SOLUTION FOR MENTAL HEALTH MED CHALLENGER ALL QUESTION AND ANSWERS SUCCESS A+, Exams of Nursing

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SOLUTION FOR

MENTAL HEALTH MED

CHALLENGER

ALL QUESTION AND ANSWERS

SUCCESS A+

A 41-year-old man has developed increasing anxiety over his job performance as a manager of an international corporation. He is Caucasian, holds a master’s of business administration degree, and has a long track record of professional success. Which therapeutic intervention for anxiety is this patient particularly suited for? Cognitive behavioral therapy A 26-year-old woman has developed generalized anxiety disorder over the last year, and she has not benefited from cognitive behavioral therapy. At the time of presentation she is in good physical health and has no psychiatric comorbidities. You decide to treat her with medication. Which of the following would be most appropriate? SSRI or SNRI A 48-year-old man complains of extreme anxiety whenever he visits his parents, and over the last several years he has tried to avoid contact with them. He also fears that he could act in a way that would make his family disapprove of him. Going on actual visits over the last several years has provoked extreme anxiety on each occasion. He realizes the fear is irrational and it impairs his quality of life. He has no history of substance abuse or mental disorder, and no other medical condition that could explain his physiologic symptoms of anxiety. Which of the following is the most likely diagnosis for this patient? Nongeneralized social anxiety disorder A 35-year-old man complains of extreme shyness in social situations that go along with blushing, sweating, and, oftentimes, increased heart rate. He has started to avoid social contact largely because of this anxiety. He also reports missing interactions with friends and family. He shows symptoms of depression and assumes the depression arises from social isolation. Which of the following is the most likely diagnosis for this patient? Generalized social anxiety disorder

An 81-year-old woman nursing home resident has developed increased anxiety, so benzodiazepine treatment is considered. How is the dosing of benzodiazepines in this patient different from dosing in younger patients? decreased drug clearance, increased plasma concentrations, increased sensitivity to benzodiazepine effects A 23-year-old woman presents with a complaint of not being able to stop thinking about situations at her job and imagining situations in which she fails. She says these thoughts are present throughout the day and consume upward of 2 hours of her day. Because she is constantly fearful, she has trouble going about her daily routines. As a result, she feels worthless and also shows marked psychomotor agitation in the form of restless pacing. What should her diagnosis be? OCD A 34-year-old woman has been having episodes during which she consumes large amounts of food, often sweets and baked goods, in a relatively short period of time. At presentation, her body mass index is 32 kg/m^2. The episodes usually occur between the time she returns from work and bedtime and last 3-4 hours and recur 2-3 times per week. She is horrified by the amount of weight she has gained over the last 5 months since her eating episodes started. Upon questioning, she admits to inducing vomiting to undo the eating episode. She feels she has little or no control over the eating episodes and is deeply ashamed of her eating behavior. What should her diagnosis be? bulimia nervosa A 27-year-old woman has been diagnosed with anorexia nervosa. Which possible functional changes in the cardiovascular system should you be aware of in this scenario? bradycardia, hypotension, arrhythmia A 27-year-old woman has been diagnosed with anorexia nervosa. Her current body mass index is 16. 5 kg/m^2. She is living with her boyfriend and expresses

the desire to have a child. Which gynecologic and reproductive complications should you be aware of in this scenario? amenorrhea, complications of pregnancy, neonatal complications A 26-year-old woman with anorexia nervosa has a body mass index of 14. kg/m^2 and amenorrhea for the last 8 months. Suspected osteoporosis was confirmed by dual-energy x-ray absorptiometry. How should this patient's osteoporosis be treated? weight gain, resumption of menstrual function A 21-year-old woman with anorexia nervosa is treated with nutritional rehabilitation in an inpatient setting. She has an initial body mass index of 16 kg/m^2 and has been amenorrheic for 5 months. Which of the following is NOT an effect of early recovery? Acute inffections A 30-year-old woman with an initial body mass index of 16.5 is treated in an inpatient setting with nutritional rehabilitation. As refeeding is started, the patient may be at risk for refeeding syndrome. Which are the characteristics of refeeding syndrome? hypophosphatemia; hypokalemia; hypomagnesemia; vitamin and trace mineral deficiencies; volume overload; edema A 33-year-old woman is being treated for anorexia nervosa on an inpatient basis, but she continues to lose weight despite the use of maximal intensive care. Pharmacologic treatment is considered. Which medication is contraindicated for this patient? Bupropion A 26-year-old woman has had episodes of binge eating and subsequent purging. She was recently diagnosed with bulimia nervosa. At presentation, her body mass index is 38 kg/m^2. What is the treatment of choice for this patient? cognitive behavioral therapy

• missing^ genuine^ or^ comorbid^ illness,^ breakdown^ of^ the^ therapeutic^ alliance,^ aggressive acting out by providers against the patient, breaches of confidentiality A 47-year-old woman has been treated for hematuria, which has turned out to be factitious. Which of the following best describes the role in which the consulting psychiatrist should play during follow-up treatment help staff members focus on minimizing the disruption of care, help lessen iatrogenic complications, help staff members deal with feelings toward the patient A 51-year-old man who was involved in a traffic collision is referred by an attorney for a medical evaluation of his postconcussion syndrome in the context of a lawsuit for punitive damages. His claims of disability are overstated relative to the clinical findings, and he is uncooperative during the examination. As the examining physician, which of the following are you likely to suspect? Malingering A 30-year-old woman presents with extreme and persistent pain as well as partial paralysis of her right hand. However, neurologic defects that can account for her symptoms are lacking, so you suspect a nonorganic origin for her pain. Which of the following options best describes characteristics that may lead a health care professional to suspect a conscious production of the symptoms as opposed to conversion disorder? The patient resists opportunities to get around her disability, provides detailed
• descriptions about premorbid events, and appears highly concerned about her symptoms. A 56-year-old man presents for treatment and is complaining of low mood and insomnia that have been bothering him for the last 3 weeks. Further questioning reveals that on most days during this time he has had trouble concentrating on his work, has lost his appetite, and has experienced some weight loss. He recently stopped coaching a little league soccer team. During the interview he appears increasingly irritated by the questions, and further questioning reveals that he has been increasingly irritable at home and at work. Which of the following is the most likely diagnosis?

Major depression A 34-year-old man presents with complaints of sleeplessness and loss of appetite. An interview reveals symptoms sufficient for the diagnosis of major depression. As part of the diagnostic workup, the patient completes the Patient Health Questionnaire-9. His score is indicative of moderate depression. Which of the following best describes what this patient’s initial treatment should be? psychotherapy or pharmacotherapy with a second-generation antidepressant A 37-year-old man with a previous history of two episodes of major depression presents with new complaints of low mood and marked irritability. He also complains about marital difficulties. A quick screening test reveals that he is likely depressed, and a subsequent interview establishes that he meets the diagnostic criteria for major depression. In particular, his sleeping patterns have changed so that he now sleeps more, rather than less, and his appetite and weight have increased. The diagnostic interview takes place in mid-December, and his medical records reveal that previous depressive episodes also had their onset in the fall, and then reached remission in February or March. Which of the following represents the most appropriate diagnosis for this patient? major depressive disorder with seasonal pattern A 37-year-old man was diagnosed with fall-onset seasonal depression. At the time of diagnosis and at the 6 - week follow-up visit, he showed no signs of psychosis or suicidal ideation. However, a 12-week medication trial with citalopram 20 mg/day has not led to any improvement in his depressive symptoms; instead, it has appeared to increase somnolence. The patient is dissatisfied with this therapeutic regimen, so he requests to try light therapy. Which of the following indicates how his treatment should proceed? taper the citalopram and add light therapy A 24-year-old woman presents with complaints of sleeplessness and an inability to concentrate on her work. A subsequent interview reveals that the symptoms are sufficient for a diagnosis of major depression. Upon further

• Remission^ is^ reached^ after^2 months^ without^ symptoms.^ Withdrawal^ of^ antidepressant medication can be considered 4 - 6 months after reaching remission. Lithium is contraindicated in which of the following patients? patients with significant renal impairment or cardiovascular disease, sodium depletion, or dehydration A 23-year-old woman developed postpartum depression after the birth of her first child. She is started on 20 mg/day of fluoxetine. Which possible medication effect must she be warned about?
• increased suicide risk A 30-year-old male who was recently diagnosed with depression presents requesting initiation of pharmacotherapy to help his symptoms. He denies any suicidal or homicidal ideations or manic symptoms. He does not smoke cigarettes, drink alcohol or use illicit substances. He does not take any medications. Blood pressure is 120/80, pulse 88, respirations 14, temperature 99F. General physical examination is unremarkable. His complete blood count, serum chemistries, and thyroid stimulating hormone levels are within normal limits. Urine drug screen is negative. He expresses concern that there may be an increased risk of suicide in patients who are treated with anti- depressants and asks which class of medications carries the highest suicide risk? There is no difference in suicide risk between the classes of anti-depressants. A 50-year-old female with a history of unipolar depression presents for evaluation requesting medication to help with depression. She notes no manic symptoms or suicidal or homicidal ideations currently but notes that several of her relatives have a history of depression and have committed suicide. She does not smoke cigarettes, drink alcohol, or use illicit substances. She does not take any medications. Blood pressure is 110/80 mmHg, pulse 80, respirations 14, oxygen saturation 100% on room air, temperature 99F. General physical examination is within normal limits. Complete blood count, serum chemistries, liver enzymes, and thyroid function tests are within normal limits. Urine drug screen is negative. She asks which of the following medications have been shown to prevent suicide?

Lithium A 31-year-old man presents with rash, night sweats, weight loss, and fatigue. He describes the rash as starting 1 day ago and is located on his fingers and toes. The rash is painful. The weight loss began 1 week ago, around the same time the fatigue and night sweats began. He’s not sure how much weight he has lost, but says his jeans are now too big. Social history includes intravenous heroin abuse, and he smokes 1 pack of cigarettes a day. His vital signs are: temperature 102.2 °F (39 ° C), pulse 126 beats/minute, blood pressure 105/56 mm Hg, respiratory rate 15 breaths/minute, and oxygen saturation 9 7% on room air. His body mass index is 19. 1 kg/m^2. There are multiple, tender erythematous and violaceous papules along the ventral surface of his fingers and toes. Fingernails bilaterally have erythematous, vertical streaks within the nail beds. A regurgitant murmur is heard in the aortic position, and there are subconjunctival petechiae noted bilaterally. His hemoglobin level is 9.1 g/dL (normal range, 11-14 g/dL), and his hematocrit level is 27% (range, 32%-42%). What is the most likely diagnosis? Infectious endocardiatis A 26-year-old woman is brought to you because of an acute panic attack she had at a dance party. She feels warm to the touch, acts restless, and is pacing the room. There is no past medical history of illnesses. Social history includes alcohol consumption of 5 to 6 drinks per night on the weekends. Friends with the patient reveal she was "maybe trying some stuff" while she was at the dance party. Her vital signs are: temperature 103.8 °F (40 °C), pulse 120 beats/minute, blood pressure 16 0/90 mm Hg, respiratory rate 25 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 19.1 kg/m2. The patient is salivating and sweating profusely, and she has pressured speech. Laboratory studies are as follows: Glucose: 89 mg/dL (normal range, 70-100 mg/dL) Sodium: 138 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.2 mmol/L (normal range, 3.5-5.4 mmol/L)

Start a benzodiazepine taper to manage her withdrawal symptoms. A 35-year-old, nonpregnant woman presents with a request to begin smoking cessation. Social history includes a 22-year smoking history. She denies any alcohol or illicit drug use. Past medical history includes hypertension. Past surgical history is pertinent for cesarean delivery at age 27 years. Current medications include lisinopril 10 mg daily. Her vital signs are: temperature 98.6 °F (37 °C), pulse 65 beats/minute, blood pressure 114/72 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 25.8 kg/m2. Laboratory studies are as follows: Glucose: 96 mg/dL (normal range, 70-100 mg/dL) Sodium: 140 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.4 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.8 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 10 mg/dL (normal range, 7 - 18 mg/dL) Alanine aminotransferase: 12.0 U/L (normal range, 0 - 55 U/L) Aspartate aminotransferase:10.0 U/L (normal range, 5-34 U/L) Alkaline phosphatase: 43.0 U/L (normal range, 40-150 U/L) Hemoglobin: 13.7 g/dL (normal range, 11 - 14 g/dL) Hematocrit: 38% (normal range, 32%-42%) Which of the following interventions should be considered for this patient? smoking cessation program plus either nicotine replacement or bupropion A 28-year-old woman presents to discuss smoking cessation. She reports a home pregnancy test was positive last week and desires to quit smoking. Social history includes heroin abuse, smoking 1 pack of cigarettes per day, and drinking 10 beers per day. She reports she is still using heroin daily. Past medical history includes alcohol use disorder. Her vital signs are: temperature 98.6 °F (37 ° C), pulse 78 beats/minute, blood pressure 105/56 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 23.4 kg/m2. Laboratory studies are as follows: Glucose: 83 mg/dL (normal range, 70-100 mg/dL) Sodium: 143 mmol/L (normal range, 136 - 145 mmol/L)

Potassium: 3.9 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.9 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 13 mg/dL (normal range, 7 - 18 mg/dL) Alanine aminotransferase: 17.0 U/L (normal range, 0-55 U/L) Aspartate aminotransferase: 18.0 U/L (normal range, 5-34 U/L) Alkaline phosphatase: 58.0 U/L (normal range, 40-150 U/L) Hemoglobin: 11.9 g/dL (normal range, 11 - 14 g/dL) Hematocrit: 34% (normal range, 32%-42%) Urine drug screen is positive for opiates. Urine pregnancy test is positive. What is the preferred method of managing this patient’s substance use disorders during her pregnancy? maintenance therapy with methadone, smoking cessation counseling, alcohol withdrawal treatment using long-acting benzodiazepines A 47-year-old former construction worker presents to you with low back pain. She reports it began 3 years ago and has progressively worsened, making it difficult for her to continue to work. She describes the pain as dull, nonradiating, and worse with bending, twisting, or lifting more than 10 pounds. There is no numbness or tingling. Past medical history includes hypertension, prediabetes and obesity. Current medications are amlodipine 10 mg daily, ibuprofen 800 mg every 8 hours as needed for pain, metformin 500 mg twice daily, and valsartan 40 mg daily. vital signs are: temperature 98.6 °F (37 °C), pulse 67 beats/minute, blood pressure 132/84 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 37.1 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Deep tendon patellar reflexes are equal and normal bilaterally. Paraspinal muscle spasms are noted at levels L3 to L5. Laboratory studies are as follows: Glucose: 106 mg/dL (normal range, 70-100 mg/dL) Sodium: 142 mmol/L (normal range, 136-145 mmol/L) Potassium: 3.9 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.8 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 12 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 13.3 g/dL (normal range, 11-14 g/dL) Hematocrit: 35% (normal range, 32%-42%)

A 68-year-old retired dentist presents with long-term low back pain. She reports it began more than 35 years ago with the birth of her last child and has progressively worsened. She was diagnosed 5 years ago with severe herniation at level L4 to L5 and severe left spinal canal stenosis. She tells you that she had "back surgery." At the time, she was having low back pain with severe, burning, and stinging pain radiating down her left posterior thigh and into her calf with numbness in her foot. The burning pain has resolved since surgery; however, the throbbing, low back pain has worsened. She rates her pain as an 8 on a 10-point scale most days, with difficulty functioning and inability to participate in family activities. She has been to physical therapy 8 times over the past 5 years, and saw a chiropractor regularly for 3 years until she stopped because "it just didn’t seem to help much." Past medical history includes long-term low back pain, radiculopathy, and hypertension. Current medications are gabapentin 1200 mg thrice daily, baclofen 20 mg every 12 hours as needed for spasms, ibuprofen 800 mg every 8 hours as needed for pain, and lisinopril 40 mg daily. Her vital signs are: temperature 98.7 °F (37 °C), pulse 68 beats/minute, blood pressure 131/73 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 28.8 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Laboratory studies are as follows: Glucose: 78 mg/dL (normal range, 70-100 mg/dL) Sodium: 144 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.4 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 1.0 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 15 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 11.6 g/dL (normal range, 11-14 g/dL) Hematocrit: 38% (normal range, 32%-42%) X- ray of the lumbar spine shows diffuse, severe arthritis, and degenerative disc disease at level L4 to L5. What is the most appropriate next treatment option?

• Stop gabapentin and recommend another medication for pain control such as duloxetine.

A 63-year-old woman presents to you with low back pain that she says is a 7 on a 10-point scale for 1 day following a "mud run." She reports her entire family was participating in the event. Her symptoms began yesterday after she tried to lift a large log on the course. She reports throbbing with radiation to the right posterior thigh with changing positions. She cannot recall any previous issues with her back. She denies leg weakness or numbness. Past medical history is negative for any long-term disease. She is not on any medications. Vital signs are: temperature 98.5 °F (37 °C), pulse 61 beats/minute, blood pressure 122/74 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 20.8 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Deep tendon patellar reflexes are equal and normal bilaterally. Laboratory studies are as follows: Glucose: 86 mg/dL (normal range, 70-100 mg/dL) Sodium: 137 mmol/L (normal range, 136-145 mmol/L) Potassium: 3.8 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 0.9 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 14 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 12.5 g/dL (normal range, 11-14 g/dL) Hematocrit: 37% (normal range, 32%-42%) X- ray of the lumbar spine shows mild and diffuse arthritis. Which duration of immediate opioid therapy would be the most appropriate for this patient?

• 3 days A 59-year-old man presents to you severe low back pain that he says he has had for 8 years. He initially injured his back while working on his home. He has just completed 8 weeks of physical therapy, and he has been receiving chiropractic care for 1 year. He had been evaluated by a neurosurgeon and has declines any surgical interventions. He elects medical management of his pain. He has attempted multiple nonpharmacologic therapies, including tai chi, cognitive behavioral therapy, acupuncture, exercise, low-level laser therapy, and electromyography biofeedback. However, none of these modalities have reduced his pain.

She has been to physical therapy 8 times in the past 5 years, and she saw a chiropractor regularly for 3 years until she stopped because "it just didn’t seem to help much." Past medical history includes long-term low back pain, radiculopathy, and hypertension. Current medications are gabapentin 1200 mg thrice daily, baclofen 20 mg every 12 hours as needed for spasms, ibuprofen 800 mg every 8 hours as needed for pain, and lisinopril 40 mg daily. She has tried duloxetine, tramadol, carbamazepine, nortriptyline, and amitriptyline for pain management, but she has had no success. She has also tried multiple skeletal muscle relaxants but noticed only minimal reduction in her pain. Her vital signs are: temperature 98.7 °F (37 °C), pulse 68 beats/minute, blood pressure 131/73 mm Hg, respiratory rate 12 breaths/minute, and oxygen saturation 100% on room air. Her body mass index is 28.8 kg/m2. Decreased range of motion of the lumbar spine due to pain is noted on physical examination. Laboratory studies are as follows: Glucose: 78 mg/dL (normal range, 70-100 mg/dL) Sodium: 144 mmol/L (normal range, 136-145 mmol/L) Potassium: 4.4 mmol/L (normal range, 3.5-5.4 mmol/L) Creatinine: 1.0 mg/dL (normal range, 0.6-1.1 mg/dL) Urea nitrogen: 15 mg/dL (normal range, 7-18 mg/dL) Hemoglobin: 11.6 g/dL (normal range, 11-14 g/dL) Hematocrit: 38% (normal range, 32%-42%) X- ray of the lumbar spine shows diffuse, severe arthritis and degenerative disc disease at L4 to L5. What is the most appropriate next treatment option?

• Evaluate^ risk^ factors^ for^ opioid-related^ harms^ and,^ if^ the^ benefit^ outweighs^ the^ risk,^ begin immediate-release opioid therapy (≤ 50 morphine milligram equivalents [MMEs]/day). In the course of routine medical treatments, it becomes apparent that a 34- year-old man is subject to frequent anxiety and mood swings and tends toward angry outbursts, which are also evident during other medical visits. With few variations, this behavior pattern has been present since the patient's late teens. Further assessment also reveals that he abuses multiple drugs. The patient also admits to several traffic tickets for speeding. Which of the following conditions should be suggested on the basis of these symptoms?

Personality disorder A 28-year-old man presents after a suicide attempt. His medical records reveal that this is the third attempt he has made over the course of 3 years. He states that his motivation was concern over the relationship with his girlfriend, fearing that she might be leaving him. His girlfriend describes the patient as extremely clingy and jealous. The relationship has gone through phases where the patient has idolized his girlfriend alternating with periods where he is cold and distant and his behavior demeaning. Further questioning reveals that the patient is sexually promiscuous, and he frequently overspends on items he does not really need. At times his behavior can be grandiose, and he frequently has angry outbursts with little or no provocation. He also states that the world seems to be out to get him and that he does not really feel safe. However, he says this feeling of being threatened is not always present and he goes through long periods without feeling this way. Which of the following represents the most likely diagnosis for this patient? Borderline personality disorder A 23-year-old man presents after he has been arrested for speeding on his motorcycle in rush hour traffic. He has engaged in similar bouts of speeding several times before. He also has a criminal record, reaching back several years, mostly for theft. He abruptly left his job 2 days before the speeding incident, and he did not have steady employment before the incident. His behavior problems started when he was 12 years of age and have been continued ever since. He was diagnosed with conduct disorder at the age of

14. Which of the following represents the most likely diagnosis for this patient? Antisocial personality disorder A 51-year-old woman with a longstanding diagnosis of borderline personality disorder is assessed in the course of planning the management of her condition. Which of the following best describes an area that is NOT required routinely in the initial assessment? Drug screen