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NR 547 Differential Dx Midterm Exam
Questions and Answers 2024 GUARANTEE
PASS
Differential Dx - Solution Diagnostic reasoning is the process of questioning one's thinking to determine if all possible avenues have been explored and if the conclusions that are drawn are based on evidence. This is a critical step for providers who are trying to uncover a cause, or diagnosis, for their clients' signs and symptoms. The provider's initial hypothesis is known as the differential diagnosis. The differential diagnosis, or differential, is a working list of potential problems that can be associated with the initial or chief complaint. Establishing a differential diagnosis is a critical step in providing safe, quality care. This evolving process of clinical reasoning and decision making involves examining the client's presentation, clinical data, and when appropriate, screening and diagnostic test results to distinguish one disease from another and arrive at the correct diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)provides guidance for identifying psychiatric diagnosest History of Present Illness - Solution How long have you been feeling this way? Did something happen in your life that may have triggered these emotions? How is this current situation impacting your life? The Psychiatric History - Solution Have you ever been hospitalized for any mental health issues? Have you ever had counseling or psychotherapy? Have you ever taken medications for your mental health in the past? Are you currently on any medications for mental health or sleep? Medical History/Screening for General Medical Conditions - Solution Do you have a primary care provider? Do you have any medical illnesses? Are you currently taking any medications or herbal supplements? Do you have any allergies to medications? Have you ever been hospitalized for any reason? Have you ever had surgery?
Family Psychiatric History - Solution Has any relative of yours ever been hospitalized for a mental health issue? Has any blood relative of yours ever been diagnosed with a mental health issue? Has any blood relative of yours had a history of seizures or dementia/Alzheimer's? Social and Developmental History - Solution Tell me a little bit about your childhood and how you grew up. How was your experience in school when you were younger? Did you enjoy school? How do you support yourself with your finances? Do you have a good support system? Are you currently in a relationship? Where do you live? Who do you live with? What do you do in your free time? What activities do you enjoy? Which of the following should be included when providing client education about medication regimens? Select all that apply. - Solution A)Explain how the medication targets the symptoms, specific benefits, and expected time course. ( Solution ) B)Identify potential side effects, duration of side effects, and adverse effects. ( Solution ) C)Explain the instructions, dosing, and special requirements. ( Solution ) D)Use teach-back methods to ensure client understanding. ( Solution ) Apply the Ask Suicide-Screening Questions (ASQ) Suicide Risk Screening Tool (Links to an external site.) to the scenario below. A 52-year-old client presents to the emergency department following a car accident. The emergency department (ED) physician is concerned that the client may have intentionally crashed her car and requests a stat PMHNP consult. In speaking with the PMHNP, the client describes persistent feelings of sadness and hopelessness. She states that she often wonders if her husband would be happier if she wasn't around anymore since she's never happy and sometimes thinks about what it would be like to just take a handful of sleeping pills and go to sleep forever. The client reports a previous suicide attempt when she was 16 but denies that she is considering killing herself right now. Based on the client's ASQ score, what is the most appropriate response? A) No action is necessary as the client is not - Solution B)Provide a brief suicide safety assessment.
Lymphocytes: 20%-35% Monocytes: 3%-8% Platelets: 150,000-300,000/microliter Comprehensive Metabolic Panel (CMP) - Solution The CMP is another common blood test used to determine general health status. The CMP includes several tests that provide information about fluid and electrolyte balance as well as the status of the body's metabolism, liver function, and kidney function. In psychiatric care, the CMP may be used to rule out medical conditions that could cause symptoms such as changes in mood or cognition. The CMP is also used to monitor the effects of medications, such as antipsychotics, on liver function and glucose levels. Normal CMP Levels Electrolytes Sodium (Na+): Postassium (K+): Chloride (Cl-): Bicarbonate (HCO3-): - Solution Normal CMP Levels Electrolytes Sodium (Na+): 136-145 mEq/L Postassium (K+): 3.5-5.0 mEq/L Chloride (Cl-): 95-105 mEq/L Bicarbonate (HCO3-): 22-28 mEq/L Normal CMP levels Misc. Calcium, serum (Ca 2+) Glucose, serum Fasting: 2-h postprandial: Cholesterol, serum: Total Protein Albumin - Solution Calcium, serum (Ca 2+) 8.4-10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl Cholesterol, serum: REC<200 mg/dl Total Protein 6.0-7.8 g/dl Albumin 3.5-5.5 g/dl Kidney Tests
Creatinine, serum Urea nitrogen, serum (BUN) - Solution Creatinine, serum 0.6-1.2mg/dl Urea nitrogen, serum (BUN) 7-18mg/dl Liver Tests Alanine aminotransferase (ALT), serum: Aspartate aminotransferase (AST), Bilirubin, serum (adult) Total//Direct: Phosphatase (alkaline), serum: - Solution Liver Tests Alanine aminotransferase (ALT), serum: 8-20 U/L Aspartate aminotransferase (AST), serum: 8-20 U/L Bilirubin, serum (adult) Total//Direct: 0.1-1.0 mg/dl // 0.0-0.3 mg/dl Phosphatase (alkaline), serum: 20-70 U/L Normal TFT levels TSH: T3: T4: - Solution Normal TFT levels TSH: 0.4-4.5 mIU/L T3: 100-200 ng/dL T4: 5-11 ug/dL Vitamin B12 Level - Solution Providers may choose to check vitamin B levels. Deficiency of vitamin B12 can affect mood and other brain functions. Common psychiatric symptoms associated with B12 deficiency include depression, mania, psychotic symptoms, and cognitive impairment ( A normal vitamin B12 level is between 190-950 picograms/mL. Between 200-300/mL indicates a borderline level with a possible need for additional testing. Vitamin D Level - Solution Vitamin D affects functions such as neurotransmission, neuroprotection, and neuroimmunomodulation. Studies have indicated a high prevalence of vitamin D deficiency in clients with psychiatric disorders such as schizophrenia, depression, seasonal affective disorder, and cognitive impairment (Cuomo et al., 2019). Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis, and poor brain development.
Julio is a 66-year-old who presents with depression. His vitamin D level 11 ng/mL. A) Begin Treatment B) Refer - Solution B) Refer Rationale: Vitamin D deficiency is associated with depressive symptoms. The PMHNP may refer or treat vitamin D deficiency depending on the level of comfort of the provider. Beth is a 24-year-old who presents with anxiety. Her T3 is 260 ng/dL. A) Begin Treatment B) Refer - Solution B) Refer Rationale: Clients with hyperthyroidism have elevated T3 levels. Hyperthyroidism is associated with anxiety symptoms. Client can be reevaluated for anxiety once hyperthyroid treatment has been initiated and T3 levels are within normal limits. Fred is a 19-year-old who presents with psychosis. His vitamin B12 level is 900 picograms/mL. A) Begin Treatment B) Refer - Solution A) Begin treatment Rationale: The B12 level is within normal limits. Treatment for symptoms of psychosis should be initiated. Ted is a 64-year-old who presents with confusion. His serum creatinine is 7.0 mg/dL and BUN is 32 A) Begin Treatment B) Refer - Solution B) Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion. Social Determinants of Health (SDOH) - Solution 1: Discrimination, racism, social exclusion 2: Adverse early life experiences 3: Poor education 4: Unemployment, underemployment, job insecurity 5: Poverty 6: Neighborhood deprivation 7: Food insecurity 8: Poor housing quality and housing instability
Holistic Care: Culture, Values, and Health Beliefs - Solution Holistic approaches to mental health care consider all aspects of the individual, not just the symptoms and diagnosis. A holistic approach not only addresses psychiatric and medical considerations, it recognizes that social, spiritual, lifestyle, and behavioral elements also impact mental health. Psychiatric symptoms may be secondary to environmental factors or life events. Clients' culture, values, and health beliefs may affect how mental health diagnoses are manifest or described and may impact treatment choices. Healing and rehabilitation are most likely to occur when providers address client needs holistically and involve clients in treatment planning. A commonly used method is the "SNAPPS" method, which follows a mnemonic consisting of six steps. This method is often used for client presentations to preceptors. The six steps includ - Solution 1.Summarize the history and findings 2.Narrow the differential diagnosis to two or three possibilities 3.Analyze the differential by comparing and contrasting the possibilities 4.Probe the preceptor by asking questions about alternative approaches or uncertainties 5.Plan the management of the client's health issues 6.Select an issue from the case for self-directed learning What is the most common mental illness in the US? And what percentage does it affect adult and children? - Solution Anxiety disorders are the most common mental illness in the United States. Anxiety impacts approximately 18% of the adult population and 25% of children ages 13-17 each year (Anxiety & Depression Association of America [ADAA], n.d.). People who experience anxiety have a higher incidence of work and school absenteeism and higher use of medical resources, such as emergency department and provider visits than the general population First line of Tx for Generalized anxiety disorder? - Solution SSRIs SNRIs Buspirone Drug Therapy at least 12 months First line of Tx for Panic Disorder? - Solution Paroxetine Sertraline Fluoxetine Drug therapy 6-9 months
Pt's with GAD show persistent, uncontrollable worrying that causes emotional distress and show symptoms on most days for a period of how long? - Solution 6 months Pt's with anxiety often show increase activity in where? - Solution Amygdala and prefrontal cortex Positron emission tomography (PET) scans show reduced what in pt's with anxiety? - Solution Reduced serotonin binding What are risk factors for developing anxiety? - Solution 1) family Hx
- being female
- recent life stressors
- chronic physical illness
- lack of support during childhood Increased brain activity in prefrontal cortex is a sign of? - Solution Anxiety According to NIMH approximately ___% of US adults will experience GAD in the past year and approximately ____% of the US adults will experience GAD at some point in their lifetime - Solution 3, 6 GAD is twice as common in ___________ than in __________ - Solution Women, men How is GAD characterized by? - Solution Persistent, uncontrollable worry about ordinary everyday situations Functional neuroimaging studies of GAD show? - Solution Functional neuroimaging studies of GAD show increased activation of the amygdala and reduced activation in the prefrontal cortex, indicating heightened activation of the fear response with diminished capacity for reasoning GAD often presents with physical symptoms, including: - Solution restlessness or edginess fatigue difficulty concentrating irritability muscle tension
sleep disturbance Thyroid Function Tests - Solution In psychiatric diagnosing, TFTs are used to rule out thyroid disorders as a cause for symptoms. Common symptoms related to thyroid disorders include anxiety, restlessness, depression, mood swings, sleeping difficulties, difficulties with concentration, short-term memory lapses, and lack of mental alertness. Social Anxiety Disorder - Solution While it is common to feel nervous in some social situations, social anxiety disorder (also called social phobia) is a condition in which typical, everyday social interactions cause significant anxiety, self-consciousness, fear of embarrassment, or a feeling of being judged negatively by others. DSM-5 defines SAD - Solution as an individual's fear of acting in a way that might cause judgment by others Anxiety leads to avoidance of social situations which disrupts an individual's relationships and daily routines. The anxiety is persistent, lasting greater than six months. What anxiety can become so severe that derealization, or a feeling of "spacing out"? - Solution SAD What may individuals with SAD resort to? - Solution Drugs or alcohol to reduce social inhibitions In the past year SAD has impacted approximately ____% of adults and _____% of adolescents - Solution 7, 9 Risk Factors for SAD - Solution HX of abuse or Neglect Close relative with SAD SAD causes distress in what kind of social situations? - Solution Making small talk with other Meeting new people Performing in front of other (called performance anxiety) Greta who is clingy to her mom when meeting adults but does not have anxiety in peer setting. Would this meet DSM-5 criteria? - Solution Greta displays anxiety when meeting adults in a social situation. Her anxiety is
Based on the DSM-5-TR, does Fabrizia meet diagnostic criteria for panic disorder? A) Yes B) No - Solution B) No Rationale: Fabrizia meets diagnostic criteria for a panic attack, but not for panic disorder. During her panic attack, she reported having four cardinal symptoms associated with a panic attack. She has only had one panic attack, and although she has expressed worry about symptoms recurring, it is not persistent concern or worry. Phobia - Solution phobia is an intense fear of a specific situation or object. The fear associated with a phobia is not in proportion to the actual danger associated with the situation or object. The prevalence of specific phobias is approximately 8%. Specific phobias often occur after experiencing or witnessing a traumatic event and typically develop in childhood. Clients who have specific phobias often fear more than one object or situation. Each specific phobia is diagnosed separately Ella is a 17-year-old who presents to the clinic with her mother. Her mom reports that Ella will not go to the basement in their home, and she is concerned about the behavior. During the interview, Ella confirms that even thinking about going to the basement causes her extreme anxiety because she knows that there are spiders in the basement. She has had her phone taken away in the past because she will not go to the basement to gather her laundry, but she states, "I will take the punishment because it is better than being around those spiders." She states she has been afraid of spiders for as long as she can remember Which of the following is the most appropriate ICD-10-CM code for Ella? 40.2 Specific phobias 40.218 Specific phobia - animal F40.298 Other specified phobia F40.9 Phobia, phobic - Solution 40.218 Specific phobia - animal Rationale: Ella meets diagnostic criteria for F40.218 Specific Phobia: Animal.
Agoraphobia - Solution involves intense fear, anxiety, or panic out of proportion to the situation that occurs in two or more of the following specific scenarios: public transportation (bus) open spaces (parking lot or bridge) enclosed spaces (store, theater) standing in a crowd or line (crowd) being outside of their home Coping mechanism for agoraphobia - Solution Although some clients with agoraphobia are completely homebound, many clients cope by actively avoiding situations that create anxiety; for instance, a person who fears public transportation may choose to live within walking distance to employment and shopping. Clients may be able to function better when a support person comes with them Sigourney is a 47-year-old who presents to the clinic with complaints of anxiety. She states that certain situations seem to trigger her anxiety, including using the subway, attending concerts and movies, and going to the corner bodega. She states that these types of situations make her fear that she will be trapped in the event of an emergency. To cope, she has been walking rather than using public transportation and using an online ordering app for grocery delivery. She has not been to a concert or movie theater in years and feels that she has lost some friends because of her reluctance to attend. Based on the DSM-5-TR, does Sigourney meet diagnostic criteria for agoraphobia? A) Yes B) No - Solution A) Yes Rationale: Sigourney meets the following diagnostic criteria for agoraphobia: she has marked anxiety about using public transportation and being in enclosed spaces and crowds. She fears a situation because she worries about her ability to escape. She has changed her behaviors to avoid situations that cause her anxiety, and she has caused social impairment in her life. Adjustment Disorder with Anxiety - Solution The DSM-5 classifies adjustment disorder as a trauma- and stressor-related disorder; however, symptoms of adjustment disorder with anxiety are similar to those found in
company where many of the employees are no longer deemed essential. Because of the automatic self-check-out systems, there is no longer the need to employ as many cashiers as possible. Jeremy has been given the task of notifying his employees of this major change in staffing. He plans to share these decisions at next week's staff meeting. From the moment Jeremy received this directive, he started to feel fearful of the possibility of announcing the decision to downsize as well as deciding on who would be eliminated. On the day of the staff meeting, his employees were present. As he started the staff meeting, he began to feel nausea. He even noticed his heart pounding. When he was questioned by an employee on - Solution C) panic attack Rationale: Jeremy's anxiety is associated with a stressful situation (delivering the bad news) and a fear that something bad will happen (staff's reaction to the announcement). He experiences physical symptoms of heart pounding, nausea, dizziness, and inability to formulate an organized answer to the question. The setting is also in a familiar place among colleagues where no real threat exists. Sari is a 34-year-old female who is engaged to be married in one month. This will be her second marriage. She has been divorced for three years. Her fiancé, who is also divorced, has arranged for Sari to meet his three teenagers. Sari learns through a mutual friend of hers and the fiancé, that his teenagers, although hesitant, are willing to meet her. On the day of the arranged meeting, Sari is asked to arrive to the restaurant to meet the teens prior to the fiancé's arrival because he has been held up at a meeting. Sari agrees but starts to feel uneasy about it. She is concerned that they will not accept her because of her previous divorce and the fact that she is not their mother although they were willing to meet her. The closer she got to the restaurant, the more uneasy she felt to the point of disorientation. Just before entering the restaurant, she turned around and called her fiancé to inform him that her - Solution D) Social Anxiety Rationale: Sari feels like she will be judged by the teens because she is not their mother. She avoids the situation by creating an excuse for not meeting them at the restaurant. The feelings are unwarranted since the teens agreed to meet with Sari. Complete the case study below by utilizing the HAM-A scale. Rashard, a 54-year-old, presents for a walk-in visit with the PMHNP due to increased anxiety and requests an early refill of his clonazepam. He reports
his brother died a week ago and he is very anxious. He has taken all the clonazepam #20 tabs that the PMHNP refilled 3 weeks earlier. The client understands that his benzodiazepine is to be used as needed and only for severe anxiety, but he said he used it all because he "just couldn't cope." He reveals that he was hospitalized after the death of his father 7 years ago and does not want that to happen again; he wants to avoid the hospital. Upon assessment, the client has difficulty sitting still, his leg is swinging continuously, and he taps his fingers; he is constantly shifting in his chair. His anxiety symptoms include feeling short of breath, heart racing, and some chest pain, "jumping out of his skin" - Solution C) moderate to severe anxiety Rationale: The HAM-A is a clinician-rated anxiety screening tool. Based on Rashard's interview and examination, his positive findings score as follows: Anxious mood - 4 (daily worry, fearful anticipation) Tension- 4 (startle, tense, trembling daily) Fears- 3 (daily fear something will happen) Insomnia- 3 (nightly sleep issues) Intellectual- 2 (poor memory) Depressed mood- 3 (daily loss of interest, lack of pleasure) Cardiovascular symptoms- 3 (tachycardia, chest pain) Respiratory symptoms- 2 (pressure or constriction in chest, dyspnea) Behavior at interview- 3 (fidgeting, restlessness, or pacing) Rashard's total HAM-A screening score is 28, indicating moderate to severe anxiety. Which of the following medical conditions is likely to present with symptoms that mimic anxiety? A) hypothyroidism B)hyperthyroidism (C C)dysrhythmias ( Solution ) D) irritable bowel syndrome ( Solution ) E) anemia F) diabetes type 2 G)migraine headache ( Solution ) H) Covid- I) rheumatoid arthritis ( Solution )
and estrogens. Substances with effects that may mimic anxiety include cocaine, ecstasy, marijuana, psychoactive compounds, and caffeine. What is the Tx of GAD? - Solution Pyschotherapy, medication, or both What is the most widely studied and efficacious form of Tx of GAD? - Solution Serotonergic antidepressants in combinations with CBT If symptoms are severe of GAD what is the line of Tx? - Solution Short course of a benzodiazepine at the beginning of treatment may be indicated Anxiolytic Pros vs Cons - Solution PROS: ↓ adverse effects ↓ drug interactions CONS limited effectiveness Anxiolytic time to efficacy? - Solution 2-4 weeks Anxiolytic agents? - Solution Buspirone SSRIs/SNRIs Pros vs Cons - Solution PROS: Highly effective CONS: ↑ drug interactions risk of hyponatremia SSRIs/ SNRIs time to efficacy? - Solution Up to 6 months SSRIs/ SNRIs Agents - Solution escilatopram (Lexapro) paroxetine (Paxil) duloxetine (Cymbalta) Benzodiazepines Pros vs Cons - Solution PROS highly effective rapid onset can be used PRN CONS multiple adverse effects fall risk
risk of misuse Benzodiazepines time to efficacy? - Solution Immediate Benzodiazepines Agents - Solution alprazolam (Xanax) clonazepam (Klonopin) Non pharmacologic Treatment of GAD - Solution Some clients may consider complementary and alternative treatments. Treatments may include physical, cognitive, and spiritual activities aimed at decreasing anxiety. High-intensity aerobic exercise is a good complement to first-line therapy for GAD. Mindfulness-based stress reduction activities, such as meditation and yoga, have shown a reduction in symptoms of GAD Relaxation or meditation Art of music therapy Yoga or other exercise Acupuncture Prayer or spiritual counselling What is Silexan? - Solution Is a branded extract of lavender. OTC in the US. Similar to CAM therapies Harold is a 32-year-old who presents to the clinic with complaints of fatigue, difficulty concentrating, and difficulty falling asleep at night. He states he worries about finances, his performance at work, and his relationship, and his worries have been "almost constant" for 8 months. He denies substance use and recently had a normal physical exam. He feels that his relationship is suffering due to his constant worry. Based on the DSM-5-TR, does Harold meet diagnostic criteria for generalized anxiety disorder? A) Yes B) No - Solution A) Yes Rationale: Harold meets the following diagnostic criteria for generalized anxiety disorder: He has three symptoms associated with worry, including fatigue, difficulty concentrating, and sleep difficulties. He has experienced anxiety more days than not for over 6 months, and his worries are impacting his relationship. SAD treatment plan? - Solution Not all clients with social anxiety disorder (SAD) require treatment. Young adults may experience benefits from
