Sarah is a 52-year-old female who is referred to psychiatric care by her primary care provider. Sarah clearly does not feel that the evaluation is necessary and indicates that she has essentially been “blackmailed” by her long-time primary care provider who says he will no longer see Sarah until she has a mental health assessment. The referring PCP reports that Sarah is convinced that she has a cancer that he cannot diagnose. Sarah’s mother, brother, and sister all died from various cancers, and Sarah has become convinced that she has one too, although no one can fnd it. A genetic evaluation indicates no genetic or familial risk. Sarah has had a thorough physical examination; been screened for colorectal, breast, and cervical cancer; and has also had CT scans of the head and chest; the last two at her request as her mother and brother had brain and lung cancer, respectively. Sarah has no specifc symptoms but is fxed in the belief that she has cancer that no one can fnd. When considering a diagnosis of delusional disorder, the PMHNP would expect Sarah’s evaluation to reveal: Selected Answer: [None Given] Answers: Mental status examination is normal Hallucinations consistent with occult cancer A willingness to consider objective evidence that her belief is unrealisticFamily history of psychotic or mood disorder Response Feedback : (a) is the correct answer. Other than the rigidly fxed delusion, the patient’s presentation and mental status examination are usually within normal limits, and their occupational and social function is not impaired. Hallucinations rarely occur but are unlikely; in that case, schizophrenia should be considered. The patient is absolutely fxed in his or her belief and is unwilling to consider any discussion to the contrary. Family studies have revealed no increased incidence of psychotic or mood disorder.  Question 70 0 out of 1 points Physiologic assessment of patients with paraphilias has demonstrated that most them have: Selected Answer: [None Given] Answers: Abnormal hormone levels Hard or soft neurological signs Chromosomal abnormalities Electroencephalogram (EEG) abnormalities Response Feedback : (a) is the correct answer. While there are no randomized samples, studies of patient with paraphilia referred to large medical centers reveal that 74% have some sort of hormone abnormality. Only 27% have hard or soft neurological signs, 24% have chromosomal abnormalities, and 4% have EEG fndings.  Question 71 0 out of 1 points Ron D. is a 67-year-old man who has been referred by his primary care provider for management of sleep disorder. He has seen his PCP many times complaining of insomnia. He reports that he lays in bed for “hours” every night before falling asleep and then often wakes up every 90 minutes, sometimes staying awake for more than an hour before he goes back to sleep. He has been trialed on both zolpidem (Ambien) and zaleplon (Sonata) without improvement. Polysomnography did not support the pattern of sleep described by Ron D. During his sleep study, he reported the same complaints, while the objective test results indicated that he fell asleep in < 15 minutes with a total sleep time > 7 hours and 93% sleep efciency. This is known as: Selected Answer: [None Given] Answers: Psychophysiological insomnia Conditioned insomnia Paradoxical insomniaIdiopathic insomnia Response Feedback : (c) is the correct answer. Paradoxical insomnia, also known as subjective insomnia or sleep state misconception, is a said to occur when the patient’s impression of sleep is in conflict with the objective evidence of sleep experience. Psychophysiological or conditioned insomnia is a chronic insomnia, characterized primarily as difculty falling asleep and usually occurs as a function of some other factor causing difculty falling asleep after which the patient then develops a conditioned response; in other words, perhaps as a response to a stressor such as anxiety, the patient developed difculty falling asleep. The patient then begins to have difculty falling asleep, and a chronic insomnia due essentially to classical conditioning. Idiopathic insomnia, also called childhood onset, is a chronic, lifelong problem with all phases of the sleep cycle commonly associated with daily tiredness and poor functioning.  Question 72 0 out of 1 points Successful management of narcolepsy often involves combination treatment with both pharmacotherapy and a lifestyle regimen of regularly scheduled forced daytime naps. Which class of medications is used for its REM-suppressant properties in order to reduce cataplexy? Selected Answer: [None Given] Answers: Alpha-adrenergic receptor agonists Psychostimulants Tricyclic antidepressants Benzodiazepines Response Feedback : (c) is the correct answer. While all of these except benzodiazepines are used to manage narcolepsy, TCAs and SSRIs are used by sleep specialists specifcally to capitalize on their REM suppressant properties as the theory is that cataplexy is an intrusion of REM sleep phenomena into the waking state.  Question 73 0 out of 1 points When considering biological issues in gender dysphoria, the PMHNP recognizes that: Selected Answer: [None Given] Answers: Sexual behavior in humans is governed primarily by sex steroids The resting state of mammalian tissue is initially male; estrogen is required to differentiate into females Masculinity, femininity, and gender identity in humans are due more to prenatal hormone distribution than postnatal life events Transgender people are more likely to be left handedResponse Feedback : (d) is the correct answer. Although the signifcance is unclear, an incidental fnding in studies of transgender people is that they are more often left-handed than nontransgender peers. Sexual behavior in lower animals is governed by sex steroids, but the more complex the species, the less important this is. The resting state of mammalian tissue is female, with androgens required to differentiate testicular development. Masculinity, femininity, and gender identity is more likely a result of postnatal life events than prenatal hormones.  Question 74 0 out of 1 points Jenna is 21-year-old female who is referred to college behavioral health services by her academic advisor following an advising session that made the advisor very uncomfortable. Jenna indicated that she wanted to change her major to religious studies. Jenna says that she was surfng the Internet trying to fnd an affordable used car, but every website she saw contained hidden messages just for her. These messages told her that she needed to fnd the religious meaning in her life and that she should start by redirecting her college pathway. The PMHNP recognizes that this represents: Selected Answer: [None Given] Answers: Cosmic identity Magical thinking Loss of ego boundaries Disordered form of thought Response Feedback : (c) is the correct answer. Jenna does not have an accurate or clear sense of boundary between her own thought process and the inanimate objects around her. Cosmic identity is better described as the patient thinking she has disintegrated and fused with some element of the environment or universe. Magical thinking suggest that she can cause something by thinking about it, e.g., making it rain. Disordered form of thought is more apparent in spoken or written language, in which the patient appears incoherent, tangential, or easily derailed to the extent that communication is nonsensical.  Question 75 0 out of 1 points The PMHNP is asked to prepare a presentation for non-nursing health care workers in a local long-term care facility on the various causes of cognitive impairment in the elderly. A case presentation approach is used to reinforce principles of identifying delirium, which needs to be reported to the patient’s attending provider right away. The case should emphasize which of the following features as being closely correlated with delirium? Selected Answer: [None Given] Answers: Perceptualdisturbances Rapid onset Agitation Abnormal sleep patterns Response Feedback : (b) is the correct answer. While perceptual disturbances, agitation, and abnormal sleep patterns may occur in delirium, they may occur in any other variety of neurocognitive or medical disorders as well. Rapid onset of symptoms, however, is very closely correlated to delirium and needs to be evaluated immediately.