APEA PSYCHIATRIC-MENTAL HEALTH NURSE
PRACTITIONER (PMHNP) COMPREHENSIVE
EXAMINATION| 250 MCQ Revision Questions with
Answers & Rationales
1. A 32-year-old patient presents with a 2-week history of depressed mood, anhedonia,
hypersomnia, psychomotor retardation, and feelings of worthlessness. Which diagnosis
BEST fits this presentation?
A. Persistent depressive disorder (dysthymia) B. Bipolar II disorder, depressive episode C. Major
depressive disorder (MDD), single episode D. Adjustment disorder with depressed mood
Correct Answer: C
Rationale: MDD requires at least 5 of 9 DSM-5 criteria present for ≥2 weeks, with at least
one being depressed mood or anhedonia. This patient meets criteria: depressed mood,
anhedonia, hypersomnia, psychomotor retardation, and worthlessness. Dysthymia requires
≥2 years of symptoms. Bipolar II requires a history of hypomania. Adjustment disorder
follows an identifiable stressor with symptoms disproportionate to it.
2. Which of the following neurotransmitter abnormalities is MOST associated with
schizophrenia?
,A. Decreased serotonin in the prefrontal cortex B. Excess dopamine activity in the mesolimbic
pathway C. Decreased norepinephrine in the locus coeruleus D. Excess GABA activity in the
basal ganglia
Correct Answer: B
Rationale: The dopamine hypothesis of schizophrenia proposes that hyperactivity of
dopamine D2 receptors in the mesolimbic pathway underlies positive symptoms
(hallucinations, delusions). Hypoactivity of dopamine in the mesocortical pathway is
associated with negative and cognitive symptoms. All antipsychotics work primarily by
blocking D2 receptors. Glutamate (NMDA receptor hypofunction) is also implicated in
schizophrenia pathophysiology.
3. A patient is started on clozapine for treatment-resistant schizophrenia. Which
monitoring parameter is MOST critical?
A. Liver function tests weekly B. Absolute neutrophil count (ANC) monitoring C. Renal
function tests monthly D. Thyroid function every 6 months
Correct Answer: B
Rationale: Clozapine carries a black box warning for agranulocytosis, a potentially fatal
reduction in white blood cells (specifically neutrophils). The REMS (Risk Evaluation and
Mitigation Strategy) program requires mandatory ANC monitoring: weekly for the first 6
months, every 2 weeks for months 6–12, and monthly thereafter. Clozapine must be
discontinued if ANC falls below 1000/µL. It also carries warnings for myocarditis, seizures,
and metabolic syndrome.
4. Which of the following antipsychotics is MOST associated with causing tardive
dyskinesia with long-term use?
,A. Clozapine B. Quetiapine C. Haloperidol D. Aripiprazole
Correct Answer: C
Rationale: Tardive dyskinesia (TD) is a potentially irreversible movement disorder
characterized by repetitive, involuntary choreiform movements (lip smacking, tongue
protrusion, grimacing) caused by chronic dopamine receptor blockade. First-generation
(typical) antipsychotics like haloperidol have the highest risk of TD. Clozapine has the
lowest risk. Aripiprazole and quetiapine (atypical antipsychotics) have lower TD risk than
typicals. Valbenazine and deutetrabenazine are FDA-approved for TD treatment.
5. A 28-year-old patient presents with recurrent, unexpected panic attacks with
anticipatory anxiety about future attacks for 3 months. The MOST appropriate first-line
pharmacological treatment is:
A. Alprazolam as needed B. Sertraline (SSRI) with short-term benzodiazepine coverage C.
Buspirone D. Propranolol
Correct Answer: B
Rationale: First-line pharmacotherapy for panic disorder is an SSRI (sertraline,
paroxetine, fluoxetine) or SNRI (venlafaxine). SSRIs take 4–6 weeks to achieve full effect; a
short-term benzodiazepine may be used as a bridge during initiation. Benzodiazepines
alone (alprazolam) are not recommended as monotherapy due to dependence risk.
Buspirone is effective for GAD but not panic disorder. Cognitive-behavioral therapy (CBT)
is the first-line psychotherapy.
6. Which of the following is the MOST common side effect of SSRIs that leads to
medication discontinuation?
, A. Weight gain B. Sedation C. Sexual dysfunction D. Hyponatremia
Correct Answer: C
Rationale: Sexual dysfunction (decreased libido, delayed orgasm, anorgasmia, erectile
dysfunction) is the most common long-term SSRI side effect leading to non-adherence and
discontinuation. It affects up to 30–40% of patients on SSRIs. Bupropion and mirtazapine
have the lowest rates of sexual dysfunction. Strategies include dose reduction, drug holiday,
or switching to bupropion or adding bupropion or buspirone as augmentation.
7. A patient on lithium presents with coarse tremor, confusion, ataxia, and slurred speech.
The MOST appropriate action is:
A. Reduce the lithium dose by half B. Add a beta-blocker for tremor management C. Hold
lithium and check serum lithium level immediately — suspect toxicity D. Reassure the patient
that these are expected side effects
Correct Answer: C
Rationale: Lithium has a narrow therapeutic index (0.6–1.2 mEq/L for maintenance).
Toxic symptoms occur at levels >1.5 mEq/L: coarse tremor, confusion, ataxia, slurred
speech (mild-moderate); at >2.0 mEq/L: seizures, coma, cardiac arrhythmias (severe).
Lithium must be held immediately and a serum level drawn. Treatment includes
hydration, sodium replacement, and in severe cases, hemodialysis. Risk factors for toxicity:
dehydration, NSAIDs, ACE inhibitors, and low-sodium diet.
8. According to DSM-5, which of the following is a diagnostic criterion for generalized
anxiety disorder (GAD)?
PRACTITIONER (PMHNP) COMPREHENSIVE
EXAMINATION| 250 MCQ Revision Questions with
Answers & Rationales
1. A 32-year-old patient presents with a 2-week history of depressed mood, anhedonia,
hypersomnia, psychomotor retardation, and feelings of worthlessness. Which diagnosis
BEST fits this presentation?
A. Persistent depressive disorder (dysthymia) B. Bipolar II disorder, depressive episode C. Major
depressive disorder (MDD), single episode D. Adjustment disorder with depressed mood
Correct Answer: C
Rationale: MDD requires at least 5 of 9 DSM-5 criteria present for ≥2 weeks, with at least
one being depressed mood or anhedonia. This patient meets criteria: depressed mood,
anhedonia, hypersomnia, psychomotor retardation, and worthlessness. Dysthymia requires
≥2 years of symptoms. Bipolar II requires a history of hypomania. Adjustment disorder
follows an identifiable stressor with symptoms disproportionate to it.
2. Which of the following neurotransmitter abnormalities is MOST associated with
schizophrenia?
,A. Decreased serotonin in the prefrontal cortex B. Excess dopamine activity in the mesolimbic
pathway C. Decreased norepinephrine in the locus coeruleus D. Excess GABA activity in the
basal ganglia
Correct Answer: B
Rationale: The dopamine hypothesis of schizophrenia proposes that hyperactivity of
dopamine D2 receptors in the mesolimbic pathway underlies positive symptoms
(hallucinations, delusions). Hypoactivity of dopamine in the mesocortical pathway is
associated with negative and cognitive symptoms. All antipsychotics work primarily by
blocking D2 receptors. Glutamate (NMDA receptor hypofunction) is also implicated in
schizophrenia pathophysiology.
3. A patient is started on clozapine for treatment-resistant schizophrenia. Which
monitoring parameter is MOST critical?
A. Liver function tests weekly B. Absolute neutrophil count (ANC) monitoring C. Renal
function tests monthly D. Thyroid function every 6 months
Correct Answer: B
Rationale: Clozapine carries a black box warning for agranulocytosis, a potentially fatal
reduction in white blood cells (specifically neutrophils). The REMS (Risk Evaluation and
Mitigation Strategy) program requires mandatory ANC monitoring: weekly for the first 6
months, every 2 weeks for months 6–12, and monthly thereafter. Clozapine must be
discontinued if ANC falls below 1000/µL. It also carries warnings for myocarditis, seizures,
and metabolic syndrome.
4. Which of the following antipsychotics is MOST associated with causing tardive
dyskinesia with long-term use?
,A. Clozapine B. Quetiapine C. Haloperidol D. Aripiprazole
Correct Answer: C
Rationale: Tardive dyskinesia (TD) is a potentially irreversible movement disorder
characterized by repetitive, involuntary choreiform movements (lip smacking, tongue
protrusion, grimacing) caused by chronic dopamine receptor blockade. First-generation
(typical) antipsychotics like haloperidol have the highest risk of TD. Clozapine has the
lowest risk. Aripiprazole and quetiapine (atypical antipsychotics) have lower TD risk than
typicals. Valbenazine and deutetrabenazine are FDA-approved for TD treatment.
5. A 28-year-old patient presents with recurrent, unexpected panic attacks with
anticipatory anxiety about future attacks for 3 months. The MOST appropriate first-line
pharmacological treatment is:
A. Alprazolam as needed B. Sertraline (SSRI) with short-term benzodiazepine coverage C.
Buspirone D. Propranolol
Correct Answer: B
Rationale: First-line pharmacotherapy for panic disorder is an SSRI (sertraline,
paroxetine, fluoxetine) or SNRI (venlafaxine). SSRIs take 4–6 weeks to achieve full effect; a
short-term benzodiazepine may be used as a bridge during initiation. Benzodiazepines
alone (alprazolam) are not recommended as monotherapy due to dependence risk.
Buspirone is effective for GAD but not panic disorder. Cognitive-behavioral therapy (CBT)
is the first-line psychotherapy.
6. Which of the following is the MOST common side effect of SSRIs that leads to
medication discontinuation?
, A. Weight gain B. Sedation C. Sexual dysfunction D. Hyponatremia
Correct Answer: C
Rationale: Sexual dysfunction (decreased libido, delayed orgasm, anorgasmia, erectile
dysfunction) is the most common long-term SSRI side effect leading to non-adherence and
discontinuation. It affects up to 30–40% of patients on SSRIs. Bupropion and mirtazapine
have the lowest rates of sexual dysfunction. Strategies include dose reduction, drug holiday,
or switching to bupropion or adding bupropion or buspirone as augmentation.
7. A patient on lithium presents with coarse tremor, confusion, ataxia, and slurred speech.
The MOST appropriate action is:
A. Reduce the lithium dose by half B. Add a beta-blocker for tremor management C. Hold
lithium and check serum lithium level immediately — suspect toxicity D. Reassure the patient
that these are expected side effects
Correct Answer: C
Rationale: Lithium has a narrow therapeutic index (0.6–1.2 mEq/L for maintenance).
Toxic symptoms occur at levels >1.5 mEq/L: coarse tremor, confusion, ataxia, slurred
speech (mild-moderate); at >2.0 mEq/L: seizures, coma, cardiac arrhythmias (severe).
Lithium must be held immediately and a serum level drawn. Treatment includes
hydration, sodium replacement, and in severe cases, hemodialysis. Risk factors for toxicity:
dehydration, NSAIDs, ACE inhibitors, and low-sodium diet.
8. According to DSM-5, which of the following is a diagnostic criterion for generalized
anxiety disorder (GAD)?
