Depression is diagnosed and treated in primary care far more often than in psychiatry. These questions cover screening and interpreting the PHQ-9, assessing suicide risk directly rather than around it, selecting and starting an antidepressant, the follow-up interval that matters most, and when referral is the right call.
Question 1
You are assessing suicidal ideation severity in a 21-year-old patient during an initial intake evaluation to establish their current clinical risk level. Which timeframe should the nurse practitioner use for the C-SSRS ideation questions?
- A) Ask if the patient has experienced these thoughts over their entire lifetime.
- B) Inquire if the patient has had these specific thoughts within the past year.
- C) Determine if the patient has experienced these thoughts over the past month.✓
- D) Assess whether the patient has had these thoughts during the past week.
💡 Key Takeaway
The C-SSRS assesses current suicidal ideation severity based on the patient's experiences over the past month.
Show rationale
When assessing current clinical risk using the C-SSRS, the standard timeframe for evaluating suicidal ideation severity is the past month. Option C is correct because recent ideation is the most accurate predictor of immediate risk. Option A is incorrect; while lifetime behavior is assessed, current ideation focuses on recent weeks. Option B is incorrect because a one-year timeframe is too broad for determining acute ideation severity. Option D is incorrect because limiting the assessment to the past week might miss significant fluctuations in ideation that occurred earlier in the month, which is why the validated tool specifies thirty days.
Question 2
A patient presents for her 4 weeks postpartum visit reporting fatigue and frequent crying spells. Her EPDS total score of 9, but you note she marked a score of 1 on item 10, which asks about thoughts of self-harm. What is the most appropriate action?
- A) Initiate an immediate suicide risk assessment.✓
- B) Reassure her about typical postpartum blues.
- C) Prescribe a low-dose antidepressant medication today.
- D) Schedule a routine follow-up in two weeks.
💡 Key Takeaway
Any positive score on EPDS item 10 mandates an immediate suicide risk assessment.
Show rationale
The Edinburgh Postnatal Depression Scale includes a specific question (item 10) regarding thoughts of self-harm. Even if the total score is below the typical threshold for depression, any score greater than zero on this item requires an immediate safety assessment. Option B is incorrect because self-harm ideation is never a component of normal baby blues. Option C is premature; prescribing medication without first completing a thorough psychiatric and safety evaluation is unsafe. Option D is dangerous because it delays urgent care for a potentially suicidal patient.
Question 3
A 19-year-old male reports a loss of interest in his hobbies, decreased appetite, and poor concentration over the last six weeks. He admits to drinking a six-pack of beer nightly to help him fall asleep. What is the most critical subjective assessment to complete during this intake?
- A) Evaluating readiness for alcohol rehabilitation
- B) Determining the exact onset of alcohol use
- C) Assessing family history of substance abuse
- D) Clarifying the temporal sequence of symptoms✓
💡 Key Takeaway
Establishing the timeline between substance use and depressive symptoms is required to differentiate primary MDD from substance-induced mood disorder.
Show rationale
When a young adult presents with depressive symptoms and significant daily alcohol use, clarifying the temporal sequence of symptoms is essential to differentiate primary major depressive disorder from a substance-induced mood disorder. This distinction dictates whether the primary treatment focus should be psychiatric medication or substance use cessation. Evaluating readiness for alcohol rehabilitation, determining the exact onset of alcohol use, and assessing family history of substance abuse are highly relevant for comprehensive addiction management. However, they do not help the clinician establish the primary psychiatric diagnosis required to formulate an accurate, safe, and effective treatment plan.
Question 4
A 20-year-old male is initiating citalopram for severe anxiety. He has no prior psychiatric history. The NP is establishing the monitoring plan for the first month of therapy. What must be explicitly included?
- A) Assess for new or worsening suicidal thoughts during early treatment.✓
- B) Monitor for signs of physical dependence and severe withdrawal cravings.
- C) Evaluate for the development of severe dietary tyramine reaction risks.
- D) Check weekly fasting lipid panels to monitor for metabolic syndrome.
💡 Key Takeaway
Young adults under twenty-four require close monitoring for emergent suicidality when initiating antidepressant therapy.
Show rationale
When initiating any SSRI like citalopram in a young adult under the age of twenty-four, the NP must adhere to the FDA black box warning regarding the potential for increased suicidal ideation and behavior during the first month of treatment. Option A is the correct plan, as establishing a strict monitoring schedule for worsening mood or emergent suicidality is a critical safety standard. Option B is incorrect because SSRIs do not cause physical dependence with severe withdrawal cravings like controlled substances do, though they can cause discontinuation syndrome if stopped abruptly. Option C describes the dietary monitoring required for monoamine oxidase inhibitors, not SSRIs. Option D outlines the metabolic monitoring parameters typically required when prescribing second-generation antipsychotics, which is completely unnecessary and inappropriate for a young adult starting a standard SSRI for anxiety.
Question 5
25-year-old female reports chronic feelings of emptiness, frantic efforts to avoid abandonment, and unstable relationships. She experiences intense sadness lasting a few hours to two days after interpersonal conflicts, but denies any prolonged depressive or elevated periods.
- A) Bipolar I disorder, current depressive episode
- B) Bipolar II disorder, current depressive episode
- C) Major depressive disorder, recurrent severe episode
- D) Borderline personality disorder with mood lability✓
💡 Key Takeaway
Borderline personality disorder features rapid, stress-reactive mood shifts lasting hours to days, unlike sustained bipolar mood episodes.
Show rationale
The patient's mood changes are highly reactive to interpersonal stress, lasting only a few hours to two days, which is a hallmark of Borderline personality disorder. Bipolar I, Bipolar II, and Major depressive disorder all require distinct, sustained mood episodes lasting at least four to fourteen days. Her frantic efforts to avoid abandonment and chronic emptiness further confirm a personality disorder rather than a primary mood disorder.
Question 6
A 15-year-old male returns for a 4-week SSRI follow-up. He tearfully admits to writing a suicide note and hoarding over-the-counter Tylenol in his bedroom closet over the past week. What is the most appropriate action?
- A) Formulate a strict outpatient safety plan with the parents.
- B) Discontinue the SSRI immediately to eliminate the suicide risk.
- C) Facilitate an immediate transfer to an emergency psychiatric facility.✓
- D) Switch the current medication to a different antidepressant class.
💡 Key Takeaway
Active suicidal ideation with a specific plan and intent requires immediate emergency psychiatric evaluation and stabilization.
Show rationale
This patient demonstrates active suicidal ideation with a highly specific plan, intent, and preparatory behaviors (writing a note, hoarding pills). This constitutes a psychiatric emergency requiring a higher level of care to ensure immediate safety, making C the only correct choice. Option A is grossly insufficient for a patient at imminent risk of lethal self-harm. Options B and D focus on outpatient medication management, which completely ignores the immediate life-threatening crisis that must be stabilized in a controlled environment first.
Question 7
A 60-year-old male started on duloxetine 30 mg exactly four weeks ago. His baseline PHQ-9 was 18. Today, his PHQ-9 is 14. He reports excellent medication compliance and good tolerability.
- A) Increase the duloxetine dosage to 60 mg daily.✓
- B) Switch the prescription to a different SNRI medication.
- C) Continue current dosage and reassess in four weeks.
- D) Augment the current therapy with a mood stabilizer.
💡 Key Takeaway
Titrate well-tolerated subtherapeutic starting doses to target therapeutic levels when evaluating early partial responses.
Show rationale
At four weeks, a PHQ-9 drop from 18 to 14 indicates a partial early response. Because 30 mg is a starting dose for duloxetine and the patient demonstrates good tolerability, the provider should titrate to target therapeutic dosing, which is typically 60 mg daily for depression. Switching to a different SNRI is premature because the patient has not yet trialed a fully therapeutic dose of the current medication. Continuing the subtherapeutic 30 mg dosage for another four weeks unnecessarily delays optimal treatment and symptom relief. Augmenting with a mood stabilizer is far too aggressive for a patient who simply needs a standard dose titration to reach the established therapeutic window.
Question 8
A 60-year-old female is evaluated two weeks post-CABG surgery. During a routine outpatient cardiac rehabilitation session, she develops mild exertional chest tightness, and her telemetry strip reveals 1.5 mm downsloping ST depressions. How should the nurse practitioner manage this clinical presentation?
- A) Document this as an expected benign post-surgical repolarization abnormality.
- B) Halt the exercise session and evaluate for residual subendocardial ischemia.✓
- C) Administer a rapid intravenous bolus of a systemic thrombolytic agent.
- D) Increase the treadmill speed to assess maximal functional cardiac capacity.
💡 Key Takeaway
Exertional ST depressions with symptoms post-CABG indicate demand ischemia and require immediate cessation of activity.
Show rationale
Downsloping ST depressions during physical exertion, particularly when accompanied by chest tightness, are classic signs of subendocardial ischemia. In a patient recently post-CABG, this suggests incomplete revascularization or early graft failure. The immediate priority is to halt the exercise to reduce myocardial oxygen demand and evaluate the patient. Documenting this as a benign abnormality is incorrect, as symptomatic ST depression is a marker of active ischemia. Administering a thrombolytic agent is absolutely contraindicated due to the recent major surgery and the fact that thrombolytics are not indicated for non-ST-elevation ischemia. Increasing the treadmill speed would dangerously exacerbate the ischemic burden and risk precipitating a myocardial infarction.
Question 9
A 74-year-old patient with severe osteoarthritis and mild cognitive impairment presents with unwashed clothing. The patient explains they cannot carry the laundry basket downstairs. What is the primary cause of this functional limitation?
- A) Cognitive decline affecting the ability to sequence tasks.
- B) Lack of motivation associated with undiagnosed late-life depression.
- C) Physical impairment restricting the completion of household chores.✓
- D) Progression of dementia impairing basic self-care activities.
💡 Key Takeaway
Functional limitations in IADLs must be carefully evaluated to distinguish between cognitive decline and physical impairments.
Show rationale
When assessing IADLs like laundry and housekeeping, the nurse practitioner must differentiate between cognitive and physical etiologies. The patient's clear explanation that they cannot carry the basket downstairs due to severe osteoarthritis indicates a physical impairment restricting the completion of household chores, rather than a cognitive deficit. Cognitive decline affecting task sequencing would present as forgetting how to use the washing machine. Progression of dementia impairing basic self-care refers to ADLs like dressing, not IADLs. There are no cues suggesting lack of motivation or depression in this scenario.
Question 10
During a routine visit, a 60-year-old male scores a positive on question four of the Columbia-Suicide Severity Rating Scale, indicating active suicidal ideation with some intent but no specific plan. He lives with his supportive spouse. Which of the following is the most appropriate next step?
- A) Initiate an immediate involuntary psychiatric inpatient hold.
- B) Advise the supportive spouse to monitor the patient closely.
- C) Conduct a comprehensive clinical suicide risk assessment.✓
- D) Prescribe a short course of anxiolytic medications immediately.
💡 Key Takeaway
Positive screening for suicidal intent requires a comprehensive clinical risk assessment before determining disposition.
Show rationale
The Columbia-Suicide Severity Rating Scale is a valuable screening tool, and a positive response indicating active suicidal ideation with some intent requires immediate further investigation. However, a screening tool alone does not provide enough context to determine the appropriate level of care. The most appropriate next step is to conduct a comprehensive clinical suicide risk assessment to evaluate the patient's specific risk factors, protective factors, and overall clinical picture. Initiating an immediate involuntary psychiatric inpatient hold is premature; you must first complete the full assessment to determine if the risk is truly imminent. Advising the supportive spouse to monitor the patient closely is a good component of a safety plan, but it cannot replace the provider's responsibility to fully assess the risk level first. Prescribing anxiolytics does not address the core risk of suicide and may increase impulsivity.
