NRNP 6675 FINAL EXAM READINESS
ASSESSMENT 2026/2027 | 150 Q&A PMHNP
Practice Exam | Certification-Level Complexity |
Advanced Practice Psychiatric Nursing | Pass
Guaranteed - A+ Graded
Q1: A 34-year-old female presents with treatment-resistant major depressive disorder
(MDD). She has failed trials of sertraline 200mg, venlafaxine XR 225mg, and
augmentation with aripiprazole. She reports persistent anhedonia, psychomotor
retardation, and passive suicidal ideation without plan. Her PHQ-9 score remains 18
after 12 weeks of current treatment. She has no psychotic features. Which intervention
represents the most appropriate next step according to current evidence-based
guidelines?
A. Increase aripiprazole to 15mg daily and add lamotrigine 25mg titrating to 200mg
B. Discontinue current regimen and initiate phenelzine 15mg TID with dietary counseling
[CORRECT]
C. Add lithium carbonate 300mg TID with target serum level 0.8-1.2 mEq/L
D. Refer immediately for electroconvulsive therapy (ECT) as first-line for this
presentation
Correct Answer: B
Rationale: This patient meets criteria for treatment-resistant depression (TRD), defined
as failure of two or more adequate antidepressant trials of different classes. According
to the APA Practice Guideline for Treatment of Patients with Major Depressive Disorder
,(Third Edition) and STAR*D trial sequenced treatment algorithms, switching to a
monoamine oxidase inhibitor (MAOI) such as phenelzine is indicated after failure of
SSRIs and SNRIs, particularly when atypical features (mood reactivity, significant weight
gain, hypersomnia, leaden paralysis, interpersonal rejection sensitivity) may be
present—suggested here by persistent anhedonia and psychomotor changes. MAOIs
demonstrate superior efficacy in TRD with atypical features compared to TCAs and
subsequent SSRI trials.
Why A is incorrect: While aripiprazole augmentation is evidence-based for MDD,
increasing the dose beyond 15mg daily shows diminishing returns for depression and
increases akathisia and metabolic risks. Adding lamotrigine lacks robust evidence for
TRD without bipolar spectrum features; its primary utility is in bipolar depression
maintenance and borderline personality disorder emotional dysregulation.
Why C is incorrect: Lithium augmentation (target 0.6-0.8 mEq/L for augmentation) is a
valid strategy, but typically considered after 3-4 antidepressant failures or when
bipolarity is suspected. However, given the pattern of SSRI and SNRI failure without
response to atypical antipsychotic augmentation, a class switch to MAOI represents a
more definitive therapeutic shift rather than continued augmentation of a failed strategy.
Why D is incorrect: While ECT remains the gold standard for severe, treatment-resistant
depression with suicidal ideation, this patient has passive ideation without intent or
plan, adequate outpatient support, and has not exhausted pharmacological options
including MAOIs, tricyclics, or combination strategies. ECT should be reserved for
imminent suicide risk, catatonia, psychotic depression, or failure of multiple medication
classes including MAOIs.
Q2: A 28-year-old male veteran with PTSD, alcohol use disorder (in early remission, 6
months), and chronic lower back pain presents for psychiatric evaluation. He reports
,nightmares, hypervigilance, and emotional numbing. His primary care provider started
him on prazosin 2mg QHS for nightmares, which helped initially but efficacy has waned.
He is interested in trauma-focused psychotherapy but is concerned about alcohol
relapse during exposure. Which comprehensive treatment plan best addresses his
complex presentation?
A. Increase prazosin to 6mg QHS, initiate prolonged exposure therapy with concurrent
naltrexone 50mg daily, and coordinate with pain management for non-opioid
multimodal analgesia
B. Switch prazosin to terazosin 5mg QHS, initiate Cognitive Processing Therapy (CPT)
with relapse prevention planning, and maintain current pain management [CORRECT]
C. Add topiramate 100mg BID for alcohol craving prevention, continue current prazosin
dose, defer trauma therapy until 12 months sobriety, and request opioid analgesics from
pain management
D. Initiate paroxetine 40mg daily, discontinue prazosin due to tachyphylaxis, begin eye
movement desensitization and reprocessing (EMDR) immediately, and avoid pain
medication changes
Correct Answer: B
Rationale: This complex case requires integrated management of PTSD, substance use
disorder (SUD) in remission, and chronic pain. Cognitive Processing Therapy (CPT) is a
first-line, trauma-focused cognitive therapy with robust evidence for PTSD in veterans
and can be safely implemented with proper relapse prevention planning in patients with
stable SUD remission (6+ months). Unlike prolonged exposure, CPT does not require
detailed imaginal exposure to trauma narratives, potentially reducing acute distress that
could trigger relapse. Switching from prazosin to terazosin addresses potential
tachyphylaxis to selective α1-adrenergic blockade; terazosin's longer half-life and
additional effects on α1B receptors may provide more sustained nightmare reduction.
Maintaining current pain management avoids polypharmacy risks while psychiatric
stabilization proceeds.
, Why A is incorrect: While increasing prazosin is reasonable (evidence supports up to
6mg), prolonged exposure therapy involves intense imaginal and in-vivo exposure that
may increase acute arousal and relapse risk in patients with recent SUD history, despite
naltrexone. The combination of high-dose alpha-blockade with naltrexone (which can
cause hypotension) increases syncope risk, particularly with concurrent alcohol use.
Why C is incorrect: Deferring trauma-focused therapy contradicts evidence that
integrated treatment of PTSD and SUD produces better outcomes than sequential
treatment. Topiramate has limited efficacy for PTSD and significant cognitive side
effects. Requesting opioids in a patient with alcohol use disorder history is
contraindicated due to cross-addiction liability and represents poor interprofessional
collaboration.
Why D is incorrect: Discontinuing prazosin entirely removes an effective adjunctive
treatment for PTSD nightmares; tachyphylaxis should prompt dose adjustment or agent
switch rather than abandonment. Paroxetine requires 8-12 weeks for PTSD efficacy, and
initiating EMDR without adequate preparation and stabilization in a patient with active
SUD risk factors is premature. Avoiding pain management consultation neglects the
biopsychosocial model.
Q3: A 19-year-old college student presents with new-onset paranoia, disorganized
speech, and auditory hallucinations commenting on his behavior. Symptoms began 3
weeks ago following a period of increased cannabis use (daily high-potency
concentrates). Urine drug screen is positive for THC. Family history is significant for
schizophrenia in a maternal uncle. Mental status exam reveals loosening of
associations, inappropriate affect, and poor insight. Which diagnostic formulation and
initial management strategy is most appropriate?
ASSESSMENT 2026/2027 | 150 Q&A PMHNP
Practice Exam | Certification-Level Complexity |
Advanced Practice Psychiatric Nursing | Pass
Guaranteed - A+ Graded
Q1: A 34-year-old female presents with treatment-resistant major depressive disorder
(MDD). She has failed trials of sertraline 200mg, venlafaxine XR 225mg, and
augmentation with aripiprazole. She reports persistent anhedonia, psychomotor
retardation, and passive suicidal ideation without plan. Her PHQ-9 score remains 18
after 12 weeks of current treatment. She has no psychotic features. Which intervention
represents the most appropriate next step according to current evidence-based
guidelines?
A. Increase aripiprazole to 15mg daily and add lamotrigine 25mg titrating to 200mg
B. Discontinue current regimen and initiate phenelzine 15mg TID with dietary counseling
[CORRECT]
C. Add lithium carbonate 300mg TID with target serum level 0.8-1.2 mEq/L
D. Refer immediately for electroconvulsive therapy (ECT) as first-line for this
presentation
Correct Answer: B
Rationale: This patient meets criteria for treatment-resistant depression (TRD), defined
as failure of two or more adequate antidepressant trials of different classes. According
to the APA Practice Guideline for Treatment of Patients with Major Depressive Disorder
,(Third Edition) and STAR*D trial sequenced treatment algorithms, switching to a
monoamine oxidase inhibitor (MAOI) such as phenelzine is indicated after failure of
SSRIs and SNRIs, particularly when atypical features (mood reactivity, significant weight
gain, hypersomnia, leaden paralysis, interpersonal rejection sensitivity) may be
present—suggested here by persistent anhedonia and psychomotor changes. MAOIs
demonstrate superior efficacy in TRD with atypical features compared to TCAs and
subsequent SSRI trials.
Why A is incorrect: While aripiprazole augmentation is evidence-based for MDD,
increasing the dose beyond 15mg daily shows diminishing returns for depression and
increases akathisia and metabolic risks. Adding lamotrigine lacks robust evidence for
TRD without bipolar spectrum features; its primary utility is in bipolar depression
maintenance and borderline personality disorder emotional dysregulation.
Why C is incorrect: Lithium augmentation (target 0.6-0.8 mEq/L for augmentation) is a
valid strategy, but typically considered after 3-4 antidepressant failures or when
bipolarity is suspected. However, given the pattern of SSRI and SNRI failure without
response to atypical antipsychotic augmentation, a class switch to MAOI represents a
more definitive therapeutic shift rather than continued augmentation of a failed strategy.
Why D is incorrect: While ECT remains the gold standard for severe, treatment-resistant
depression with suicidal ideation, this patient has passive ideation without intent or
plan, adequate outpatient support, and has not exhausted pharmacological options
including MAOIs, tricyclics, or combination strategies. ECT should be reserved for
imminent suicide risk, catatonia, psychotic depression, or failure of multiple medication
classes including MAOIs.
Q2: A 28-year-old male veteran with PTSD, alcohol use disorder (in early remission, 6
months), and chronic lower back pain presents for psychiatric evaluation. He reports
,nightmares, hypervigilance, and emotional numbing. His primary care provider started
him on prazosin 2mg QHS for nightmares, which helped initially but efficacy has waned.
He is interested in trauma-focused psychotherapy but is concerned about alcohol
relapse during exposure. Which comprehensive treatment plan best addresses his
complex presentation?
A. Increase prazosin to 6mg QHS, initiate prolonged exposure therapy with concurrent
naltrexone 50mg daily, and coordinate with pain management for non-opioid
multimodal analgesia
B. Switch prazosin to terazosin 5mg QHS, initiate Cognitive Processing Therapy (CPT)
with relapse prevention planning, and maintain current pain management [CORRECT]
C. Add topiramate 100mg BID for alcohol craving prevention, continue current prazosin
dose, defer trauma therapy until 12 months sobriety, and request opioid analgesics from
pain management
D. Initiate paroxetine 40mg daily, discontinue prazosin due to tachyphylaxis, begin eye
movement desensitization and reprocessing (EMDR) immediately, and avoid pain
medication changes
Correct Answer: B
Rationale: This complex case requires integrated management of PTSD, substance use
disorder (SUD) in remission, and chronic pain. Cognitive Processing Therapy (CPT) is a
first-line, trauma-focused cognitive therapy with robust evidence for PTSD in veterans
and can be safely implemented with proper relapse prevention planning in patients with
stable SUD remission (6+ months). Unlike prolonged exposure, CPT does not require
detailed imaginal exposure to trauma narratives, potentially reducing acute distress that
could trigger relapse. Switching from prazosin to terazosin addresses potential
tachyphylaxis to selective α1-adrenergic blockade; terazosin's longer half-life and
additional effects on α1B receptors may provide more sustained nightmare reduction.
Maintaining current pain management avoids polypharmacy risks while psychiatric
stabilization proceeds.
, Why A is incorrect: While increasing prazosin is reasonable (evidence supports up to
6mg), prolonged exposure therapy involves intense imaginal and in-vivo exposure that
may increase acute arousal and relapse risk in patients with recent SUD history, despite
naltrexone. The combination of high-dose alpha-blockade with naltrexone (which can
cause hypotension) increases syncope risk, particularly with concurrent alcohol use.
Why C is incorrect: Deferring trauma-focused therapy contradicts evidence that
integrated treatment of PTSD and SUD produces better outcomes than sequential
treatment. Topiramate has limited efficacy for PTSD and significant cognitive side
effects. Requesting opioids in a patient with alcohol use disorder history is
contraindicated due to cross-addiction liability and represents poor interprofessional
collaboration.
Why D is incorrect: Discontinuing prazosin entirely removes an effective adjunctive
treatment for PTSD nightmares; tachyphylaxis should prompt dose adjustment or agent
switch rather than abandonment. Paroxetine requires 8-12 weeks for PTSD efficacy, and
initiating EMDR without adequate preparation and stabilization in a patient with active
SUD risk factors is premature. Avoiding pain management consultation neglects the
biopsychosocial model.
Q3: A 19-year-old college student presents with new-onset paranoia, disorganized
speech, and auditory hallucinations commenting on his behavior. Symptoms began 3
weeks ago following a period of increased cannabis use (daily high-potency
concentrates). Urine drug screen is positive for THC. Family history is significant for
schizophrenia in a maternal uncle. Mental status exam reveals loosening of
associations, inappropriate affect, and poor insight. Which diagnostic formulation and
initial management strategy is most appropriate?
