Anxiety presents physically as often as emotionally, so the first task is ruling out what mimics it. These questions cover GAD-7 screening, distinguishing generalised anxiety from panic and social anxiety, first-line pharmacologic and behavioural therapy, and why benzodiazepines are rarely the answer in primary care.
Question 1
A 28-year-old patient has taken sertraline 200 mg daily for generalized anxiety disorder for ten weeks. The baseline GAD-7 score was 15, and today's GAD-7 score is 14. The patient denies any side effects but reports no meaningful relief from constant worry. Which intervention is most appropriate?
- A) Maintain the current sertraline dose for four more weeks.
- B) Add a daily benzodiazepine to the current sertraline regimen.
- C) Cross-taper the sertraline to a different class of antidepressant.✓
- D) Increase the sertraline dose beyond the standard maximum limit.
💡 Key Takeaway
Lack of GAD-7 improvement after an adequate trial at maximum dose requires switching medication classes.
Show rationale
A minimal change in the GAD-7 score after ten weeks at the maximum therapeutic dose indicates clear non-response. The most appropriate approach is to switch to a different medication class, such as a serotonin-norepinephrine reuptake inhibitor. Maintaining the dose is ineffective since the trial duration is already adequate. Adding a daily benzodiazepine is not recommended for long-term anxiety management due to tolerance and dependence risks. Exceeding the maximum recommended dose of sertraline increases the risk of adverse effects without offering proven clinical benefit.
Question 2
A 28-year-old woman is being evaluated after twelve sessions of CBT for PTSD following a motor vehicle accident. She states she recently drove on the highway for the first time but still feels mild anxiety when passing trucks.
- A) Recommend extending CBT to eliminate all driving-related anxiety.
- B) Document successful reduction in avoidance and taper therapy.✓
- C) Prescribe a daily benzodiazepine to manage residual anxiety.
- D) Refer the patient for intensive inpatient psychiatric treatment.
💡 Key Takeaway
Successful CBT outcomes in PTSD are defined by functional improvement and reduced avoidance, not absolute anxiety elimination.
Show rationale
The primary goal of CBT in PTSD is to reduce avoidance behaviors and improve daily functioning, rather than completely eliminating all anxiety. Driving on the highway demonstrates functional improvement and successful exposure. Option B is correct because she is functioning well despite experiencing mild anxiety. Option A is incorrect because eliminating all anxiety is an unrealistic therapeutic goal. Option C is contraindicated because benzodiazepines can interfere with fear extinction during trauma therapy. Option D is incorrect because an inpatient referral is an inappropriate level of care for mild, manageable residual symptoms.
Question 3
An 82-year-old with end-stage COPD on hospice is prescribed liquid morphine 5 mg sublingually every 4 hours for severe breathlessness. The family reports he is breathing easier but sleeping more, with a respiratory rate of 10/min. He rouses easily to voice.
- A) Continue the current morphine dose and monitor symptoms.✓
- B) Decrease the morphine dose to prevent respiratory arrest.
- C) Administer a low dose of naloxone for sedation.
- D) Discontinue the morphine and initiate a benzodiazepine instead.
💡 Key Takeaway
Mild sedation and decreased respiratory rate are acceptable when evaluating opioid efficacy for terminal dyspnea.
Show rationale
In hospice care, mild sedation and a decreased respiratory rate are expected and acceptable side effects of morphine for dyspnea, provided the patient rouses easily. The plan of care is effective because his breathing is easier and he is comfortable. Decreasing the dose (B) risks returning his severe dyspnea. Administering naloxone (C) is contraindicated as it will precipitate withdrawal and severe distress. Switching to a benzodiazepine (D) is inappropriate because opioids remain the gold standard for dyspnea, and benzodiazepines do not treat the physiological sensation of breathlessness as effectively.
Question 4
After discussing a new diagnosis of ovarian cancer, the 68-year-old female appears calm but visibly overwhelmed. The FNP transitions to the Strategy and Summary phase. Which action is most appropriate at this time?
- A) Ask the patient to explain her understanding of the new diagnosis.
- B) Provide a printed list of all possible standard chemotherapy side effects.
- C) Establish a clear, step-by-step plan for the upcoming oncology specialist referral.✓
- D) Inquire if she wants to discuss her overall prognosis in detail.
💡 Key Takeaway
The Strategy and Summary step provides a clear, manageable plan to reduce patient anxiety and confusion.
Show rationale
The final step of the SPIKES protocol is Strategy and Summary, which involves outlining a clear plan for the future to reduce patient anxiety and confusion. Option C effectively establishes a tangible next step for the patient. Option A reverts to the Perception step, which is used at the beginning of the encounter. Option B overwhelms the patient with excessive information; during the strategy phase, information should be given in manageable chunks rather than exhaustive lists. Option D reverts to the Invitation step, which should have been clarified before the diagnosis was delivered.
Question 5
A 72-year-old male with well-controlled hypertension requests a PSA test because his friend was recently diagnosed. He has a life expectancy of eight years.
- A) Order the PSA test to alleviate his health anxiety.
- B) Perform a digital rectal exam instead of drawing PSA.
- C) Explain that guidelines recommend against screening due to risks.✓
- D) Refer him to urology for comprehensive prostate cancer evaluation.
💡 Key Takeaway
Routine prostate cancer screening is not recommended for men aged 70 and older due to competing mortality risks.
Show rationale
The USPSTF recommends against PSA-based screening for men 70 and older because the harms generally outweigh the benefits, especially for those with a limited life expectancy. Option C uses therapeutic communication to explain the guideline rationale regarding competing risks. Option A inappropriately orders a non-indicated test just to treat anxiety. Option B is incorrect as a digital rectal exam is not recommended for routine screening. Option D is an unnecessary referral that increases healthcare burden without clinical justification.
Question 6
A 42-year-old male with sleep maintenance insomnia is prescribed eszopiclone. He works early morning shifts. Which essential patient education must the nurse practitioner provide?
- A) Take the medication immediately after a heavy dinner.
- B) Limit time in bed to exactly six hours nightly.
- C) Dedicate at least eight hours for a full sleep.✓
- D) Expect a temporary increase in early morning awakenings.
💡 Key Takeaway
Patients taking eszopiclone must dedicate at least eight hours to sleep to prevent next-day psychomotor impairment.
Show rationale
Eszopiclone is a nonbenzodiazepine hypnotic with a relatively long half-life. Patients must be instructed to dedicate at least seven to eight hours of sleep time to prevent severe next-day psychomotor impairment and memory issues. Taking the medication after a heavy dinner delays its absorption and onset. Limiting sleep to six hours exacerbates morning impairment. The medication is designed to treat, not cause, early morning awakenings.
Question 7
A 22-year-old patient started fluoxetine 10 mg daily for severe anxiety two weeks ago. The initial GAD-7 score was 16, and today the GAD-7 score is 18. The patient reports feeling more restless and jittery since starting the medication but denies suicidal ideation. Which action is most appropriate?
- A) Stop the fluoxetine and prescribe a daily benzodiazepine immediately.
- B) Increase the fluoxetine dose to twenty milligrams for efficacy.
- C) Switch the fluoxetine to a different serotonin reuptake inhibitor.
- D) Reassure the patient and maintain the current fluoxetine dosage.✓
💡 Key Takeaway
Early transient worsening of anxiety after starting an SSRI is common and requires reassurance.
Show rationale
An initial increase in anxiety and jitteriness is a common activation syndrome seen two weeks after starting an activating medication like fluoxetine. Because this is a known transient effect and full efficacy takes four to six weeks, providing reassurance and maintaining the current dose is the best approach. Increasing the dose would likely worsen the jitteriness. Stopping or switching the medication prematurely prevents an adequate therapeutic trial and misinterprets a common early side effect as a true treatment failure.
Question 8
A forty-eight-year-old female has a 10-year ASCVD risk of 8.5% but is hesitant to initiate daily statin therapy. The nurse practitioner reviews her chart for risk-enhancing factors to help guide the shared decision-making process. Which finding would strongly favor initiating statin therapy?
- A) A documented history of severe rheumatoid arthritis.✓
- B) A documented history of recurrent migraine headaches.
- C) A documented history of mild persistent asthma.
- D) A documented history of generalized anxiety disorder.
💡 Key Takeaway
Chronic inflammatory conditions act as risk-enhancing factors that favor statin initiation in intermediate-risk patients.
Show rationale
For patients with an intermediate 10-year risk (7.5% to 19.9%) who are uncertain about statin therapy, clinicians should assess for risk-enhancing factors. Chronic inflammatory conditions like rheumatoid arthritis significantly accelerate atherogenesis and favor statin initiation. Option B is incorrect because while migraines with aura have some cardiovascular associations, they are not formal ASCVD risk-enhancing factors in the current lipid guidelines. Options C and D are incorrect as asthma and anxiety do not independently enhance atherosclerotic risk or alter the primary prevention decision pathway.
Question 9
A 34-year-old patient returns after taking escitalopram 10 mg daily for generalized anxiety disorder for eight weeks. The baseline GAD-7 score was 16, and today's GAD-7 score is 12. The patient tolerates the medication well but still struggles with daily worry. Which action is most appropriate?
- A) Increase the escitalopram dosage to 20 mg daily.✓
- B) Switch the medication to duloxetine 30 mg daily.
- C) Maintain the current dose and reassess in four weeks.
- D) Augment the current regimen with buspirone 10 mg daily.
💡 Key Takeaway
A partial GAD-7 reduction without remission warrants maximizing the current well-tolerated medication dose before switching.
Show rationale
At eight weeks, a drop from 16 to 12 indicates a partial response but the patient remains highly symptomatic. Because the patient tolerates the medication well, maximizing the current selective serotonin reuptake inhibitor dose is the preferred next step over switching or augmenting. Maintaining the current dose is incorrect because the patient has not reached remission after an adequate initial trial, so waiting longer without a change will likely leave them symptomatic. Switching to duloxetine or adding buspirone are secondary strategies reserved for when maximizing the primary agent fails or causes intolerable side effects.
Question 10
A 17-year-old female undergoing outpatient weight restoration for anorexia nervosa has gained 2 pounds this month but reports severe anxiety and body image distress after meals. What is the most appropriate evaluation of this progress?
- A) The weight gain indicates a dangerous fluid volume shift
- B) The physical plan is failing due to severe anxiety
- C) The anxiety suggests the onset of a psychotic disorder
- D) The distress is an expected phase of weight restoration✓
💡 Key Takeaway
Psychological distress often intensifies during early weight restoration and does not indicate treatment failure.
Show rationale
It is highly common for patients with anorexia nervosa to experience a temporary increase in psychological distress, anxiety, and body image distortion as they begin to gain weight. The brain's cognitive recovery often lags behind physical weight restoration. Therefore, Option D is the best evaluation; the distress is an expected hurdle, not a sign that the nutritional plan is failing as suggested in Option B. Option A is incorrect because a 2-pound gain over a month is a safe, appropriate outpatient rate, not a massive fluid shift. Option C misinterprets eating disorder-related anxiety as psychosis.
