Advanced practice skills, the assessment domain

During a mental status examination, a 42-year-old woman says her mood is "great, never better" while she is tearful, speaks softly, and looks at the floor. How should the PMHNP document this finding?

1. Mood in her own words and an incongruent affect
   Mood is recorded in the patient's own words and affect is what the clinician observes; her tearful, soft-spoken presentation does not match "great, never better," so the affect is incongruent with the stated mood.
2. Labile affect with rapid shifts in expression
   Lability is rapid swinging of expression over minutes; one steady mismatch between report and presentation is incongruence.
3. Dysphoric mood with a constricted affect
   Writing 'dysphoric mood' replaces her stated mood with the clinician's inference; the MSE records mood in the patient's words and puts the observation under affect.
4. Flat affect and poverty of thought content
   Flat affect is an absence of emotional expression, and nothing suggests poverty of content; her tearfulness is visible emotion.

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A 31-year-old woman with bipolar I disorder stopped lithium 3 weeks ago. Today she has slept 2 hours a night for 5 days, is spending heavily, and says she is "on a mission from God" to confront her ex-partner. What should the PMHNP assess first?

1. Her serum lithium level and thyroid function tests
   After 3 weeks off, the level will be near zero and thyroid tests do not change today's disposition; labs first delay the safety assessment.
2. Whether she has health insurance that covers an inpatient stay
   Coverage never sets the order of a risk assessment; level of care follows danger, not payer.
3. Her reason for stopping lithium and her beliefs about the medication
   Her reasons matter for the long-term plan, but adherence work comes after the immediate danger is assessed.
4. Whether she intends to harm anyone or herself
   A grandiose mission aimed at a named person puts violence and suicide risk first; the answer decides level of care and whether a duty to protect applies.

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A 47-year-old man says his mood is "okay." During the interview he speaks in a monotone, his facial expression barely changes when discussing his divorce or his children, and he shows little gesturing. Which MSE term best describes this observation?

1. Labile affect
   Labile affect shifts quickly and widely; his expression barely moves.
2. Blunted affect
   Monotone speech, little facial change, and few gestures across emotionally loaded topics show reduced intensity of expression, which is blunted affect.
3. Dysthymic mood
   Mood is his own report, which is 'okay'; dysthymia is also a diagnosis (persistent depressive disorder), not an observation of expression.
4. Inappropriate affect
   Inappropriate affect clashes with the content, such as smiling while describing a death; his problem is too little expression, not the wrong kind.

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A 56-year-old man with no psychiatric history arrives at the clinic with sudden chest tightness, shortness of breath, sweating, and fear that he is dying. He asks for help with his "panic." What is the priority action?

1. Arrange urgent medical evaluation with an ECG
   New chest tightness, dyspnea, and sweating in a 56-year-old with no psychiatric history are possible acute coronary syndrome; an ECG and urgent evaluation come before any psychiatric label.
2. Start an SSRI and schedule CBT for panic disorder
   Panic disorder needs recurrent unexpected attacks and medical causes excluded; long-term treatment after one possible cardiac event is a diagnostic shortcut.
3. Give lorazepam for the acute panic attack
   A benzodiazepine can blunt the symptoms of an evolving infarction and leaves the cardiac question open.
4. Coach slow diaphragmatic breathing until symptoms ease
   Breathing coaching accepts the label he chose and delays the workup; a first episode at his age is cardiac until proven otherwise.

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A 27-year-old woman with schizophrenia is starting olanzapine. Her baseline weight, BMI, waist, BP, fasting glucose, and lipids are normal. Under the ADA–APA consensus protocol for second-generation antipsychotics, when should fasting glucose and lipids be rechecked?

1. When she has gained more than 10% of body weight
   Olanzapine can raise glucose and triglycerides before much weight gain, so tying labs to a weight threshold misses metabolic harm.
2. At the 12-week follow-up visit
   The ADA–APA consensus repeats fasting glucose and lipids 12 weeks after starting a second-generation antipsychotic, when olanzapine's metabolic effects usually appear.
3. Weekly during the first 3 months
   Weekly fasting labs add cost without changing decisions; the protocol tracks weight at 4, 8, and 12 weeks.
4. At her annual physical examination
   Annual checks follow the 12-week recheck; waiting a year misses the early period when olanzapine-induced hyperglycemia and dyslipidemia show up.

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A 36-year-old man who uses cannabis daily rates the importance of cutting down as 4 on a 0 to 10 scale. Which follow-up question best elicits change talk?

1. "What keeps you from rating it higher?"
   Asking about obstacles at this point draws out the case against change; barriers come after reasons for change are on the table.
2. "Is a 4 enough for you to succeed?"
   A closed, evaluative question can be answered yes or no and asks him to judge his chances; it neither explores reasons nor builds motivation.
3. "Why did you pick a 4 and not a 1?"
   Asking why the score is not lower invites him to list his own reasons for change, which is change talk he can build on.
4. "Why did you pick a 4 and not a 10?"
   Asking why it is not higher sounds similar but invites him to defend cannabis use and voice sustain talk.

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A 19-year-old college student is worried she is "going crazy" because she sometimes sees shadowy figures and hears her name called just as she is falling asleep. She has no other symptoms and functions well. What is the most appropriate interpretation?

1. Visual hallucinations from a seizure disorder, requiring an EEG
   Seizures cause stereotyped episodes that are not tied to sleep onset; the link to drowsiness points away from epilepsy.
2. Brief psychotic disorder, requiring psychiatric admission
   Brief psychotic disorder needs delusions, hallucinations, or disorganization while awake for at least a day; she has insight and no other symptoms.
3. Prodromal schizophrenia, requiring an antipsychotic trial
   A prodrome brings functional decline, withdrawal, and odd beliefs with perceptual changes while awake; isolated sleep-onset events do not qualify.
4. Hypnagogic hallucinations, which are not a sign of psychosis
   Brief images or voices at sleep onset are hypnagogic hallucinations, common in healthy young adults; with no other symptoms and intact functioning, reassurance is enough.

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A PMHNP needs to ask a 23-year-old woman with depression about binge eating and vomiting, which she may feel ashamed to discuss. Which question is most likely to get an accurate answer?

1. "Would you say that you have an eating disorder such as bulimia nervosa?"
   Asking her to accept a diagnostic label is easy to reject and skips the specific behaviors the assessment needs.
2. "Why do you think you would need to make yourself vomit after you eat?"
   A 'why' question sounds accusatory and pushes a defensive answer before the behavior is even established.
3. "You wouldn't ever make yourself vomit after eating a big meal, would you?"
   A question built to expect 'no' tells her the honest answer is unwelcome and invites denial.
4. "Many people under stress overeat and then vomit. Has that happened to you?"
   Normalizing the behavior before asking lowers shame and signals that any answer is acceptable, which raises disclosure of stigmatized symptoms.

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Asked what "People in glass houses shouldn't throw stones" means, a 30-year-old man with schizophrenia says, "Because the glass would break." How should the PMHNP document this finding?

1. Concrete thinking
   A literal reading of a proverb shows impaired abstraction, recorded as concrete thinking; it is common in schizophrenia and neurocognitive disorders.
2. Loose associations
   His answer follows logically from glass and stones; loose associations jump between unrelated ideas.
3. Circumstantial thinking
   Circumstantial thinking takes a long detour through detail before reaching the point; his reply is short and literal.
4. Poor insight
   Insight is awareness of illness and the need for treatment; proverb interpretation tests abstraction.

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A 15-year-old reports occasional weekend cannabis use. Which finding best distinguishes problematic use from normative experimentation?

1. Curiosity about cannabis with no change in daily functioning
   Curiosity without any change in school, mood, or relationships is typical adolescent experimentation.
2. Trying cannabis once at a party several months ago
   A single episode with peers months ago is experimentation; frequency, context, and consequences define a problem.
3. Falling grades and using alone to cope with stress
   Functional decline plus solitary, coping-motivated use marks problem use and a higher risk of cannabis use disorder, which calls for a fuller substance-use assessment.
4. Knowing several classmates who have tried cannabis
   Peer use raises general risk but says nothing about this teen's own pattern or impairment.

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A 40-year-old with recurrent depression is guarded and gives inconsistent answers about suicidal thoughts. Beyond administering the C-SSRS, what should the PMHNP do to determine risk and ensure safety?

1. Review his past history first and defer questions about intent
   Past attempts matter, but deferring current intent leaves the most important risk factor unknown.
2. Gather collateral and observe him, then assess plan and means now
   When a guarded patient's answers do not line up, collateral and direct observation fill the gaps, and plan, intent, and access to means are still assessed before he leaves.
3. Explore the inconsistencies at a follow-up visit next week
   Inconsistent answers about suicide raise concern; postponing the safety assessment leaves acute risk unmanaged.
4. Rely on his C-SSRS answers alone, since he knows himself best
   Self-report is essential but a guarded patient can minimize it; a screener score is not a risk formulation.

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Which finding best meets a standard criterion for involuntary psychiatric hospitalization?

1. Imminent danger to self or others from a mental disorder
   State commitment laws center on danger to self or others, or grave disability, caused by a mental disorder; a diagnosis alone is never enough.
2. Refusal of a recommended non-urgent outpatient referral
   Competent adults may decline non-urgent care; refusing a referral is not a danger criterion.
3. A long-standing schizophrenia diagnosis, now well controlled
   A controlled illness with no current danger meets no commitment criterion, however long-standing the diagnosis.
4. A family request for admission while the patient is stable
   Family preference cannot override the liberty of a stable adult; commitment needs dangerousness or grave disability.

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A patient uses invented words such as "flumitrate" that have meaning only to him. This finding is best described as:

1. Perseveration
   Perseveration is persistent repetition of a word or idea despite a new question, not invention of words.
2. Circumstantiality
   Circumstantiality is over-detailed speech that eventually reaches the goal; it uses ordinary words.
3. Clang association
   Clang associations link words by sound or rhyme; they do not create new words.
4. Neologism
   A coined word whose meaning only the patient knows is a neologism, a sign of psychotic thought disorder.

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A 35-year-old man in a manic episode is brought to the emergency department. He talks nonstop, jumps between topics, and becomes irritable when interrupted. What is the most effective interviewing approach?

1. Let him talk without interruption to build rapport
   With pressured speech and flight of ideas, an unstructured interview loses the safety questions; rapport comes from calm structure.
2. Ask short focused questions in a quiet room
   Mania brings distractibility and irritability, so brief structured questions with gentle redirection in a low-stimulus room gather the safety data and lower the chance of escalation.
3. Interview him in the busy triage area near staff
   A noisy, busy area adds stimulation that worsens manic agitation; safety comes from staffing the quiet room.
4. Challenge his grandiose plans to test insight
   Confronting grandiosity tends to provoke anger in mania and tells the clinician little in the emergency setting.

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A PMHNP managing inpatients with schizophrenia wants to track changes in hallucinations, delusions, social withdrawal, and amotivation over the first weeks of an antipsychotic trial. Which instrument is most appropriate?

1. Positive and Negative Syndrome Scale (PANSS)
   The PANSS rates positive, negative, and general psychopathology on separate subscales, which is what tracking response across symptom domains needs.
2. Mini-Mental State Examination (MMSE)
   The MMSE screens cognition and does not register hallucinations, delusions, or negative symptoms.
3. Abnormal Involuntary Movement Scale (AIMS)
   The AIMS rates involuntary movements for tardive dyskinesia; it belongs in antipsychotic monitoring but measures a side effect, not psychosis.
4. Clinical Global Impression-Improvement (CGI-I)
   The CGI-I gives one global rating of change and cannot separate positive from negative symptoms.

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Four inpatients are being assessed for violence risk before discharge. Which patient is at highest risk of future violence?

1. A 40-year-old woman with schizophrenia and no violence history
   Psychosis without past violence, command content, or substance use raises risk only modestly; assuming danger from the diagnosis reflects stigma.
2. A 25-year-old man with 3 past assaults who uses methamphetamine
   Past violence is the strongest single predictor of future violence, and active stimulant use adds disinhibition and paranoia; he has both.
3. A 60-year-old man with major depression and new insomnia
   Depression with insomnia calls for a suicide assessment, but it is not a major predictor of violence toward others.
4. A 30-year-old woman with OCD who fears she will stab her child
   Harm obsessions in OCD are unwanted and resisted, and people with them almost never act; reading them as intent is a common error.

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Using the NIAAA single-question screen, a PMHNP asks a 45-year-old woman, "How many times in the past year have you had 4 or more drinks in a day?" She answers, "Maybe 3 times, at weddings." How should this be interpreted?

1. A negative screen, because the threshold is 5 drinks for women
   Five or more drinks is the threshold for men; applying it to women misses their lower threshold.
2. A negative screen, because she drinks at social events
   Setting does not cancel risk; heavy-drinking days at celebrations still count.
3. A positive screen that calls for further assessment
   For women the NIAAA threshold is 4 or more drinks in a day, and any such day in the past year is a positive screen that leads to a fuller assessment such as the AUDIT.
4. A positive screen that confirms alcohol use disorder
   A screen identifies risk; diagnosing alcohol use disorder takes DSM-5-TR criteria and a full history.

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A 75-year-old man with 10 years of formal education scores 25 on the Montreal Cognitive Assessment (MoCA). How should the PMHNP interpret this score?

1. Mild cognitive impairment is present
   Reading the raw 25 as impairment skips the education correction the MoCA instructions require.
2. Invalid; use the MMSE instead
   The MoCA is valid at this education level and more sensitive to mild deficits than the MMSE; switching tools loses sensitivity.
3. Within normal range once adjusted
   The MoCA adds 1 point for 12 or fewer years of education, so his score becomes 26, which meets the usual normal cutoff of 26 or more.
4. Moderate dementia
   Even unadjusted, 25 is far above scores seen in moderate dementia, and severity rests on daily function, not a screen.

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