NR 547 PMHNP Exam ACTUAL
EXAM 2026/2027 | NR547
Chamberlain | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1: Mood Disorders (MDD, Bipolar) (18 Questions)
Q1: A 32-year-old female with no prior psychiatric history presents with depressed mood, anhedonia,
insomnia, fatigue, and poor concentration for the past 8 weeks. She denies mania, psychosis, or suicidal
ideation. Her PHQ-9 score is 18. What is the most appropriate first-line pharmacologic treatment?
A. Alprazolam 0.5 mg three times daily as needed
B. Bupropion 150 mg extended-release once daily
C. Sertraline 50 mg once daily [CORRECT]
D. Quetiapine 50 mg at bedtime
Rationale: Sertraline (an SSRI) is first-line for moderate-to-severe MDD per APA guidelines, with a
favorable side effect profile and starting dose of 50 mg. Choice B (bupropion) is effective but not
typically first-line due to potential for anxiety/agitation; choice A (alprazolam) treats anxiety but not
depression and carries dependence risk; choice D (quetiapine) is for treatment-resistant or psychotic
depression, not first-line. Clinical pearl: SSRIs take 4-6 weeks for full effect; always monitor for activation
syndrome early in treatment.
Q2: A 28-year-old male with bipolar I disorder presents to the clinic manic for 5 days with decreased
need for sleep, pressured speech, racing thoughts, and excessive spending. He is agitated but
cooperative. Vital signs: HR 102, BP 138/88. Current meds: lithium 900 mg daily (level 0.4 mEq/L). What
is the next best step?
A. Increase lithium to 1200 mg daily and recheck level in 5 days
B. Add valproic acid 500 mg twice daily
C. Add a second-generation antipsychotic such as olanzapine 10 mg daily [CORRECT]
D. Discontinue lithium and switch to carbamazepine
,Rationale: For acute mania, guideline-concordant care recommends adding a second-generation
antipsychotic (SGA) or valproate to lithium, or switching to monotherapy with these agents. His lithium
level is subtherapeutic (target 0.8-1.2 mEq/L for mania), but given acuity, adding an SGA provides faster
mood stabilization than lithium titration alone. Increasing lithium alone (A) is too slow for acute mania.
Valproic acid (B) is reasonable but slower than SGAs. Discontinuing lithium (D) is unnecessary—
combination therapy is standard for breakthrough mania. Clinical pearl: Olanzapine requires monitoring
for metabolic syndrome; baseline weight, fasting glucose, and lipids are essential.
Q3: A 45-year-old female with treatment-resistant depression has failed trials of sertraline, venlafaxine,
and bupropion. She asks about augmentation strategies. Her BMI is 32, and she has type 2 diabetes.
Which augmentation agent is contraindicated?
A. Aripiprazole 2-5 mg daily
B. Lithium 300 mg daily
C. Quetiapine 150 mg daily [CORRECT]
D. Thyroid hormone (T3) 25 mcg daily
Rationale: Quetiapine carries significant metabolic risks (weight gain, hyperglycemia, dyslipidemia) that
would exacerbate her diabetes and obesity, making it relatively contraindicated despite FDA approval
for adjunctive MDD treatment. Aripiprazole (A) and lithium (B) are FDA-approved augmentation
strategies with more favorable metabolic profiles. T3 (D) is used off-label for augmentation without
metabolic risks. Clinical pearl: When choosing augmentation, match side effect profiles to patient
comorbidities—avoid metabolic agents in patients with metabolic syndrome.
Q4: A 19-year-old college student presents with 2 weeks of elevated mood, grandiosity, decreased need
for sleep (2 hours/night), hypersexuality, and reckless spending. She is not psychotic. Her mother has
bipolar I disorder. What is the most likely diagnosis?
A. Major depressive disorder with anxious features
B. Bipolar II disorder
C. Bipolar I disorder, current episode manic [CORRECT]
D. Cyclothymic disorder
Rationale: This patient meets DSM-5-TR criteria for manic episode (≥1 week with elevated/irritable
mood plus 3+ symptoms including grandiosity, decreased sleep, hypersexuality, excessive involvement
in risky activities) causing impairment. Family history supports genetic loading. Bipolar I (C) requires only
one manic episode; hospitalization isn't required if not severe. Bipolar II (B) requires hypomania and
MDD—this is full mania. Cyclothymia (D) requires 2+ years of subthreshold symptoms. Clinical pearl:
First manic episodes often occur late adolescence/early adulthood; always screen for family history and
assess for psychosis to guide treatment intensity.
,Q5: A 52-year-old male with MDD on venlafaxine 225 mg daily for 6 months reports improved mood but
persistent sexual dysfunction (delayed ejaculation). He wants to switch medications. Which option
preserves efficacy while minimizing sexual side effects?
A. Switch to paroxetine 40 mg daily
B. Add bupropion 150 mg XL
C. Switch to mirtazapine 30 mg at bedtime [CORRECT]
D. Add trazodone 100 mg at bedtime
Rationale: Mirtazapine has minimal sexual side effects compared to SSRIs/SNRIs and is effective for
MDD. Paroxetine (A) has the highest sexual dysfunction rates among SSRIs. Adding bupropion (B) may
help but doesn't guarantee resolution. Trazodone (D) can cause priapism and is sedating—not ideal for
this patient. Clinical pearl: Mirtazapine is also useful for insomnia and appetite stimulation but monitor
for weight gain and sedation at lower doses (antihistaminic effect stronger at 15 mg than 30 mg).
Q6: A 35-year-old female with bipolar II disorder stabilized on lamotrigine 200 mg daily presents with
depressed mood, hypersomnia, and psychomotor retardation for 3 weeks. She denies suicidal ideation.
Her lamotrigine level is 2.8 mcg/mL (therapeutic 2.5-15). What is the best next step?
A. Increase lamotrigine to 300 mg daily
B. Add quetiapine 50 mg daily
C. Add fluoxetine 20 mg daily with close monitoring for mania [CORRECT]
D. Switch to lithium monotherapy
Rationale: For bipolar depression, FDA-approved options include quetiapine, lurasidone, lamotrigine
(maintenance), and olanzapine-fluoxetine combination. Adding an SSRI (C) with mood stabilizer is
acceptable for breakthrough depression with mania monitoring. Increasing lamotrigine (A) has delayed
onset and may not address acute symptoms. Quetiapine (B) is effective but sedating—patient already
has hypersomnia. Switching to lithium (D) risks destabilization during transition. Clinical pearl: When
using antidepressants in bipolar disorder, always maintain mood stabilizer and monitor closely for
switching—discontinue antidepressant if manic symptoms emerge.
Q7: A 29-year-old female 8 weeks postpartum presents with depressed mood, anxiety, intrusive
thoughts about harming her baby (ego-dystonic, no plan), insomnia, and guilt. She is breastfeeding.
What is the safest first-line treatment?
A. Paroxetine 20 mg daily [CORRECT]
B. Nortriptyline 75 mg daily
, C. Phenelzine 15 mg three times daily
D. Lithium 900 mg daily
Rationale: Paroxetine has the lowest transfer into breast milk among SSRIs and is first-line for
postpartum depression. Nortriptyline (B) has higher infant exposure. Phenelzine (C) is an MAOI with
dietary restrictions and limited data in lactation. Lithium (D) requires monitoring in breastfeeding and is
reserved for bipolar disorder or severe refractory cases. Clinical pearl: Postpartum depression affects 10-
15% of mothers; intrusive thoughts are common and ego-dystonic (unwanted), distinguishing them from
psychosis where thoughts may be acted upon—always assess for homicidal ideation with plan/intent.
Q8: A 41-year-old male with MDD and comorbid ADHD presents with persistent depressive symptoms
on escitalopram 20 mg. He struggles with concentration, energy, and motivation. Which medication
switch addresses both conditions?
A. Switch to citalopram 40 mg
B. Add methylphenidate 10 mg twice daily
C. Switch to bupropion XL 300 mg daily [CORRECT]
D. Add aripiprazole 5 mg daily
Rationale: Bupropion is effective for MDD and ADHD (off-label), addressing both conditions with single
agent. Citalopram (A) offers no advantage over escitalopram. Adding stimulant (B) is reasonable but
adds complexity and controlled substance considerations. Aripiprazole (D) augments depression but
doesn't treat ADHD. Clinical pearl: Bupropion is also useful for smoking cessation and sexual dysfunction
but contraindicated in eating disorders and seizure disorders due to lowered seizure threshold.
Q9: A 55-year-old male with bipolar I disorder on lithium 1200 mg daily (level 0.9 mEq/L) presents with
tremor, polyuria, and mild confusion. Labs show Na+ 148, Cr 1.4 (baseline 0.9), TSH 6.2. What is the
priority intervention?
A. Increase lithium to achieve level 1.2 mEq/L
B. Discontinue lithium and switch to valproic acid [CORRECT]
C. Add levothyroxine and continue lithium
D. Reduce lithium to 900 mg daily
Rationale: This patient has lithium toxicity manifestations (tremor, confusion, nephrogenic diabetes
insipidus with hypernatremia, renal impairment) and hypothyroidism. Given renal impairment and
multiple adverse effects, switching to alternative mood stabilizer (B) is safest. Continuing or increasing
lithium (A, C, D) risks progression to severe toxicity. Valproic acid doesn't cause renal dysfunction or
diabetes insipidus. Clinical pearl: Lithium adverse effects include renal dysfunction, hypothyroidism,
hyperparathyroidism, and diabetes insipidus—monitor eGFR, TSH, calcium, and urine specific gravity
regularly; maintain levels 0.6-0.8 in older adults.
EXAM 2026/2027 | NR547
Chamberlain | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1: Mood Disorders (MDD, Bipolar) (18 Questions)
Q1: A 32-year-old female with no prior psychiatric history presents with depressed mood, anhedonia,
insomnia, fatigue, and poor concentration for the past 8 weeks. She denies mania, psychosis, or suicidal
ideation. Her PHQ-9 score is 18. What is the most appropriate first-line pharmacologic treatment?
A. Alprazolam 0.5 mg three times daily as needed
B. Bupropion 150 mg extended-release once daily
C. Sertraline 50 mg once daily [CORRECT]
D. Quetiapine 50 mg at bedtime
Rationale: Sertraline (an SSRI) is first-line for moderate-to-severe MDD per APA guidelines, with a
favorable side effect profile and starting dose of 50 mg. Choice B (bupropion) is effective but not
typically first-line due to potential for anxiety/agitation; choice A (alprazolam) treats anxiety but not
depression and carries dependence risk; choice D (quetiapine) is for treatment-resistant or psychotic
depression, not first-line. Clinical pearl: SSRIs take 4-6 weeks for full effect; always monitor for activation
syndrome early in treatment.
Q2: A 28-year-old male with bipolar I disorder presents to the clinic manic for 5 days with decreased
need for sleep, pressured speech, racing thoughts, and excessive spending. He is agitated but
cooperative. Vital signs: HR 102, BP 138/88. Current meds: lithium 900 mg daily (level 0.4 mEq/L). What
is the next best step?
A. Increase lithium to 1200 mg daily and recheck level in 5 days
B. Add valproic acid 500 mg twice daily
C. Add a second-generation antipsychotic such as olanzapine 10 mg daily [CORRECT]
D. Discontinue lithium and switch to carbamazepine
,Rationale: For acute mania, guideline-concordant care recommends adding a second-generation
antipsychotic (SGA) or valproate to lithium, or switching to monotherapy with these agents. His lithium
level is subtherapeutic (target 0.8-1.2 mEq/L for mania), but given acuity, adding an SGA provides faster
mood stabilization than lithium titration alone. Increasing lithium alone (A) is too slow for acute mania.
Valproic acid (B) is reasonable but slower than SGAs. Discontinuing lithium (D) is unnecessary—
combination therapy is standard for breakthrough mania. Clinical pearl: Olanzapine requires monitoring
for metabolic syndrome; baseline weight, fasting glucose, and lipids are essential.
Q3: A 45-year-old female with treatment-resistant depression has failed trials of sertraline, venlafaxine,
and bupropion. She asks about augmentation strategies. Her BMI is 32, and she has type 2 diabetes.
Which augmentation agent is contraindicated?
A. Aripiprazole 2-5 mg daily
B. Lithium 300 mg daily
C. Quetiapine 150 mg daily [CORRECT]
D. Thyroid hormone (T3) 25 mcg daily
Rationale: Quetiapine carries significant metabolic risks (weight gain, hyperglycemia, dyslipidemia) that
would exacerbate her diabetes and obesity, making it relatively contraindicated despite FDA approval
for adjunctive MDD treatment. Aripiprazole (A) and lithium (B) are FDA-approved augmentation
strategies with more favorable metabolic profiles. T3 (D) is used off-label for augmentation without
metabolic risks. Clinical pearl: When choosing augmentation, match side effect profiles to patient
comorbidities—avoid metabolic agents in patients with metabolic syndrome.
Q4: A 19-year-old college student presents with 2 weeks of elevated mood, grandiosity, decreased need
for sleep (2 hours/night), hypersexuality, and reckless spending. She is not psychotic. Her mother has
bipolar I disorder. What is the most likely diagnosis?
A. Major depressive disorder with anxious features
B. Bipolar II disorder
C. Bipolar I disorder, current episode manic [CORRECT]
D. Cyclothymic disorder
Rationale: This patient meets DSM-5-TR criteria for manic episode (≥1 week with elevated/irritable
mood plus 3+ symptoms including grandiosity, decreased sleep, hypersexuality, excessive involvement
in risky activities) causing impairment. Family history supports genetic loading. Bipolar I (C) requires only
one manic episode; hospitalization isn't required if not severe. Bipolar II (B) requires hypomania and
MDD—this is full mania. Cyclothymia (D) requires 2+ years of subthreshold symptoms. Clinical pearl:
First manic episodes often occur late adolescence/early adulthood; always screen for family history and
assess for psychosis to guide treatment intensity.
,Q5: A 52-year-old male with MDD on venlafaxine 225 mg daily for 6 months reports improved mood but
persistent sexual dysfunction (delayed ejaculation). He wants to switch medications. Which option
preserves efficacy while minimizing sexual side effects?
A. Switch to paroxetine 40 mg daily
B. Add bupropion 150 mg XL
C. Switch to mirtazapine 30 mg at bedtime [CORRECT]
D. Add trazodone 100 mg at bedtime
Rationale: Mirtazapine has minimal sexual side effects compared to SSRIs/SNRIs and is effective for
MDD. Paroxetine (A) has the highest sexual dysfunction rates among SSRIs. Adding bupropion (B) may
help but doesn't guarantee resolution. Trazodone (D) can cause priapism and is sedating—not ideal for
this patient. Clinical pearl: Mirtazapine is also useful for insomnia and appetite stimulation but monitor
for weight gain and sedation at lower doses (antihistaminic effect stronger at 15 mg than 30 mg).
Q6: A 35-year-old female with bipolar II disorder stabilized on lamotrigine 200 mg daily presents with
depressed mood, hypersomnia, and psychomotor retardation for 3 weeks. She denies suicidal ideation.
Her lamotrigine level is 2.8 mcg/mL (therapeutic 2.5-15). What is the best next step?
A. Increase lamotrigine to 300 mg daily
B. Add quetiapine 50 mg daily
C. Add fluoxetine 20 mg daily with close monitoring for mania [CORRECT]
D. Switch to lithium monotherapy
Rationale: For bipolar depression, FDA-approved options include quetiapine, lurasidone, lamotrigine
(maintenance), and olanzapine-fluoxetine combination. Adding an SSRI (C) with mood stabilizer is
acceptable for breakthrough depression with mania monitoring. Increasing lamotrigine (A) has delayed
onset and may not address acute symptoms. Quetiapine (B) is effective but sedating—patient already
has hypersomnia. Switching to lithium (D) risks destabilization during transition. Clinical pearl: When
using antidepressants in bipolar disorder, always maintain mood stabilizer and monitor closely for
switching—discontinue antidepressant if manic symptoms emerge.
Q7: A 29-year-old female 8 weeks postpartum presents with depressed mood, anxiety, intrusive
thoughts about harming her baby (ego-dystonic, no plan), insomnia, and guilt. She is breastfeeding.
What is the safest first-line treatment?
A. Paroxetine 20 mg daily [CORRECT]
B. Nortriptyline 75 mg daily
, C. Phenelzine 15 mg three times daily
D. Lithium 900 mg daily
Rationale: Paroxetine has the lowest transfer into breast milk among SSRIs and is first-line for
postpartum depression. Nortriptyline (B) has higher infant exposure. Phenelzine (C) is an MAOI with
dietary restrictions and limited data in lactation. Lithium (D) requires monitoring in breastfeeding and is
reserved for bipolar disorder or severe refractory cases. Clinical pearl: Postpartum depression affects 10-
15% of mothers; intrusive thoughts are common and ego-dystonic (unwanted), distinguishing them from
psychosis where thoughts may be acted upon—always assess for homicidal ideation with plan/intent.
Q8: A 41-year-old male with MDD and comorbid ADHD presents with persistent depressive symptoms
on escitalopram 20 mg. He struggles with concentration, energy, and motivation. Which medication
switch addresses both conditions?
A. Switch to citalopram 40 mg
B. Add methylphenidate 10 mg twice daily
C. Switch to bupropion XL 300 mg daily [CORRECT]
D. Add aripiprazole 5 mg daily
Rationale: Bupropion is effective for MDD and ADHD (off-label), addressing both conditions with single
agent. Citalopram (A) offers no advantage over escitalopram. Adding stimulant (B) is reasonable but
adds complexity and controlled substance considerations. Aripiprazole (D) augments depression but
doesn't treat ADHD. Clinical pearl: Bupropion is also useful for smoking cessation and sexual dysfunction
but contraindicated in eating disorders and seizure disorders due to lowered seizure threshold.
Q9: A 55-year-old male with bipolar I disorder on lithium 1200 mg daily (level 0.9 mEq/L) presents with
tremor, polyuria, and mild confusion. Labs show Na+ 148, Cr 1.4 (baseline 0.9), TSH 6.2. What is the
priority intervention?
A. Increase lithium to achieve level 1.2 mEq/L
B. Discontinue lithium and switch to valproic acid [CORRECT]
C. Add levothyroxine and continue lithium
D. Reduce lithium to 900 mg daily
Rationale: This patient has lithium toxicity manifestations (tremor, confusion, nephrogenic diabetes
insipidus with hypernatremia, renal impairment) and hypothyroidism. Given renal impairment and
multiple adverse effects, switching to alternative mood stabilizer (B) is safest. Continuing or increasing
lithium (A, C, D) risks progression to severe toxicity. Valproic acid doesn't cause renal dysfunction or
diabetes insipidus. Clinical pearl: Lithium adverse effects include renal dysfunction, hypothyroidism,
hyperparathyroidism, and diabetes insipidus—monitor eGFR, TSH, calcium, and urine specific gravity
regularly; maintain levels 0.6-0.8 in older adults.
