BARKLEY PMHNP 2026 | 200-QUESTION MEGA
EXAM BANK COMPREHENSIVE PRACTICE EXAMS &
ADVANCED CASE SCENARIOS
TOTAL ITEMS: 200 Multiple-Choice & Multi-Part Case Vignettes
TARGET: ANCC/AANP PMHNP Board Certification
DOMAINS COVERED:
I. Psychopharmacology (Q1-40)
II. Neurobiology & Pathophysiology (Q41-80)
III. Differential Diagnosis & Psychiatric Assessment (Q81-120)
IV. Psychotherapy & Therapeutic Interventions (Q121-150)
V. Ethics, Law, & Professional Roles (Q151-170)
VI. Integrated Complex Case Scenarios (Q171-200)
DOMAIN I: PSYCHOPHARMACOLOGY (Q1-40)
1. A 62-year-old male with Parkinson's disease develops visual hallucinations
of small animals. He has been on Carbidopa-Levodopa for 10 years. His MMSE
is 28/30. What is the FIRST-LINE pharmacological strategy?
A) Add Quetiapine 12.5mg at bedtime.
B) Add Pimavanserin 34mg daily.
C) Increase the Carbidopa-Levodopa dose to suppress motor symptoms.
D) Start Donepezil 5mg daily.
ANSWER: B
RATIONALE: Pimavanserin is a selective 5-HT2A inverse agonist approved
specifically for Parkinson's disease psychosis. It does not worsen motor
symptoms, unlike typical/atypical antipsychotics (even quetiapine carries a
black-box warning and can worsen EPS in this population).
2. A 19-year-old female with anorexia nervosa (BMI 16.5) presents with
1|Page
, profound anxiety and obsessive-compulsive rituals around food. She is
started on Fluoxetine 20mg. Which lab parameter requires MONTHLY monitoring
specific to this patient's comorbidity?
A) Serum sodium.
B) Complete blood count with differential.
C) Serum potassium and phosphorus.
D) Hepatic transaminases.
ANSWER: C
RATIONALE: In malnourished patients with anorexia, SSRI initiation can
precipitate refeeding syndrome (hypophosphatemia, hypokalemia,
hypomagnesemia) as insulin shifts electrolytes intracellularly. Baseline and
frequent electrolyte monitoring is critical; Fluoxetine also prolongs QT in
the context of electrolyte derangements.
3. A 55-year-old male with treatment-resistant depression (TRD) has failed
four antidepressants. His PHQ-9 is 22. He has no active substance use.
You initiate Esketamine nasal spray. What is the ESSENTIAL monitoring
protocol immediately following each administration?
A) Orthostatic blood pressure and pulse for 2 hours.
B) Serum creatinine and BUN for nephrotoxicity.
C) EEG for subclinical seizure activity.
D) Blood glucose level due to hyperglycemic effect.
ANSWER: A
RATIONALE: Esketamine causes transient hypertension and dissociative
side effects. The FDA REMS requires monitoring for at least 2 hours
post-administration for blood pressure elevation and sedation, as
hypertensive crises or severe dissociative events can occur.
2|Pa g e
,4. A 30-year-old female with Bipolar II disorder is on Lamotrigine 200mg
daily. She presents with a new, widespread, morbilliform rash without
mucosal involvement or fever. What is the BEST course of action?
A) Immediately discontinue Lamotrigine and start Carbamazepine.
B) Prescribe Diphenhydramine and continue Lamotrigine.
C) Hold Lamotrigine, obtain a dermatology consult, and evaluate for benign
rash vs. early SJS/TEN.
D) Increase Lamotrigine to 300mg to overcome the allergic reaction.
ANSWER: C
RATIONALE: Any rash on Lamotrigine requires immediate evaluation to rule
out Stevens-Johnson Syndrome (SJS). While benign rashes occur in ~10%,
SJS is life-threatening. The safe approach is to hold the dose pending
dermatology assessment. Do not automatically restart or increase.
5. A 48-year-old male with PTSD and insomnia is prescribed Prazosin 1mg at
bedtime. He reports improvement in nightmares but now complains of
"lightheadedness" and "fainting spells" when standing up from his chair.
What is the PRIMARY mechanism responsible for this effect?
A) Central alpha-2 agonism causing bradycardia.
B) Peripheral alpha-1 antagonism causing vasodilation.
C) H1 receptor antagonism causing sedative hypotension.
D) 5-HT3 antagonism causing orthostatic fluid shifts.
ANSWER: B
RATIONALE: Prazosin is a peripheral alpha-1 adrenergic antagonist.
Blockade of alpha-1 receptors on vascular smooth muscle causes venous and
arterial dilation, leading to orthostatic hypotension. This is the primary
3|Pa g e
, dose-limiting side effect.
6. A 72-year-old female with major depression and severe insomnia is started
on Mirtazapine 15mg at bedtime. She has a history of benign prostatic
hyperplasia (BPH). Which adverse effect is MOST likely to exacerbate her BPH?
A) Anticholinergic urinary retention.
B) Alpha-1 antagonism worsening outflow obstruction.
C) Serotonin syndrome-induced clonus.
D) Hyponatremia-induced confusion.
ANSWER: A
RATIONALE: Mirtazapine has strong antihistaminic (H1) and moderate
anticholinergic (M1) activity. Anticholinergic effects can precipitate
urinary retention in men with BPH. Alpha-1 antagonism is more associated
with Tamsulosin, not Mirtazapine.
7. A 26-year-old male with ADHD and a history of cocaine use disorder
(abstinent 6 months) requests medication for focus. Which stimulant
formulation has the LEAST abuse potential and should be prioritized?
A) Dextroamphetamine-amphetamine extended-release (Adderall XR).
B) Lisdexamfetamine (Vyvanse).
C) Methylphenidate immediate-release (Ritalin).
D) Mixed amphetamine salts immediate-release.
ANSWER: B
RATIONALE: Lisdexamfetamine is a prodrug that requires enzymatic
hydrolysis in the RBCs to become active. It has a slower onset and lower
peak plasma concentration compared to immediate-release amphetamines,
resulting in significantly lower abuse potential and subjective "likability."
4|Page
EXAM BANK COMPREHENSIVE PRACTICE EXAMS &
ADVANCED CASE SCENARIOS
TOTAL ITEMS: 200 Multiple-Choice & Multi-Part Case Vignettes
TARGET: ANCC/AANP PMHNP Board Certification
DOMAINS COVERED:
I. Psychopharmacology (Q1-40)
II. Neurobiology & Pathophysiology (Q41-80)
III. Differential Diagnosis & Psychiatric Assessment (Q81-120)
IV. Psychotherapy & Therapeutic Interventions (Q121-150)
V. Ethics, Law, & Professional Roles (Q151-170)
VI. Integrated Complex Case Scenarios (Q171-200)
DOMAIN I: PSYCHOPHARMACOLOGY (Q1-40)
1. A 62-year-old male with Parkinson's disease develops visual hallucinations
of small animals. He has been on Carbidopa-Levodopa for 10 years. His MMSE
is 28/30. What is the FIRST-LINE pharmacological strategy?
A) Add Quetiapine 12.5mg at bedtime.
B) Add Pimavanserin 34mg daily.
C) Increase the Carbidopa-Levodopa dose to suppress motor symptoms.
D) Start Donepezil 5mg daily.
ANSWER: B
RATIONALE: Pimavanserin is a selective 5-HT2A inverse agonist approved
specifically for Parkinson's disease psychosis. It does not worsen motor
symptoms, unlike typical/atypical antipsychotics (even quetiapine carries a
black-box warning and can worsen EPS in this population).
2. A 19-year-old female with anorexia nervosa (BMI 16.5) presents with
1|Page
, profound anxiety and obsessive-compulsive rituals around food. She is
started on Fluoxetine 20mg. Which lab parameter requires MONTHLY monitoring
specific to this patient's comorbidity?
A) Serum sodium.
B) Complete blood count with differential.
C) Serum potassium and phosphorus.
D) Hepatic transaminases.
ANSWER: C
RATIONALE: In malnourished patients with anorexia, SSRI initiation can
precipitate refeeding syndrome (hypophosphatemia, hypokalemia,
hypomagnesemia) as insulin shifts electrolytes intracellularly. Baseline and
frequent electrolyte monitoring is critical; Fluoxetine also prolongs QT in
the context of electrolyte derangements.
3. A 55-year-old male with treatment-resistant depression (TRD) has failed
four antidepressants. His PHQ-9 is 22. He has no active substance use.
You initiate Esketamine nasal spray. What is the ESSENTIAL monitoring
protocol immediately following each administration?
A) Orthostatic blood pressure and pulse for 2 hours.
B) Serum creatinine and BUN for nephrotoxicity.
C) EEG for subclinical seizure activity.
D) Blood glucose level due to hyperglycemic effect.
ANSWER: A
RATIONALE: Esketamine causes transient hypertension and dissociative
side effects. The FDA REMS requires monitoring for at least 2 hours
post-administration for blood pressure elevation and sedation, as
hypertensive crises or severe dissociative events can occur.
2|Pa g e
,4. A 30-year-old female with Bipolar II disorder is on Lamotrigine 200mg
daily. She presents with a new, widespread, morbilliform rash without
mucosal involvement or fever. What is the BEST course of action?
A) Immediately discontinue Lamotrigine and start Carbamazepine.
B) Prescribe Diphenhydramine and continue Lamotrigine.
C) Hold Lamotrigine, obtain a dermatology consult, and evaluate for benign
rash vs. early SJS/TEN.
D) Increase Lamotrigine to 300mg to overcome the allergic reaction.
ANSWER: C
RATIONALE: Any rash on Lamotrigine requires immediate evaluation to rule
out Stevens-Johnson Syndrome (SJS). While benign rashes occur in ~10%,
SJS is life-threatening. The safe approach is to hold the dose pending
dermatology assessment. Do not automatically restart or increase.
5. A 48-year-old male with PTSD and insomnia is prescribed Prazosin 1mg at
bedtime. He reports improvement in nightmares but now complains of
"lightheadedness" and "fainting spells" when standing up from his chair.
What is the PRIMARY mechanism responsible for this effect?
A) Central alpha-2 agonism causing bradycardia.
B) Peripheral alpha-1 antagonism causing vasodilation.
C) H1 receptor antagonism causing sedative hypotension.
D) 5-HT3 antagonism causing orthostatic fluid shifts.
ANSWER: B
RATIONALE: Prazosin is a peripheral alpha-1 adrenergic antagonist.
Blockade of alpha-1 receptors on vascular smooth muscle causes venous and
arterial dilation, leading to orthostatic hypotension. This is the primary
3|Pa g e
, dose-limiting side effect.
6. A 72-year-old female with major depression and severe insomnia is started
on Mirtazapine 15mg at bedtime. She has a history of benign prostatic
hyperplasia (BPH). Which adverse effect is MOST likely to exacerbate her BPH?
A) Anticholinergic urinary retention.
B) Alpha-1 antagonism worsening outflow obstruction.
C) Serotonin syndrome-induced clonus.
D) Hyponatremia-induced confusion.
ANSWER: A
RATIONALE: Mirtazapine has strong antihistaminic (H1) and moderate
anticholinergic (M1) activity. Anticholinergic effects can precipitate
urinary retention in men with BPH. Alpha-1 antagonism is more associated
with Tamsulosin, not Mirtazapine.
7. A 26-year-old male with ADHD and a history of cocaine use disorder
(abstinent 6 months) requests medication for focus. Which stimulant
formulation has the LEAST abuse potential and should be prioritized?
A) Dextroamphetamine-amphetamine extended-release (Adderall XR).
B) Lisdexamfetamine (Vyvanse).
C) Methylphenidate immediate-release (Ritalin).
D) Mixed amphetamine salts immediate-release.
ANSWER: B
RATIONALE: Lisdexamfetamine is a prodrug that requires enzymatic
hydrolysis in the RBCs to become active. It has a slower onset and lower
peak plasma concentration compared to immediate-release amphetamines,
resulting in significantly lower abuse potential and subjective "likability."
4|Page
