BARKLEY PMHNP 2026 ULTIMATE
EXAM REVIEW 450 HIGH-YIELD
QUESTIONS WITH CORRECT
ANSWERS– GUARANTEED PASS
1–10: Major Depressive Disorder & Antidepressants
1. A 32-year-old patient with major depressive disorder (MDD) has failed two adequate trials of
SSRIs. Which of the following is the most appropriate next step?
a) Add bupropion
b) Switch to a tricyclic antidepressant (TCA)
c) Add aripiprazole
d) Refer for electroconvulsive therapy (ECT)
✔✔✔ANSW✔✔ c) Add aripiprazole
Rationale: The STAR*D trial and APA guidelines support augmentation with a second-generation
antipsychotic (e.g., aripiprazole) after two failed antidepressant trials. Bupropion augmentation is
also a consideration, but aripiprazole has the strongest evidence among antipsychotics.
2. A patient starting fluoxetine reports nausea, headache, and insomnia. These side effects are
most likely due to:
a) Allergic reaction
,b) Serotonin reuptake inhibition
c) Histamine receptor blockade
d) Alpha-1 adrenergic blockade
✔✔✔ANSW✔✔ b) Serotonin reuptake inhibition
Rationale: Nausea, headache, and insomnia are common early side effects of SSRIs, related to
increased serotonin tone. They often subside within 1–2 weeks. Histamine blockade causes
sedation; alpha-1 blockade causes orthostasis.
3. Which of the following antidepressants has the highest risk of sexual dysfunction?
a) Bupropion
b) Mirtazapine
c) Sertraline
d) Vortioxetine
✔✔✔ANSW✔✔ c) Sertraline
Rationale: SSRIs (especially sertraline, paroxetine) have a high incidence of sexual dysfunction.
Bupropion, mirtazapine, and vortioxetine have lower rates.
4. A patient with MDD and a history of prolonged QT interval should avoid which antidepressant?
a) Escitalopram
b) Citalopram
c) Venlafaxine
d) Duloxetine
,✔✔✔ANSW✔✔ b) Citalopram
Rationale: Citalopram is associated with dose-dependent QT prolongation; the FDA
recommends maximum 40 mg/day (20 mg/day in patients >60). Escitalopram has a lower risk.
5. A patient is switched from paroxetine to phenelzine (MAOI). What is the required washout
period?
a) 2 days
b) 7 days
c) 14 days
d) 30 days
✔✔✔ANSW✔✔ c) 14 days
Rationale: A 14-day washout is required when switching from an SSRI/SNRI to an MAOI to avoid
serotonin syndrome. Paroxetine has a long half-life and active metabolites, making a full 14 days
necessary.
6. Which laboratory test should be obtained before starting a patient on duloxetine?
a) Liver function tests
b) Renal function
c) ECG
d) Complete blood count
✔✔✔ANSW✔✔ a) Liver function tests
Rationale: Duloxetine can cause hepatotoxicity; LFTs are recommended at baseline. It is
contraindicated in chronic liver disease.
, 7. A patient with MDD and comorbid chronic pain is best managed with:
a) Bupropion
b) Fluoxetine
c) Duloxetine
d) Paroxetine
✔✔✔ANSW✔✔ c) Duloxetine
Rationale: Duloxetine (and other SNRIs) have efficacy for both MDD and chronic pain (e.g.,
diabetic neuropathy, fibromyalgia). Bupropion has no pain indication.
8. After starting escitalopram, a patient develops confusion, myoclonus, and tachycardia. The
most likely diagnosis is:
a) Extrapyramidal symptoms
b) Serotonin syndrome
c) Neuroleptic malignant syndrome
d) Anticholinergic delirium
✔✔✔ANSW✔✔ b) Serotonin syndrome
Rationale: The triad of mental status changes, autonomic instability, and neuromuscular
hyperactivity suggests serotonin syndrome. It is often precipitated by serotonergic agents.
9. A patient on venlafaxine 225 mg/day reports severe sweating and hypertension. The next step
is:
a) Add a beta-blocker
b) Switch to another SNRI
c) Reduce venlafaxine dose
d) Monitor and reassure
EXAM REVIEW 450 HIGH-YIELD
QUESTIONS WITH CORRECT
ANSWERS– GUARANTEED PASS
1–10: Major Depressive Disorder & Antidepressants
1. A 32-year-old patient with major depressive disorder (MDD) has failed two adequate trials of
SSRIs. Which of the following is the most appropriate next step?
a) Add bupropion
b) Switch to a tricyclic antidepressant (TCA)
c) Add aripiprazole
d) Refer for electroconvulsive therapy (ECT)
✔✔✔ANSW✔✔ c) Add aripiprazole
Rationale: The STAR*D trial and APA guidelines support augmentation with a second-generation
antipsychotic (e.g., aripiprazole) after two failed antidepressant trials. Bupropion augmentation is
also a consideration, but aripiprazole has the strongest evidence among antipsychotics.
2. A patient starting fluoxetine reports nausea, headache, and insomnia. These side effects are
most likely due to:
a) Allergic reaction
,b) Serotonin reuptake inhibition
c) Histamine receptor blockade
d) Alpha-1 adrenergic blockade
✔✔✔ANSW✔✔ b) Serotonin reuptake inhibition
Rationale: Nausea, headache, and insomnia are common early side effects of SSRIs, related to
increased serotonin tone. They often subside within 1–2 weeks. Histamine blockade causes
sedation; alpha-1 blockade causes orthostasis.
3. Which of the following antidepressants has the highest risk of sexual dysfunction?
a) Bupropion
b) Mirtazapine
c) Sertraline
d) Vortioxetine
✔✔✔ANSW✔✔ c) Sertraline
Rationale: SSRIs (especially sertraline, paroxetine) have a high incidence of sexual dysfunction.
Bupropion, mirtazapine, and vortioxetine have lower rates.
4. A patient with MDD and a history of prolonged QT interval should avoid which antidepressant?
a) Escitalopram
b) Citalopram
c) Venlafaxine
d) Duloxetine
,✔✔✔ANSW✔✔ b) Citalopram
Rationale: Citalopram is associated with dose-dependent QT prolongation; the FDA
recommends maximum 40 mg/day (20 mg/day in patients >60). Escitalopram has a lower risk.
5. A patient is switched from paroxetine to phenelzine (MAOI). What is the required washout
period?
a) 2 days
b) 7 days
c) 14 days
d) 30 days
✔✔✔ANSW✔✔ c) 14 days
Rationale: A 14-day washout is required when switching from an SSRI/SNRI to an MAOI to avoid
serotonin syndrome. Paroxetine has a long half-life and active metabolites, making a full 14 days
necessary.
6. Which laboratory test should be obtained before starting a patient on duloxetine?
a) Liver function tests
b) Renal function
c) ECG
d) Complete blood count
✔✔✔ANSW✔✔ a) Liver function tests
Rationale: Duloxetine can cause hepatotoxicity; LFTs are recommended at baseline. It is
contraindicated in chronic liver disease.
, 7. A patient with MDD and comorbid chronic pain is best managed with:
a) Bupropion
b) Fluoxetine
c) Duloxetine
d) Paroxetine
✔✔✔ANSW✔✔ c) Duloxetine
Rationale: Duloxetine (and other SNRIs) have efficacy for both MDD and chronic pain (e.g.,
diabetic neuropathy, fibromyalgia). Bupropion has no pain indication.
8. After starting escitalopram, a patient develops confusion, myoclonus, and tachycardia. The
most likely diagnosis is:
a) Extrapyramidal symptoms
b) Serotonin syndrome
c) Neuroleptic malignant syndrome
d) Anticholinergic delirium
✔✔✔ANSW✔✔ b) Serotonin syndrome
Rationale: The triad of mental status changes, autonomic instability, and neuromuscular
hyperactivity suggests serotonin syndrome. It is often precipitated by serotonergic agents.
9. A patient on venlafaxine 225 mg/day reports severe sweating and hypertension. The next step
is:
a) Add a beta-blocker
b) Switch to another SNRI
c) Reduce venlafaxine dose
d) Monitor and reassure
