ANCC Certification PMHNP Chapter 7
Mood Disorders – Most common psych illnesses
Primary characteristic is persistent disturbance in mood – Major Depressive Disorder
Often occurs without precipitating event – MDD
Object loss theory – Fairbairn, Winnicott & guntrip
Aggression turned inward theory of MDD – Freud
Cognitive Theory – Beck
Learned Helplessness-Hopelessness Theory – Seligman
Genetic predisposition – Strong genetic load for depression for child of depressed parent
-having 3 fold increase in lifetime risk of MDD & 40% chance of depressive episode
before age 18.
Endocrine dysfunction Theory – Probably related to etiology of MDD
Sleep disturbances, appetite disturbances, libido disturbances, lethargy, anhedonia are
neurovegitative symptoms that are related to functions of the – Hypothalamus and
pituitary gland secretions
Endocrine dysfunction and pregnancy – A high incidence of postpartum mood
disturbances is suggested with this
Hypothalamic-pituitary-adrenal axis (HPA) – A theory of MDD, may be a result of an
abnormal stress response related to dysregulation of this system
HPA axis – Controls the physiological response to stress and is composed of
interconnective feedback pathways between the hypothalamus, pituitary gland, and
adrenal gland.
Hypothalamus releases – corticotropin-releasing hormone (CRH)
Adrenocorticotropin hormone (ACTH) – Released by pituitary in response to CRH by
hypothalamus
Cortisol – Released by adrenal glands in response to ACTH by pituitary gland
Hyperactivity of the HPA axis – Demonstrated to be present in individuals with MDD.
May also have elevated cortisol levels
Elevated cortisol levels – Over time damages the CNS by altering neurotransmission
and electrical signal conduction. Cortisol over time can cause changes in size and
function of brain tissue
Dexamethasone suppression test (DST) – Not commonly used in clinical practice for
screening of depression as it is too non specific.
Hypovolemic hippocampus and hypovolemic prefrontal cortex-limbic striatal regions –
Abnormalities demonstrated by neuroimaging in individuals with chronic and severe
depression
Brain damage, including that from stroke and trauma – Depression is a acommon
comorbidity in individuals who have experienced these events
What is the Chronobiological theory of MDD – Desynchronization of the circadian
rhythms produces the symptom constellation collectively called MDD
Circadian rhythms control these biological processes that are frequent problems with
depressed individuals – Sleep-rest cycle disturbances * Increased cortisol secretions *
REM abnormalities Increased emotional reactivity
Frequent waking
More intensified dreaming
Diurnal variations to circadian-related behaviors
Decreased arousal and energy levels
Decreased activity patterns *
Incidence of MDD – 5% of U.S. population ages 18 and older each year. About 9.9
million Americans
Most common psychiatric illness seen in primary care practices; only 50% of people
receive treatment – MDD
25% women, 12% men – Risk during reproductive years
Risk of MDD is __ for both genders below puberty and after menopause – equal
MDD is (greater) or (lesser) source of morbidity for women than other illnesses. –
Greater
Fifteen percent (15%) – Of people with MDD will commit suicide
People with MDD – Four times greater risk of premature death – Than normal control
population
Georgettes LMR study set/PMHNP Review items
When questions ask for a priority action…think about… – THE CORRECT ASNWER IS
ABC, airway breathing, circulation
Maslows hierarchy
If undecided on an answer due to high similarities, choose: – THE CORRECT ASNWER
IS the umbrella answer
What is the most common side effect of olanzapine/zyprexa – THE CORRECT
ASNWER IS metabolic syndrome
what is the difference between typical and atypical antipsychotics – THE CORRECT
ASNWER IS Atypical 5HT2A specific
1st psychotic break… two actions to take – THE CORRECT ASNWER IS UDS and r/o
sub
Consider IM Geodon or Invega
Three AP with least weight gain – THE CORRECT ASNWER IS Latuda, Abilify, Geodon
Always encourage interprofessional collaboration – THE CORRECT ASNWER IS
between therapists/pcps/SW/RN, the ENTIRE team
TSH High, then….t3/t4 – THE CORRECT ASNWER IS T3, T4 low
TSH low, then…t3/t4 – THE CORRECT ASNWER IS T3, T4 high
cold/hot sensitivity with t3/t4 relationship – THE CORRECT ASNWER IS T3/T4 low,
hypothyroid, cold, slow
T3/T4 high, hyperthyroid, hot, flushed, tachy
What birth defect can be caused by depakote? – THE CORRECT ASNWER IS Spina
bifida
What organ does depakote cause toxicity? and what sx would you expect to see? labs
to run? – THE CORRECT ASNWER IS Hepatotoxicity: RUQ pain, reddish brown urineDo LFTs
kava kava is used to treat – THE CORRECT ASNWER IS anxiety and insomnia
Rash and fever associated with tegretol, suspect – THE CORRECT ASNWER IS
What allele is HLAB 1502 associated? – THE CORRECT ASNWER IS Asians. They
CANNOT have tegretol. Test all asians for this allele.
what rare and dangerous side effects are associated with tegretol – THE CORRECT
ASNWER IS Aplastic anemia
Agranulocytosis-DC at ANC less than 1000
Sx’s of agranulocytosis – THE CORRECT ASNWER IS unusual bleeding or bruising,
mouth sores, infections, fever, sore throat, fatigue
if starting a woman on lithium what test should be done? why? – THE CORRECT
ASNWER IS HCG–risk of ebstein anomaly
adverse s/e of lamictal/lamotrigine – THE CORRECT ASNWER IS SJS
labs to checke BEFORE starting on lithium – THE CORRECT ASNWER IS BUN
CRE
urine protein
What does protein in urine indicate – THE CORRECT ASNWER IS kidney impairment;
4+ protein in urine=you cannot start on lithium
best choice med for decreasing si in bipolar disorder. – THE CORRECT ASNWER IS
lithium
best choice med for si in schizophrenia – THE CORRECT ASNWER IS clozaril
best choice med for SI in borderline – THE CORRECT ASNWER IS lithium
What medications will INCREASE Li levels – THE CORRECT ASNWER IS NSAIDS
ACE’s
Thiazides/HCTZ
Besides medications, what else can cause increased Li levels – THE CORRECT
ASNWER IS dehydration
hyponatremia
lithium s/e inc N/V, which will effect electrolytes, and dehydration status
what type of tremors will you see with lithium toxicity? – THE CORRECT ASNWER IS
course tremors
lithium can cause what other comorbidities? – THE CORRECT ASNWER IS
hypothyroidism
maculopapular rash
leukocytosis
twave inversion
what is a defining characteristic of NMS vs SS – THE CORRECT ASNWER IS muscle
rigidity
Sx’s/labs associated with NMS – THE CORRECT ASNWER IS Inc CPK, WBC, LFT
Rhabdomyolosis
myoglobinuria
Can lead to mutism
myoglobinuria/rhabdo can cause cherry colored urine
Treatment for NMS and what each does – THE CORRECT ASNWER IS DC the
offending agent
bromocriptin-D2 agonis
dantrolene: muscle relaxant
Make sure if ? is asking for agonist or relaxant
Sx of SS – THE CORRECT ASNWER IS HYPERREFLEXIA
myoclonic jerks
treatment for SS – THE CORRECT ASNWER IS ciproheptadine
how to best PREVENT SS – THE CORRECT ASNWER IS follow proper transition
protocols
SSRI to MAOI=14 days
Prozac to MAOI=5-6 weeks
Triptans can also cause SS due to serotonin increase with use
Why are SSRIs considered the safest for use in depression – THE CORRECT ASNWER
IS safest for OD
depressed patient presents with fatigue and low energy, consider: – THE CORRECT
ASNWER IS NDRI wellbutrin
sexual s/e with ssri? try… – THE CORRECT ASNWER IS wellbutrin due to lower risk of
sexual s/e
What medication must be avoided if client has seizure history or eating disorder? why? –
THE CORRECT ASNWER IS wellbutrin due to decreasing the seizure threshold
if client has depression and neuropathic pain – THE CORRECT ASNWER IS SNRI or
TCA for treatment of BOTH
What med class treats neuropathic pain well – THE CORRECT ASNWER IS alpha 2
delta ligands
Gabapentin
Lyrica
ANCC Georgette Review For Boards
3 yr old play with self, says naughty things. Normal for which theorist – THE CORRECT
ASNWER IS Piaget
Which cranial nerve for 14yr old clenching teeth – THE CORRECT ASNWER IS
Trigeminal, Cranial nerve V
16yr old falls with wrong crowd may have what disorder – THE CORRECT ASNWER IS
Conduct disorder
Ace inhibitors are drug choice for what – THE CORRECT ASNWER IS Heart failure,
HTN
Acute distress disorder must occur within what time frame – THE CORRECT ASNWER
IS 1 month of trauma and resolve within the month
Exposure to a major stressor with anxiety, dissociation, nightmares, sleep disturbances,
concentration problems from trauma 3 weeks prior leads to what diagnosis – THE
CORRECT ASNWER IS Acute Stress Disorder
If symptoms of traumatic event lead to anxiety ,nightmares, sleep issues, concentration
problems and last past one month, what is the diagnosis – THE CORRECT ASNWER IS
PTSD
Med for adult with panic disorder – THE CORRECT ASNWER IS Buspar
What is used as a bridge medication for panic disorder when starting an SSRI or
another antidepressant – THE CORRECT ASNWER IS Benzodiazepine
Term for fear of open spaces – THE CORRECT ASNWER IS Agoraphobia
Medication for Agoraphobia short term – THE CORRECT ASNWER IS Benzodiazepine
3 SSRI to treat agoraphobia long term – THE CORRECT ASNWER IS Prozac, Paxil,
and Zoloft
One SNRI to treat Agoraphobia long term – THE CORRECT ASNWER IS Effexor
What part of the brain regulates fear, anxiety, aggression – THE CORRECT ASNWER
IS Amygdala
what style of therapy for a patient with anorexia – THE CORRECT ASNWER IS Family
therapy
Hospitalization criteria for anorexia – THE CORRECT ASNWER IS Weight loss over
30% in 6 months, heart rate less than 40, hypokalemia less than 3 mEq
To qualify for anorexia Nervosa the BMI would be less than what – THE CORRECT
ASNWER IS 18.5
an eating disorder in which an irrational fear of weight gain leads people to starve
themselves – THE CORRECT ASNWER IS Anorexia Nervosa
Cell death in aging/elderly is known as what – THE CORRECT ASNWER IS Apoptosis
A process of building on what works rather than focusing on and fixing what doesn’t is
known as what – THE CORRECT ASNWER IS Appreciative Inquiry
In this stage a person has no intent to change – THE CORRECT ASNWER IS
Precontemplation
In this stage the person is thinking of change and aware of the problem but not
committed to change – THE CORRECT ASNWER IS Contemplation
In this stage the person has made the decision to change and is ready for action – THE
CORRECT ASNWER IS Preparation
In this stage the person is engaging in specific actions to change – THE CORRECT
ASNWER IS Action
This is taken 15 minutes before sex – THE CORRECT ASNWER IS Avanafil (Stendra)
Take this 45 minutes before sex – THE CORRECT ASNWER IS Tadalafil (Cialis) and
Vardenafil (Levitra)
Take this one hour before sex – THE CORRECT ASNWER IS Sildenafil (Viagra)
According to Beck depression scale, 0-13 is considered – THE CORRECT ASNWER IS
Minimal Depression
According to Beck depression scale, 14-19 is considered – THE CORRECT ASNWER
IS Mild Depression
According to Beck depression scale, 20-28 is considered – THE CORRECT ASNWER
IS Moderate Depression
According to Beck depression scale, 29-63 is considered – THE CORRECT ASNWER
IS Severe Depression
PMHNP certification Exam
Which patient is at highest risk for SI
A. 30y/o married AA female with previous SI attempt *1 risk factor
B. 35 y/o single Asian male with previous SI attempt *3 risk factors
C. 38 y/o single AA male who is a manager of a bank *2 risk factors
D. 68 y/o single white male with depression *5 risk factors (age, male, white,
depression) – THE CORRECT ASNWER IS D. 68 y/o single white male with depression
*5 risk factors (age, male, white, depression)
Count the risk factors
When interview teenagers (16 y/o) that arrive with their parents what should you do? –
THE CORRECT ASNWER IS interview them separately from parents.
-This helps Build therapeutic rapport with teens by telling them the info is confidential.
Parents may be upset but remember you are advocating for the child.
Which Ethnic group has the highest rate of suicide? – THE CORRECT ASNWER IS
Native Americans
Example A patient is being treated for schizophrenia with olanzapine. Which of the
following is the most common side effect of olanzapine?
A. Increased waist circumference
B. EPS (not as common in atypical antipsychotics d/t 5HT2A)-receptor antagonism
C. Increased Lipids
D. Metabolic Syndrome – THE CORRECT ASNWER IS D. Metabolic Syndrome
(UMBRELLA ANSWER)
Which antipsychotics have the least weight gain? – THE CORRECT ASNWER IS
Latuda, Abilify, (also least sedating), Geodon-if patient has metabolic syndrome
consider switching to one of the medications above. Or if the patient is overly sedated
try switching to ABILIFY
Which mood stabilizer have the least weight gain? – THE CORRECT ASNWER IS
Lamictal
-But remember all mood stabilizers cause some weight gain
When presented with a question about typical vs atypical antipsychotic the answer is
usually to start of a – THE CORRECT ASNWER IS atypical
A client presents with complains of changes in appetite, feeling fatigued, problems with
sleep-rest cycle, and changes in libido. What is the neuroanatomical area of the brain
that is responsible for the normal regulation of these functions?
A. Thalamus
B. Hypothalamus
C. Limbic System
D. Hippocampus – THE CORRECT ASNWER IS Hypothalamus
A, B, & D are all part of the limbic system so you can rule that out
When a patient is hesitant to participate in treatment you should encourage? – THE
CORRECT ASNWER IS Bring a support person like a husband
Thyroid-Stimulating hormone normal level – THE CORRECT ASNWER IS 0.5-5.0 Mu/L
When T4 and T3 are high and TSH is low what is the diagnosis – THE CORRECT
ASNWER IS HYPERTHYROIDISM, TSH secretion decreases: TSH LOW à key
symptoms HEAT INTOLERANCE
Key symptoms of Heat Intolerance – THE CORRECT ASNWER IS Hyperthyroidism
When T4 and T3 are Low and TSH is high what is the diagnosis – THE CORRECT
ASNWER IS (HYPOTHYROIDISM) TSH secretion increased: TSH HIGH à COLD
INTERANCE
Key symptoms of Cold Intolerance – THE CORRECT ASNWER IS Hypothyroidism
Hyperthyroid can mimic – THE CORRECT ASNWER IS Mania
Hypothyroid can mimic – THE CORRECT ASNWER IS Depression
A patient on depakote complains of RUQ pain and has reddish/brown urine – THE
CORRECT ASNWER IS Hepatoxicity
-Check LFTs
Signs of Depakote toxicity – THE CORRECT ASNWER IS Disorientation, confusion,
lethargy
You suspect depakote toxicity what do you do? – THE CORRECT ASNWER IS Check
-LFT
-Ammonia
-Depakote Level
What herbal supplement can cause hepatoxicity? – THE CORRECT ASNWER IS Kava
Kava
When taking Kava Kava in combinations with other medications you should caution
about – THE CORRECT ASNWER IS Risk of Hepatoxicity and Sedation
TCAs carry a risk of – THE CORRECT ASNWER IS Hepatotoxicity
Signs of Stevens-Johnson Syndrome – THE CORRECT ASNWER IS -fever, mouth
pain, swelling, burning eyes, blisters, skin pain
two psychotropics known to cause steven johnson syndrome – THE CORRECT
ASNWER IS lamictal and tegretol
What nationality is most suseptible of getting steven johnson? – THE CORRECT
ASNWER IS Asians
When treating asians with tegretal screen for? – THE CORRECT ASNWER IS HLAB1502 Allele
What two medications cause agranulocytosis? – THE CORRECT ASNWER IS Clozaril
& Tegretal
Agranulocytosis when to discontinue medication – THE CORRECT ASNWER IS Less
than 1000
When monitoring for agranulocytosis in patients look for s/s of what? – THE CORRECT
ASNWER IS Infection
-Fever, sore throat, fatigue, chills
Before starting any mood stabilizer in a female of childbearing age be sure to check? –
THE CORRECT ASNWER IS HCG
Which two medications may decrease the risk of suicide? – THE CORRECT ASNWER
IS clozaril and lithium
Medications that increase lithium level – THE CORRECT ASNWER IS NSAID-ibuprofen,
INDOCIN
THIAZIDES-hydrochlorithiazide ACE INHIBITORS-lisinopril
Ace inhibitors are treatment of choice for? – THE CORRECT ASNWER IS Heart Failure
Certain medications are known to increase lithium level, but HOW? – THE CORRECT
ASNWER IS by reducing renal clearance
When educating a patient about lithium teach them about – THE CORRECT ASNWER
IS Hyponatremia
Dehydration-hot days, exercise
Normal Lithium Level – THE CORRECT ASNWER IS 0.6-1.2
Lithium Toxicity – THE CORRECT ASNWER IS 1.5 or above
Discontinue and re-order lithium level
Lithium level of 1.4 – THE CORRECT ASNWER IS Monitor for toxicity
Labs before starting lithium – THE CORRECT ASNWER IS TSH, BUN, CREATININE,
HCG, U/A to check for presence of protein in the urine (4+ protein is concerning for
renal impairment)à4+ protein in urine=MONITOR FOR TOXICITY
4+ protein in the urine of a patient on lithium – THE CORRECT ASNWER IS 4+ protein
is concerning for renal impairment
4+ protein in urine=MONITOR FOR TOXICITY
Lithium side effects – THE CORRECT ASNWER IS hypothyroid, leukocytosis,
maculopapular rash, t-wave inversion, Coarse Hand Tremor, GI upset (nausea,
vomiting, anorexia)
-Some of these are also signs of toxicity
Signs of lithium toxicity – THE CORRECT ASNWER IS confusion, ataxia, GI upset,
palpitation, tremor
NMS – THE CORRECT ASNWER IS muscle rigidity, mutism (because of muscle
rigidity), increased CPK (caused by muscle contraction and muscle destruction),
increase WBC, increased WBC, myoglobinuria (also from muscle destruction)
Cherry colored urine in a patient that exercises a lot – THE CORRECT ASNWER IS test
for myoglobinuria may be a sign of rhabdo
Serotonin Syndrome – THE CORRECT ASNWER IS With any drug that increases 5-HT
(e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus,
cardiovascular instability, flushing, diarrhea, seizures.
-Treatment: cyproheptadine (5-HT2 receptor antagonist).
Treatment for NMS – THE CORRECT ASNWER IS Stop Offending Medication
-Dantrolene (muscle relaxer)
-Bromocriptine (Dopamine D2 agonist).
*In question focus on what they are asking for….dopamine agonist vs muscle relaxer
Treatment for Serotonin Syndrome – THE CORRECT ASNWER IS Stop Med (1 or more
SSRI, SSNRI, TCA, MOAI)
-Cyproheptadine
Triptans – THE CORRECT ASNWER IS Used for MIGRAINES
-These meds increase serotonin
example SUMATRIPTAN