NRNP 6675 FINAL EXAM READINESS ASSESSMENT 2026/2027 | 150
Q&A PMHNP Comprehensive Practice Exam | Advanced Practice
Psychiatric Nursing | Pass Guaranteed - A+ Graded
Exam Overview:
● Total Questions: 150 Multiple Choice
● Time Recommendation: 3 hours (1.2 minutes per question)
● Passing Benchmark: 80% (120/150 correct)
● Cognitive Distribution: Recall (15%), Application (55%), Analysis (30%)
SECTION I: PSYCHOPHARMACOLOGY ACROSS THE LIFESPAN
Q1: A 28-year-old female with major depressive disorder (MDD) has failed trials of
sertraline 200mg and venlafaxine XR 225mg. She presents with persistent anhedonia,
psychomotor retardation, and passive suicidal ideation. Her PHQ-9 score remains 18.
Genotyping reveals she is a CYP2D6 poor metabolizer. Which pharmacological
intervention demonstrates the strongest evidence for treatment-resistant depression in
this patient?
A. Increase venlafaxine to 300mg daily and add lithium carbonate 300mg BID
B. Initiate phenelzine 15mg TID, with dietary counseling for MAOI diet
C. Initiate esketamine nasal spray 56mg twice weekly for 4 weeks, then weekly
D. Add aripiprazole 2mg daily to current venlafaxine regimen
Correct Answer: C
Rationale: Esketamine nasal spray is FDA-approved for treatment-resistant depression
(TRD), defined as failure of ≥2 antidepressant trials of adequate dose and duration. The
,ASPIRE trials demonstrated rapid reduction in depressive symptoms within 24 hours,
with significant response rates compared to placebo plus oral antidepressant. This
patient meets TRD criteria with two failed SSRI/SNRI trials. Option A is incorrect
because further dose escalation of venlafaxine in a CYP2D6 poor metabolizer increases
risk of toxicity without additional efficacy; lithium augmentation, while evidence-based,
typically requires 4-6 weeks for effect. Option B, while MAOIs are effective for TRD,
carries significant dietary and drug interaction burdens and is not first-line after two
failed trials. Option D, adjunctive aripiprazole, is FDA-approved for MDD augmentation
but generally considered after TRD is confirmed; esketamine has superior evidence for
rapid symptom reduction in acute suicidality and TRD. The patient requires rapid
intervention given passive suicidal ideation, making esketamine the optimal choice.
Q2: A 42-year-old male with bipolar I disorder presents with acute mania following 5
days of insomnia, pressured speech, and grandiose delusions. He has no medical
comorbidities. Current medications include lithium carbonate 900mg BID (level 0.4
mEq/L) and risperidone 2mg nightly. Vital signs: HR 112, BP 148/92, RR 18, Temp
37.2°C. Which medication adjustment is most appropriate for acute stabilization?
A. Increase lithium to 1200mg BID and add lorazepam 2mg IM q6h PRN agitation
B. Discontinue risperidone; initiate olanzapine 15mg daily with lorazepam 2mg IM
C. Increase lithium to achieve level 0.8-1.2 mEq/L and continue current risperidone
D. Initiate valproic acid 20mg/kg loading dose with continued lithium
Correct Answer: B
Rationale: This patient requires immediate mood stabilization with an atypical
antipsychotic demonstrating robust anti-manic efficacy. Olanzapine has Level 1
,evidence for acute mania with rapid onset (24-48 hours) and is superior to risperidone
for severe manic symptoms with psychotic features. The current lithium level is
subtherapeutic for acute mania (target 0.8-1.2 mEq/L), but lithium requires 5-7 days for
therapeutic effect—insufficient for acute crisis. Option A is incorrect because lithium
titration alone will not address immediate symptoms, and IM lorazepam is adjunctive
only. Option C fails to recognize that risperidone 2mg is inadequate for acute mania;
standard dosing is 2-6mg daily, but olanzapine demonstrates faster symptom
resolution. Option D, valproic acid loading, is effective but contraindicated without
knowing hepatic function and carries higher teratogenicity risk; combination with lithium
increases toxicity risk. Olanzapine plus benzodiazepine provides rapid neuroleptic
stabilization and sedation for severe mania.
Q3: A 19-year-old college freshman is diagnosed with ADHD. She reports difficulty with
morning classes, procrastination, and forgetfulness. She has a family history of
substance use disorder (brother with opioid use disorder). Which medication selection
best balances efficacy with lowest abuse potential?
A. Mixed amphetamine salts XR 20mg every morning
B. Methylphenidate OROS 36mg every morning
C. Lisdexamfetamine 30mg every morning
D. Atomoxetine 40mg daily, titrate to 80mg after 3 days
Correct Answer: D
Rationale: Atomoxetine is a selective norepinephrine reuptake inhibitor FDA-approved
for ADHD with no abuse potential, making it optimal for patients with family history of
substance use disorders. While stimulants (Options A, B, C) demonstrate superior
, efficacy for ADHD symptoms, all carry Schedule II controlled substance classification
with documented diversion and misuse potential. Lisdexamfetamine (Option C) has
lower immediate abuse potential due to prodrug formulation requiring GI metabolism,
but still carries risk. Atomoxetine requires 4-6 weeks for full therapeutic effect but
provides 24-hour coverage without rebound or insomnia, and meta-analyses
demonstrate comparable efficacy to stimulants for inattentive subtype. The patient
should be counseled that initial benefits may include decreased impulsivity within 2
weeks, with cognitive improvements following. If inadequate response after 6-8 weeks,
stimulant trial with lisdexamfetamine would be next step with close monitoring.
Q4: A 67-year-old male with Parkinson's disease develops visual hallucinations and
paranoid delusions. His neurologist requests psychiatric consultation. Current
medications: carbidopa/levodopa 25/100mg TID, entacapone 200mg with each
levodopa dose, and ropinirole 3mg BID. MMSE is 28/30. Which pharmacological
intervention is most appropriate?
A. Initiate quetiapine 25mg nightly, titrate to 100-150mg
B. Initiate rivastigmine 1.5mg BID for Parkinson's disease dementia
C. Reduce ropinirole by 50% and initiate pimavanserin 34mg daily
D. Initiate olanzapine 5mg nightly for psychotic symptoms
Correct Answer: C
Rationale: Pimavanserin is a selective serotonin 5-HT2A inverse agonist FDA-approved
specifically for Parkinson's disease psychosis without worsening motor symptoms. The
patient's hallucinations likely result from dopaminergic therapy, particularly the
dopamine agonist ropinirole, which has higher propensity for psychiatric side effects
Q&A PMHNP Comprehensive Practice Exam | Advanced Practice
Psychiatric Nursing | Pass Guaranteed - A+ Graded
Exam Overview:
● Total Questions: 150 Multiple Choice
● Time Recommendation: 3 hours (1.2 minutes per question)
● Passing Benchmark: 80% (120/150 correct)
● Cognitive Distribution: Recall (15%), Application (55%), Analysis (30%)
SECTION I: PSYCHOPHARMACOLOGY ACROSS THE LIFESPAN
Q1: A 28-year-old female with major depressive disorder (MDD) has failed trials of
sertraline 200mg and venlafaxine XR 225mg. She presents with persistent anhedonia,
psychomotor retardation, and passive suicidal ideation. Her PHQ-9 score remains 18.
Genotyping reveals she is a CYP2D6 poor metabolizer. Which pharmacological
intervention demonstrates the strongest evidence for treatment-resistant depression in
this patient?
A. Increase venlafaxine to 300mg daily and add lithium carbonate 300mg BID
B. Initiate phenelzine 15mg TID, with dietary counseling for MAOI diet
C. Initiate esketamine nasal spray 56mg twice weekly for 4 weeks, then weekly
D. Add aripiprazole 2mg daily to current venlafaxine regimen
Correct Answer: C
Rationale: Esketamine nasal spray is FDA-approved for treatment-resistant depression
(TRD), defined as failure of ≥2 antidepressant trials of adequate dose and duration. The
,ASPIRE trials demonstrated rapid reduction in depressive symptoms within 24 hours,
with significant response rates compared to placebo plus oral antidepressant. This
patient meets TRD criteria with two failed SSRI/SNRI trials. Option A is incorrect
because further dose escalation of venlafaxine in a CYP2D6 poor metabolizer increases
risk of toxicity without additional efficacy; lithium augmentation, while evidence-based,
typically requires 4-6 weeks for effect. Option B, while MAOIs are effective for TRD,
carries significant dietary and drug interaction burdens and is not first-line after two
failed trials. Option D, adjunctive aripiprazole, is FDA-approved for MDD augmentation
but generally considered after TRD is confirmed; esketamine has superior evidence for
rapid symptom reduction in acute suicidality and TRD. The patient requires rapid
intervention given passive suicidal ideation, making esketamine the optimal choice.
Q2: A 42-year-old male with bipolar I disorder presents with acute mania following 5
days of insomnia, pressured speech, and grandiose delusions. He has no medical
comorbidities. Current medications include lithium carbonate 900mg BID (level 0.4
mEq/L) and risperidone 2mg nightly. Vital signs: HR 112, BP 148/92, RR 18, Temp
37.2°C. Which medication adjustment is most appropriate for acute stabilization?
A. Increase lithium to 1200mg BID and add lorazepam 2mg IM q6h PRN agitation
B. Discontinue risperidone; initiate olanzapine 15mg daily with lorazepam 2mg IM
C. Increase lithium to achieve level 0.8-1.2 mEq/L and continue current risperidone
D. Initiate valproic acid 20mg/kg loading dose with continued lithium
Correct Answer: B
Rationale: This patient requires immediate mood stabilization with an atypical
antipsychotic demonstrating robust anti-manic efficacy. Olanzapine has Level 1
,evidence for acute mania with rapid onset (24-48 hours) and is superior to risperidone
for severe manic symptoms with psychotic features. The current lithium level is
subtherapeutic for acute mania (target 0.8-1.2 mEq/L), but lithium requires 5-7 days for
therapeutic effect—insufficient for acute crisis. Option A is incorrect because lithium
titration alone will not address immediate symptoms, and IM lorazepam is adjunctive
only. Option C fails to recognize that risperidone 2mg is inadequate for acute mania;
standard dosing is 2-6mg daily, but olanzapine demonstrates faster symptom
resolution. Option D, valproic acid loading, is effective but contraindicated without
knowing hepatic function and carries higher teratogenicity risk; combination with lithium
increases toxicity risk. Olanzapine plus benzodiazepine provides rapid neuroleptic
stabilization and sedation for severe mania.
Q3: A 19-year-old college freshman is diagnosed with ADHD. She reports difficulty with
morning classes, procrastination, and forgetfulness. She has a family history of
substance use disorder (brother with opioid use disorder). Which medication selection
best balances efficacy with lowest abuse potential?
A. Mixed amphetamine salts XR 20mg every morning
B. Methylphenidate OROS 36mg every morning
C. Lisdexamfetamine 30mg every morning
D. Atomoxetine 40mg daily, titrate to 80mg after 3 days
Correct Answer: D
Rationale: Atomoxetine is a selective norepinephrine reuptake inhibitor FDA-approved
for ADHD with no abuse potential, making it optimal for patients with family history of
substance use disorders. While stimulants (Options A, B, C) demonstrate superior
, efficacy for ADHD symptoms, all carry Schedule II controlled substance classification
with documented diversion and misuse potential. Lisdexamfetamine (Option C) has
lower immediate abuse potential due to prodrug formulation requiring GI metabolism,
but still carries risk. Atomoxetine requires 4-6 weeks for full therapeutic effect but
provides 24-hour coverage without rebound or insomnia, and meta-analyses
demonstrate comparable efficacy to stimulants for inattentive subtype. The patient
should be counseled that initial benefits may include decreased impulsivity within 2
weeks, with cognitive improvements following. If inadequate response after 6-8 weeks,
stimulant trial with lisdexamfetamine would be next step with close monitoring.
Q4: A 67-year-old male with Parkinson's disease develops visual hallucinations and
paranoid delusions. His neurologist requests psychiatric consultation. Current
medications: carbidopa/levodopa 25/100mg TID, entacapone 200mg with each
levodopa dose, and ropinirole 3mg BID. MMSE is 28/30. Which pharmacological
intervention is most appropriate?
A. Initiate quetiapine 25mg nightly, titrate to 100-150mg
B. Initiate rivastigmine 1.5mg BID for Parkinson's disease dementia
C. Reduce ropinirole by 50% and initiate pimavanserin 34mg daily
D. Initiate olanzapine 5mg nightly for psychotic symptoms
Correct Answer: C
Rationale: Pimavanserin is a selective serotonin 5-HT2A inverse agonist FDA-approved
specifically for Parkinson's disease psychosis without worsening motor symptoms. The
patient's hallucinations likely result from dopaminergic therapy, particularly the
dopamine agonist ropinirole, which has higher propensity for psychiatric side effects
