BARKLEY PMHNP EXAM REVIEW HIGH-YIELD QUESTIONS COMPLETE WITH 100% CORRECT ANSWERS 2026/2027

BARKLEY PMHNP EXAM REVIEW HIGH-YIELD QUESTIONS COMPLETE WITH 100% CORRECT ANSWERS 1. A 45-year-old male with major depressive disorder has failed trials of fluoxetine, sertraline, and venlafaxine. He reports increased appetite, hypersomnia, and extreme fatigue. Which medication would be most appropriate as an adjunctive treatment? A) Bupropion B) Mirtazapine C) Aripiprazole D) Lithium Correct Answer: C) Aripiprazole Explanation: This patient has atypical features of depression (increased appetite, hypersomnia) and has failed multiple antidepressant trials. Aripiprazole is FDA-approved as adjunctive treatment for MDD and is particularly useful in treatment-resistant cases. Bupropion is activating and might worsen anxiety; mirtazapine would increase appetite and sedation; lithium is more appropriate for bipolar depression. ________________________________________ 2. A 28-year-old woman with bipolar I disorder is maintained on lithium 900mg daily. She presents with tremors, nausea, and confusion. Her lithium level is 2.1 mEq/L. What is the most appropriate immediate intervention? A) Administer sodium polystyrene sulfonate B) Hold lithium and administer IV fluids C) Administer activated charcoal D) Increase lithium dose Correct Answer: B) Hold lithium and administer IV fluids Explanation: Lithium toxicity (level 1.5 mEq/L) requires immediate discontinuation of lithium and volume resuscitation with IV normal saline. Hemodialysis may be needed for severe toxicity. Sodium polystyrene sulfonate is not standard; activated charcoal does not bind lithium; increasing dose would be dangerous. ________________________________________ 3. Which laboratory finding is most concerning in a patient taking clozapine? A) WBC 4,500 cells/mcL B) ANC 1,800 cells/mcL C) WBC 2,800 cells/mcL D) Platelets 150,000 cells/mcL Correct Answer: C) WBC 2,800 cells/mcL Explanation: Clozapine requires mandatory monitoring due to risk of agranulocytosis. Treatment should be interrupted if WBC drops below 3,000 cells/mcL or ANC below 1,500 cells/mcL. WBC 2,800 is below the threshold requiring immediate intervention and possible discontinuation. ________________________________________ 4. A 72-year-old male with Parkinson's disease develops visual hallucinations of small animals. He is diagnosed with Parkinson's disease psychosis. Which medication is FDA-approved for this indication? A) Quetiapine B) Pimavanserin C) Olanzapine D) Haloperidol Correct Answer: B) Pimavanserin Explanation: Pimavanserin is the only FDA-approved medication specifically for hallucinations and delusions associated with Parkinson's disease psychosis. It is a 5-HT2A inverse agonist that does not worsen motor symptoms. Quetiapine and olanzapine are used off-label but can worsen motor symptoms; haloperidol is contraindicated. ________________________________________ 5. A 19-year-old college student presents with acute-onset auditory hallucinations, disorganized speech, and suspiciousness for 3 days. What is the most appropriate initial management? A) Start risperidone immediately B) Admit to inpatient psychiatric unit C) Start fluoxetine D) Refer for outpatient therapy Correct Answer: B) Admit to inpatient psychiatric unit Explanation: This patient presents with acute psychosis (hallucinations, disorganized speech) suggestive of first-episode schizophrenia or brief psychotic disorder. Acute psychosis with potential danger to self/others requires inpatient admission for evaluation, safety, and medication initiation. Outpatient management is inappropriate for acute psychosis. ________________________________________ 6. A patient on phenelzine reports eating aged cheese and now has a severe headache, hypertension, and tachycardia. Which medication should be avoided in this situation? A) Nifedipine B) Phentolamine C) Nitroglycerin D) Meperidine Correct Answer: D) Meperidine Explanation: This is a hypertensive crisis from MAOI and tyramine interaction. Meperidine is contraindicated with MAOIs due to risk of serotonin syndrome, seizures, and hyperpyrexia. Nifedipine, phentolamine, and nitroglycerin may be used to manage hypertensive crisis but meperidine should be avoided. ________________________________________ 7. A 35-year-old woman with generalized anxiety disorder has been on alprazolam 2mg TID for 2 years. She wants to discontinue. What is the most appropriate taper strategy? A) Switch to clonazepam and taper over 1 week B) Switch to diazepam and taper over 2-3 months C) Discontinue alprazolam immediately D) Continue alprazolam indefinitely Correct Answer: B) Switch to diazepam and taper over 2-3 months Explanation: Long-term benzodiazepine use requires slow taper (2-3 months) to avoid withdrawal symptoms. Switching from short-acting alprazolam to long-acting diazepam provides smoother withdrawal. Abrupt discontinuation can cause seizure, rebound anxiety, and withdrawal syndrome. ________________________________________ 8. Which of the following medications is most likely to cause QTc prolongation? A) Sertraline B) Escitalopram C) Fluoxetine D) Paroxetine Correct Answer: B) Escitalopram Explanation: Escitalopram is associated with dose-dependent QTc prolongation, particularly at doses 20mg. Citalopram has the highest risk among SSRIs for QTc prolongation. Sertraline, fluoxetine, and paroxetine have lower risk.