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NR 547 DIFFERENTIAL DX MIDTERM MOST TESTED EXAM QUESTIONS WITH REVISED CORRECT ANSWERS VERIFIED A+ LATEST VERSION Differential Dx - correct answers 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 - correct answers 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 - correct answers 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 - correct answers 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 - correct answers 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 - correct answers 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. - correct answers A)Explain how the medication targets the symptoms, specific benefits, and expected time course. (Correct answer) B)Identify potential side effects, duration of side effects, and adverse effects. (Correct answer) C)Explain the instructions, dosing, and special requirements. (Correct answer) D)Use teach-back methods to ensure client understanding. (Correct answer) 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 aften 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 - correct answers B)Provide a brief suicide safety assessment. Neutrophils: 55%-70% Eosinophils: 1%-3% Basophils: 0.5%-1% Lymphocytes: 20%-35% Monocytes: 3%-8% Platelets: 150,000-300,000/microliter Comprehensive Metabolic Panel (CMP) - correct answers 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 (CI-): Bicarbonate (HCO3-): - correct answers 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 - correct answers Calcium, serum (Ca 2+) 8.4-10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120m¢/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) - correct answers 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: - correct answers 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: - correct answers Normal TFT levels Rationale: A TSH level >4.0 is indicative of hypothyroidism, which is associated with fatigue. A referral for treatment of hypothyroidism is required. Client can be reevaluated for fatigue if symptoms persist after hypothyroid treatment has been initiated, TSH levels are within normal limits. Leo is a 49-year-old who presents with fatigue. His hemoglobin is 15 g/dL and hematocrit is 42%. A) Begin Treatment B) Refer - correct answers A) Begin treatment. Rationale: The hemoglobin and hematocrit are within normal limits. This client's complaint of fatigue is not due to anemia. Begin treatment based on a complete evaluation. Terri is a 79-year old who presents with confusion. She has positive urine leukocyte esterase. A) Begin treatment B) Refer - correct answers B)Refer Rationale: A positive Urine Leukocyte Esterase indicates the presence of a urinary tract infection (UTI), which may cause confusion. Refer this client for treatment of the UTI. Julio is a 66-year-old who presents with depression. His vitamin D level 11 ng/mL. A) Begin Treatment B) Refer - correct answers 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 - correct answers 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 - correct answers 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 - correct answers B) Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion. Social Determinants of Health (SDOH) - correct answers 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 - correct answers 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 - correct answers 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 Drug therapy takes 4 weeks to see effects First line of Tx for Post-traumatic stress disorder - correct answers Paroxetine Sertraline Hamilton Rating Scale HAM-A scoring Mild, moderate, severe - correct answers 0 (not present) 4 (severe) Total score ranges from 0-56 <17: indicated mild severity 18-24: mild to moderate severity 25-30 moderate to severe What 14 questions are on HAM-A? - correct answers 1) Anxious mood 2) Tension 3) Fears 4) Insomnia 5) Intellectual 6) Depressed mood 7) somatic (muscular) 8) Somatic (sensory) 9) cardiovascular symptoms 10) Respiratory symptoms 11) gastrointestinal symptoms 12) Genitourinary symptoms 13) Autonomic symptoms 14) Behavior at interview Anxiety is usually comorbid with? - correct answers Depression, COPD, asthma, and diabetes Pt's with GAD show persistent, uncontrollable worrying that causes emotional distress and show symptoms on most days for a period of how long? - correct answers 6 months Pt's with anxiety often show increase activity in where? - correct answers Amygdala and prefrontal cortex Positron emission tomography (PET) scans show reduced what in pt's with anxiety? - correct answers Reduced serotonin binding What are risk factors for developing anxiety? - correct answers 1) family Hx 2) being female 3) recent life stressors 4) chronic physical illness 5) lack of support during childhood Increased brain activity in prefrontal cortex is a sign of? - correct answers 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 - correct answers 3, 6 GAD is twice as common in than in - correct answers Women, men How is GAD characterized by? - correct answers Persistent, uncontrollable worry about ordinary everyday situations Functional neuroimaging studies of GAD show? - correct answers 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: - correct answers restlessness or edginess SAD causes distress in what kind of social situations? - correct answers 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-S5 criteria? - correct answers Greta displays anxiety when meeting adults in a social situation. Her anxiety is expressed as clinging to her mother and not speaking. The anxiety has been present for several years; however, Greta does not have anxiety in peer settings. Therefore, she does not meet DSM-5 criteria for social anxiety disorder Panic attacks - correct answers is a brief episode of acute anxiety during which an individual develops an intense fear of negative outcomes accompanied by a feeling of imminent danger. Panic attacks can be unpredictable, often occurring in familiar places where there are no apparent threats. The feelings are often accompanied by physiological symptoms. While symptoms typically peak within ten to twenty minutes, some may last for hours Physical symptoms of a panic attack include? - correct answers Palpitations, pounding heart, or accelerated heart rate Trembling or shaking Paresthesias (numbness or tingling sensations) Sensation of shortness of breath or smothering Derealization (feelings of unreality) or depersonalization (feeling detached from oneself) Feeling of choking Feeling of chest pain or discomfort Nausea or abdominal stress Feeling dizzy, unsteady, light-headed or faint Chills or heat sensations Panic disorder - correct answers occurs when a person experiences repeated panic attacks, usually accompanied by fears about future attacks. Anxiety about future attacks may lead to behavioral changes to avoid situations that might trigger attacks Fabrizia is a 27-year-old graphic designer who presents to the clinic two months after an emergency department visit for complaints of chest pain, palpitations, nausea, and dizziness. Her electrocardiogram (ECG) and cardiac enzyme panels showed no abnormalities. She states that the symptoms began while she was watching a movie with her boyfriend and lasted about 15 minutes. She has never experienced anything like this in the past, but since the episode, she has worried occasionally about the symptoms recurring, as her father died of a heart attack at age 45. Based on the DSM-5-TR, does Fabrizia meet diagnostic criteria for panic disorder? A) Yes B) No - correct answers 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 - correct answers 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, "! 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 Adjustment Disorder with Anxiety - correct answers The DSM-S classifies adjustment disorder as a trauma- and stressor-related disorder; however, symptoms of adjustment disorder with anxiety are similar to those found in anxiety disorders. Adjustment disorder with anxiety presents with nervousness, worry, or jitteriness. Adjustment disorder occurs in the presence of a specific and identifiable stressor. The distress experienced is out of proportion to the severity of the stressor. Adjustment Disorder with Anxiety examples - correct answers Examples of common stressors include loss of employment, getting married, a new disability, or a natural disaster. When does Adjustment Disorder with anxiety usually appear? - correct answers Symptoms begin within three months of the stressor and typically last no more than six months. Callie is an 18-year-old college student who reports to the healthcare provider that she feels anxious "about everything." Her restlessness and irritability have impacted her relationship with her significant other. She reports no significant past medical or mental health history. She states that her anxiety started about 8 months ago when she decided to transfer from her local community college to a large state university to pursue a law degree. During the law program's orientation attended by 300 students, she learned that only 100 students would be selected out of 300 applications for the fall admission. She began feeling inferior that she would not be one of the students accepted. She also started thinking about "plan B," assuming that her grades are not "good enough" to get her selected for the program. She told the PMHNP that she was preparing for the rejection because she does not measure-up to the other appli - correct answers A) generalized anxiety disorder Rationale: Callie has persistent symptoms of anxiety accompanied by restlessness and irritability. The thoughts are unrealistic since she has pre-determined that she is not good enough for the law program without evidence to support that feeling. She also compares herself to strangers where she automatically assumes that they are better prepared for the program than she is. She decides not to apply to the law program based on these unsubstantiated thoughts. Jeremy is a 44-year-old male who works as a department head for a local grocery store chain that is down-sizing due to economic reasons. Top level management has announced that there will be restructuring of the 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. Fram 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 - correct answers 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 car - correct answers D) Social Anxiety Rationale: Sari feels like she will be judged by the teens because she is not their mather. 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" - correct answers 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) Rationale: Medical conditions that commonly present with symptoms that mimic anxiety include endocrine disorders including hyperthyroidism and adrenal dysfunction cardiac disorders including angina and dysrhythmias, Gl conditions including irritable bowel syndrome and GERD, inflammatory conditions including lupus and rheumatoid arthritis, neurological disorders including migraine headaches and seizures, and respiratory conditions including asthma and COPD. Changes in the menstrual cycle, including PMS and menopause, may also cause symptoms that mimic anxiety. Which of the following medications or substances commonly cause symptoms that mimic anxiety? A)bupropion B)nasal decongestants C)metoprolal D)levothyroxine E)Insulin F)albuterol G)cocaine H)alcohol I)caffeine J)morphine - correct answers A)bupropion (Correct answer) B)nasal decongestants (Correct answer) C)metoprolal (Correct answer) D)levothyroxine (Correct answer) F)albuterol (Correct answer) G) cocaine (Correct answer) H)alcohol (Correct answer) I)caffeine (Correct answer) Rationale: Medications with side effects mimicking anxiety disorder include nasal decongestants, antidepressant medications, synthetic thyroid hormones, beta-adrenergic agonists, and hormones such as androgens and estrogens. Substances with effects that may mimic anxiety include cocaine, ecstasy, marijuana, psychoactive compounds, and caffeine. What is the Tx of GAD ? - correct answers Pyschotherapy, medication, or both What is the most widely studied and efficacious form of Tx of GAD? - correct answers Serotonergic antidepressants in combinations with CBT If symptoms are severe of GAD what is the line of Tx? - correct answers Short course of a benzodiazepine at the beginning of treatment may be indicated Anxiolytic Pros vs Cons - correct answers PROS: w adverse effects 
