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Psychiatric Nurse NP: NURS 6630 Case Study Mrs. Maria Perez

NURS 6630 Case Study Mrs. Maria Perez

BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”
SUBJECTIVE
Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.
She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.
Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.
 
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.
Diagnosis: Gambling disorder, alcohol use disorder
Decision Point One
 Antabuse (Disulfiram) 250 mg orally every morning ON
 Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

 Antabuse (Disulfiram) 250 mg orally daily

 Campral (Acamprosate) 666 mg orally three times/day
 E
·  Client returns to clinic in four weeks
·  Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse
·  Clientis She is also reporting that she is having “out of control” anxiety.. 
Decision Point Two
 
Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms
RESULTS OF DECISION POINT TWO Decision Point Two
Select what the PMHNP should do next:
 
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID

• Client returns to clinic      in four weeks
• Mrs. Perez reports that      when she first received the valium, it helped her tremendously. She states      “I was like a new person- this is a miracle drug!” However, she reports      that she has trouble “waiting” between drug administration times and      sometimes takes her valium early. She is asking today for you to increase      the valium dose or frequency
• Although she reports that      her anxiety is gone, she still reports suicidal ideation, but states “with      that valium stuff, who cares?”;;;;;;;;
• Decision Point Three
• Add on Wellbutrin (bupropion) XL 150 mg orally daily
• Guidance to Student
• Given her weight (less than 60      kg), Campral should have been started at 666 mg orally BID. It is possible      that the higher dose may be responsible for the severity of the symptoms      that Mrs. Perez is experiencing.
• Technically, the drug should      have been stopped (not simply decreased) once Mrs. Perez reported suicidal      ideation. Even with the decrease in dose, she is still having suicidal      ideation, which indicates the need to discontinue the drug. Although      controversy exists regarding how long to use pharmacologic approaches to      treatment of alcohol dependence, 8 weeks is probably insufficient,      therefore, the drug should not simply be discontinued without using a      different agent in its place.
• Mrs. Perez should be started on      Antabuse at 250 mg orally daily and referred to psychotherapy to address      her gambling issue.
• In all cases, the PMHNP needs      to discuss smoking cessation options with Mrs. Perez in order to address      the totality of addictions and to enhance her overall health. The decision      to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but      this choice does not address her abstinence from alcohol.
• Additionally, it should be      noted that although Mrs. Perez reports that she has been avoiding the      casino secondary to her fear that she will drink, this “fear” has not      actually treated her gambling addiction. This particular addiction has      resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez      needs to be referred to a counselor who specializes in the treatment of      gambling disorder, and she should also be encouraged to establish herself      with a local chapter of Gamblers Anonymous.
• Examine Case Study: A      Puerto Rican Woman With Comorbid Addiction. You will be asked to make      three decisions concerning the medication to prescribe to this client. Be      sure to consider factors that might impact the client’s pharmacokinetic      and pharmacodynamic processes.
• At each decision point stop to      complete the following:
• Decision #1
• Which decision did you select?
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #1 and the results of the      decision. Why were they different?
• Decision #2
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #2 and the results of the      decision. Why were they different?
• Decision #3
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #3 and the results of the      decision. Why were they different?

 
Assessing and Treating Clients with Impulsivity, Compulsivity and Addiction 
Pharmacotherapy practice to treating substance use disorders is often referred to as medication assisted treatment (MAT) (Sharp et al., 2018). In this practice, specific medications approved by Federal Drug Administration (FDA) are used in combination with counseling and behavioral therapies in treatment of a substance use disorder (Sharp et al, 2018) Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken ( SAMHSA, 2016). MAT has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders. This paper focuses on pharmacotherapy approaches to treatment of alcohol use disorder, gambling disorder and smoking addiction in a 53 year- old female of Puerto origin.
Case Scenario
Decision Number One
Naltraxone (Vivitrol) injection, 380 mg intramuscularly in gluteal region every four weeks.
Rationale: Pharmacotherapy should be used in patients with alcohol use disorder who have current, heavy use and ongoing risk for consequences from use, motivated to reduce alcohol intake and do not have medical contraindications to the individual drug choice (SAMHSA, 2016). As the 53 year-old female has acknowledged that she has a drinking problem and has tried psychosocial approach with alcoholic anonymous(AA) without success, adding medication such as naltrexone would be warranted as next step. In random clinical trials (RCTs) naltrexone medication has been shown to reduce heavy drinking and enhance the likelihood of abstinence ( Garbutt et al.,  2014)
Naltraxone is mu opioid receptor antagonist, can be in form of oral ( Revia) and injection( Vivitrol) ( Stahl, 2017). Naltraxone is FDA approved to treat alcohol dependence, blockade of effects of exogenously administered opioids (oral) and prevention of relapse to opioid dependence (Stahl, 2017).  Naltrexone reduces alcohol consumption through modulation of opioid systems, thereby reducing the reinforcing effects of alcohol and opioids (cravings, rewarding effects). Moreover, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption.
The recommended naltrexone injectable (vivitrol) suspension is 380mg and should be administered via intramuscular (IM)injection to the gluteal area using the provided 1.5 inch 20-gauge needle(Drugs.com, 2017).  Vivitrol is extensively metabolized in humans, and elimination half-life of naltrexone via injection is 5–10 days (Drugs. com, 2017) Common side effects of naltrexone are nausea, headache, and dizziness, joint or muscle pain which subside with continued use. Special considerations include that vivitrol should not be given to patients taking opioids, and if opioids are required to treat pain, naltrexone should be discontinued. Naltrexone is contraindicated in acute hepatitis or liver failure.
The advantage usage is that naltrexone can be initiated while the individual is still drinking (Canidate et al., 2017) This allows treatment for alcohol use disorder to be provided in community-based practice at the point of maximum crisis without the need for enforced abstinence or detoxification, thus beneficial for the client. Additionally, depot preparations of naltrexone may improve adherence by reducing the frequency of medication administration from daily to monthly and by achieving a steady therapeutic level of medication, thus avoiding peak effects that can exacerbate adverse events.
The reason I did not select disulfiram (Antabuse) which by intent leads to adverse effects ( nausea, vomiting, metallic taste, tachycardia) when combined with alcohol intake, was that it  should only be used by abstinent patients in the context of treatment intended to maintain abstinence. In regards of Acamprosate, I did not select the medication because research indicates that Acamprosate should be used once abstinence is achieved (Yahn, Witterson, & Olive, 2013).
The main goal of prescribing medication for treatment for alcohol use disorder is abstinence, which remains a primary treatment focus. However, decrease of heavy drinking can be accepted as an alternative treatment goal, especially if unwanted risks (health, social and financial) are reduced.
The client returns four weeks after the injections, she has been sober since receiving injection, she denies any side effects from medications. The main chief complaint is gambling, but client is also concerned about her smoking and anxiety.
Decision Two
Refer to a Counselor for Gambling Issues 
Rationale:  Several different types of therapy are used to treat gambling disorder, including cognitive behavior therapy, psychodynamic therapy, group therapy and family therapy (American Psychiatric Association, 2016) As recent, there is no FDA approved pharmacotherapy for gambling disorder. But, pharmacotherapy approaches for problem gambling can be effective when directed toward the patient’s comorbid psychiatric condition such as bipolar disorder, obsessive compulsive disorder(OCD), and substance abuse.
The client was concerned about her smoking and appeared to be motivated to stop smoking, hence adding medication to assist her to quit would have been a reasonable approach to avoid health complications (e.g cardiovascular, pulmonary) associated with smoking. However, I did not select the answer as the starting dosage (Varenicline 1mg PO BID) was slightly higher than recommended starting dose. Initial 0.5 mg/day; after 3 days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided dose(Stahl, 2017) . Starting at a higher would have increased the possibilities of adverse effects such nausea, vomiting and even agitation.
Adding Diazepam (Valium) would not be a good option, as Valium is an addictive benzodiazepine with longer-lasting effects than other drugs in its class. In the light of the client’s history substance use disorder and addiction, adding another addictive substance such as valium would cause more harm.
The client returns in four weeks, reports that anxiety has gone. Client reports not liking the therapist, but she has joined gambling anonymous group.
Decision Number Three
Explore the issue that Mrs Lopez is having with her counselor, and encourage her to continue attending Gamblers Anonymous meetings
Rationale: Despite that Mrs. Lopez did not have a good relationship with the counselor, but she remained committed to fighting her addiction by joining Gamblers Anonymous group. Still, counseling remains the main approach in gambling addiction treatment, hence exploring the issues that Mrs. Lopez had with counselor would help to guide the next step in treatment. Also, smoking cessation needs to be explored at this time. Assessing the client’s willingness to quit is the first step as smokers differ in their readiness to change their tobacco use (Niaura, 2017). Understanding the smokers’ perspectives is essential to providing useful assistance.
Ethical and Legal Implications in Prescribing Medications to Treat Substance Use Disorders.
In order to optimize care of clients with substance use disorder, health professionals are encouraged to learn  and appropriately use routine screening techniques, clinical laboratory tests, brief interventions, and treatment referrals ( Garbutt, 2014). Using screening tools such as CAGE Questionnaire for alcohol use dependence, would be ideal in guiding treatment approach. Additionally, client’s autonomy and confidentiality must be maintained before prescribing medications to treat an addiction. When a legal or medical obligation exists for  a health professional to test clients for substance use disorder, there is an ethical responsibility to notify clients of this testing and make a reasonable effort to obtain informed consent ( Garbutt, 2014)
References
American Psychiatric Association. (2016). What Is Gambling Disorder? Retrieved from /orders/www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder
Canidate, S. S., Carnaby, G. D., Cook, C. L., & Cook, R. L. (2017). A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders. Alcoholism: Clinical and Experimental Research, 41(3), 466-472. Retrieved from /orders/web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=14&sid=183cffb8-9da8-48b2-a1b7-66c14f735856%40sessionmgr101
Drugs.com. (2017). Vivitrol Dosage Guide – Drugs.com. Retrieved from /orders/www.drugs.com/dosage/vivitrol.html
Garbutt, J. C., Greenblatt, A. M., West, S. L., Morgan, L. C., Kampov-Polevoy, A., Jordan, H. S., & Bobashev, G. V. (2014). Clinical and biological moderators of response to naltrexone in alcohol dependence: a systematic review of the evidence. Addiction, 109(8), 1274-1284. Retrieved from /orders/web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=41ca863e-175d-45ae-ba36-43317c3c58e5%40sessionmgr4008
Niaura, R. (2017). Learning From Our Failures in Smoking Cessation Research | Nicotine & Tobacco Research | Oxford Academic. Retrieved from /orders/academic.oup.com/ntr/article/19/8/889/3888613
SAMHSA. (2016). Treatments for Substance Use Disorders | SAMHSA – Substance Abuse and Mental Health Services Administration. Retrieved from /orders/www.samhsa.gov/treatment/substance-use-disorders
Sharp, A., Jones, A., Sherwood, J., Kutsa, O., Honermann, B., & Millett, G. (2018). Impact of Medicaid Expansion on Access to Opioid Analgesic Medications and Medication-Assisted Treatment. American Journal of Public Health, 108(5), 642-648. Retrieved from /orders/web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=5&sid=21e9426c-0afa-475e-9a9a-e1872d98830d%40sess
Stahl, S. M. (2017). Essential psychopharmacology: The prescriber’s guide : antipsychotics and mood stabilizers. Cambridge: Cambridge University Press.
Yahn, S. L., Watterson, L. R., & Olive, M. F. (2013). Safety and Efficacy of Acamprosate for the Treatment of Alcohol Dependence. Substance Abuse: Research and Treatment, 7. Retrieved from /orders/www.ncbi.nlm.nih.gov/pmc/articles/PMC3565569/

Advanced Health Assessment

P1.docx Advanced Health Assessment

P1.docx Advanced Health Assessment

Main Post
Case B 14-year-old biracial male living with his grandmother in a high-density public housing complex
Summary Interview and Communication Techniques
In order to succeed in our career  as health care providers, we must  be able to develop the right plan of care for our patients, it is crucial  to develop a sense of trust with the patients, and this trust can only be achieved by using the appropriate communication techniques.  First, I would start the interview by introducing myself and acknowledging the patient and the grandmother. After, I would like to meet with the grandmother alone in order to ask about the  teenagers parents and ask regarding any issues she would like to discuss with me without the presence of the grandkid, in many occasions grandparents like to speak to the health care providers in private without the presence of the minor. In this case the grandmother might be needing help from social work services regarding their housing situation. Assuming the grandmother takes great care of the patient and offers him all the necessary support, living in a high density public housing complex can be challenging for a 14 year old male, besides that,  not having both of his parents actively participating in the teenager life can  sometimes bring physical, social and emotional consequences.  Then I would like to ask questions regarding the patient’s family history and the medical history of both parents if known.  Health risk assessment is the core of health promotion and disease prevention regardless the patient’s age, in order to conduct a risk assessment is important to always assess for family history (Wu & Orlando, 2015).
Consequently I would ask for permission to speak to the adolescent in privacy, by doing this I build a sense of trust with the patient, allowing him to be more open regarding issues that he might not want to discuss in front of his grandmother, for example,  drug use,   the need for emotional support, etc.  It is always important to make sure the questions are clearly understood, medical and technical terminology is sometimes avoided in order to adapt to the patient’s language level (Ball, Dains, Flynn, Solomon & Stewart, 2019).
Risk Assessment Instrument
            Based on my assessment in this given case scenario, I will be utilizing the CRAFFT questionnaire,  this risk assessment tool is used as a screening tool for alcohol and substance abuse in adolescents, due to this patient’s living conditions and lack of parental support this patient may be at risk for emotional instability that can lead to drugs and substance abuse.
Targeted Questions
Have you ever done any types of illicit drugs, drank alcohol or smoked cigarettes?
Do you feel you have   support or someone who talk to if necessary?
Are you sexually active?
How is school going?
How is your relationship with your grandmother?
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: an interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, 91(1079), 508. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1136/postgradmedj-2014-133195
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Need Help Assignment: Writing A Treatment Plan (Experienced In Social Work Writing)

Need Help Assignment: Writing A Treatment Plan (Experienced In Social Work Writing)

Need Help Assignment: Writing A Treatment Plan (Experienced In Social Work Writing)

Need Help Assignment: Writing A Treatment Plan (Experienced In Social Work Writing)

Need Help Assignment: Writing A Treatment Plan (Experienced In Social Work Writing)

Need Help Assignment: Writing A Treatment Plan (Experienced In Social Work Writing)

Need help with all questions listed in assignment. Please provide in APA Format with References listed. Attached Case Study.
reference 1#
/orders/www.socialworker.com/feature-articles/ethics-articles/to-record-or-not-to-record-the-ethics-of-documentation/
Reference #2
 
Kirst-Ashman, K. K., & Hull, G. H., Jr. (2018). Understanding generalist practice (8th ed.). Stamford, CT: Cengage Learning.

• Chapter 6, “Planning in Generalist Practice” (pp. 224–254)
• Chapter 16, “Recording in Generalist Social Work Practice” (pp. 599–656)

 
Everything that social workers do is an intervention; therefore, social workers develop treatment plans so that they can outline the purpose of treatment, assist in giving the client direction in the treatment process, allow the social worker to collaborate with the client, and help social workers and clients mark progress toward goals. Depending on where you work as a social worker, your funding source may be dependent upon your treatment plan.
In this Assignment, you develop a treatment plan for a client. In real practice, you should never create a treatment plan without conducting a more thorough assessment and then collaborating with the client to mutually agree on goals and steps to implement the plan. For the purpose of this Assignment, however, you explain how you might go about this process.
To prepare: Watch the video case study found in the Learning Resources. Then, go to the Walden Library and review literature related to interventions for this type of client or problem. Use this information to help develop an individual or family treatment plan for the identified client (Amy, Mrs. Bargas, or Bargas family) with whom you have chosen to work from the case study.

By Day 7

Submit a 3- to 4-page paper in which you:

• Identity the client.
• Describe the problems that need to be addressed.
• Explain how you would work with the client to identify and prioritize problems.
• Identify the related needs based on the identified problems.
• Describe how you would utilize client strengths when selecting a strategy for intervention.
• Identify at least two treatment plan goals.
• Create at least one measurable objective to meet each goal.
• Explain the specific action steps to achieve objectives.
• Discuss evidence from the research literature that supports your intervention choices.
• Describe what information is important to document in a treatment plan and explain why.
  Southside Community Services: Mrs. Bargas Case History
  © 2018 Laureate Education, Inc. 1
  Southside Community Services: Mrs. Bargas Case History Program Transcript [MUSIC PLAYING]
  LINDA FORTE: Hi, Mrs. Bargas, I’m Linda Forte, the social worker assigned to your case. It’s nice to meet you. So what brings you in, today?
  MRS. BARGAS: Well– I’ve been out of work about 3 months. And 2 weeks ago, my husband had a stroke. He’s still in the hospital. So it’s been– a lot, all at once. And the money– I don’t know how going to pay the bills, or the rent. We cannot lose our home. We have five children.
  LINDA FORTE: Has this been hard on them? It sounds like you’ve been going through a lot since losing your job and your husband being in the hospital. I can understand how you can feel stressed and concerned.
  MRS. BARGAS: My daughter Amy– she’s my oldest– she’s been having the hardest time. She’s cutting classes at school and she’s failing two of her courses.
  LINDA FORTE: So how did you hear about our agency and how can I help?
  MRS. BARGAS: Well, my pastor said that you could help me find a job and maybe help with the rent money. And maybe Amy could– speak to somebody.
  LINDA FORTE: OK. Has your daughter, Amy, has she ever expressed any interest in hoping to speak to somebody about her problems?
  MRS. BARGAS: Maybe. I don’t know. I haven’t really mentioned it to her. But my pastor thinks it’s a good idea.
  LINDA FORTE: Has Amy ever spoken to the social worker at her school, before?
  MRS. BARGAS: No, I don’t think so.
  LINDA FORTE: OK. That’s fine. We can definitely talk about getting Amy some help. But first, why don’t we talk a little bit about work experience. What kind of job are you hoping to find?
  MRS. BARGAS: Well, before I married my husband, I worked as a nanny.
  LINDA FORTE: OK. So why don’t we talk a little bit more about that, about who you worked for, and what kind of job duties you had.
  MRS. BARGAS: Well, I was much younger when I was a nanny. Let me see, it was– more than 12 years ago. But I don’t think I could do that work, now. Maybe
   
   
  Southside Community Services: Mrs. Bargas Case History
  © 2018 Laureate Education, Inc. 2
  I could work in an office. You know, I’m really good at working with people. Can you find me a job in an office?
  LINDA FORTE: I don’t know. I work with a career counselor, here. She might be able to help you.
  MRS. BARGAS: I don’t know how I’m going to pay the rent.
  LINDA FORTE: I know right now is really tough for you.
  MRS. BARGAS: I just don’t know what to do. Nothing has turned out the way I hoped it would. My whole life. I’m really worried about my daughter, Amy. She’s afraid to go to school. She loses her temper all the time. She yells at me and then locks herself in a room and she won’t speak. I am so confused. I don’t know what to do with her. I just– I don’t know.
  LINDA FORTE: It’s OK to be upset. Mrs. Bargas? Are you OK?
  MRS. BARGAS: I’m sorry, what?
  LINDA FORTE: Are you all right?
  [MUSIC PLAYING] LINDA FORTE: Good news. I spoke with the career counselor and she has an available opening for you, tomorrow. She thinks she can help you find a job.
  MRS. BARGAS: That’s great! Thank you so much. I was wondering, actually, there’s something else that you could help me with. I told you that my husband had a stroke. He’s going to need speech therapy. But it’s– we can’t afford it. And we don’t have any insurance. Is there any chance that you could call his doctor and see if my husband can get this therapy? He really needs it.
  LINDA FORTE: I may be able to help. But I’m going to need to understand your husband’s situation a little bit better. Is there any way your husband would be willing to sign a release form, so I could talk to the doctor?
  MRS. BARGAS: You can’t just call his doctor? I give you permission.
  LINDA FORTE: I’m afraid not. According to HIPAA regulations, the doctor is not allowed to discuss your husband’s condition with me without his consent. Your husband could sign a release of information form, which would then make it possible for me to talk to his doctor. I recommend you go home and talk to your husband about whether he’d want to give his consent.
  MRS. BARGAS: OK. I will. Thank you so much. You’ve been so helpful.
   
   
  Southside Community Services: Mrs. Bargas Case History
  © 2018 Laureate Education, Inc. 3
  LINDA FORTE: Absolutely. And I look forward to seeing Amy next week.
  MRS. BARGAS: Bye.
  LINDA FORTE: Bye.
  [MUSIC PLAYING]

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Assignment 3 Week 7 FINANCIAL ANALYSIS REPORT

Assignment 3 Week 7 FINANCIAL ANALYSIS REPORT

FINANCIAL ANALYSIS REPORT SAMPLE
Assignment: Decision Tree
For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting symptoms of a mental health disorder.
The Assignment:
Examine Case 2 : You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.
At each Decision Point, stop to complete the following:
· Decision #1: Differential Diagnosis
· Which Decision did you select?
· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
· Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
· Decision #2: Treatment Plan for Psychotherapy
· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
· Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
· Decision #3: Treatment Plan for Psychopharmacology
· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
· Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
· Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Case #2 Anxiety disorder, OCD, or something else?

BACKGROUND
Tyrel is an 8-year-old black male who is brought in by his mother for a variety of psychiatric complaints. Shaquana, Tyrel’s mother, reports that Tyrel has been exhibiting a lot of worry and “nervousness” over the past 2 months. She states that she notices that he has been quite “keyed up” and spends a great deal of time worrying about “germs.” She states that he is constantly washing his hands because he feels as though he is going to get sick like he did a few weeks ago, which kept him both out of school and off the playground. He was also not able to see his father for two weekends because of being sick. Shaquana explains that although she and her ex-husband Desmond divorced about 2 years ago, their divorce was amicable and they both endeavor to see that Tyrel is well cared for.
Shaquana reports that Tyrel is irritable at times and has also had some sleep disturbances (which she reports as “trouble staying asleep”). She reports that he has been more and more difficult to get to school as he has become nervous around his classmates. He has missed about 8 days over the course of the last 3 weeks. He has also stopped playing with his best friend from across the street.
His mother reports that she feels “responsible” for his current symptoms. She explains that after he was sick with strep throat a few weeks ago, she encouraged him to be more careful about washing his hands after playing with other children, handling things that did not belong to him, and especially before eating. She continues by saying “maybe if I didn’t make such a big deal about it, he would not be obsessed with germs.”
Per Shaquana, her pregnancy with Tyrel was uncomplicated, and Tyrel has met all developmental milestones on time. He has had an uneventful medical history and is current on all immunizations.
 
OBJECTIVE
During your assessment of Tyrel, he seems cautious being around you. He warms a bit as you discuss school, his friends at school, and what he likes to do. He admits that he has been feeling “nervous” lately, but when you question him as to why, he simply shrugs his shoulders.
When you discuss his handwashing with him, he tells you that “handwashing is the best way to keep from getting sick.” When you question him how many times a day he washes his hands, he again shrugs his shoulders. You can see that his bilateral hands are dry. Throughout your assessment, Tyrel reveals that he has been thinking of how dirty his hands are; and no matter how hard he tries to stop thinking about his “dirty” hands, he is unable to do so. He reports that he gets “really nervous” and “scared” that he will get sick, and that the only way to make himself feel better is to wash his hands. He reports that it does work for a while and that he feels “better” after he washes his hands, but then a little while later, he will begin thinking “did I wash my hands well enough? What if I missed an area?” He reports that he can feel himself getting more and more “scared” until he washes his hands again.
 
MENTAL STATUS EXAM
Tyrel is alert and oriented to all spheres. Eye contact varies throughout the clinical interview. He reports his mood as “good,” admits to anxiety. Affect consistent to self-reported mood. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes were apparent. He denies suicidal ideation.
Lab studies obtained from Tyrel’s pediatric nurse practitioner were all within normal parameters. An antistreptolysin O antibody titer was obtained for reasons you are unclear of, and this titer was shown to be above normal parameters.
 
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
 
 Generalized Anxiety Disorder (GAD)
 Obsessive Compulsive Disorder
 Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)
ANSWER CHOOSEN : Obsessive Compulsive Disorder
 
Decision Point Two
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
 
Begin Zoloft 50 mg orally daily
Begin Fluvoxamine immediate release 25 mg orally at bedtime
Begin Fluvoxamine controlled release 100 mg orally in the morning
 
Discontinue Zoloft and begin Fluvoxamine controlled release 100 mg orally every morning In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this. Zoloft is FDA-approved to treat OCD in children. However, between ages 6 and 12, it should be started at 25 mg orally daily. If starting doses are too high, the child may experience side effects that he associates with the medication and as such, may refuse to take the medication. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective.
 
ANSWER CHOOSEN: Begin Fluvoxamine immediate release 25
mg orally at bedtime
 
· Client returns to clinic in four weeks
· Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.
· She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.
·  She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.
 
 
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Increase Fluvoxamine to 50 mg orally at bedtime
Augment with an atypical antipsychotic such as Abilify
Augment treatment with cognitive behavioral therapy
 
ANSWER CHOOSEN:  Increase Fluvoxamine to 50 mg orally at
bedtime
Guidance to Student
In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.
Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.
At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.
Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.
Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.
Learning Resources
Required Readings
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
· Chapter 31, “Child Psychiatry” (pp. 1253–1268)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
· “Anxiety Disorders”
American Academy of Child & Adolescent Psychiatry (AACAP). (2012a). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98–113. Retrieved from http://www.jaacap.com/article/S0890-8567(11)00882-3/pdf
 
McClelland, M., Crombez, M-M., Crombez, C., Wenz, C., Lisius, M., Mattia, A., & Marku, S. (2015). Implications for advanced practice nurses when pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is suspected: A qualitative study. Journal of Pediatric Health Care, 29(5), 442–452. doi:10.1016/j.pedhc.2015.03.005
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.
  
To access information on the following medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.
 
Decision Tree: Personality Disorders

As described by the American Psychiatric Association (APA) (2013), ‘‘personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’’. There are different types of personality disorders classified into three clusters. Cluster A individuals are described as the odd or eccentric, cluster B as the dramatic, emotional, or erratic and cluster C as the anxious or fearful. The purpose of this paper is to discuss the case study of a young woman with personality disorder. This paper will explore threes decisions relating to differential diagnosis, psychotherapy and psychopharmacology based on the presented clinical manifestations.
Decision One
The clinical manifestation presented in the case study are indicative of more than one personality disorder, specifically borderline personality disorder (BPD) and antisocial personality disorder (ASPD). Patients exhibits a fear of abandonment which aligns with BPD. The patient mentioned an interpersonal relationship involvement which she exhibited idolization for the man of her interest, and now is devaluing the man. This is also evident in BPD as outlined by diagnostic criteria set forth by the APA (2013).
My diagnosis for this patient is ASPD, because the client exhibits clinical manifestations of ASPD than BPD. One of the reasons that led me to the diagnosis of ASPD is the client’s lack of remorse. The client stole from a friend, instead of being sorry, client’s blames friend instead. Client exhibits lack of respect for social norm and failure to comply with the law as evidenced by more than one record of arrest. The client fails to upholding financial obligation and is deceitful. Client shows irresponsibility evidenced by inability to keep a job. These presentations are evident in clients with ASPD as outlined in the DSM-5.
The two personality disorders which are classified as cluster B personality disorders by the APA (2013) have clinical manifestations which overlap, thus needs to be ruled out as differential diagnoses for each other. As described on the DSM-5 diagnostic criteria, BPD and ASD have similar features of impulsivity, aggression and manipulative behaviors, which client exhibits in the case study. The differing manifestation between the two is that in BPD, clients seek out interpersonal relationship, while ASPD client is unable to form any attachment to relationship. Clients with BPD exhibit self-mutilating behaviors and self-aggression, while in ASPD, aggression is directed on others. In ASPD clients are egocentric (also seen in narcisstic personality disorder), while BPD clients have a poor image of self.
Decision Two
Since the client exhibits symptoms which are synonymous with one more than personality disorder, specifically borderline and antisocial; the best decision is to opt to conduct a psychological testing. This will to further help the practitioner to decipher between the two diagnoses or conclude that patient indeed has the two personality disorders which is a possible occurrence. Psychological testing can be in the form of rating scales which includes questionnaires, checklists e.t c. According to Sadock, Sadock and Ruiz (2014), these scales are useful for monitoring patient overtime or to provide a comprehensive assessment information that was not obtained during a routine clinical interview.
There is limited evidence from existing literatures on the effectiveness of medications to target the core symptoms of ASPD. Khalifa et al. (2010) mentions that pharmacological interventions are not to be considered as monotherapy but as adjunctive intervention to target associated symptoms of ASPD such as depression, aggression etc. The option of Haldol, an antipsychotic medication can be used to address aggression but does not treat the core features of the disorder such as lack of remorse, deceitfulness. Furthermore, the plethora of side effects known to be caused by the medication can increase noncompliance. Psychotherapy can be beneficial, but psychodynamic is not appropriate for this patient because it may require patient to address emotional states. According to Hesse (2010), probing about ‘feeling states’ is unhelpful because the ASPD client may have difficulty accessing such state and may become aggressive when made to confront personal shortcoming.
Decision Three
In decision three, the recommendation is for a group-based cognitive therapy. Latuda an antipsychotic can be used to treat aggression but not the core symptoms of ASPD. Dialectical behavioral therapy will be more appropriate in the client with BPD than in ASPD. The most cited effective psychotherapeutic approach used in ASPD is cognitive behavioral therapy (CBT). This approach helps the client address distorted beliefs about self, others and the world. CBT can be used to enhance social and intrapersonal functioning.
A group setting may be beneficial for these clients as they may be able to learn from others experience or information shared about self. Psychotherapy for ASPD should be met with skepticism, but Hesse (2010) suggested that approaches that includes employing moral reasoning, cognitive behavioral approach, applying a social information processing approach, and planning for relapse prevention should be used. Additionally, the clients need a high level of external structure that includes supervision of the patient and reinforcement of positive social behaviors to yield increased outcomes for ASPD clients (Hesse, 2010).
 
Ethical and Legal Considerations
Due to the clinical manifestation of ASPD, some clinicians believe that it is hopeless to treat ASPD clients due to their clinical manifestation of aggression, deceitfulness and manipulation. Clients tends to be noncompliant, fueling the clinician’s pessimism. Existence of pessimism can hinder practitioners from upholding the ethical principles to do no harm and to do the best for the patient to full capacity. Hatchet (2015), implores clinicians to turn to published studies to become more aware of treatment options and to avoid expert opinions or clinical myths in regards to treating clients with ASPD. For these clients, autonomy may be purposely compromised to prevent harm to the patient and to others. This is seen in cases where patient refuse to comply with treatment plan or ordered into treatment and remain in treatment until deemed fit to come out of treatment.
Conclusion
It is essential for the practitioner to be knowledgeable about personality s disorder to effectively care for the patient. The practitioner should explore various options of medication, used to target accompanied symptoms. Psychotherapy, even though some might argue of its effectiveness, should not be ruled out. Assessment tools should be used to guide the clinicians, in diagnosing, especially with disorders that have overlapping symptoms. Assignment 3 Week 7 FINANCIAL ANALYSIS REPORT

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Khalifa, N., Duggan, C., Stoffers, J., Huband, N., Völlm, B. A., Ferriter, M., & Lieb, K. (2010). Pharmacological interventions for antisocial personality disorder. The cochrane database of systematic Reviews, (8). Doi: 10.1002/14651858.CD007667.pub2
Hatchett, G. T. (2015). Treatment guidelines for clients with antisocial personality disorder. Journal of mental health counseling, 37(1). Retrieved from Walden University Database
Hesse, M. (2010). What should be done with antisocial personality disorder in the new edition of the diagnostic and statistical manual of mental disorders (DSM-V)? Biomed central medicine, 8(66). DOI: 10.1186/1741-7015-8-66
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – Assignment 3 Week 7 FINANCIAL ANALYSIS REPORT

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Assignment 3 Week 7 FINANCIAL ANALYSIS REPORT

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Assignment 3 Week 7 FINANCIAL ANALYSIS REPORT

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Walden NURS6521 Week 7 Quiz Latest

Question 1 A 42-year-old man is being treated for a peptic ulcer with ranitidine (Zantac) taken PO at bedtime. Even though few adverse effects are associated with this drug, one common adverse effect that can be severe is
A) headache
B) irritability
C) dry mouth
D) heart palpitations
Question 2 A patient on 5-FU calls the clinic and reports that he has between five and seven loose bowel movements daily. The nurse will instruct the patient to
A) treat the diarrhea with OTC medications
B) avoid protein-rich foods
C) avoid grapefruit and grapefruit juice
D) notify the clinic if the stools are black or if there is evidence of blood
Question 3 A patient has been prescribed a histamine-2 (H2) receptor antagonist for the treatment of GERD. Why are H2RAs more effective than H1 receptor antagonists in the treatment of diseases of the upper GI tract?
A) H2RAs have a longer duration of action and fewer adverse effects than H1RAs
B) The parietal cells of the stomach have H2 receptors but not H1 receptors
C) H2RAs may be administered orally and in an outpatient environment but H1RAs require intravenous administration
D) H2 receptors in the upper GI tract outnumber H1 receptors by a factor of 2:1
Question 4 To maximize the therapeutic effect of diphenoxylate HCl with atropine sulfate, the nurse will instruct the patient to take the medication
A) once a day
B) twice a day
C) every 2 hours
D) four times a day
Question 5 A 22-year-old male college senior has lived with a diagnosis of Crohn’s disease for several years and has undergone several courses of treatment with limited benefit. Which of the following targeted therapies has the potential to alleviate the symptoms of Crohn’s disease?
A) Tositumomab plus 131I (Bexxar)
B) Muromonab-CD3 (Orthoclone OKT3)
C) Infliximab (Remicade)
D) Eculizumab (Soliris)
Question 6 A patient has been prescribed rabeprazole (Aciphex). It will be important for the nurse to assess the patient’s drug history to determine if the patient is taking which of the following drugs?
A) Levodopa
B) Morphine
C) Digoxin
D) Dicyclomine hydrochloride
Question 7 An adult patient who has been diagnosed with a rectal tumor is scheduled to begin treatment with cisplatin. The nurse has conducted patient teaching about the possibility of nausea and vomiting. In order to reduce the patient’s risk of severe nausea, the nurse should
A) place the patient on a low-residue diet
B) ensure that the patient is NPO from midnight prior to receiving the drug
C) administer a combination of antiemetics prior to the administration of the drug
D) encourage the patient to request antiemetics if the nausea becomes unbearable
Question 8 It is determined that a patient, who is in a hepatic coma, needs a laxative. Lactulose is prescribed. Which of the following should the nurse monitor to assess the efficacy of the lactulose therapy?
A) Water levels in the colon
B) Oncotic pressure in the colon
C) Blood ammonia levels
D) Relief from symptoms
Question 9 A 60-year-old man has scheduled a follow-up appointment with his primary care provider stating that the omeprazole (Prilosec) which he was recently prescribed is ineffective. The patient states,“I take it as soon as I feel heartburn coming on, but it doesn’t seem to help at all.” How should the nurse best respond to this patient’s statement?
A) “It could be that Prilosec isn’t the right drug for you, so it would be best to talk this over with your care provider.”
B) “Prilosec won’t really decrease the sensation of heartburn, but it is still minimizing the damage to your throat and stomach that can be caused by the problem.”
C) “Prilosec will help your heartburn but it’s not designed to provide immediate relief of specific episodes of heartburn.”
D) “A better strategy is to take a dose of Prilosec 15 to 30 minutes before meals or drinks that cause you to get heartburn.”
Question 10 A 33-year-old woman has irritable bowel syndrome (IBS). The physician has prescribed simethicone (Mylicon) for her discomfort.Which of the following will the nurse monitor most closely during the patient’s drug therapy?
A) Drug toxicity
B) Anorexia
C) Increased abdominal pain and vomiting
D) Increased urine output
Question 11 Mr. Tan is a 69-year-old man who prides himself in maintaining an active lifestyle and a healthy diet that includes adequate fluid intake. However, Mr. Tan states that he has experienced occasional constipation in recent months. What remedy should be the nurse’s first suggestion?
A) Bismuth subsalicylate
B) A bulk-forming (fiber) laxative
C) A stimulant laxative
D) A hyperosmotic laxative
Question 12 A 29-year-old woman has been prescribed alosetron (Lotronex) for irritable bowel syndrome. Before starting the drug therapy, the nurse will advise the patient about which of the following adverse effect(s)?
A) Constipation
B) Breathlessness and hypotension
C) Hyperthyroidism
D) Impaired cardiac function
Question 13 A 29-year-old female patient has been prescribed orlistat (Xenical) for morbid obesity. The nurse is providing patient education concerning the drug. An important instruction to the patient would be to
A) omit the dose if the meal does not contain fat
B) take orlistat and multivitamins together
C) take orlistat in one dose at breakfast
D) omit the dose if the meal does not contain protein
Question 14 Prior to administering a dose of 5-FU to a patient with pancreatic cancer, the nurse is conducting the necessary drug research. The nurse is aware that 5-FU is a cell cycle–specific chemotherapeutic agent. Which of the following statements best describes cell cycle–specific drugs?
A) They follow a specific sequence of cytotoxic events in order to achieve cell death
B) They affect cancerous cells during a particular phase of cellular reproduction
C) They achieve a synergistic effect when administered in combination with cell cycle–nonspecific drugs
D) They affect cancerous cells and normal body cells in a similar manner
Question 15 A patient with a long history of alcohol abuse has been admitted to an acute medical unit with signs and symptoms of hepatic encephalopathy. His current medication orders include QID doses of oral lactulose. What desired outcomes should the nurse associate with this drug order?
A) Patient will have three to four loose bowel movements each day
B) Patient will express relief from constipation
C) Patient will have formed bowel movements that do not contain frank or occult blood
D) Patient will express an understanding of his current bowel regimen
Question 16 A nurse is assessing a female patient who is taking diphenoxylate HCl with atropine sulfate. Which of the following would lead the nurse to suspect that she is experiencing an allergic reaction?
A) Numbness of extremities
B) Headache and lethargy
C) Toxic megacolon
D) Urticaria
Question 17 A 73-year-old woman has scheduled an appointment with her nurse practitioner to discuss her recurrent constipation. The woman states that she experiences constipation despite the fact that she takes docusate on a daily basis and performs cleansing enemas several times weekly.How should the nurse best respond to this patient’s statements?
A) “Because we become more prone to constipation as we age, you’ll likely need to increase the number of stool softeners you take.”
B) “I’ll refer you to a specialist because it could be that you have a disease affecting your bowels or stomach.”
C) “Taking too many laxatives can make your bowels dependent on them, making you more susceptible to constipation.”
D) “Try using a different over-the-counter laxative and see that if you resolves your problem.”
Question 18 A patient develops diarrhea secondary to antibiotic therapy. He is to receive two tablets of diphenoxylate HCl with atropine sulfate (Lomotil) orally as needed for each loose stool. The nurse should inform him that he may experience
A) dizziness
B) bradycardia
C) muscle aches
D) increase in appetite
Question 19 A patient who takes aluminum hydroxide with magnesium hydroxide (Mylanta) frequently for upset stomach, heartburn, and sour stomach is seen regularly in the clinic. The nurse should assess which of the following?
A) Blood glucose level
B) Serum phosphate level
C) Urine specific gravity
D) Aspartate transaminase levels
Question 20 A teenage boy has undergone a diagnostic workup following several months of persistent, bloody diarrhea that appears to lack an infectious etiology. The boy has also experienced intermittent abdominal pain and has lost almost 15 pounds this year. Which of the following medications is most likely to treat this boy’s diagnosis?
A) Lubiprostone
B) Mesalamine
C) Docusate
D) Bismuth subsalicylate
Question 21 Mesalamine (Asacol) is prescribed for a 22-year-old woman with Crohn disease. The nurse will discuss with the patient the possibility for which of the following adverse effects related to the new drug therapy?
A) Hair loss
B) Metallic taste
C) Fatigue
D) Increased appetite
Question 22 A 58-year-old man is prescribed dicyclomine (Bentyl) for irritable bowel syndrome. In which of the following conditions is dicyclomine therapy contraindicated?
A) Hypertension
B) Diabetes mellitus
C) Glaucoma
D) Rheumatoid arthritis
Question 23 A nurse is planning care for a 59-year-old woman who is on ranitidine therapy. The nurse is concerned for the patient’s safety.Which of the following would be an appropriate nursing diagnosis?
A) Diarrhea related to adverse effects of drug therapy
B) Acute Pain related to adverse drug effects, headache
C) Risk for Injury related to drug-induced somnolence, dizziness, confusion, or hallucinations
D) Potential Complication: Electrolyte Imbalance related to hypophosphatemia, secondary to drug therapy
Question 24 A 57-year-old man is to begin 5-FU therapy for colon cancer. It will be most important for the nurse to monitor which of the following during the first 72 hours of the initial treatment cycle?
A) Myelosuppression
B) Cardiac events
C) White blood cell nadir
D) Nausea and vomiting
Question 25 A patient is taking cholestyramine. The nurse will assess for which of the following common adverse effects of the drug?
A) Abdominal pain
B) Headache
C) Constipation
D) Indigestion
Question 26 A patient comes to the clinic asking for help to quit drinking alcohol. She has a 21-year history of heavy drinking and is worried about developing cirrhosis of the liver. The patient agrees to take disulfiram (Antabuse). The nurse will teach the patient that the combination of alcohol and Antabuse will cause which of the following?
A) Bradycardia
B) Diarrhea
C) Nausea
D) Slight headache
Question 27 A 52-year-old man is suffering from a deficiency of exocrine pancreatic secretions and is prescribed pancrelipase (Pancrease MT). Before the medication therapy begins, the nurse will assess for allergies related to
A) ragweed
B) pollen
C) pork
D) shellfish
Question 28 A nurse is providing discharge instructions to a patient who will be taking fludrocortisone at home. The nurse will encourage the patient to eat a diet that is
A) low in sodium and potassium
B) low in sodium, high in potassium
C) high in iron
D) low in proteins
Question 29 A nurse is aware that diphenoxylate HCl with atropine sulfate is an effective adjunct in the treatment of diarrhea. For which of the following patients could the administration of this drug be potentially harmful?
A) An 80-year-old man who has diarrhea secondary to Clostridium difficile infection
B) A woman who has experienced severe diarrhea associated with influenza
C) A man who has experienced diarrhea shortly after beginning tube feeding through a nasogastric tube
D) A 60-year-old woman who tends to get diarrhea during periods of intense stress
Question 30 A clinic nurse is planning care for a 68-year-old man who has been on omeprazole (Prilosec) therapy for heartburn for some time. Regarding the patient’s safety, which of the following would be a priority nursing action?
A) Teach the patient to take omeprazole 1 hour before meals
B) Emphasize that the drug should not be crushed or chewed
C) Coordinate bone density testing for the patient
D) Monitor the patient for the development of diarrhea
Question 31 A nurse is overseeing the care of a young man whose ulcerative colitis is being treated with oral prednisone. Which of the following actions should the nurse take in order to minimize the potential for adverse drug effects and risks associated with prednisone treatment?
A) Avoid OTC antacids for the duration of treatment
B) Advocate for intravenous, rather than oral, administration
C) Teach the patient strategies for dealing with headaches
D) Carefully assess the patient for infections
Question 32 A woman with numerous chronic health problems has been diagnosed with a benign gastric ulcer has begun treatment with ranitidine (Zantac). Which of the following teaching points should the nurse provide to this patient?
A) “Quitting smoking will significantly increase the chance that this drug will heal your ulcer.”
B) “This drug will help to eliminate the bacteria in your stomach that caused your ulcer.”
C) “You should eat several small meals each day rather than three larger meals.”
D) “Take each dose of ranitidine with an antacid of your choice.”
Question 33 A patient has GERD and is taking ranitidine (Zantac). She continues to have gastric discomfort and asks whether she can take an antacid. Which of the following is an appropriate response by the nurse?
A) “Sure, you may take an antacid with ranitidine.”
B) “No, the two drugs will work against each other.”
C) “Yes, but be sure to wait at least 2 hours to take the antacid after you take the ranitidine.”
D) “I wouldn’t advise it. You may experience severe constipation.”
Question 34 A woman with an inflammatory skin disorder has begun taking prednisone in an effort to control the signs and symptoms of her disease. The nurse who is providing care for this patient should prioritize which of the following potential nursing diagnoses in the organization of the patient’s care?
A) Fluid Volume Excess
B) Constipation
C) Acute Confusion
D) Impaired Gas Exchange
Question 35 Following an endoscopy, a 66-year-old man has been diagnosed with a duodenal ulcer resulting from Helicobacter pylori infection. Which of the following medications will likely be used in an attempt to eradicate the patient’s H. pylori infection? (Select all that apply.)is situation?
A) A PPI
B) Antibiotics
C) Cisapride (Propulsid)
D) Aluminum hydroxide

Week 4 Assignment – 1 Pharmacotherapy

Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs:
· Synthroid 100 mcg daily
· Nifedipine 30 mg daily
· Prednisone 10 mg daily
 
There are many causes of nausea and vomiting, most commonly these symptoms are caused by ingestion of substances or drugs, gastrointestinal disorders or metabolic disorders (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). In this particular case study it is important to take into consideration the factors that could be contributing to the nausea, vomiting and diarrhea in patient HL. The patient has a history of drug abuse. With that being said, drug withdraw can be a factor in the cause of nausea, vomiting and diarrhea. Treatment for this type of cause would be dependent on what type of drug that patient was withdrawing from. The next factor would be medications the patient is currently taking. All three of these medications have nausea and vomiting as potential side effects. If this is the cause of the patient’s chief complaint, changing the medications could be an appropriate response. The last consideration would be the patient’s diagnosis of possible Hepatitis C. The most common symptoms of Hepatitis C include nausea, vomiting, and diarrhea (Franciscus, 2015). It would be hard to diagnosis the cause of this episode of nausea vomiting without other information such as aggravating and relieving factors, how long these symptoms have been occurring and if any other symptoms are associated with these. First line treatment of nausea and vomiting include phenothiazines such as promethazine. Promethazine can be given in 12.5-25mgs every four to six hours as needed. Contraindications include hypersensitivity, seizure disorders and Parkinson’s disease. Adverse effects include sedation, agitation, dry mouth and blurred vision (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).  Second line therapy would be to add an antihistamine or anticholinergic such as diphenhydramine. This medication is dosed from 25-50mg every six to eight hours as needed. Adverse effects include drowsiness, confusion and dry mouth. Contraindications include asthma, hypersensitivity and narrow-angle glaucoma (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). If this persists the patient needs to reevaluate for other causes. Alternative therapies including herbal therapies such as vitamin b6 , ginger and even gum chewing are linked to the relief of nausea and vomiting (Darvall, Handscombe & Leslie, n.d.).
 
References:
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. (2017). Pharmacotherapeutics for Advanced Practice (Vol. 4). Philadelphia: Wolters Kluwer.
Darvall, J. N., Handscombe, M., & Leslie, K. (n.d.). Chewing gum for the treatment of postoperative nausea and vomiting: a pilot randomized controlled trial. BRITISH JOURNAL OF ANAESTHESIA, 118(1), 83–89. /orders/doi-org.ezp.waldenulibrary.org/10.1093/bja/aew375
Franciscus, A. (2015). HCV Advcocate. Retrieved from HCSP Fact Sheet : http://hcvadvocate.org/hepatitis/factsheets_pdf/SEM_Nausea.pd

WEEK 5 DCE Assignment 2: Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

• Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

• Respiratory Concept Lab (Required)
• Episodic/Focused Note for Focused Exam: Cough
• HEENT (Recommended but not required)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from /orders/www.sciencedirect.com/science/article/pii/S0042698913000217 

Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436  

Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440.

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).

Document: Episodic/Focused SOAP Note Exemplar (Word document)
 

Document: Episodic/Focused SOAP Note Template (Word document)

Assignment: Decision Tree For Neurological And Musculoskeletal Disorders

Assignment: Decision Tree For Neurological And Musculoskeletal Disorders

Development Plan Part 5: Professional Development

Part 5: Professional Development Plan

Examine Case Study: Pakistani Woman With Delusional Thought Processes

Case Study: Pakistani Woman With Delusional Thought Processes

You Will Be Asked To Make Three Decisions Concerning The Medication To Prescribe To This Client. Be Sure To Consider Factors That Might Impact The Client’s Pharmacokinetic And Pharmacology

Week 6: Antipsychotic Therapy

According to the National Alliance on Mental Illness, approximately 100,000 people experience psychosis in the United States each year (NAMI, 2016). In practice, clients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals. Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric mental health nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for clients.
This week, as you examine antipsychotic therapies, you explore the assessment and treatment of clients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.
Photo Credit: Ingram Publishing/Getty Images

Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia
Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.
Learning Objectives
Students will:
·         Assess client factors and history to develop personalized plans of antipsychotic therapy for clients
·         Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
·         Evaluate efficacy of treatment plans
·         Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
 
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
 
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
 
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
·         Chapter 4, “Psychosis and Schizophrenia”
·         Chapter 5, “Antipsychotic Agents”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
 
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
 
Review the following medications:

• amisulpride
• aripiprazole
• asenapine
• chlorpromazine
• clozapine
• flupenthixol
• fluphenazine
• haloperidol
• iloperidone
• loxapine
• lurasidone

• olanzapine
• paliperidone
• perphenazine
• quetiapine
• risperidone
• sulpiride
• thioridazine
• thiothixene
• trifluoperazine
• ziprasidone

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649-659. doi:10.2165/00023210-200923080-00002
Note: Retrieved from Walden Library databases.
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
Note: Retrieved from Walden Library databases.
 
Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from /orders/www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
 
Walden University. (2016). ASC success strategies: Studying for and taking a test. Retrieved from http://academicguides.waldenu.edu/ASCsuccess/ASCtesting
 
Required Media
 
Laureate Education. (2016j). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author
 
Note: This case study will serve as the foundation for this week’s Assignment.
 
Optional Resources
Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., & … Miller, D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124-134. doi:10.3371/CSRP.5.3.2
Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728-738. doi:10.2146/ajhp130471
Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107-121. doi:10.1007/s11126-014-9326-2
To prepare for this Assignment:
·         Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.
The Assignment
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
 
At each decision point stop to complete the following:
·         Decision #1
o    Which decision did you select?
o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o    Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
·         Decision #2
o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o    Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
·         Decision #3
o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o    Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
 
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.