ANCC Psychiatric-Mental Health Nurse Practitioner (PMHNP) board certification exam — Questions and Answers

Question 1: A PMHNP working with veterans notes that moral injury differs from PTSD in that moral injury primarily involves:

Guilt, shame, and spiritual distress from actions violating personal moral code (Correct answer)
Avoidance of trauma reminders
Intrusive flashbacks and nightmares
Hyperarousal and startle response

Correct answer: Guilt, shame, and spiritual distress from actions violating personal moral code

Moral injury results from witnessing or participating in events that transgress deeply held moral beliefs, leading to guilt, shame, and loss of meaning rather than fear-based PTSD responses.

Question 2: A patient discloses they plan to harm a specific, identifiable third party. According to the Tarasoff duty-to-protect principle, the PMHNP is obligated to:

Maintain confidentiality as therapeutic alliance takes priority
Consult a supervisor but take no external action
Document the threat in the chart and increase session frequency
Warn the intended victim and notify law enforcement (Correct answer)

Correct answer: Warn the intended victim and notify law enforcement

Tarasoff establishes a legal and ethical duty to protect identifiable potential victims by warning them and/or notifying authorities when a credible threat exists.

Question 3: Which of the aforementioned tasks for a patient should a psychiatric and mental health nurse assign to untrained support staff?

Performing a psychosocial assessment
Taking routine vital signs (Correct answer)
Applying restraints
Conducting health teaching

Correct answer: Taking routine vital signs

Routine vital sign taking is a work that the psychiatric and mental health nurse may assign to unlicensed assistive people (UAP). In general, UAP can help patients with daily living activities like grooming, dressing, and walking. UAP can move patients, help with meals and socialization activities, and reinforce health education, but it cannot be in charge of organizing it. UAP is never allowed to administer medication to a patient or conduct physical or psychosocial evaluations.

Question 4: A patient experiencing acute dystonia after receiving haloperidol is best treated with:

Lorazepam IV
Dantrolene IV
Diphenhydramine IM or benztropine IM (Correct answer)
Propranolol PO

Correct answer: Diphenhydramine IM or benztropine IM

Acute dystonia is treated with anticholinergic agents such as benztropine or antihistamines such as diphenhydramine, which rapidly reverse muscle spasms.

Question 5: Which mood stabilizer has the most evidence for suicide prevention in patients with bipolar disorder?

Carbamazepine
Lamotrigine
Lithium (Correct answer)
Valproate

Correct answer: Lithium

Lithium has robust long-term evidence for reducing suicide and suicidal behavior in patients with mood disorders, likely through serotonergic and neuroprotective mechanisms.

Question 6: A patient with schizophrenia is prescribed risperidone and develops galactorrhea. What is the mechanism underlying this side effect?

Dopamine D2 blockade in the tuberoinfundibular pathway elevating prolactin (Correct answer)
Muscarinic receptor blockade increasing prolactin indirectly
Serotonin 2A antagonism in the pituitary gland
Histamine H1 blockade stimulating prolactin release

Correct answer: Dopamine D2 blockade in the tuberoinfundibular pathway elevating prolactin

Dopamine normally inhibits prolactin release; blocking D2 receptors in the tuberoinfundibular pathway removes this inhibition, causing hyperprolactinemia and galactorrhea.

Question 7: Bulimia is being treated for by nurse Mench's patient. The most suitable first objective for a client with bulimia is to:

Control eating impulses.
Identify anxiety-causing situations. (Correct answer)
Eat only three meals per day.
Avoid shopping for large amounts of food.

Correct answer: Identify anxiety-causing situations.

Bulimia is typically an unhelpful way of dealing with stress and underlying problems. The client must recognize the anxious circumstances that trigger bulimic behavior and then acquire new coping mechanisms. Adolescent females are more likely than boys to develop bulimia nervosa, which is characterized by binge eating and inappropriate compensatory behaviors.

Question 8: A patient on carbamazepine for bipolar disorder develops diplopia, ataxia, and elevated carbamazepine levels despite no dose change. What is the most likely explanation?

The patient developed carbamazepine-induced hypothyroidism
A new drug inhibited CYP3A4, raising carbamazepine levels (Correct answer)
Renal failure reduced carbamazepine clearance
Carbamazepine autoinduction of CYP3A4 has reversed

Correct answer: A new drug inhibited CYP3A4, raising carbamazepine levels

Carbamazepine is metabolized by CYP3A4; adding a CYP3A4 inhibitor (e.g., erythromycin, fluconazole) raises carbamazepine levels and can precipitate toxicity.

Question 9: Which protective factor most strongly reduces suicide risk during crisis assessment?

Previous psychiatric hospitalizations
Financial stability
Reasons for living and strong social support (Correct answer)
Current antidepressant use

Correct answer: Reasons for living and strong social support

Strong reasons for living and robust social support networks are among the most consistently identified protective factors against suicide.

Question 10: A woman of childbearing potential is being started on valproate for bipolar disorder. What is the most critical counseling point?

Valproate is preferred over lithium in pregnancy
Valproate is safe during the first trimester only
Folate supplementation eliminates valproate's teratogenic risk
Valproate carries a high risk of neural tube defects and requires reliable contraception (Correct answer)

Correct answer: Valproate carries a high risk of neural tube defects and requires reliable contraception

Valproate is a major teratogen associated with neural tube defects (spina bifida), cognitive impairment in offspring, and requires a REMS program with mandatory contraception.

Question 11: A patient with PTSD is treated with Prolonged Exposure (PE) therapy. What is the core mechanism of this treatment?

Reducing avoidance by systematically confronting trauma-related stimuli (Correct answer)
Restructuring maladaptive core beliefs through Socratic questioning
Teaching relaxation skills to manage physiological arousal
Replacing traumatic memories with positive ones through EMDR

Correct answer: Reducing avoidance by systematically confronting trauma-related stimuli

PE works through extinction learning by having patients repeatedly confront avoided trauma cues, reducing fear responses over time.

Question 12: A PMHNP documents 'loosening of associations' in a patient. This thought process abnormality means:

The patient's thinking shifts between topics with tenuous connections (Correct answer)
The patient abruptly stops mid-sentence
The patient shifts topic in response to sound rather than meaning
The patient repeats words or phrases involuntarily

Correct answer: The patient's thinking shifts between topics with tenuous connections

Loosening of associations describes fragmented, illogical thinking where ideas shift with weak or absent logical connections.

Question 13: A PMHNP is evaluating a patient who takes lithium and is prescribed ibuprofen for arthritis pain. What pharmacokinetic concern must be addressed?

Ibuprofen displaces lithium from plasma protein binding sites, increasing free lithium levels acutely
NSAIDs reduce renal prostaglandin synthesis, decreasing GFR and increasing lithium reabsorption, risking toxicity (Correct answer)
No clinically significant interaction exists between NSAIDs and lithium at standard arthritis doses
NSAIDs induce renal CYP450 enzymes, accelerating lithium clearance and reducing efficacy

Correct answer: NSAIDs reduce renal prostaglandin synthesis, decreasing GFR and increasing lithium reabsorption, risking toxicity

NSAIDs inhibit prostaglandin-mediated renal efferent arteriolar dilation, reducing GFR and increasing lithium reabsorption in the proximal tubule, potentially raising lithium levels by 25-50%.

Question 14: In the DSM-5, 'with peripartum onset' specifier for a major depressive episode requires that symptoms begin:

At any point in the first year postpartum
Only postpartum, within 4 weeks of delivery
During pregnancy or within 4 weeks after delivery (Correct answer)
Only during pregnancy, not postpartum

Correct answer: During pregnancy or within 4 weeks after delivery

DSM-5 changed the specifier from 'postpartum' to 'peripartum onset,' applying it to episodes beginning during pregnancy or within 4 weeks of delivery.

Question 15: A patient experiencing a serotonin syndrome crisis would most likely present with which triad of symptoms?

Neuromuscular abnormalities, autonomic instability, altered mental status (Correct answer)
Rigidity, fever, elevated CK from neuroleptic malignant syndrome only
Bradycardia, hypothermia, miosis
Sedation, respiratory depression, pinpoint pupils

Correct answer: Neuromuscular abnormalities, autonomic instability, altered mental status

Serotonin syndrome's classic triad includes neuromuscular findings (clonus, hyperreflexia), autonomic instability, and altered mental status.

Question 16: For alcohol detoxification, a male client is admitted to the drug addiction unit. Which of the following drugs is Nurse Carmen most likely to prescribe to lessen alcohol withdrawal symptoms?

Magnesium sulfate
Chlordiazepoxide (Librium) (Correct answer)
Naloxone (Narcan)
Haloperidol (Haldol)

Correct answer: Chlordiazepoxide (Librium)

Alcohol withdrawal symptoms are lessened with tranquilizers such chlordiazepoxide (Librium). An FDA-approved medicine for individuals with mild-moderate to severe anxiety disorders, preoperative apprehension and anxiety, and withdrawal symptoms of acute alcohol use disorder is chlordiazepoxide, a long-acting benzodiazepine. Chlordiazepoxide contains hypnotic, appetite-stimulating, anti-anxiety, and modest analgesic properties. It improves the inhibitory effects of GABA by attaching to benzodiazepine receptors at the GABA-A ligand-gated chloride channel complex.

Question 17: A PMHNP using the SLAP mnemonic to assess lethality of a suicide plan is assessing which four elements?

Severity, Location, Availability, Proximity to rescue
Severity, Likelihood, Agitation, Plan
Suicidal thoughts, Lethality, Attempt history, Plan specificity
Seriousness, Lethality, Availability, Proximity (Correct answer)

Correct answer: Seriousness, Lethality, Availability, Proximity

The SLAP mnemonic assesses the Seriousness of intent, Lethality of the chosen method, Availability of the means, and Proximity of rescue.

Question 18: Which therapy is most evidence-based for treating borderline personality disorder (BPD)?

Rational emotive behavior therapy
Psychoanalysis
Solution-focused therapy
Dialectical Behavior Therapy (DBT) (Correct answer)

Correct answer: Dialectical Behavior Therapy (DBT)

DBT was specifically developed by Marsha Linehan for BPD and has the strongest evidence base for this population.

Question 19: Which nursing diagnosis best fits the needs of a patient who is away from home for the first time in a year, arrives at the mental in-patient unit wearing a surgical mask and white gloves, and cries, "The germs in here are going to kill me."

Social isolation R /T fear of germs AEB continually refusing to leave the home. (Correct answer)
Ineffective coping AEB dysfunctional isolation R /T unrealistic fear of germs.
Fear of germs R /T obsessive-compulsive disorder, resulting in dysfunctional isolation.
Anxiety R /T the inability to leave home, resulting in dysfunctional fear of germs.

Correct answer: Social isolation R /T fear of germs AEB continually refusing to leave the home.

The North American Nursing Diagnosis Association (NANDA) states that the nursing diagnosis format must include three key elements: (1) identification of the health problem; (2) presentation of the etiology (or cause) of the problem; and (3) description of a group of symptoms known as "defining characteristics." The correct response includes all three elements in the proper order: health problem/NANDA stem (social isolation); etiology/cause, or R /T Due to a fear of germs, this client has been unable to leave the house for a year. As a result, the client's behaviors fit the description of social isolation.

Question 20: A patient taking lithium presents with coarse tremor, ataxia, slurred speech, and confusion. Serum lithium is 2.4 mEq/L. What is the priority nursing action?

Administer sodium bicarbonate to alkalinize the urine
Administer activated charcoal
Prepare the patient for hemodialysis and ensure IV access (Correct answer)
Hold the next dose and recheck level in 6 hours

Correct answer: Prepare the patient for hemodialysis and ensure IV access

A lithium level above 2.0 mEq/L with neurological symptoms is a life-threatening emergency; hemodialysis is the definitive treatment to rapidly remove lithium.

Question 21: A PMHNP is conducting a risk assessment using the Columbia Suicide Severity Rating Scale (C-SSRS). Which finding indicates the highest level of suicidal ideation?

Active ideation with a specific plan and intent to act (Correct answer)
Ideation present only in response to an interpersonal stressor
Passive ideation without intent to act
Ideation that occurs less than once per week

Correct answer: Active ideation with a specific plan and intent to act

On the C-SSRS, ideation with a specific plan AND intent to act represents the most severe and clinically urgent category requiring immediate intervention.

Question 22: A PMHNP is assessing an elderly patient for depression. Which instrument is specifically validated for detecting depression in older adults?

Hamilton Depression Rating Scale (HAM-D)
PHQ-9
Geriatric Depression Scale (GDS) (Correct answer)
Beck Depression Inventory (BDI)

Correct answer: Geriatric Depression Scale (GDS)

The GDS was specifically designed and validated for use with older adults, omitting somatic items that confound depression screening in the elderly.

Question 23: Under HIPAA, which situation allows a PMHNP to disclose psychiatric records without patient authorization?

Law enforcement requests records to investigate a minor traffic violation
A patient's employer requests information to assess fitness for duty
Disclosure is necessary to avert a serious and imminent threat to the patient or others (Correct answer)
A patient's spouse requests information out of concern

Correct answer: Disclosure is necessary to avert a serious and imminent threat to the patient or others

HIPAA permits disclosure without authorization when necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Question 24: A male patient who overdosed on oxazepam (Serax) has been prescribed flumazenil (Romazicon). Which typical side effect should nurse Gina be ready for before to delivering the medication?

Seizures (Correct answer)
Anxiety
Shivering
Chest pain

Correct answer: Seizures

The most frequent significant side effect of administering flumazenil to treat benzodiazepine overdose is seizures. If the client overdoses on both benzodiazepines and tricyclic antidepressants, the damage is amplified. Seizures and benzodiazepine reversal are related. Patients who have used benzodiazepines for prolonged sedation or who are exhibiting symptoms of severe tricyclic antidepressant overdose may experience seizures more frequently. To treat seizures, doctors should measure and prepare the appropriate dosage of Flumazenil. In patients who depend on a benzodiazepine for seizure control, flumazenil use needs to be cautious.

Question 25: A patient with schizophrenia is prescribed clozapine. Which laboratory monitoring is MOST critical due to the risk of agranulocytosis?

Liver function tests weekly
Thyroid function tests quarterly
Serum creatinine monthly
Absolute neutrophil count (ANC) per REMS protocol (Correct answer)

Correct answer: Absolute neutrophil count (ANC) per REMS protocol

Clozapine carries a black box warning for agranulocytosis, requiring ANC monitoring through the Clozapine REMS program before dispensing.

Question 26: Which pharmacological property of quetiapine at lower doses (25–100 mg) is primarily responsible for its sedating effects used in sleep or anxiety?

Alpha-1 adrenergic agonism
5-HT2A antagonism
H1 (histamine) receptor antagonism (Correct answer)
D2 receptor antagonism

Correct answer: H1 (histamine) receptor antagonism

At low doses, quetiapine's sedating effects are primarily driven by potent H1 histamine receptor antagonism before significant D2 or 5-HT2A blockade occurs.

Question 27: A PMHNP is evaluating a patient who reports 'hearing voices telling me to hurt myself.' What is the priority intervention?

Administer a PRN antipsychotic
Teach the patient to distract from the voices
Immediately initiate involuntary hospitalization
Assess the nature, frequency, and command quality of the hallucinations (Correct answer)

Correct answer: Assess the nature, frequency, and command quality of the hallucinations

A thorough assessment of command hallucinations—including content, frequency, and the patient's intent to act—is the priority before determining next steps.

Question 28: A PMHNP caring for a pregnant patient with bipolar disorder should avoid which mood stabilizer in the first trimester due to risk of Ebstein's anomaly?

Valproate
Quetiapine
Lithium (Correct answer)
Lamotrigine

Correct answer: Lithium

Lithium use in the first trimester is associated with an increased risk of Ebstein's anomaly, a cardiac malformation of the tricuspid valve.

Question 29: When assessing a patient using the Columbia Suicide Severity Rating Scale (C-SSRS), which finding indicates the HIGHEST level of ideation?

Passive ideation with no intent or plan
Active ideation with intent but no plan
Ideation only upon asking by the clinician
Active ideation with a specific plan and intent to act (Correct answer)

Correct answer: Active ideation with a specific plan and intent to act

On the C-SSRS, active suicidal ideation with a specific plan and intent to act represents the highest ideation severity and requires immediate intervention.

Question 30: Which personality disorder cluster includes paranoid, schizoid, and schizotypal personality disorders?

Cluster D (not a DSM cluster)
Cluster C (anxious/fearful)
Cluster A (odd/eccentric) (Correct answer)
Cluster B (dramatic/emotional)

Correct answer: Cluster A (odd/eccentric)

Cluster A personality disorders are characterized by odd, eccentric behavior and include paranoid, schizoid, and schizotypal types.

Question 31: A patient is brought to the ED agitated and confused after ingesting an unknown substance. The nurse notes hyperthermia, diaphoresis, muscular rigidity, clonus, and hyperreflexia. The PMHNP suspects:

Neuroleptic malignant syndrome (NMS)
Malignant hyperthermia
Anticholinergic toxidrome
Serotonin syndrome (Correct answer)

Correct answer: Serotonin syndrome

Serotonin syndrome presents with the triad of mental status changes, autonomic instability, and neuromuscular abnormalities including clonus and hyperreflexia, distinguishing it from NMS.

Question 32: A PMHNP receives a subpoena for a patient's psychotherapy records. The most appropriate initial action is to:

Release a summary but not the complete record
Notify the patient and consult with legal counsel before releasing any records (Correct answer)
Refuse to release any records under all circumstances
Immediately release all records to comply with the subpoena

Correct answer: Notify the patient and consult with legal counsel before releasing any records

A subpoena for psychotherapy records requires notification of the patient and consultation with legal counsel, as therapist-patient privilege may protect the records from disclosure depending on jurisdiction and circumstances.

Question 33: A PMHNP evaluates a 70-year-old patient with new-onset paranoid delusions and visual hallucinations. Which assessment finding would most strongly suggest a medical etiology rather than a primary psychiatric disorder?

Auditory hallucinations with command features
Acute onset with fluctuating consciousness and disorientation (Correct answer)
Family history of schizophrenia
Social withdrawal over the past year

Correct answer: Acute onset with fluctuating consciousness and disorientation

Acute onset, fluctuating consciousness, and disorientation are hallmarks of delirium—a medical emergency—rather than a primary psychiatric illness like schizophrenia.

Question 34: A patient with GAD has not responded to two trials of SSRIs. Which medication class is FDA-approved as a second-line option for GAD?

Benzodiazepines
Atypical antipsychotics as monotherapy
Tricyclic antidepressants
SNRIs such as venlafaxine (Correct answer)

Correct answer: SNRIs such as venlafaxine

SNRIs such as venlafaxine (Effexor XR) and duloxetine are FDA-approved for GAD and represent a first- or second-line alternative to SSRIs.

Question 35: Which neurotransmitter imbalance is most associated with the positive symptoms of schizophrenia?

Norepinephrine excess in the locus coeruleus
Serotonin excess in prefrontal cortex
Dopamine excess in the mesolimbic pathway (Correct answer)
GABA deficiency in the hippocampus

Correct answer: Dopamine excess in the mesolimbic pathway

Excess dopaminergic activity in the mesolimbic pathway is the primary mechanism underlying positive symptoms such as hallucinations and delusions in schizophrenia.

Question 36: A PMHNP is assessing negative symptoms of schizophrenia. Which symptom cluster is classified as 'negative'?

Thought insertion and broadcasting
Hallucinations and delusions
Disorganized speech and behavior
Alogia, anhedonia, avolition, and flat affect (Correct answer)

Correct answer: Alogia, anhedonia, avolition, and flat affect

Negative symptoms represent a diminution of normal functions, including restricted speech (alogia), lack of pleasure (anhedonia), lack of motivation (avolition), and flattened affect.

Question 37: A patient with anorexia nervosa is medically stable and has been restricting intake. What is the most serious refeeding risk the PMHNP must monitor for?

Hyperkalemia
Refeeding syndrome with hypophosphatemia (Correct answer)
Hyperglycemia
Metabolic alkalosis

Correct answer: Refeeding syndrome with hypophosphatemia

Refeeding syndrome causes a dangerous drop in serum phosphate as insulin shifts phosphate intracellularly, risking cardiac arrhythmias and respiratory failure.

Question 38: Which educational requirement is crucial when buspirone (BuSpar) 5 mg tid is first prescribed to a patient?

Encourage the patient to be compliant with monthly lab tests to monitor for medication toxicity.
Encourage the patient to avoid drinking alcohol while taking this medication because of the additive central nervous system depressant effects.
Encourage the patient to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks. (Correct answer)
Encourage the patient to monitor for signs and symptoms of anxiety to determine need for additional buspirone (BuSpar) PRN.

Correct answer: Encourage the patient to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks.

Unlike benzodiazepines, which depress the central nervous system, buspirone (BuSpar) is an anti-anxiety drug. The drug's exact mechanism of action is unknown, however it is thought to interact with serotonin, dopamine, and other neurotransmitter receptors to achieve the intended effects. It is crucial to inform the client that buspirone (BuSpar) takes 2–3 weeks to start working. Because of the benzodiazepine's early beginning of action, the nurse may frequently observe the prescription of clonazepam before the buspirone starts to take effect.

Question 39: When prescribing psychotropics to elderly patients, the PMHNP should follow the Beers Criteria, which primarily warns against using:

SSRIs for all elderly patients
Benzodiazepines, anticholinergics, and first-generation antipsychotics due to fall and cognitive risks (Correct answer)
Lithium in any patient over 65
All antipsychotics regardless of indication

Correct answer: Benzodiazepines, anticholinergics, and first-generation antipsychotics due to fall and cognitive risks

The Beers Criteria specifically flags benzodiazepines, anticholinergic medications, and first-generation antipsychotics as potentially inappropriate for older adults due to risks of falls, delirium, and cognitive impairment.

Question 40: A PMHNP is initiating lithium therapy. Which baseline laboratory test is MOST critical before starting treatment?

Lipid panel and fasting glucose
Serum creatinine and thyroid-stimulating hormone (TSH) (Correct answer)
Hemoglobin A1c
Liver function tests and CBC

Correct answer: Serum creatinine and thyroid-stimulating hormone (TSH)

Renal function (creatinine/GFR) and thyroid function (TSH) must be assessed before lithium initiation because lithium is renally cleared and causes hypothyroidism with long-term use.

Question 41: A patient who has been diagnosed with a thinking disorder and is taking clozapine (Clozaril) 25 mg QD is having his or her lab results reviewed by the nurse. RBC 4.7 million/mcL, WBC 2000/mcL, and TSH 1.3 mc-IU levels are recorded. Considering these values, which would the nurse anticipate the doctor to prescribe?

“Discontinue clozapine (Clozaril).” (Correct answer)
“Ferrous sulfate (Feosol) 100 mg tid.”
“Discontinue clozapine (Clozaril) and start levothyroxine sodium (Synthroid) 150 mcg QD.”
“Levothyroxine sodium (Synthroid) 150 mcg QD.”

Correct answer: “Discontinue clozapine (Clozaril).”

White blood cell (WBC) counts in adults should range between 4500 to 10,000/mcL. The WBC count for this patient is 2000/mcL, which denotes agranulocytosis, a potentially lethal blood condition. Therapy with the antipsychotic drug clozapine (Clozaril) carries a substantial risk for agranulocytosis. The nurse would anticipate that the doctor will stop prescribing clozapine (Clozaril).

Question 42: A patient with a long history of alcohol use disorder abruptly stops drinking after heavy daily use. Which vital sign pattern should alert the PMHNP to a risk of severe alcohol withdrawal (AWS)?

Hypotension and bradypnea
Tachycardia, hypertension, and fever (Correct answer)
Orthostatic hypotension alone
Bradycardia and hypothermia

Correct answer: Tachycardia, hypertension, and fever

Tachycardia, hypertension, diaphoresis, and fever during alcohol withdrawal reflect autonomic hyperactivity and can progress to seizures and delirium tremens.

Question 43: The psychiatric and mental health nurse is followed by a patient who has been really angry because his girlfriend dumped him while he was in the hospital. He insults the nurse and claims that she is trying to thwart his therapy. This is probably an illustration of:

Transference (Correct answer)
Countertransference
Displacement
Obsession

Correct answer: Transference

When a patient starts to follow the psychiatric and mental health nurse, criticizing her and implying that she is attempting to sabotage his therapy, he is displaying transference. This patient has been really unhappy because his girlfriend dumped him while he was in the hospital. Affection or anger can be transferred from one person to another due to unconscious identification, which is known as transference. A nurse's or therapist's emotional response to the patient is called countertransference.

Question 44: A patient reports hearing voices that tell them they are worthless. This auditory hallucination is best characterized as:

Referential hallucinations
Commentary hallucinations
Derogatory hallucinations (Correct answer)
Command hallucinations

Correct answer: Derogatory hallucinations

Derogatory hallucinations involve voices that insult or demean the patient, often worsening self-esteem and depression.

Question 45: A PMHNP suspects factitious disorder in a patient who fabricates symptoms. How does factitious disorder differ from malingering?

They are the same disorder with different names
Factitious disorder involves unconscious symptom production
Factitious disorder has external incentives; malingering does not
Malingering has external incentives; factitious disorder is driven by psychological need to assume the sick role (Correct answer)

Correct answer: Malingering has external incentives; factitious disorder is driven by psychological need to assume the sick role

In factitious disorder, symptom falsification is motivated by a psychological need to assume the sick role, with no external gains; malingering involves intentional feigning for external rewards.

Question 46: Which of the following medications should Nurse Rose get ready to give to a patient who has dangerous levels of acetaminophen (Tylenol)?

Succimer (Chemet)
Flumazenil (Romazicon)
Acetylcysteine (Mucomyst) (Correct answer)
Deferoxamine mesylate (Desferal)

Correct answer: Acetylcysteine (Mucomyst)

Acetylcysteine is the remedy for acetaminophen poisoning. It speeds up the transition from harmful to nontoxic metabolites. The fact that acetaminophen (N-acetyl-para-aminophenol, also known as paracetamol or APAP) is widely available and widely believed to be safe is a major contributing factor to its frequent toxicity. Every week, more than 60 million Americans take acetaminophen. N-acetyl-cysteine (NAC) therapy is required for all individuals with excessive acetaminophen levels. If administered within eight hours of consumption, this medication offers complete protection against liver damage.

Question 47: A therapist notices that a patient is unconsciously attributing their own unacceptable feelings to the therapist. This is known as:

Transference
Displacement
Countertransference
Projection (Correct answer)

Correct answer: Projection

Projection is a defense mechanism in which a person attributes their own unwanted feelings or impulses onto another person.

Question 48: Which of the following is a black box warning associated with atomoxetine (Strattera)?

Risk of agranulocytosis
Increased suicidal ideation in children and adolescents (Correct answer)
Sudden cardiac death in adults
Severe hepatotoxicity leading to liver failure

Correct answer: Increased suicidal ideation in children and adolescents

Atomoxetine carries a black box warning for increased suicidal ideation in pediatric patients, requiring close monitoring especially during dose initiation and adjustment.

Question 49: Which neurotransmitter imbalance is most strongly associated with the positive symptoms of schizophrenia?

Serotonin excess in the prefrontal cortex
Dopamine excess in the mesolimbic pathway (Correct answer)
GABA deficiency in the hippocampus
Norepinephrine deficiency in the locus coeruleus

Correct answer: Dopamine excess in the mesolimbic pathway

Hyperactivity of dopamine in the mesolimbic pathway is the primary mechanism underlying positive symptoms such as hallucinations and delusions.

Question 50: Male client being treated by nurse Mench has erroneous sensory sensations that have no rational justification. This impression is referred to as:

Hallucinations (Correct answer)
Neologisms
Loose associations
Delusions

Correct answer: Hallucinations

Hallucinations are unfounded sensory sensations, such as those that are visual, aural, gustatory, tactile, or olfactory. Hallucinations are defined as "sensory experiences that are not caused by stimulation of the relevant sensory organs" and the "perception of a nonexistent object or event" Hallucinations are common in people with psychiatric conditions, such as schizophrenia and bipolar disorder, but you don't necessarily need to have a mental illness to experience them.

Question 51: A patient on clozapine develops a WBC of 2,800/mm³. What is the most appropriate action?

Discontinue clozapine immediately and do not rechallenge (Correct answer)
Reduce the clozapine dose by 50%
Add prophylactic G-CSF and continue clozapine
Continue clozapine and recheck WBC in 1 week

Correct answer: Discontinue clozapine immediately and do not rechallenge

A WBC below 3,000/mm³ indicates agranulocytosis risk; clozapine must be stopped immediately and is permanently contraindicated for that patient.

Question 52: A PMHNP is conducting a safety planning intervention. Which element should be placed FIRST on the safety plan?

Names of mental health professionals to contact
Reasons for living
Warning signs that a crisis may be developing (Correct answer)
Emergency contact numbers

Correct answer: Warning signs that a crisis may be developing

Warning signs are placed first on safety plans so patients can recognize early signals and activate coping strategies before reaching crisis level.

Question 53: A patient with major depressive disorder has failed two adequate SSRI trials. The PMHNP considers augmentation. Which agent is FDA-approved as an augmentation strategy for treatment-resistant depression?

Aripiprazole (Abilify) (Correct answer)
Lamotrigine as monotherapy
Gabapentin
Clonazepam

Correct answer: Aripiprazole (Abilify)

Aripiprazole is FDA-approved as an adjunctive therapy to antidepressants for major depressive disorder in patients with an inadequate response.

Question 54: The American Nurses Association Code of Ethics requires PMHNPs to address what in relation to cultural competence?

Advocate for health equity and recognize the influence of culture on mental health (Correct answer)
Require patients to adapt to the dominant cultural framework of treatment
Only provide care to patients who share the PMHNP's cultural background
Refer all patients from minority backgrounds to culturally matched providers

Correct answer: Advocate for health equity and recognize the influence of culture on mental health

The ANA Code of Ethics requires nurses to practice with cultural sensitivity, advocate for health equity, and recognize how cultural factors influence the patient's experience of mental health and treatment.

Question 55: Exposure and response prevention (ERP) is the behavioral component of CBT most effective for treating:

Dissociative identity disorder
Bipolar II disorder
Obsessive-compulsive disorder (OCD) (Correct answer)
Major depressive disorder

Correct answer: Obsessive-compulsive disorder (OCD)

ERP involves exposing patients to feared stimuli while preventing compulsive responses, directly targeting OCD's core cycle.

Question 56: Which professional standard best defines the PMHNP's scope of practice?

Defined by the ANA/APNA Psychiatric-Mental Health Nursing: Scope and Standards of Practice, state nurse practice acts, and institutional policies (Correct answer)
Limited to what Medicare and Medicaid reimburse
Set only by the employing institution
Determined solely by the individual PMHNP's personal skills and comfort level

Correct answer: Defined by the ANA/APNA Psychiatric-Mental Health Nursing: Scope and Standards of Practice, state nurse practice acts, and institutional policies

PMHNP scope of practice is governed by the ANA/APNA Scope and Standards of Practice, state nurse practice acts and regulations, and facility-level policies and credentialing.

Question 57: A PMHNP treating a transgender patient should understand that gender dysphoria refers to:

A personality disorder variant
Clinically significant distress resulting from incongruence between assigned sex and gender identity (Correct answer)
Refusal to accept biological sex
A mental illness caused by gender identity

Correct answer: Clinically significant distress resulting from incongruence between assigned sex and gender identity

Gender dysphoria describes the distress caused by the incongruence between an individual's experienced gender and their assigned sex at birth, not the gender identity itself.

Question 58: The concept of 'least restrictive environment' in psychiatric care means:

Patients should always be treated in outpatient settings regardless of acuity
Treatment should be provided in the setting that meets clinical needs while maximizing patient freedom (Correct answer)
Inpatient hospitalization should never be used for voluntary patients
Patients should only receive treatment in community settings

Correct answer: Treatment should be provided in the setting that meets clinical needs while maximizing patient freedom

The least restrictive environment principle requires that psychiatric treatment occur in the setting that addresses the patient's clinical needs while preserving the greatest degree of personal freedom and autonomy.

Question 59: Which cognitive distortion is characterized by a patient concluding they are a 'complete failure' after receiving one negative performance review?

Mind reading
Overgeneralization (Correct answer)
Personalization
Catastrophizing

Correct answer: Overgeneralization

Overgeneralization involves drawing broad negative conclusions from a single event, such as labeling oneself a total failure based on one setback.

Question 60: Which ethical principle is most directly supported when a PMHNP provides a patient with complete information about treatment options and risks before obtaining consent?

Autonomy (Correct answer)
Justice
Nonmaleficence
Beneficence

Correct answer: Autonomy

Informed consent is a direct application of the principle of autonomy, which respects the patient's right to make informed decisions about their own care.

Question 61: Which validated tool is commonly used by PMHNPs to assess suicide risk in emergency settings?

PHQ-9
Columbia Suicide Severity Rating Scale (C-SSRS) (Correct answer)
GAD-7
CAGE questionnaire

Correct answer: Columbia Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a standardized, evidence-based tool that quantifies suicidal ideation and behavior severity.

Question 62: Which scenario would lead the nurse to suspect a social phobia diagnosis?

A patient abuses marijuana daily and avoids social situations because of fear of humiliation.
An 8-year-old child isolates from adults because of fear of embarrassment, but has good peer relationships in school.
A college student avoids taking classes that include an oral presentation because of fear of being scrutinized by others. (Correct answer)
A patient diagnosed with Parkinson’s disease avoids social situations because of embarrassment regarding tremors and drooling.

Correct answer: A college student avoids taking classes that include an oral presentation because of fear of being scrutinized by others.

A student who avoids class out of concern for peer scrutiny satisfies the requirements for a social phobia diagnosis.

Question 63: A patient on disulfiram for alcohol use disorder inadvertently uses an aftershave containing 70% ethanol. What reaction is expected and what is the mechanism?

Severe respiratory depression from combined CNS depressant effects
Mild euphoria due to disulfiram potentiating ethanol's CNS effects
No reaction because skin absorption of ethanol is insufficient to cause a disulfiram reaction
Flushing, nausea, tachycardia, and hypotension due to acetaldehyde accumulation from ALDH inhibition (Correct answer)

Correct answer: Flushing, nausea, tachycardia, and hypotension due to acetaldehyde accumulation from ALDH inhibition

Disulfiram inhibits aldehyde dehydrogenase (ALDH), causing acetaldehyde to accumulate when any ethanol source is absorbed, producing the aversive disulfiram-ethanol reaction even from topical exposures.

Question 64: When a patient meets criteria for involuntary psychiatric hospitalization, which legal standard most commonly applies in the US?

Court order required in all cases
Physician agreement with family
Preponderance of evidence
Imminent danger to self or others due to mental illness (Correct answer)

Correct answer: Imminent danger to self or others due to mental illness

Involuntary holds in the US require evidence of a mental illness causing imminent risk of harm to self or others.

Question 65: A PMHNP treating a patient with anorexia nervosa should monitor MOST closely for which life-threatening electrolyte complication?

Hypernatremia
Hypercalcemia
Hypermagnesemia
Hypokalemia and hypophosphatemia (Correct answer)

Correct answer: Hypokalemia and hypophosphatemia

Hypokalemia and hypophosphatemia (especially refeeding syndrome) in anorexia nervosa can cause fatal cardiac arrhythmias and require vigilant electrolyte monitoring.

Question 66: Efraim was brought to the emergency room after receiving an amphetamine psychosis diagnosis. Which of the following medications would Nurse Philippe most likely get ready to administer?

Haldol (Correct answer)
Ativan
Valium
Librium

Correct answer: Haldol

To lessen agitation and psychotic symptoms, such as delusions, hallucinations, and cognitive impairment, the nurse would get ready to give an amphetamine psychosis patient an antipsychotic drug like Haldol. A first-generation (typical) antipsychotic drug with widespread usage is haloperidol. Haloperidol has been approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia, Tourette syndrome (control of tics and vocal utterances in adults and children), hyperactivity (which may present as impulsivity, difficulty focusing, severe aggression, mood instability, and frustration intolerance), severe childhood behavioral issues (such as combative, explosive hyperexcitability), and intractable hiccups. It treats positive symptoms of schizophrenia such hallucinations and delusions, making it a typical antipsychotic.

Question 67: According to DSM-5, a major depressive episode requires at least how many symptoms persisting for a minimum of how many weeks?

4 symptoms for 3 weeks
7 symptoms for 1 month
5 symptoms for 2 weeks (Correct answer)
3 symptoms for 1 week

Correct answer: 5 symptoms for 2 weeks

DSM-5 requires at least 5 of 9 specified symptoms present for a minimum of 2 weeks, with at least one being depressed mood or anhedonia.

Question 68: Which DSM-5 specifier distinguishes a manic episode with flight of ideas, decreased need for sleep, and grandiosity lasting 4 days without hospitalization?

Cyclothymic disorder
Hypomanic episode (Correct answer)
Mixed features specifier
Manic episode

Correct answer: Hypomanic episode

Hypomanic episodes last at least 4 days, are not severe enough to require hospitalization, and do not cause marked functional impairment.

Question 69: Which legal principle established the duty to warn potential third-party victims of a patient's credible threat of harm?

O'Connor v. Donaldson
Wyatt v. Stickney
Olmstead v. L.C.
Tarasoff v. Regents of the University of California (Correct answer)

Correct answer: Tarasoff v. Regents of the University of California

Tarasoff v. Regents of the University of California (1976) established the legal duty to protect identifiable third parties when a patient makes a credible threat of harm.

Question 70: Which long-acting injectable antipsychotic formulation has the longest dosing interval, allowing once-every-3-month administration?

Risperidone microspheres (Risperdal Consta)
Paliperidone palmitate 1-month (Invega Sustenna)
Aripiprazole monohydrate (Abilify Maintena)
Paliperidone palmitate 3-month (Invega Trinza) (Correct answer)

Correct answer: Paliperidone palmitate 3-month (Invega Trinza)

Paliperidone palmitate 3-month (Invega Trinza) is the only LAI antipsychotic approved for once-every-3-month dosing, improving adherence in stabilized patients.

Question 71: A 70-year-old patient develops sudden onset confusion, agitation, and disorganized thinking 2 days after hip replacement surgery. The most likely diagnosis is:

First-episode schizophrenia
Delirium (Correct answer)
Dementia with Lewy bodies
Frontotemporal dementia

Correct answer: Delirium

Delirium is characterized by acute onset, fluctuating course, and disturbed attention/cognition, commonly precipitated by surgery, infection, or medications in older adults.

Question 72: A patient with major depressive disorder has not responded to two adequate SSRI trials. The PMHNP considers augmentation. Which agent is FDA-approved for adjunctive treatment of MDD?

Clonazepam
Gabapentin
Aripiprazole (Correct answer)
Hydroxyzine

Correct answer: Aripiprazole

Aripiprazole is FDA-approved as an adjunctive therapy to antidepressants in adults with major depressive disorder who have had an inadequate response.

Question 73: A PMHNP is conducting psychoeducation. Which statement best describes its primary goal?

To provide in-depth psychoanalytic insight
To eliminate the need for ongoing therapy
To help patients and families understand the illness and treatment (Correct answer)
To replace pharmacotherapy

Correct answer: To help patients and families understand the illness and treatment

Psychoeducation improves treatment adherence and outcomes by informing patients and families about the illness, medications, and coping strategies.

Question 74: A patient on clozapine develops a fever, sore throat, and absolute neutrophil count (ANC) of 400 cells/mm³. What is the appropriate action?

Discontinue clozapine immediately and notify the prescriber (Correct answer)
Recheck the ANC in 48 hours before making changes
Administer prophylactic antibiotics and continue clozapine
Reduce the clozapine dose by 50%

Correct answer: Discontinue clozapine immediately and notify the prescriber

An ANC below 500 cells/mm³ indicates severe neutropenia (agranulocytosis), requiring immediate discontinuation of clozapine to prevent fatal infection.

Question 75: Which axis of the former DSM-IV multiaxial system was designated for personality disorders and intellectual disabilities?

Axis IV
Axis II (Correct answer)
Axis I
Axis III

Correct answer: Axis II

DSM-IV Axis II was designated for personality disorders and intellectual developmental disorders, distinguishing them from Axis I clinical syndromes.

Question 76: A PMHNP prescribes naltrexone for a patient with alcohol use disorder. What must be confirmed BEFORE initiating this medication?

The patient has completed an inpatient detoxification program
The patient has no history of depression
The patient is opioid-free for at least 7–10 days (Correct answer)
The patient's BMI is within normal limits

Correct answer: The patient is opioid-free for at least 7–10 days

Naltrexone is an opioid antagonist and must not be started until the patient has been opioid-free for 7–10 days to avoid precipitating acute opioid withdrawal.

Question 77: A patient presents to the ED after a suicide attempt by overdose. After medical stabilization, the PMHNP's priority assessment is:

Level of suicidal intent before, during, and after the attempt (Correct answer)
Cognitive functioning
Marital status and living situation only
Insurance coverage for inpatient care

Correct answer: Level of suicidal intent before, during, and after the attempt

Assessing the intent level before, during, and after the attempt provides critical information about ongoing suicide risk.

Question 78: The best way to promote participation in an outreach program to evaluate homeless people for mental health and/or substance misuse disorders is to:

Advertise on TV and radio and in local newspapers.
Advertise through community volunteers.
Ask the police department to refer homeless people.
Offer free food, water, and hygiene products. (Correct answer)

Correct answer: Offer free food, water, and hygiene products.

Free food, water, and hygiene supplies are arguably the best incentives to utilize because homeless persons are more likely to be driven by self-interest due to their ongoing need. The psychiatric and mental health nurse may need to think about collaborating with or working with other community resources, such as homeless shelters and food kitchens, as these organizations can refer the homeless, even though funding may be limited. However, occasionally community members or organizations, like the Salvation Army®, will contribute.

Question 79: A PMHNP learns during therapy that a patient is being physically abused by a caregiver. What is the PMHNP's legal obligation?

Report the suspected abuse to appropriate authorities as a mandatory reporter (Correct answer)
Consult with the patient about whether they want the abuse reported
Maintain confidentiality because the patient is an adult
Refer the patient to a social worker to handle the report

Correct answer: Report the suspected abuse to appropriate authorities as a mandatory reporter

PMHNPs are mandatory reporters in all U.S. states and are legally required to report suspected abuse of vulnerable individuals, including adults who may be incapacitated, to protective services.

Question 80: Which criterion differentiates schizophrenia from schizoaffective disorder?

In schizoaffective disorder, mood episodes are present for the majority of the illness duration (Correct answer)
Schizophrenia always includes negative symptoms
Presence of hallucinations
Schizoaffective disorder has a shorter duration requirement

Correct answer: In schizoaffective disorder, mood episodes are present for the majority of the illness duration

Schizoaffective disorder requires that mood episodes (manic or depressive) are present for the majority of the total illness duration alongside psychotic symptoms.

Question 81: A patient with treatment-resistant depression is started on ketamine infusions. Which mechanism best explains its rapid antidepressant effect?

NMDA receptor antagonism followed by AMPA receptor upregulation and BDNF release (Correct answer)
D2 receptor partial agonism stabilizing dopamine circuits
Potent MAO-A inhibition leading to serotonin accumulation
Blockade of 5-HT3 receptors in the limbic system

Correct answer: NMDA receptor antagonism followed by AMPA receptor upregulation and BDNF release

Ketamine blocks NMDA receptors, causing a glutamate surge that activates AMPA receptors, releasing BDNF and promoting rapid synaptogenesis in the prefrontal cortex and hippocampus.

Question 82: A care plan is being created by nurse Shenny for a female client who has anorexia nervosa. Which action has to be included in the plan by the nurse?

Set-up a strict eating plan for the client. (Correct answer)
Encourage the client to exercise to reduce anxiety.
Provide privacy during meals.
Restrict visits with the family.

Correct answer: Set-up a strict eating plan for the client.

Setting up a steady eating schedule and keeping track of the client's weight are crucial for this disorder. Monitor the patient at mealtimes and for a predetermined amount of time (typically an hour) after meals. to guarantee adherence to the nutritional therapy plan. Food is regarded as a medication for anorexic hospital patients. Maintain a regular plan for weighing yourself, such as every Monday and Friday before breakfast while wearing the same clothes, and graph your results. gives a precise continuing record of weight growth or decrease. Reduces worrying excessively about weight changes as well.

Question 83: A patient taking an MAOI needs analgesia for acute pain. Which agent is CONTRAINDICATED due to risk of serotonin syndrome?

Meperidine (Correct answer)
Acetaminophen
Ketorolac
Ibuprofen

Correct answer: Meperidine

Meperidine (pethidine) combined with MAOIs can precipitate a fatal serotonin syndrome or hypertensive crisis and is absolutely contraindicated.

Question 84: Fetal alcohol spectrum disorder (FASD) results from prenatal alcohol exposure. Which characteristic is most associated with the neurodevelopmental profile of FASD?

Rapid language acquisition with social deficits
High IQ with behavioral regulation difficulties
Intellectual disability, executive function deficits, and poor adaptive behavior (Correct answer)
Primarily motor delays without cognitive impact

Correct answer: Intellectual disability, executive function deficits, and poor adaptive behavior

FASD commonly causes intellectual disability, executive function impairment, poor impulse control, and adaptive behavior deficits due to teratogenic brain damage.

Question 85: A PMHNP assessing insight asks a patient, 'Do you think you have a mental illness?' A patient who denies having any illness despite clear evidence demonstrates:

Nihilistic delusions
Concrete thinking
Poor insight (Correct answer)
Anosognosia

Correct answer: Poor insight

Poor insight refers to a patient's limited awareness or acknowledgment of their mental illness, which often impacts medication adherence.

Question 86: Neuroleptic malignant syndrome (NMS) is a psychiatric emergency characterized by which four findings?

Hyperthermia, muscle rigidity, autonomic instability, altered consciousness (Correct answer)
Seizures, rash, hepatotoxicity, myoclonus
Akathisia, tardive dyskinesia, galactorrhea, QTc prolongation
Bradycardia, hypotension, tremor, sedation

Correct answer: Hyperthermia, muscle rigidity, autonomic instability, altered consciousness

NMS is characterized by hyperthermia, lead-pipe rigidity, autonomic instability, and altered mental status following antipsychotic use.

Question 87: The Montreal Cognitive Assessment (MoCA) differs from the MMSE in that it:

Assesses psychotic symptoms
Takes longer to administer
Focuses exclusively on memory
Is more sensitive to mild cognitive impairment (MCI) (Correct answer)

Correct answer: Is more sensitive to mild cognitive impairment (MCI)

The MoCA has greater sensitivity than the MMSE for detecting mild cognitive impairment, particularly in executive functioning and attention.

Question 88: A patient taking phenelzine (an MAOI) asks which food they must strictly avoid. What is the correct response?

Shellfish
Green leafy vegetables
Aged cheeses (Correct answer)
Grapefruit juice

Correct answer: Aged cheeses

Aged cheeses contain high levels of tyramine, which can trigger a hypertensive crisis when combined with MAOIs.

Question 89: An admission assessment is being done by the nurse on a patient who has paranoid schizophrenia. Which should the nurse take into account in order to get the most accurate evaluation information?

Much data will need to be gained by reviewing old records and talking with family members and significant others. (Correct answer)
Assessment of this client will be simple because of the commonly occurring nature of the disease process of schizophrenia.
The nurse will refer to the client’s global assessment of functioning score to determine client problems and nursing interventions.
This client will be able to make a significant contribution to history data collection.

Correct answer: Much data will need to be gained by reviewing old records and talking with family members and significant others.

Information for a background check must be acquired from a variety of sources, such as relatives and old documents. Due to communication and thinking deficiencies, a client experiencing an acute episode would be unable to provide accurate and insightful assessment data.

Question 90: Which of the following is the best way to respond to a male patient who has been brought to the psychiatric ward for drug misuse therapy when he says to the nurse, "It felt so wonderful to get high?"

“You told me you got fired from your last job for missing too many days after taking drugs all night.” (Correct answer)
“If you continue to talk like that, I’m going to stop speaking to you.”
“Don’t you know it’s illegal to use drugs?”
“Tell me more about how it felt to get high.”

Correct answer: “You told me you got fired from your last job for missing too many days after taking drugs all night.”

Removing the client's denial requires confronting them with the negative effects of substance addiction. Since your physical presence is the reality, present reality to the customer by spending time with them to encourage reality orientation. When speaking to the client, be clear, concise, and easy to understand. Avoid ideological or theoretical conversations when speaking with the client and instead focus on concrete or known topics. The client has trouble processing abstractions or complexity.

Question 91: A teenager presents with sudden onset of paralysis in one arm with no neurological findings on MRI. The patient recently witnessed a traumatic accident. The PMHNP suspects which condition?

Somatic symptom disorder
Factitious disorder
Conversion disorder (Functional Neurological Symptom Disorder) (Correct answer)
Malingering disorder

Correct answer: Conversion disorder (Functional Neurological Symptom Disorder)

Conversion disorder presents with neurological symptoms (paralysis, blindness, seizures) incompatible with neurological disease, often triggered by psychological stress.

Question 92: A female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time," during postprandial monitoring. I was still able to purge after you sat with me yesterday. What is the best reply from the nurse? "Today, my objective is to do it twice."

“I trust you not to purge.”
“I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.” (Correct answer)
“Don’t worry. I won’t allow you to purge today.”
“How are you purging and when do you do it?”

Correct answer: “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.”

By undertaking postprandial monitoring to stop self-induced emesis, the nurse is establishing limits that the client is testing, and this response acknowledges that the client is doing so. Because they believe they have no control over any other element of their lives, clients with bulimia nervosa need to feel in charge of their diet. Nursing patients through treatment can be emotionally taxing because recovery requires patients to confront their darkest, most agonizing, and traumatic thoughts and feelings. When a patient also has a diagnosis of Obsessive-Compulsive Disorder (OCD), depression, or substance misuse, this emotional struggle may be made worse because these conditions may call for more intensive one-on-one counseling.

Question 93: A PMHNP working with patients who have co-occurring serious mental illness (SMI) and substance use disorder should prioritize which treatment model?

Treat the mental illness first, then address substance use
Refer to separate programs for each condition
Integrated dual diagnosis treatment addressing both conditions simultaneously (Correct answer)
Treat substance use first before initiating psychiatric medications

Correct answer: Integrated dual diagnosis treatment addressing both conditions simultaneously

Integrated dual diagnosis treatment has the strongest evidence base for co-occurring SMI and SUD, as both disorders interact and must be addressed concurrently.

Question 94: Which rating scale is used specifically to assess extrapyramidal side effects (EPS) in patients taking antipsychotics?

Positive and Negative Syndrome Scale (PANSS)
Simpson-Angus Scale (SAS) (Correct answer)
Young Mania Rating Scale (YMRS)
Columbia Suicide Severity Rating Scale (C-SSRS)

Correct answer: Simpson-Angus Scale (SAS)

The Simpson-Angus Scale assesses drug-induced parkinsonism and other extrapyramidal side effects associated with antipsychotic use.

Question 95: A PMHNP is treating a patient with intellectual disability (ID) and severe self-injurious behavior. Pharmacotherapy should:

Be avoided entirely in patients with ID
Be the first and only treatment modality
Be used adjunctively with behavioral interventions after identifying the function of the behavior (Correct answer)
Always begin with antipsychotics regardless of diagnosis

Correct answer: Be used adjunctively with behavioral interventions after identifying the function of the behavior

In ID, behavioral analysis to identify the function of self-injury is essential before or alongside pharmacotherapy, as medications address symptoms rather than causes.

Question 96: A patient who is voluntarily admitted to an inpatient psychiatric unit states they want to leave. What is the PMHNP's first action?

Immediately discharge the patient
Assess the patient's current mental status and risk to self or others (Correct answer)
Contact the patient's family before doing anything else
Initiate involuntary commitment proceedings without assessment

Correct answer: Assess the patient's current mental status and risk to self or others

The PMHNP must first assess the patient's mental status and risk level to determine whether voluntary discharge is safe or whether involuntary hold criteria are met.

Question 97: A PMHNP using Acceptance and Commitment Therapy (ACT) would primarily help patients to:

Practice progressive muscle relaxation
Accept difficult emotions and commit to value-driven actions (Correct answer)
Analyze childhood experiences
Eliminate all negative thoughts

Correct answer: Accept difficult emotions and commit to value-driven actions

ACT promotes psychological flexibility by accepting internal experiences and aligning behavior with personal values.

Question 98: A patient with bipolar I disorder is prescribed lithium. Which laboratory value requires the most immediate intervention?

TSH of 3.2 mIU/L
Serum lithium level of 0.8 mEq/L
Serum creatinine of 0.9 mg/dL
Serum lithium level of 1.8 mEq/L (Correct answer)

Correct answer: Serum lithium level of 1.8 mEq/L

A serum lithium level of 1.8 mEq/L is above the therapeutic range (0.6–1.2 mEq/L) and indicates toxicity requiring immediate intervention.

Question 99: The patient is not in the dining room for lunch, the nursing assistant informs nurse Philippe. Which of the following would Nurse Philippe instruct the nursing assistant to carry out?

Tell the client he’ll need to wait until supper to eat if he misses lunch.
Inform the client that he has 10 minutes to get to the dining room for lunch.
Invite the client to lunch and accompany him to the dining room. (Correct answer)
Take the client a lunch tray and let the client eat in his room.

Correct answer: Invite the client to lunch and accompany him to the dining room.

In order to reduce manipulation, secondary gain, dependency, and reinforcement of negative conduct while maintaining the client's worth, the nurse directs the nursing assistant to invite the client to lunch and accompany him to the dining room. The best way for staff to deal with manipulative patients is to develop tough guidelines that are strictly adhered to and consistently applied by all members of the healthcare team. Regular updates on the patient's progress helps lessen worker isolation and annoyance as well as the patient's attempts to separate the staff.

Question 100: When a PMHNP experiences strong emotional reactions to a patient based on their own unresolved issues, this is called:

Vicarious traumatization
Empathic resonance
Countertransference (Correct answer)
Transference

Correct answer: Countertransference

Countertransference refers to the clinician's emotional reactions to the patient that are rooted in the clinician's own history and conflicts.

Question 101: Which statement about lamotrigine dosing in the context of valproate co-administration is correct?

Lamotrigine reduces valproate levels by 50%, requiring valproate dose increases
Valproate inhibits lamotrigine glucuronidation, requiring slower titration and lower target doses (Correct answer)
Valproate induces lamotrigine metabolism, requiring higher lamotrigine doses
Valproate has no effect on lamotrigine pharmacokinetics

Correct answer: Valproate inhibits lamotrigine glucuronidation, requiring slower titration and lower target doses

Valproate inhibits UGT enzymes responsible for lamotrigine glucuronidation, doubling lamotrigine half-life; the combination requires halved lamotrigine doses and slower titration to prevent Stevens-Johnson syndrome.

Question 102: A PMHNP is conducting a psychiatric evaluation of an adolescent. Assent (versus consent) means:

Only the adolescent signs forms without parental involvement
The parent gives permission and the adolescent agrees to participate in treatment (Correct answer)
The court authorizes treatment over family objection
The adolescent is treated as an adult for all legal purposes

Correct answer: The parent gives permission and the adolescent agrees to participate in treatment

Assent is the adolescent's affirmative agreement to treatment alongside parental consent, recognizing the minor's developing autonomy even when they cannot legally consent.

Question 103: Which medication requires monitoring of fasting glucose and HbA1c due to its high risk of causing metabolic syndrome?

Olanzapine (Correct answer)
Aripiprazole
Haloperidol
Ziprasidone

Correct answer: Olanzapine

Olanzapine has the highest metabolic risk among antipsychotics, causing significant weight gain, hyperglycemia, and dyslipidemia requiring routine metabolic monitoring.

Question 104: Which documentation standard is most critical for the PMHNP to follow when managing a suicidal patient in an outpatient setting?

Document the risk assessment, clinical reasoning, safety plan, and rationale for treatment decisions (Correct answer)
Document only the patient's verbal statements about suicidality
Documentation is only required for inpatient settings
Document only the interventions performed

Correct answer: Document the risk assessment, clinical reasoning, safety plan, and rationale for treatment decisions

Thorough documentation of risk assessment findings, clinical reasoning, safety planning, and the rationale for level-of-care decisions is essential for both patient safety and professional liability protection.

Question 105: A PMHNP is implementing Dialectical Behavior Therapy (DBT). Which skill module teaches patients to tolerate painful emotions without acting impulsively?

Distress tolerance (Correct answer)
Emotion regulation
Interpersonal effectiveness
Mindfulness

Correct answer: Distress tolerance

Distress tolerance skills help patients endure crisis situations without making them worse.

Question 106: What legal standard is used to evaluate whether a PMHNP's conduct met the expected level of care in a malpractice case?

What the individual PMHNP personally believed was appropriate
What the most skilled specialist in the field would have done
What is listed in any textbook on psychiatric nursing
What a reasonably prudent PMHNP with similar training and in similar circumstances would have done (Correct answer)

Correct answer: What a reasonably prudent PMHNP with similar training and in similar circumstances would have done

The legal standard of care in malpractice cases is what a reasonably prudent practitioner with similar education, training, and experience would have done under the same or similar circumstances.

Question 107: A patient on bupropion reports new-onset generalized tonic-clonic seizure. Which pre-existing condition most likely increased this risk?

Hypertension
Hypothyroidism
Diabetes mellitus
Bulimia nervosa (Correct answer)

Correct answer: Bulimia nervosa

Bupropion lowers seizure threshold and is contraindicated in patients with eating disorders such as bulimia nervosa due to electrolyte imbalances that further increase seizure risk.

Question 108: Which psychotherapy approach focuses on identifying and modifying distorted thought patterns that contribute to emotional distress?

Gestalt therapy
Psychoanalytic therapy
Cognitive-behavioral therapy (CBT) (Correct answer)
Interpersonal therapy

Correct answer: Cognitive-behavioral therapy (CBT)

CBT targets maladaptive cognitive distortions and behaviors to reduce psychological symptoms.

Question 109: Which structured clinical assessment instrument is considered the gold standard for diagnosing DSM-5 disorders in research settings?

Beck Depression Inventory (BDI)
Structured Clinical Interview for DSM Disorders (SCID) (Correct answer)
PHQ-9
Hamilton Anxiety Rating Scale (HAM-A)

Correct answer: Structured Clinical Interview for DSM Disorders (SCID)

The SCID is a semi-structured diagnostic interview conducted by trained clinicians and is considered the gold standard for establishing DSM diagnoses.

Question 110: When treating an autistic patient with psychiatric comorbidities, which communication strategy is most appropriate?

Avoid written instructions to prevent overwhelm
Use clear, literal, concrete language and provide structure (Correct answer)
Use metaphors and abstract language for better engagement
Focus sessions on emotional expression only

Correct answer: Use clear, literal, concrete language and provide structure

Concrete, literal language with clear structure accommodates common communication and cognitive processing differences in autistic patients.

Question 111: A patient with ADHD and comorbid bipolar disorder requires pharmacological treatment. Which approach is MOST appropriate?

Use an MAOI to address both conditions simultaneously
Avoid all pharmacotherapy due to the complexity of comorbidity
Stabilize the bipolar disorder with a mood stabilizer before treating ADHD (Correct answer)
Start a stimulant immediately to address ADHD as the primary diagnosis

Correct answer: Stabilize the bipolar disorder with a mood stabilizer before treating ADHD

In ADHD-bipolar comorbidity, the bipolar disorder must be stabilized first with a mood stabilizer to prevent stimulants from triggering mania or rapid cycling.

Question 112: Under the Olmstead v. L.C. Supreme Court decision, states are required to:

Provide community-based mental health services to qualified individuals with disabilities who do not oppose such placement (Correct answer)
Eliminate all inpatient psychiatric facilities
Require all individuals with mental illness to live in supervised housing
Provide inpatient psychiatric beds for all individuals with mental illness

Correct answer: Provide community-based mental health services to qualified individuals with disabilities who do not oppose such placement

The Olmstead decision (1999) held that unjustified institutionalization of persons with disabilities constitutes discrimination under the ADA and requires states to provide integrated, community-based services when clinically appropriate and desired by the patient.

Question 113: Which therapeutic modality uses structured family sessions to identify dysfunctional communication patterns and realign family roles?

Narrative therapy
Existential therapy
Structural family therapy (Correct answer)
Individual psychodynamic therapy

Correct answer: Structural family therapy

Structural family therapy, developed by Salvador Minuchin, focuses on reorganizing family structure to improve functioning.

Question 114: A patient describes feeling detached from their own body and observing themselves from the outside during periods of stress. This symptom is BEST described as:

Dissociative amnesia
Depersonalization (Correct answer)
Derealization
Déjà vu

Correct answer: Depersonalization

Depersonalization is the subjective experience of feeling detached from or outside of one's own body, thoughts, or feelings.

Question 115: A female client who has been diagnosed with grandiosity delusions is admitted. According to this diagnostic, the patient is:

Connected to the client unrelated to oneself.
Highly famous and important. (Correct answer)
Being Killed.
Responsible for an evil world.

Correct answer: Highly famous and important.

A false sense of fame and importance is called a delusion of grandeur. The erroneous conviction of one's own superiority, greatness, or brilliance is known as a delusion of grandeur. People who suffer from delusions of grandeur don't merely have high self-esteem; they actually hold this belief despite the tremendous amount of evidence to the contrary. For instance, someone who has never held a leadership position and has trouble interacting with others can think they are destined to rule the world. Persistence is the hallmark of grandiose delusions. They are not merely fleeting fantasies or future aspirations.

Question 116: The Mini-Mental State Examination (MMSE) is used primarily to assess which domain?

Cognitive functioning (Correct answer)
Depressive symptom severity
Personality pathology
Psychotic symptom severity

Correct answer: Cognitive functioning

The MMSE screens for cognitive impairment across orientation, memory, attention, language, and visuospatial domains.

Question 117: A patient presents with pressured speech, decreased need for sleep, grandiosity, and increased goal-directed activity lasting 4 days without causing marked functional impairment. This presentation is most consistent with:

Bipolar II disorder, hypomanic episode (Correct answer)
Cyclothymic disorder
Major depressive disorder with mixed features
Bipolar I disorder, manic episode

Correct answer: Bipolar II disorder, hypomanic episode

A hypomanic episode is defined by elevated mood lasting at least 4 days that does not cause marked impairment or require hospitalization, distinguishing it from mania.

Question 118: A patient taking sertraline for 3 weeks reports nausea and insomnia but no improvement in mood. What is the BEST clinical response?

Educate the patient that SSRIs typically require 4–8 weeks for antidepressant effect (Correct answer)
Increase the dose to achieve faster therapeutic effect
Switch immediately to a different antidepressant class
Add bupropion augmentation for faster response

Correct answer: Educate the patient that SSRIs typically require 4–8 weeks for antidepressant effect

SSRIs typically take 4–8 weeks to produce full antidepressant effects, while side effects such as nausea and insomnia often appear first and tend to resolve within the first 1–2 weeks.

Question 119: A patient with borderline personality disorder (BPD) displays a pattern of idealizing and then abruptly devaluing their treatment providers. This defense mechanism is called:

Intellectualization
Reaction formation
Projection
Splitting (Correct answer)

Correct answer: Splitting

Splitting is the hallmark defense mechanism of BPD, where individuals perceive people as all good or all bad without integration.

Question 120: A PMHNP in private practice begins dating a former patient who terminated therapy 6 months ago. This behavior is best described as:

A boundary violation that is ethically prohibited (Correct answer)
Acceptable only if both parties freely consent
Acceptable given the therapeutic relationship has ended
Permissible after a waiting period specified in state law

Correct answer: A boundary violation that is ethically prohibited

Sexual or romantic relationships with former patients are considered boundary violations and are prohibited by professional ethics codes due to the power differential inherent in the therapeutic relationship, which persists after termination.

Question 121: A PMHNP is treating a patient with obsessive-compulsive disorder (OCD). Which first-line pharmacological treatment is recommended?

Fluvoxamine (an SSRI) (Correct answer)
Mirtazapine
Buspirone
Alprazolam

Correct answer: Fluvoxamine (an SSRI)

SSRIs, such as fluvoxamine, are the first-line pharmacological agents for OCD, often at higher doses than used for depression.

Question 122: A 70-year-old patient with dementia-related psychosis is prescribed haloperidol. What critical warning must be communicated to the family?

Haloperidol causes irreversible memory loss in elderly patients
Haloperidol must be stopped after 4 weeks to prevent dependence
The drug requires mandatory REMS enrollment for patients over 65
Antipsychotics are associated with increased mortality in elderly patients with dementia-related psychosis (Correct answer)

Correct answer: Antipsychotics are associated with increased mortality in elderly patients with dementia-related psychosis

All antipsychotics carry a black box warning of increased mortality (primarily cardiovascular and infectious causes) when used in elderly patients with dementia-related psychosis.

Question 123: Which of the following best describes the primary goal of dialectical behavior therapy (DBT) as originally developed for borderline personality disorder?

Exposing patients to feared stimuli to reduce avoidance
Balancing acceptance and change strategies to reduce emotional dysregulation (Correct answer)
Restructuring dysfunctional core schemas through behavioral experiments
Uncovering unconscious conflicts driving self-destructive behavior

Correct answer: Balancing acceptance and change strategies to reduce emotional dysregulation

DBT integrates acceptance-based strategies (drawn from mindfulness) with change-based cognitive-behavioral techniques to treat emotional dysregulation.

Question 124: A nurse is applying motivational interviewing (MI) techniques. Which response best exemplifies a reflective listening statement?

'Have you tried attending an AA meeting?'
'You should consider stopping drinking for your health.'
'Most people in your situation find it helps to set a quit date.'
'It sounds like you feel torn between wanting to change and enjoying alcohol.' (Correct answer)

Correct answer: 'It sounds like you feel torn between wanting to change and enjoying alcohol.'

Reflective listening in MI involves mirroring the patient's expressed ambivalence without judging or directing, which builds rapport and fosters change talk.

Question 125: A PMHNP notes that a patient consistently misinterprets neutral facial expressions as hostile. This cognitive distortion is best described as:

Catastrophizing
Mind reading (Correct answer)
Personalization
Emotional reasoning

Correct answer: Mind reading

Mind reading is the distortion of assuming one knows what others are thinking, often in a negative direction, without actual evidence.

Question 126: Which medication is considered first-line pharmacotherapy for PTSD according to current evidence-based guidelines?

Buspirone
Haloperidol
Lorazepam
Sertraline (Correct answer)

Correct answer: Sertraline

Sertraline (and paroxetine) are FDA-approved SSRIs for PTSD and are recommended as first-line pharmacotherapy by VA/DoD and APA guidelines.

Question 127: A PMHNP screens a patient using the GAD-7 and obtains a score of 15. This score indicates:

Minimal anxiety
Severe anxiety (Correct answer)
Mild anxiety
Moderate anxiety

Correct answer: Severe anxiety

GAD-7 scores of 15–21 indicate severe anxiety, prompting urgent clinical attention and treatment.

Question 128: Which condition is characterized by at least 6 months of inattention and/or hyperactivity-impulsivity before age 12 with impairment in two or more settings?

Conduct disorder
Autism spectrum disorder
Attention-deficit/hyperactivity disorder (ADHD) (Correct answer)
Bipolar disorder

Correct answer: Attention-deficit/hyperactivity disorder (ADHD)

DSM-5 ADHD criteria require symptom onset before age 12 and impairment across multiple settings, such as home and school.

Question 129: A patient discloses in an outpatient session that they molested a child two years ago but claim it will never happen again. The PMHNP is legally required to:

Only report if there is evidence of ongoing or current abuse
Report the disclosed past abuse to child protective services per mandatory reporting laws (Correct answer)
Maintain confidentiality since the abuse occurred in the past
Refer the patient to a specialized therapist and transfer care

Correct answer: Report the disclosed past abuse to child protective services per mandatory reporting laws

Mandatory reporting laws in most states require clinicians to report known or reasonably suspected child abuse regardless of when it occurred, as a child may still be at risk or other children could be in danger.

Question 130: In psychiatric advanced practice nursing, competency refers to:

Whether a patient can perform activities of daily living independently
A clinical judgment made by the PMHNP at the bedside
The patient's score on a cognitive screening tool
A legal determination made by a court regarding a person's ability to make decisions (Correct answer)

Correct answer: A legal determination made by a court regarding a person's ability to make decisions

Competency is a legal determination made by a court or judge, whereas decision-making capacity is a clinical assessment performed by the treating clinician.

Question 131: Which second-generation antipsychotic carries the highest risk for metabolic syndrome, including significant weight gain and dyslipidemia?

Lurasidone
Clozapine (Correct answer)
Ziprasidone
Aripiprazole

Correct answer: Clozapine

Clozapine and olanzapine carry the highest risk of metabolic side effects among second-generation antipsychotics.

Question 132: A patient with schizophrenia believes that a television news anchor is sending personal messages specifically to them. This is an example of:

Ideas of reference (Correct answer)
Thought broadcasting
Persecutory delusion
Grandiose delusion

Correct answer: Ideas of reference

Ideas of reference involve the belief that external events, objects, or people have special personal significance directed specifically at oneself.

Question 133: A patient with borderline personality disorder frequently calls the crisis line, threatens self-harm, and then denies having any problems during sessions. This pattern BEST illustrates which concept central to DBT?

Cognitive restructuring
Motivational ambivalence
Dialectical dilemma: active passivity vs. apparent competence (Correct answer)
Secondary gain from the sick role

Correct answer: Dialectical dilemma: active passivity vs. apparent competence

DBT describes the dialectical dilemma of 'active passivity vs. apparent competence,' where patients appear capable in some contexts but feel unable to cope in others, creating confusion for providers.

Question 134: In motivational interviewing, what does the acronym OARS stand for?

Open questions, Alternatives, Reasoning, Strategies
Open questions, Affirmations, Reflections, Summaries (Correct answer)
Outcomes, Assessments, Referrals, Support
Objectives, Actions, Reflections, Solutions

Correct answer: Open questions, Affirmations, Reflections, Summaries

OARS represents the core communication techniques used in motivational interviewing to build rapport and elicit change talk.

Question 135: Hana's thoughts about her father's passing take up all of her conscious space. Hana should expect assistance from Nurse Matt during this period of sorrow, which is referred described as:

Shock and disbelief
Restitution
Resolving the loss (Correct answer)
Developing awareness

Correct answer: Resolving the loss

The process of getting over a loss is gradual, difficult, and ongoing until a nearly perfect mental picture of the deceased individual emerges. The person is concerned with their loss, idealizes the lost person or thing, and may even impersonate the deceased. The fixation eventually fades, usually after a year or possibly more.

Question 136: Which of the following is the mechanism of action of aripiprazole that differentiates it from most other second-generation antipsychotics?

D2 receptor partial agonism (Correct answer)
Selective serotonin reuptake inhibition
D1 receptor full agonism
Full D2 receptor antagonism

Correct answer: D2 receptor partial agonism

Aripiprazole acts as a partial agonist at D2 and D3 receptors, stabilizing dopamine activity rather than fully blocking it, which reduces EPS risk.

Question 137: Which antidepressant is most appropriate for a patient with major depressive disorder who also has significant insomnia but cannot tolerate anticholinergic side effects?

Doxepin
Paroxetine
Mirtazapine (Correct answer)
Amitriptyline

Correct answer: Mirtazapine

Mirtazapine is highly sedating via H1 antagonism and has minimal anticholinergic activity, making it suitable for patients needing sleep aid without anticholinergic burden.

Question 138: Which psychotherapy is based on the idea that improving interpersonal relationships and role functioning reduces psychiatric symptoms?

Existential therapy
Cognitive processing therapy
Interpersonal therapy (IPT) (Correct answer)
Behavioral activation

Correct answer: Interpersonal therapy (IPT)

IPT focuses on grief, role disputes, role transitions, and interpersonal deficits as key areas contributing to depression and other disorders.

Question 139: A PMHNP discovers that a colleague is prescribing controlled substances to patients without appropriate clinical indications. The PMHNP's ethical obligation is to:

Ignore the situation as it involves a colleague
Confront the colleague publicly at a staff meeting
Report the behavior through appropriate institutional or regulatory channels (Correct answer)
Only act if a patient files a formal complaint

Correct answer: Report the behavior through appropriate institutional or regulatory channels

Ethical and legal obligations require PMHNPs to report unsafe or illegal prescribing practices through appropriate channels such as hospital administration, the state board of nursing, or the DEA.

Question 140: A patient with schizophrenia refuses antipsychotic medication. What must be established before medication can be administered involuntarily?

The patient has been determined to lack decision-making capacity by appropriate legal or clinical process (Correct answer)
The patient's family has given consent
A psychiatric diagnosis alone is sufficient justification
The PMHNP believes treatment is in the patient's best interest

Correct answer: The patient has been determined to lack decision-making capacity by appropriate legal or clinical process

A psychiatric diagnosis does not automatically remove a patient's right to refuse treatment; lack of decision-making capacity must be formally established through clinical and/or legal processes before involuntary medication.

Question 141: In prolonged exposure (PE) therapy for PTSD, which technique involves the patient repeatedly narrating the traumatic memory aloud?

Systematic desensitization
Flooding
In vivo exposure
Imaginal exposure (Correct answer)

Correct answer: Imaginal exposure

Imaginal exposure requires the patient to verbally revisit the traumatic memory in detail to reduce its emotional charge.

Question 142: A patient with obsessive-compulsive disorder has spent the past four days in the hospital. Which intervention is most important right now?

Say “stop” to the patient as a thought-stopping technique.
Reinforce the use of learned relaxation techniques. (Correct answer)
Notify the patient of the expected limitations on compulsive behaviors.
Allow the patient the time needed to complete the compulsive behaviors.

Correct answer: Reinforce the use of learned relaxation techniques.

The patient must acquire methods for lowering general anxiety levels in order to lessen the need for obsessive behaviors. By day four, these techniques should be taught.

Question 143: A PMHNP prescribes lithium for a patient with bipolar I disorder. Which patient statement indicates a need for additional teaching?

I should maintain consistent fluid and sodium intake.
I can skip blood levels once I feel stable on lithium. (Correct answer)
I will avoid NSAIDs and use acetaminophen for pain.
I will call if I experience tremor, nausea, or confusion.

Correct answer: I can skip blood levels once I feel stable on lithium.

Lithium has a narrow therapeutic index and requires ongoing serum level monitoring even when the patient feels stable to prevent toxicity.

Question 144: A patient on clozapine has an ANC of 1,200 cells/mm³. What is the PMHNP's priority action?

Immediately discontinue clozapine and notify the prescriber (Correct answer)
Add lithium augmentation to support bone marrow function
Reduce the clozapine dose by 50% and monitor closely
Continue clozapine and recheck ANC in one week

Correct answer: Immediately discontinue clozapine and notify the prescriber

An ANC below 1,500 cells/mm³ (severe neutropenia threshold) requires immediate discontinuation of clozapine to prevent life-threatening agranulocytosis.

Question 145: Which brief, structured therapy is specifically designed for suicidal patients and focuses on reasons for living and building safety plans?

Mentalization-based therapy
Collaborative Assessment and Management of Suicidality (CAMS) (Correct answer)
Cognitive processing therapy
Schema therapy

Correct answer: Collaborative Assessment and Management of Suicidality (CAMS)

CAMS is an evidence-based framework for assessing and treating suicidal patients through collaborative goal-setting and safety planning.

Question 146: A PMHNP documents that a patient with schizophrenia sits motionless for hours, maintains an unusual posture when repositioned, and does not speak. These symptoms best describe:

Akathisia
Tardive dyskinesia
Catatonia (Correct answer)
Negative symptom avolition

Correct answer: Catatonia

Catatonia is characterized by motor immobility, posturing (waxy flexibility), mutism, and negativism, which can occur in schizophrenia, mood disorders, and medical conditions.

Question 147: A patient with bipolar I disorder needs an antimanic agent but has liver disease precluding valproate use and renal disease precluding lithium. Which atypical antipsychotic is FDA-approved for acute mania with the least metabolic risk?

Ziprasidone (Correct answer)
Clozapine
Quetiapine
Olanzapine

Correct answer: Ziprasidone

Ziprasidone is FDA-approved for acute manic episodes and has the lowest weight-gain and metabolic risk profile among second-generation antipsychotics, though it requires QTc monitoring.

Question 148: Which DSM-5 neurodevelopmental disorder requires persistent deficits in social communication across multiple contexts AND restricted, repetitive behaviors for diagnosis?

Intellectual disability
Autism spectrum disorder (ASD) (Correct answer)
ADHD
Specific learning disorder

Correct answer: Autism spectrum disorder (ASD)

ASD requires both persistent social communication deficits AND restricted, repetitive behaviors present in early development per DSM-5 criteria.

Question 149: A PMHNP is conducting a Mental Status Examination (MSE). 'Affect' refers to:

The patient's reported subjective emotional experience
The patient's ability to think abstractly
The patient's insight into their illness
The observed external expression of emotion (Correct answer)

Correct answer: The observed external expression of emotion

Affect is the clinician-observed emotional expression, while mood is the patient's subjective report of their internal emotional state.

Question 150: Behavioral activation therapy for depression primarily works by:

Increasing engagement in rewarding activities to improve mood (Correct answer)
Analyzing dream content
Teaching breathing relaxation techniques
Exploring childhood trauma

Correct answer: Increasing engagement in rewarding activities to improve mood

Behavioral activation breaks the cycle of depression and avoidance by scheduling and increasing participation in pleasurable or meaningful activities.

Question 151: Which finding on mental status examination is MOST characteristic of a patient experiencing a major depressive episode?

Grandiosity and decreased need for sleep
Psychomotor retardation and constricted affect (Correct answer)
Tangentiality and loose associations
Pressured speech and flight of ideas

Correct answer: Psychomotor retardation and constricted affect

Psychomotor retardation (slowed movement and speech) and constricted affect (reduced emotional expression) are hallmark MSE findings in major depressive disorder.

Question 152: Which psychotherapy modality uses homework assignments, Socratic questioning, and thought records as core techniques?

Cognitive-behavioral therapy (CBT) (Correct answer)
Gestalt therapy
Narrative therapy
Psychodynamic therapy

Correct answer: Cognitive-behavioral therapy (CBT)

CBT uses structured tools like thought records, behavioral experiments, and Socratic questioning to challenge cognitive distortions.

Question 153: The nurse is evaluating a patient with schizophrenia who is disorganized. Which signs should the nurse anticipate the patient displaying?

The patient is exhibiting delusions of persecution or grandeur. Auditory hallucinations related to a persecutory theme are present. The client is tense, suspicious, and guarded, and may be argumentative, hostile, and aggressive.
Marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movements and activity. Waxy flexibility is exhibited.
Markedly regressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme. (Correct answer)
The patient has a history of active psychotic symptoms, but prominent psychotic symptoms are currently not exhibited.

Correct answer: Markedly regressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme.

A patient is most likely to be diagnosed with disorganized schizophrenia if they display clearly regressive and primitive conduct and have very little interaction with reality. A client's affect is flat or blatantly wrong in this subcategory. Social impairment is severe, and personal hygiene is disregarded.

Question 154: A patient in an inpatient psychiatric unit is placed in seclusion. According to CMS regulations, how frequently must the patient be assessed by a qualified clinician?

Within 1 hour of initiation and then per state/facility policy with physician oversight (Correct answer)
Every 4 hours by any staff member
Every 1 hour by a physician or licensed independent practitioner
Every 15 minutes by a registered nurse only

Correct answer: Within 1 hour of initiation and then per state/facility policy with physician oversight

CMS Conditions of Participation require that a licensed independent practitioner (LIP) conduct an in-person evaluation within 1 hour of initiating seclusion or restraint, with ongoing monitoring per policy.

Question 155: Which cognitive distortion does a patient demonstrate when they say, 'I failed one exam, so I'll never pass any test and I'm a total failure'?

Mind reading
Personalization
Magnification
Overgeneralization (Correct answer)

Correct answer: Overgeneralization

Overgeneralization involves drawing sweeping negative conclusions from a single event and applying them broadly across situations.

Question 156: A female client who poses a serious suicide risk requires strict surveillance. In order to best guarantee the client's safety, Nurse Shenny ought to?

Disregard decreased communication by the client because this is common with suicidal clients.
Assure the client that the nurse will hold in confidence anything the client says.
Check the client frequently at irregular intervals throughout the night. (Correct answer)
Repeatedly discuss previous suicide attempts with the client.

Correct answer: Check the client frequently at irregular intervals throughout the night.

The patient cannot predict when an observation will occur and change behavior in a misleading way at these times if they are checked often but at unpredictable intervals. When the patient is determined to be at risk of suicide, immediate intervention measures must be taken. The person cannot be left alone. While at home, enlist the assistance of a support person. The suicidal person has to be treated in a secure setting. The area also has to be watched over.

Question 157: Which element is NOT required to establish malpractice in psychiatric nursing practice?

The PMHNP breached the standard of care
The patient experienced harm or damages
A duty of care existed between the PMHNP and patient
The PMHNP intended to harm the patient (Correct answer)

Correct answer: The PMHNP intended to harm the patient

Malpractice (negligence) requires duty, breach of duty, causation, and damages — intent to harm is not an element, distinguishing negligence from intentional torts.

Question 158: The evening report has been sent to the nurse. The nurse would need to evaluate which patient first.

A patient who slept 2 to 3 hours last night because of flashbacks.
A patient diagnosed with generalized anxiety disorder awaiting discharge.
A newly admitted patient with a history of panic attacks.
A patient pacing the halls and stating that his anxiety is an 8/10. (Correct answer)

Correct answer: A patient pacing the halls and stating that his anxiety is an 8/10.

A patient who is pacing the hallways and becoming more anxious needs to be evaluated right away. There is a chance that the patient could hurt himself or other people if the nurse does nothing about this assessment.

Question 159: A PMHNP evaluating a patient in crisis should first prioritize which action?

Establish safety and assess risk of harm to self or others (Correct answer)
Contact the patient's family
Schedule a follow-up appointment
Initiate pharmacotherapy immediately

Correct answer: Establish safety and assess risk of harm to self or others

Safety assessment is always the first priority in any psychiatric crisis situation.

Question 160: Dependent personality disorder was identified in a patient who is 20 years old. Which conduct is least likely to be indicative of inadequate personal coping?

Avoiding relationships.
Inability to make choices and decisions without advice. (Correct answer)
Recurrent self-destructive behavior.
Showing interest in solitary activities.

Correct answer: Inability to make choices and decisions without advice.

To get others to make decisions with them, people with dependent personality disorder frequently exhibit indecisiveness, submission, and clinging behaviors. Anxious personality disorders include dependent personality disorder (DPD). People with DPD frequently experience feelings of helplessness, submission, or impotence. They could struggle to come to easy judgments. However, a person with a dependent personality can develop self-confidence and independence with assistance.

Question 161: A PMHNP conducting a mental status exam notes that a patient's speech jumps from one topic to another based on the sound of words rather than logical meaning. This is documented as:

Flight of ideas
Circumstantiality
Clang associations (Correct answer)
Tangentiality

Correct answer: Clang associations

Clang associations occur when the patient's speech is driven by the rhyme or sound of words rather than their semantic meaning, commonly seen in mania.

Question 162: The psychiatric and mental health nurse should recognize that when a patient with substance addiction disorder says he has been using "beanies," he is referring to:

Heroin
Cocaine
Marijuana
Methamphetamine (Correct answer)

Correct answer: Methamphetamine

The psychiatric and mental health nurse should recognize that if a patient with substance abuse disorder says they have been using "beanies," they are referring to methamphetamine, also known as "blue devils," "crank," and "crystal" as well as a variety of other local names. Heroin is also known as "horse," "H," "Aunt Hazel," "smack," and "charley," among other less popular names, while marijuana is known as "weed," "Aunt Mary," "Mary Jane," and "pot." Cocaine is also known as "coke," "blow,", "snow," and "sugar."

Question 163: A patient with PTSD is most likely to benefit from which evidence-based, trauma-focused psychotherapy?

Prolonged exposure (PE) therapy (Correct answer)
Supportive therapy
Interpersonal psychotherapy (IPT)
Client-centered therapy

Correct answer: Prolonged exposure (PE) therapy

Prolonged exposure therapy is a first-line, evidence-based treatment for PTSD that systematically reduces avoidance and fear through in vivo and imaginal exposure to trauma-related stimuli.

Question 164: A PMHNP is applying Dialectical Behavior Therapy (DBT). Which skill module teaches patients to tolerate distress without making a crisis worse?

Interpersonal effectiveness
Emotion regulation
Distress tolerance (Correct answer)
Mindfulness

Correct answer: Distress tolerance

Distress tolerance skills in DBT teach patients to survive crisis moments without engaging in behaviors that worsen the situation, using techniques like TIPP and ACCEPTS.

Question 165: Which of the following describes the appropriate use of flumazenil in benzodiazepine overdose?

It reverses opioid co-ingestion as well, making it useful in mixed overdoses
It should be avoided in patients with chronic benzodiazepine use due to risk of precipitating seizures (Correct answer)
It is the first-line treatment and should be given to all benzodiazepine overdose patients
It provides sustained reversal lasting 8-12 hours, eliminating need for monitoring

Correct answer: It should be avoided in patients with chronic benzodiazepine use due to risk of precipitating seizures

Flumazenil can precipitate life-threatening withdrawal seizures in benzodiazepine-dependent patients and should be used cautiously; it is not routinely recommended in chronic users.

Question 166: A PMHNP is assessing a patient using motivational interviewing. Which technique best exemplifies the 'rolling with resistance' strategy?

Reflecting the patient's ambivalence without challenging it directly (Correct answer)
Confronting the patient about the consequences of their behavior
Arguing against the patient's denial of a substance problem
Providing direct advice about stopping substance use immediately

Correct answer: Reflecting the patient's ambivalence without challenging it directly

Rolling with resistance in motivational interviewing involves acknowledging ambivalence and reflecting it back rather than confronting or arguing, reducing defensiveness.

Question 167: A patient taking phenelzine eats a meal containing aged cheese and develops a severe hypertensive crisis. What is the pharmacological explanation?

Phenelzine blocks alpha-2 receptors, enhancing norepinephrine release
Cheese directly inhibits MAO-B, potentiating phenelzine's effects
MAO inhibition prevents tyramine breakdown, causing massive norepinephrine release (Correct answer)
Phenelzine inhibits dopamine beta-hydroxylase, concentrating dopamine

Correct answer: MAO inhibition prevents tyramine breakdown, causing massive norepinephrine release

MAO normally degrades tyramine in the gut and liver; when MAO is inhibited, tyramine enters circulation and triggers massive norepinephrine release causing hypertensive crisis.

Question 168: A patient with a psychiatric advance directive has specified they do not want ECT under any circumstances. The patient is now incapacitated and the treatment team believes ECT is the best option. The PMHNP should:

Ask the family to override the advance directive
Override the directive because the patient lacked insight when writing it
Honor the advance directive and explore alternative treatments (Correct answer)
Administer ECT because the team's clinical judgment supersedes advance directives

Correct answer: Honor the advance directive and explore alternative treatments

Psychiatric advance directives are legally binding documents that express the patient's autonomous treatment preferences; they must be honored when the patient lacks decision-making capacity unless emergency exceptions apply.

Question 169: Eye Movement Desensitization and Reprocessing (EMDR) is the first-line evidence-based treatment for which condition?

Obsessive-compulsive disorder
Post-traumatic stress disorder (PTSD) (Correct answer)
Bipolar I disorder
Schizophrenia

Correct answer: Post-traumatic stress disorder (PTSD)

EMDR is a well-established, evidence-based treatment specifically validated for PTSD.

Question 170: A patient with bipolar depression is prescribed quetiapine. At which dose range does quetiapine primarily exert antidepressant effects versus antipsychotic effects?

Antidepressant effects only occur at plasma levels above 800 ng/mL regardless of dose
Low doses (50-150 mg) for antidepressant via H1/5-HT2 blockade; higher doses for antipsychotic via D2 blockade (Correct answer)
Low doses (25-100 mg) for antipsychotic; high doses (400-800 mg) for antidepressant
Equal antidepressant and antipsychotic effects at all doses above 200 mg

Correct answer: Low doses (50-150 mg) for antidepressant via H1/5-HT2 blockade; higher doses for antipsychotic via D2 blockade

At lower doses, quetiapine preferentially blocks H1 and 5-HT2A receptors (contributing to antidepressant/sedating effects); D2 blockade (antipsychotic effect) predominates at higher doses.

Question 171: The PMHNP role as a patient advocate is best demonstrated when the PMHNP:

Limits advocacy to patients who are verbally able to express their own preferences
Agrees with all treatment decisions made by the attending physician without question
Advocates only for medication-based treatments
Ensures the patient's rights, preferences, and needs are communicated and represented in care planning (Correct answer)

Correct answer: Ensures the patient's rights, preferences, and needs are communicated and represented in care planning

Patient advocacy in psychiatric advanced practice nursing involves ensuring that the patient's rights, values, and preferences are articulated, respected, and incorporated into all aspects of care planning regardless of the patient's communication ability.

Question 172: The AUDIT-C is a brief screening tool used to detect which condition?

Stimulant use disorder
Tobacco use disorder
Opioid use disorder
Alcohol use disorder (Correct answer)

Correct answer: Alcohol use disorder

The AUDIT-C is a validated 3-item alcohol screening tool derived from the full Alcohol Use Disorders Identification Test.

Question 173: A patient with OCD is not responding to adequate SSRI trials. According to evidence-based guidelines, what is the next pharmacological step?

Switch to an SNRI such as duloxetine
Switch to a TCA such as imipramine
Add a benzodiazepine for anxiety reduction
Augment with a low-dose antipsychotic such as risperidone or aripiprazole (Correct answer)

Correct answer: Augment with a low-dose antipsychotic such as risperidone or aripiprazole

For SSRI-refractory OCD, augmentation with a low-dose D2-blocking antipsychotic (risperidone, aripiprazole, haloperidol) has the strongest evidence and is guideline-recommended.

Question 174: Under the duty to protect (Tarasoff ruling), a PMHNP is legally obligated to act when a patient:

Describes violent video game content
Makes a specific, credible threat against an identifiable third party (Correct answer)
Reports historical violence committed years ago
Expresses generalized anger about society

Correct answer: Makes a specific, credible threat against an identifiable third party

The Tarasoff duty to protect is triggered when a patient makes a specific, serious, and credible threat against an identifiable victim, requiring the clinician to warn the potential victim and/or notify law enforcement.

Question 175: In group therapy, the therapeutic factor where patients realize they are not alone in their struggles is called:

Cohesiveness
Altruism
Catharsis
Universality (Correct answer)

Correct answer: Universality

Universality, identified by Yalom, is the therapeutic factor in which group members recognize that others share similar problems.

Question 176: A PMHNP identifies a patient as having homicidal ideation toward a specific person. Under Tarasoff duty, the clinician must:

Refer the patient to social work only
Increase medication doses and monitor
Warn the identified victim and notify law enforcement (Correct answer)
Maintain confidentiality and document only

Correct answer: Warn the identified victim and notify law enforcement

The Tarasoff ruling established the duty to protect identifiable potential victims, including warning them and notifying law enforcement.

Question 177: A psychiatric patient in crisis states, 'I have a plan and I have the means.' According to risk stratification, this patient is best classified as:

High risk (Correct answer)
Moderate risk
Indeterminate risk
Low risk

Correct answer: High risk

Having a specific plan with access to the means significantly elevates suicide risk to high, warranting immediate intervention.

ANCC Psychiatric-Mental Health Nurse Practitioner (PMHNP) board certification exam

This exam certifies the knowledge and skills of advanced practice registered nurses specializing in psychiatric-mental health care across the lifespan.

175

Questions

210 min

Time Limit

70%

To Pass

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