NR547 Differential Diagnosis in Psychiatric-Mental Health
Across the Lifespan Practicum Midterm Exam Complete Guide
Question Bank (Latest 2026/2027 Edition) – Questions, Answers
& Detailed Rationales
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SECTION 1: Diagnostic Reasoning and the Differential Diagnosis Process
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Question 1
A psychiatric-mental health nurse practitioner is evaluating a 34-year-old patient who
reports 3 weeks of depressed mood, fatigue, and insomnia. The patient also mentions
starting a new blood pressure medication 1 month ago. Which step in differential
diagnosis should be prioritized before assigning a psychiatric diagnosis?
A. Order a comprehensive metabolic panel to rule out electrolyte imbalance
B. Review the pharmacologic profile of the new antihypertensive agent
C. Administer a standardized depression screening instrument
D. Refer the patient for immediate psychiatric hospitalization
Correct Answer:
B — Review the pharmacologic profile of the new antihypertensive agent
Rationale:
Medication-induced mood changes must be ruled out before diagnosing a primary
psychiatric disorder. Beta-blockers, centrally acting antihypertensives, and other agents
can cause depressive symptoms. While lab work and screening tools are valuable,
identifying iatrogenic causes is the most immediate priority in the differential process.
Question 2
,A PMHNP is formulating a differential diagnosis for a 28-year-old patient presenting
with auditory hallucinations and paranoid ideation. Which medical condition must be
ruled out first according to standard diagnostic hierarchy?
A. Schizophrenia spectrum disorder with first-episode psychosis
B. Substance-induced psychotic disorder from recent cannabis use
C. Brief psychotic disorder triggered by acute stress
D. Delusional disorder with persecutory subtype
Correct Answer:
B — Substance-induced psychotic disorder from recent cannabis use
Rationale:
The diagnostic hierarchy requires ruling out substance-induced conditions before
diagnosing primary psychotic disorders. Cannabis, stimulants, and other substances
can produce psychotic symptoms that resolve with abstinence. Failing to assess
substance use first may lead to misdiagnosis and inappropriate long-term antipsychotic
treatment.
Question 3
A 45-year-old patient presents with anxiety, tremor, and tachycardia. The PMHNP notes
the patient is taking levothyroxine 200 mcg daily. Which laboratory test is most
essential to differentiate anxiety disorder from a medical mimic?
A. Comprehensive metabolic panel with liver function tests
B. Thyroid-stimulating hormone and free T4 levels
C. Vitamin B12 and folate levels
D. Complete blood count with differential
Correct Answer:
B — Thyroid-stimulating hormone and free T4 levels
Rationale:
,Excessive thyroid hormone replacement can produce anxiety, tremor, and tachycardia
mimicking generalized anxiety disorder or panic disorder. TSH and free T4 assessment
is essential to identify iatrogenic hyperthyroidism before diagnosing a primary anxiety
disorder. Other labs are important but less directly relevant to this medication history.
Question 4
A PMHNP is evaluating a 52-year-old patient with new-onset depressive symptoms. The
patient has hypertension, diabetes, and chronic kidney disease. Which comorbid
medical condition most commonly mimics depression in older adults?
A. Hyperthyroidism with sympathetic overactivity
B. Hypothyroidism with fatigue and cognitive slowing
C. Hyperparathyroidism with anxiety and bone pain
D. Cushing syndrome with mood lability and weight gain
Correct Answer:
B — Hypothyroidism with fatigue and cognitive slowing
Rationale:
Hypothyroidism is one of the most common medical mimics of depression, presenting
with fatigue, depressed mood, cognitive slowing, and psychomotor retardation.
Screening for thyroid dysfunction is standard practice in the psychiatric evaluation of
depression, particularly in patients with multiple medical comorbidities.
Question 5
A 19-year-old college student presents with 2 weeks of insomnia, pressured speech, and
risky sexual behavior after starting a selective serotonin reuptake inhibitor for
depression. Which diagnostic consideration is most critical?
A. Bipolar disorder with antidepressant-induced mood switching
B. SSRI-induced activation syndrome with akathisia
C. Substance-induced mania from concurrent stimulant use
, D. Adjustment disorder with disturbance of conduct
Correct Answer:
A — Bipolar disorder with antidepressant-induced mood switching
Rationale:
Antidepressant-induced mania or hypomania in a patient with underlying bipolar
disorder is a critical diagnostic consideration. The temporal relationship to SSRI
initiation, presence of classic manic symptoms, and absence of prior unipolar
depression history suggest possible bipolar spectrum disorder. Activation syndrome
typically causes irritability and restlessness without full manic syndrome.
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SECTION 2: Child and Adolescent Psychiatric Differential Diagnosis
──────────────────────────────
Question 6
A 7-year-old boy is referred for evaluation due to difficulty sitting still, interrupting others,
and incomplete schoolwork. His parents report he can focus for hours on building
detailed Lego structures. Which diagnosis should be differentiated from ADHD?
A. Autism spectrum disorder with restricted interests and hyperfocus
B. Generalized anxiety disorder with excessive motor tension
C. Oppositional defiant disorder with defiance toward authority
D. Specific learning disorder with attentional deficits
Correct Answer:
A — Autism spectrum disorder with restricted interests and hyperfocus
Rationale:
The ability to hyperfocus on preferred activities while demonstrating inattention in
non-preferred tasks is characteristic of ASD rather than ADHD, where inattention is more
pervasive. Differentiating ASD from ADHD is critical as treatment approaches differ
Across the Lifespan Practicum Midterm Exam Complete Guide
Question Bank (Latest 2026/2027 Edition) – Questions, Answers
& Detailed Rationales
──────────────────────────────
SECTION 1: Diagnostic Reasoning and the Differential Diagnosis Process
──────────────────────────────
Question 1
A psychiatric-mental health nurse practitioner is evaluating a 34-year-old patient who
reports 3 weeks of depressed mood, fatigue, and insomnia. The patient also mentions
starting a new blood pressure medication 1 month ago. Which step in differential
diagnosis should be prioritized before assigning a psychiatric diagnosis?
A. Order a comprehensive metabolic panel to rule out electrolyte imbalance
B. Review the pharmacologic profile of the new antihypertensive agent
C. Administer a standardized depression screening instrument
D. Refer the patient for immediate psychiatric hospitalization
Correct Answer:
B — Review the pharmacologic profile of the new antihypertensive agent
Rationale:
Medication-induced mood changes must be ruled out before diagnosing a primary
psychiatric disorder. Beta-blockers, centrally acting antihypertensives, and other agents
can cause depressive symptoms. While lab work and screening tools are valuable,
identifying iatrogenic causes is the most immediate priority in the differential process.
Question 2
,A PMHNP is formulating a differential diagnosis for a 28-year-old patient presenting
with auditory hallucinations and paranoid ideation. Which medical condition must be
ruled out first according to standard diagnostic hierarchy?
A. Schizophrenia spectrum disorder with first-episode psychosis
B. Substance-induced psychotic disorder from recent cannabis use
C. Brief psychotic disorder triggered by acute stress
D. Delusional disorder with persecutory subtype
Correct Answer:
B — Substance-induced psychotic disorder from recent cannabis use
Rationale:
The diagnostic hierarchy requires ruling out substance-induced conditions before
diagnosing primary psychotic disorders. Cannabis, stimulants, and other substances
can produce psychotic symptoms that resolve with abstinence. Failing to assess
substance use first may lead to misdiagnosis and inappropriate long-term antipsychotic
treatment.
Question 3
A 45-year-old patient presents with anxiety, tremor, and tachycardia. The PMHNP notes
the patient is taking levothyroxine 200 mcg daily. Which laboratory test is most
essential to differentiate anxiety disorder from a medical mimic?
A. Comprehensive metabolic panel with liver function tests
B. Thyroid-stimulating hormone and free T4 levels
C. Vitamin B12 and folate levels
D. Complete blood count with differential
Correct Answer:
B — Thyroid-stimulating hormone and free T4 levels
Rationale:
,Excessive thyroid hormone replacement can produce anxiety, tremor, and tachycardia
mimicking generalized anxiety disorder or panic disorder. TSH and free T4 assessment
is essential to identify iatrogenic hyperthyroidism before diagnosing a primary anxiety
disorder. Other labs are important but less directly relevant to this medication history.
Question 4
A PMHNP is evaluating a 52-year-old patient with new-onset depressive symptoms. The
patient has hypertension, diabetes, and chronic kidney disease. Which comorbid
medical condition most commonly mimics depression in older adults?
A. Hyperthyroidism with sympathetic overactivity
B. Hypothyroidism with fatigue and cognitive slowing
C. Hyperparathyroidism with anxiety and bone pain
D. Cushing syndrome with mood lability and weight gain
Correct Answer:
B — Hypothyroidism with fatigue and cognitive slowing
Rationale:
Hypothyroidism is one of the most common medical mimics of depression, presenting
with fatigue, depressed mood, cognitive slowing, and psychomotor retardation.
Screening for thyroid dysfunction is standard practice in the psychiatric evaluation of
depression, particularly in patients with multiple medical comorbidities.
Question 5
A 19-year-old college student presents with 2 weeks of insomnia, pressured speech, and
risky sexual behavior after starting a selective serotonin reuptake inhibitor for
depression. Which diagnostic consideration is most critical?
A. Bipolar disorder with antidepressant-induced mood switching
B. SSRI-induced activation syndrome with akathisia
C. Substance-induced mania from concurrent stimulant use
, D. Adjustment disorder with disturbance of conduct
Correct Answer:
A — Bipolar disorder with antidepressant-induced mood switching
Rationale:
Antidepressant-induced mania or hypomania in a patient with underlying bipolar
disorder is a critical diagnostic consideration. The temporal relationship to SSRI
initiation, presence of classic manic symptoms, and absence of prior unipolar
depression history suggest possible bipolar spectrum disorder. Activation syndrome
typically causes irritability and restlessness without full manic syndrome.
──────────────────────────────
SECTION 2: Child and Adolescent Psychiatric Differential Diagnosis
──────────────────────────────
Question 6
A 7-year-old boy is referred for evaluation due to difficulty sitting still, interrupting others,
and incomplete schoolwork. His parents report he can focus for hours on building
detailed Lego structures. Which diagnosis should be differentiated from ADHD?
A. Autism spectrum disorder with restricted interests and hyperfocus
B. Generalized anxiety disorder with excessive motor tension
C. Oppositional defiant disorder with defiance toward authority
D. Specific learning disorder with attentional deficits
Correct Answer:
A — Autism spectrum disorder with restricted interests and hyperfocus
Rationale:
The ability to hyperfocus on preferred activities while demonstrating inattention in
non-preferred tasks is characteristic of ASD rather than ADHD, where inattention is more
pervasive. Differentiating ASD from ADHD is critical as treatment approaches differ
