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 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? Also include how ethical considerations might impact your treatment plan and communication with clients. BACKGROUND The client is a 34-year-old Pakistani female who moved to the United  States in her late teens/early 20s. She is currently in an “arranged”  marriage (her husband was selected for her since she was 9 years old).  She presents to your office today following a 21 day hospitalization for  what was diagnosed as “brief psychotic disorder.” She was given this  diagnosis as her symptoms have persisted for less than 1 month.  Prior to admission, she was reporting visions of Allah, and over the  course of a week, she believed that she was the prophet Mohammad. She  believed that she would deliver the world from sin. Her husband became  concerned about her behavior to the point that he was afraid of leaving  their 4 children with her. One evening, she was “out of control” which  resulted in his calling the police and her subsequent admission to an  inpatient psych unit. During today’s assessment, she appears quite calm, and insists that  the entire incident was “blown out of proportion.” She denies that she  believed herself to be the prophet Mohammad and states that her husband  was just out to get her because he never loved her and wanted an  “American wife” instead of her. She tells you that she knows this  because the television is telling her so.   She currently weighs .

1. 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
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?

2. 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?
Also include how ethical considerations might impact your
treatment plan and communication with clients.
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the
United States in her late teens/early 20s. She is currently in an
“arranged” marriage (her husband was selected for her since
she was 9 years old). She presents to your office today
following a 21 day hospitalization for what was diagnosed as

3. “brief psychotic disorder.” She was given this diagnosis as her
symptoms have persisted for less than 1 month.
Prior to admission, she was reporting visions of Allah, and over
the course of a week, she believed that she was the prophet
Mohammad. She believed that she would deliver the world
from sin. Her husband became concerned about her behavior to
the point that he was afraid of leaving their 4 children with her.
One evening, she was “out of control” which resulted in his
calling the police and her subsequent admission to an inpatient
psych unit.
During today’s assessment, she appears quite calm, and insists
that the entire incident was “blown out of proportion.” She
denies that she believed herself to be the prophet Mohammad
and states that her husband was just out to get her because he
never loved her and wanted an “American wife” instead of her.
She tells you that she knows this because the television is
telling her so.
She currently weighs 140 lbs, and is 5’ 5”
SUBJECTIVE
Client reports that her mood is “good.” She denies
auditory/visual hallucinations, but believes that the television
does talk to her. She believes that Allah sends her messages
through the TV. At times throughout the clinical interview, she
becomes hostile towards the PMHNP, but then calms down.
You reviewed her hospital records and find that she has been
medically worked up by a physician who reported her to be in
overall good health. Lab studies were all within normal limits.
Client admits that she stopped taking her Risperdal about a
week after she got out of the hospital because she thinks her

4. husband is going to poison her so that he can marry an
American woman.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event.
She is dressed appropriately for the weather and time of year.
She demonstrates no noteworthy mannerisms, gestures, or tics.
Her speech is slow and at times, interrupted by periods of
silence. Self-reported mood is euthymic. Affect constricted.
Although the client denies visual or auditory hallucinations,
she appears to be “listening” to something. Delusional and
paranoid thought processes as described, above. Insight and
judgment are impaired. She is currently denying suicidal or
homicidal ideation.
The PMHNP administers the PANSS which reveals the
following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Diagnosis: Schizophrenia, paranoid type
Decision Point One
Start Invega Sustenna 234 mg intramuscular X1 followed by
156 mg intramuscular on day 4 and monthly thereafter
RESULTS OF DECISION POINT ONE

5. Client returns to clinic in four weeks
A decrease in PANSS score of 25% is noted at this visit
Client seems to be tolerating medication
Client's husband has made sure she makes her appointments for
injections (one thus far)
Client has noted a 2 pound weight gain but it does not seem to
be an important point for her
Client complains of injection site pain telling the PMHNP that
she has trouble siting for a few hours after the injections and
doesn’t like having to walk around for such a long period of
time
Decision Point Two
Continue same decision made but instruct administering nurse
to begin injections into the deltoid at this visit and moving
forward
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client's PANNS has reduced by a total of 50% from the
initiation of Invega sustenna
When questioned about injection site pain, client states it is

6. much better in the arm
Client's weight has increased by an additional 2.5 pounds (total
of 4.5 pounds in a 2 month period). She is somewhat bothered
by the weight gain and is afraid that her husband does not like
it. He is not present at this visit as she brought herself
Client likes how she feels on the Invega Sustenna but is
wondering if there is another drug like it that would not cause
the weight gain
Decision Point Three
Continue with the Invega Sustenna. Counsel client on the fact
that weight gain from Invega Sustenna is not as much as what
other drugs with similar efficacy can cause. Make appointment
with a dietician and an exercise physiologist. Follow up in one
month
Guidance to Student
Weight gain can occur with Invega Sustenna. It is modest in
nature and can be controlled with proper nutrition and exercise.
It is always a good idea to try and control a client’s weight
through consultation with a dietician and exercise physiologist
(life coach) before switching to another agent when a product
is showing efficacy for at least 6 months.
Abilify Maintena is a good option for someone who has good
response to abilify oral. Remember that Abilify does not bind
to the D2 receptor for a great period of time (such as Invega)
and can be less affective in certain individuals. Also, remember

7. that akathisia can be a possible side effect. Once an IM long
acting medication is given, the effects of the drug (both
efficacious and untoward effects) can be maintained for a long
duration (up to a month or longer). Tolerability and efficacy
should be established with oral medication first before
administering the first injection. Also a disadvantage to Abilify
Maintena is a 2-week overlap of oral therapy is required due to
effective blood levels lagging behind the induction dose.
Qsymia is a weight loss medication that is a combination of
Phenteramine and Topiramate. It is only indicated to treat
obesity. This client’s BMI (28.9 kg/M2) does not fit the
definition of obesity (BMI >30 Kg/M2- Following from CDC
website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to <
40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes
categorized as “extreme” or “severe” obesity). There are two
things wrong with this therapy option. First, there are only a
few occasions where add-on therapy to treat a side effect is
acceptable and weight gain is not one of those scenarios.
Secondly, Phenteramine has a lot of cardiovascular toxicities
(such as elevated BP, HR, increased workload on the heart).