ANCC Psychiatric-Mental Health Nurse Practitioner (PMHNP) board certification exam — Questions and Answers

Question 1: Which therapeutic modality uses structured family sessions to identify dysfunctional communication patterns and realign family roles?

Structural family therapy (Correct answer)
Individual psychodynamic therapy
Narrative therapy
Existential therapy

Correct answer: Structural family therapy

Structural family therapy, developed by Salvador Minuchin, focuses on reorganizing family structure to improve functioning.

Question 2: Hana's thoughts about her father's passing take up all of her conscious space. Hana should expect assistance from Nurse Matt during this period of sorrow, which is referred described as:

Shock and disbelief
Developing awareness
Resolving the loss (Correct answer)
Restitution

Correct answer: Resolving the loss

The process of getting over a loss is gradual, difficult, and ongoing until a nearly perfect mental picture of the deceased individual emerges. The person is concerned with their loss, idealizes the lost person or thing, and may even impersonate the deceased. The fixation eventually fades, usually after a year or possibly more.

Question 3: A patient presents with pressured speech, decreased need for sleep, grandiosity, and increased goal-directed activity lasting 4 days without causing marked functional impairment. This presentation is most consistent with:

Cyclothymic disorder
Bipolar I disorder, manic episode
Bipolar II disorder, hypomanic episode (Correct answer)
Major depressive disorder with mixed features

Correct answer: Bipolar II disorder, hypomanic episode

A hypomanic episode is defined by elevated mood lasting at least 4 days that does not cause marked impairment or require hospitalization, distinguishing it from mania.

Question 4: Which of the following is a cardinal feature that differentiates borderline personality disorder (BPD) from bipolar II disorder?

Recurrent depressive episodes
Mood episodes lasting less than one hour triggered by interpersonal events (Correct answer)
Sleep disturbance during mood episodes
Impulsive behavior during mood shifts

Correct answer: Mood episodes lasting less than one hour triggered by interpersonal events

In BPD, dysphoric mood episodes are typically brief (hours), reactive to interpersonal stressors, and return to baseline, unlike the days-long episodes seen in bipolar disorder.

Question 5: A patient with OCD is not responding to adequate SSRI trials. According to evidence-based guidelines, what is the next pharmacological step?

Switch to a TCA such as imipramine
Switch to an SNRI such as duloxetine
Add a benzodiazepine for anxiety reduction
Augment with a low-dose antipsychotic such as risperidone or aripiprazole (Correct answer)

Correct answer: Augment with a low-dose antipsychotic such as risperidone or aripiprazole

For SSRI-refractory OCD, augmentation with a low-dose D2-blocking antipsychotic (risperidone, aripiprazole, haloperidol) has the strongest evidence and is guideline-recommended.

Question 6: Which statement best describes the ethical principle of autonomy in psychiatric nursing practice?

The nurse avoids actions that could harm the patient
The provider acts in the patient's best interest even against their stated wishes
Resources are distributed fairly across all patients in the system
The patient has the right to make informed decisions about their own care (Correct answer)

Correct answer: The patient has the right to make informed decisions about their own care

Autonomy means respecting the patient's right to self-determination and informed decision-making in their own healthcare.

Question 7: Which of the following liquids would nurse Kate give to a female patient who is high on phencyclidine (PCP) in order to speed up the drug's excretion?

Shake
Grape juice
Tea
Cranberry Juice (Correct answer)

Correct answer: Cranberry Juice

PCP is more easily excreted when the environment is acidic. Cranberry juice will undoubtedly be administered by the nurse to the PCP-impaired client in order to hasten excretion and acidify the urine to a pH of 5.5. PCP starts to show symptoms at 0.05 mg/kg, and a dose of 20 mg or more can result in coma, death, and seizures. 10% of it is eliminated in the urine and 90% is processed primarily by the liver. The most common mode of administration, inhalation, and intravenous both cause effects in 2 to 5 minutes. Symptoms from oral ingestion appear within 30 to 60 minutes.

Question 8: A therapist notices that a patient is unconsciously attributing their own unacceptable feelings to the therapist. This is known as:

Transference
Displacement
Countertransference
Projection (Correct answer)

Correct answer: Projection

Projection is a defense mechanism in which a person attributes their own unwanted feelings or impulses onto another person.

Question 9: A patient taking phenelzine eats a meal containing aged cheese and develops a severe hypertensive crisis. What is the pharmacological explanation?

Cheese directly inhibits MAO-B, potentiating phenelzine's effects
Phenelzine inhibits dopamine beta-hydroxylase, concentrating dopamine
Phenelzine blocks alpha-2 receptors, enhancing norepinephrine release
MAO inhibition prevents tyramine breakdown, causing massive norepinephrine release (Correct answer)

Correct answer: MAO inhibition prevents tyramine breakdown, causing massive norepinephrine release

MAO normally degrades tyramine in the gut and liver; when MAO is inhibited, tyramine enters circulation and triggers massive norepinephrine release causing hypertensive crisis.

Question 10: A PMHNP considers prescribing valproate to a woman of childbearing age. Which critical counseling point is mandatory?

Valproate has no documented teratogenic effects at low doses
Valproate is a Category X teratogen associated with neural tube defects and requires effective contraception (Correct answer)
Valproate is safe in the first trimester but must be stopped in the third
Monthly liver function tests replace the need for contraception counseling

Correct answer: Valproate is a Category X teratogen associated with neural tube defects and requires effective contraception

Valproate is a potent teratogen with a high risk of neural tube defects, spina bifida, and cognitive impairment in the fetus; contraception counseling is mandatory.

Question 11: A patient with a psychiatric advance directive has specified they do not want ECT under any circumstances. The patient is now incapacitated and the treatment team believes ECT is the best option. The PMHNP should:

Honor the advance directive and explore alternative treatments (Correct answer)
Ask the family to override the advance directive
Administer ECT because the team's clinical judgment supersedes advance directives
Override the directive because the patient lacked insight when writing it

Correct answer: Honor the advance directive and explore alternative treatments

Psychiatric advance directives are legally binding documents that express the patient's autonomous treatment preferences; they must be honored when the patient lacks decision-making capacity unless emergency exceptions apply.

Question 12: A PMHNP is conducting a Mental Status Examination (MSE). 'Affect' refers to:

The patient's ability to think abstractly
The observed external expression of emotion (Correct answer)
The patient's reported subjective emotional experience
The patient's insight into their illness

Correct answer: The observed external expression of emotion

Affect is the clinician-observed emotional expression, while mood is the patient's subjective report of their internal emotional state.

Question 13: A PMHNP is initiating lithium therapy. Which baseline laboratory test is MOST critical before starting treatment?

Hemoglobin A1c
Serum creatinine and thyroid-stimulating hormone (TSH) (Correct answer)
Liver function tests and CBC
Lipid panel and fasting glucose

Correct answer: Serum creatinine and thyroid-stimulating hormone (TSH)

Renal function (creatinine/GFR) and thyroid function (TSH) must be assessed before lithium initiation because lithium is renally cleared and causes hypothyroidism with long-term use.

Question 14: Which personality disorder cluster includes paranoid, schizoid, and schizotypal personality disorders?

Cluster D (not a DSM cluster)
Cluster A (odd/eccentric) (Correct answer)
Cluster B (dramatic/emotional)
Cluster C (anxious/fearful)

Correct answer: Cluster A (odd/eccentric)

Cluster A personality disorders are characterized by odd, eccentric behavior and include paranoid, schizoid, and schizotypal types.

Question 15: A nurse is applying motivational interviewing (MI) techniques. Which response best exemplifies a reflective listening statement?

'You should consider stopping drinking for your health.'
'It sounds like you feel torn between wanting to change and enjoying alcohol.' (Correct answer)
'Have you tried attending an AA meeting?'
'Most people in your situation find it helps to set a quit date.'

Correct answer: 'It sounds like you feel torn between wanting to change and enjoying alcohol.'

Reflective listening in MI involves mirroring the patient's expressed ambivalence without judging or directing, which builds rapport and fosters change talk.

Question 16: Which medication requires monitoring of fasting glucose and HbA1c due to its high risk of causing metabolic syndrome?

Haloperidol
Olanzapine (Correct answer)
Ziprasidone
Aripiprazole

Correct answer: Olanzapine

Olanzapine has the highest metabolic risk among antipsychotics, causing significant weight gain, hyperglycemia, and dyslipidemia requiring routine metabolic monitoring.

Question 17: A patient with PTSD is most likely to benefit from which evidence-based, trauma-focused psychotherapy?

Supportive therapy
Prolonged exposure (PE) therapy (Correct answer)
Client-centered therapy
Interpersonal psychotherapy (IPT)

Correct answer: Prolonged exposure (PE) therapy

Prolonged exposure therapy is a first-line, evidence-based treatment for PTSD that systematically reduces avoidance and fear through in vivo and imaginal exposure to trauma-related stimuli.

Question 18: Which legal principle established the duty to warn potential third-party victims of a patient's credible threat of harm?

Olmstead v. L.C.
O'Connor v. Donaldson
Wyatt v. Stickney
Tarasoff v. Regents of the University of California (Correct answer)

Correct answer: Tarasoff v. Regents of the University of California

Tarasoff v. Regents of the University of California (1976) established the legal duty to protect identifiable third parties when a patient makes a credible threat of harm.

Question 19: A PMHNP prescribes naltrexone for a patient with alcohol use disorder. What must be confirmed BEFORE initiating this medication?

The patient is opioid-free for at least 7–10 days (Correct answer)
The patient has completed an inpatient detoxification program
The patient's BMI is within normal limits
The patient has no history of depression

Correct answer: The patient is opioid-free for at least 7–10 days

Naltrexone is an opioid antagonist and must not be started until the patient has been opioid-free for 7–10 days to avoid precipitating acute opioid withdrawal.

Question 20: A patient with a long history of alcohol use disorder abruptly stops drinking after heavy daily use. Which vital sign pattern should alert the PMHNP to a risk of severe alcohol withdrawal (AWS)?

Orthostatic hypotension alone
Hypotension and bradypnea
Tachycardia, hypertension, and fever (Correct answer)
Bradycardia and hypothermia

Correct answer: Tachycardia, hypertension, and fever

Tachycardia, hypertension, diaphoresis, and fever during alcohol withdrawal reflect autonomic hyperactivity and can progress to seizures and delirium tremens.

Question 21: A patient reports hearing voices that tell them they are worthless. This auditory hallucination is best characterized as:

Command hallucinations
Derogatory hallucinations (Correct answer)
Commentary hallucinations
Referential hallucinations

Correct answer: Derogatory hallucinations

Derogatory hallucinations involve voices that insult or demean the patient, often worsening self-esteem and depression.

Question 22: A 70-year-old patient with dementia-related psychosis is prescribed haloperidol. What critical warning must be communicated to the family?

Antipsychotics are associated with increased mortality in elderly patients with dementia-related psychosis (Correct answer)
Haloperidol must be stopped after 4 weeks to prevent dependence
Haloperidol causes irreversible memory loss in elderly patients
The drug requires mandatory REMS enrollment for patients over 65

Correct answer: Antipsychotics are associated with increased mortality in elderly patients with dementia-related psychosis

All antipsychotics carry a black box warning of increased mortality (primarily cardiovascular and infectious causes) when used in elderly patients with dementia-related psychosis.

Question 23: A PMHNP conducting a mental status exam notes that a patient's speech jumps from one topic to another based on the sound of words rather than logical meaning. This is documented as:

Tangentiality
Flight of ideas
Circumstantiality
Clang associations (Correct answer)

Correct answer: Clang associations

Clang associations occur when the patient's speech is driven by the rhyme or sound of words rather than their semantic meaning, commonly seen in mania.

Question 24: The psychiatric and mental health nurse should recognize that when a patient with substance addiction disorder says he has been using "beanies," he is referring to:

Heroin
Methamphetamine (Correct answer)
Marijuana
Cocaine

Correct answer: Methamphetamine

The psychiatric and mental health nurse should recognize that if a patient with substance abuse disorder says they have been using "beanies," they are referring to methamphetamine, also known as "blue devils," "crank," and "crystal" as well as a variety of other local names. Heroin is also known as "horse," "H," "Aunt Hazel," "smack," and "charley," among other less popular names, while marijuana is known as "weed," "Aunt Mary," "Mary Jane," and "pot." Cocaine is also known as "coke," "blow,", "snow," and "sugar."

Question 25: A female client who has been diagnosed with grandiosity delusions is admitted. According to this diagnostic, the patient is:

Being Killed.
Responsible for an evil world.
Highly famous and important. (Correct answer)
Connected to the client unrelated to oneself.

Correct answer: Highly famous and important.

A false sense of fame and importance is called a delusion of grandeur. The erroneous conviction of one's own superiority, greatness, or brilliance is known as a delusion of grandeur. People who suffer from delusions of grandeur don't merely have high self-esteem; they actually hold this belief despite the tremendous amount of evidence to the contrary. For instance, someone who has never held a leadership position and has trouble interacting with others can think they are destined to rule the world. Persistence is the hallmark of grandiose delusions. They are not merely fleeting fantasies or future aspirations.

Question 26: Efraim was brought to the emergency room after receiving an amphetamine psychosis diagnosis. Which of the following medications would Nurse Philippe most likely get ready to administer?

Valium
Haldol (Correct answer)
Ativan
Librium

Correct answer: Haldol

To lessen agitation and psychotic symptoms, such as delusions, hallucinations, and cognitive impairment, the nurse would get ready to give an amphetamine psychosis patient an antipsychotic drug like Haldol. A first-generation (typical) antipsychotic drug with widespread usage is haloperidol. Haloperidol has been approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia, Tourette syndrome (control of tics and vocal utterances in adults and children), hyperactivity (which may present as impulsivity, difficulty focusing, severe aggression, mood instability, and frustration intolerance), severe childhood behavioral issues (such as combative, explosive hyperexcitability), and intractable hiccups. It treats positive symptoms of schizophrenia such hallucinations and delusions, making it a typical antipsychotic.

Question 27: A female patient with moderate dementia-related cognitive impairment would provide a health history, and the nurse would anticipate noting the following:

Accentuated premorbid traits (Correct answer)
Hypervigilance
Increased inhibitions
Enhance intelligence

Correct answer: Accentuated premorbid traits

Increased reliance on the environment and social structure, increased psychological rigidity, and amplified prior attitudes and behaviors are characteristics of dementia-related mild cognitive impairment. There are some situations where a treatable illness or disease's side effects are the root cause of minor cognitive impairment. The majority of people with mild cognitive impairment (MCI) are on the route to dementia, according to new findings from researchers. The MCI is regarded as the period that occurs between normal aging-related cognitive impairments and early-onset dementia.

Question 28: The nurse is evaluating a patient with schizophrenia who is disorganized. Which signs should the nurse anticipate the patient displaying?

Markedly regressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme. (Correct answer)
The patient is exhibiting delusions of persecution or grandeur. Auditory hallucinations related to a persecutory theme are present. The client is tense, suspicious, and guarded, and may be argumentative, hostile, and aggressive.
The patient has a history of active psychotic symptoms, but prominent psychotic symptoms are currently not exhibited.
Marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movements and activity. Waxy flexibility is exhibited.

Correct answer: Markedly regressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme.

A patient is most likely to be diagnosed with disorganized schizophrenia if they display clearly regressive and primitive conduct and have very little interaction with reality. A client's affect is flat or blatantly wrong in this subcategory. Social impairment is severe, and personal hygiene is disregarded.

Question 29: A patient is brought to the ED agitated and confused after ingesting an unknown substance. The nurse notes hyperthermia, diaphoresis, muscular rigidity, clonus, and hyperreflexia. The PMHNP suspects:

Serotonin syndrome (Correct answer)
Malignant hyperthermia
Anticholinergic toxidrome
Neuroleptic malignant syndrome (NMS)

Correct answer: Serotonin syndrome

Serotonin syndrome presents with the triad of mental status changes, autonomic instability, and neuromuscular abnormalities including clonus and hyperreflexia, distinguishing it from NMS.

Question 30: The concept of 'least restrictive environment' in psychiatric care means:

Treatment should be provided in the setting that meets clinical needs while maximizing patient freedom (Correct answer)
Patients should always be treated in outpatient settings regardless of acuity
Inpatient hospitalization should never be used for voluntary patients
Patients should only receive treatment in community settings

Correct answer: Treatment should be provided in the setting that meets clinical needs while maximizing patient freedom

The least restrictive environment principle requires that psychiatric treatment occur in the setting that addresses the patient's clinical needs while preserving the greatest degree of personal freedom and autonomy.

Question 31: Which finding on mental status examination is MOST characteristic of a patient experiencing a major depressive episode?

Grandiosity and decreased need for sleep
Tangentiality and loose associations
Pressured speech and flight of ideas
Psychomotor retardation and constricted affect (Correct answer)

Correct answer: Psychomotor retardation and constricted affect

Psychomotor retardation (slowed movement and speech) and constricted affect (reduced emotional expression) are hallmark MSE findings in major depressive disorder.

Question 32: A 70-year-old patient develops sudden onset confusion, agitation, and disorganized thinking 2 days after hip replacement surgery. The most likely diagnosis is:

Dementia with Lewy bodies
Frontotemporal dementia
First-episode schizophrenia
Delirium (Correct answer)

Correct answer: Delirium

Delirium is characterized by acute onset, fluctuating course, and disturbed attention/cognition, commonly precipitated by surgery, infection, or medications in older adults.

Question 33: A patient with a persistent alcohol use disorder presents physically with ophthalmoplegia, ataxia, disorientation, stupor, and somnolence. These statistics indicate that: is the most likely reason.

Thiamine deficiency (Correct answer)
Vitamin D deficiency
Iron deficiency
Vitamin C deficiency

Correct answer: Thiamine deficiency

The most common cause of ophthalmoplegia, ataxia, disorientation, stupor, and somnolence in a patient with persistent alcohol use disorder is vitamin B insufficiency, particularly thiamine (vitamin B1). These signs and symptoms make up the usual Wernicke disease triad. Wernicke-Korsakoff syndrome is the name given to the condition in which patients frequently also display confabulation, anterograde and retrograde amnesia, and other symptoms of Korsakoff's psychosis. If thiamine replacement therapy is not applied aggressively, these diseases are fatal.

Question 34: A patient on carbamazepine for bipolar disorder develops diplopia, ataxia, and elevated carbamazepine levels despite no dose change. What is the most likely explanation?

Renal failure reduced carbamazepine clearance
The patient developed carbamazepine-induced hypothyroidism
A new drug inhibited CYP3A4, raising carbamazepine levels (Correct answer)
Carbamazepine autoinduction of CYP3A4 has reversed

Correct answer: A new drug inhibited CYP3A4, raising carbamazepine levels

Carbamazepine is metabolized by CYP3A4; adding a CYP3A4 inhibitor (e.g., erythromycin, fluconazole) raises carbamazepine levels and can precipitate toxicity.

Question 35: A patient prescribed lithium develops nausea, vomiting, coarse tremor, and confusion. Serum lithium level is 2.1 mEq/L. What is the priority intervention?

Hold one dose and recheck in 6 hours
Administer activated charcoal
Reduce the lithium dose and add an antiemetic
Initiate hemodialysis (Correct answer)

Correct answer: Initiate hemodialysis

A lithium level above 2.0 mEq/L with severe neurological symptoms requires hemodialysis to rapidly remove lithium, as lithium is not bound to activated charcoal.

Question 36: Which neurotransmitter imbalance is most associated with the positive symptoms of schizophrenia?

Norepinephrine excess in the locus coeruleus
Serotonin excess in prefrontal cortex
Dopamine excess in the mesolimbic pathway (Correct answer)
GABA deficiency in the hippocampus

Correct answer: Dopamine excess in the mesolimbic pathway

Excess dopaminergic activity in the mesolimbic pathway is the primary mechanism underlying positive symptoms such as hallucinations and delusions in schizophrenia.

Question 37: An admission assessment is being done by the nurse on a patient who has paranoid schizophrenia. Which should the nurse take into account in order to get the most accurate evaluation information?

Much data will need to be gained by reviewing old records and talking with family members and significant others. (Correct answer)
Assessment of this client will be simple because of the commonly occurring nature of the disease process of schizophrenia.
This client will be able to make a significant contribution to history data collection.
The nurse will refer to the client’s global assessment of functioning score to determine client problems and nursing interventions.

Correct answer: Much data will need to be gained by reviewing old records and talking with family members and significant others.

Information for a background check must be acquired from a variety of sources, such as relatives and old documents. Due to communication and thinking deficiencies, a client experiencing an acute episode would be unable to provide accurate and insightful assessment data.

Question 38: Which second-generation antipsychotic carries the highest risk for metabolic syndrome, including significant weight gain and dyslipidemia?

Aripiprazole
Lurasidone
Ziprasidone
Clozapine (Correct answer)

Correct answer: Clozapine

Clozapine and olanzapine carry the highest risk of metabolic side effects among second-generation antipsychotics.

Question 39: A patient stabilized on sertraline begins rifampin for tuberculosis treatment. Which clinical outcome should the PMHNP anticipate?

No clinically significant interaction between these agents
Increased QTc prolongation risk from the combination
Elevated sertraline levels causing serotonin syndrome
Reduced sertraline efficacy due to CYP3A4 and CYP2C19 induction (Correct answer)

Correct answer: Reduced sertraline efficacy due to CYP3A4 and CYP2C19 induction

Rifampin is a potent inducer of multiple CYP enzymes including CYP3A4 and CYP2C19, significantly increasing sertraline metabolism and potentially causing recurrence of depression.

Question 40: Which neurotransmitter imbalance is most strongly associated with the positive symptoms of schizophrenia?

Dopamine excess in the mesolimbic pathway (Correct answer)
Norepinephrine deficiency in the locus coeruleus
GABA deficiency in the hippocampus
Serotonin excess in the prefrontal cortex

Correct answer: Dopamine excess in the mesolimbic pathway

Hyperactivity of dopamine in the mesolimbic pathway is the primary mechanism underlying positive symptoms such as hallucinations and delusions.

Question 41: Neuroleptic malignant syndrome (NMS) is a psychiatric emergency characterized by which four findings?

Hyperthermia, muscle rigidity, autonomic instability, altered consciousness (Correct answer)
Seizures, rash, hepatotoxicity, myoclonus
Bradycardia, hypotension, tremor, sedation
Akathisia, tardive dyskinesia, galactorrhea, QTc prolongation

Correct answer: Hyperthermia, muscle rigidity, autonomic instability, altered consciousness

NMS is characterized by hyperthermia, lead-pipe rigidity, autonomic instability, and altered mental status following antipsychotic use.

Question 42: The American Nurses Association Code of Ethics requires PMHNPs to address what in relation to cultural competence?

Only provide care to patients who share the PMHNP's cultural background
Advocate for health equity and recognize the influence of culture on mental health (Correct answer)
Refer all patients from minority backgrounds to culturally matched providers
Require patients to adapt to the dominant cultural framework of treatment

Correct answer: Advocate for health equity and recognize the influence of culture on mental health

The ANA Code of Ethics requires nurses to practice with cultural sensitivity, advocate for health equity, and recognize how cultural factors influence the patient's experience of mental health and treatment.

Question 43: A female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time," during postprandial monitoring. I was still able to purge after you sat with me yesterday. What is the best reply from the nurse? "Today, my objective is to do it twice."

“I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.” (Correct answer)
“I trust you not to purge.”
“Don’t worry. I won’t allow you to purge today.”
“How are you purging and when do you do it?”

Correct answer: “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.”

By undertaking postprandial monitoring to stop self-induced emesis, the nurse is establishing limits that the client is testing, and this response acknowledges that the client is doing so. Because they believe they have no control over any other element of their lives, clients with bulimia nervosa need to feel in charge of their diet. Nursing patients through treatment can be emotionally taxing because recovery requires patients to confront their darkest, most agonizing, and traumatic thoughts and feelings. When a patient also has a diagnosis of Obsessive-Compulsive Disorder (OCD), depression, or substance misuse, this emotional struggle may be made worse because these conditions may call for more intensive one-on-one counseling.

Question 44: In prolonged exposure (PE) therapy for PTSD, which technique involves the patient repeatedly narrating the traumatic memory aloud?

Imaginal exposure (Correct answer)
In vivo exposure
Systematic desensitization
Flooding

Correct answer: Imaginal exposure

Imaginal exposure requires the patient to verbally revisit the traumatic memory in detail to reduce its emotional charge.

Question 45: A PMHNP identifies a patient as having homicidal ideation toward a specific person. Under Tarasoff duty, the clinician must:

Warn the identified victim and notify law enforcement (Correct answer)
Increase medication doses and monitor
Refer the patient to social work only
Maintain confidentiality and document only

Correct answer: Warn the identified victim and notify law enforcement

The Tarasoff ruling established the duty to protect identifiable potential victims, including warning them and notifying law enforcement.

Question 46: Exposure and response prevention (ERP) is the behavioral component of CBT most effective for treating:

Bipolar II disorder
Dissociative identity disorder
Obsessive-compulsive disorder (OCD) (Correct answer)
Major depressive disorder

Correct answer: Obsessive-compulsive disorder (OCD)

ERP involves exposing patients to feared stimuli while preventing compulsive responses, directly targeting OCD's core cycle.

Question 47: In the DSM-5, 'with peripartum onset' specifier for a major depressive episode requires that symptoms begin:

Only postpartum, within 4 weeks of delivery
Only during pregnancy, not postpartum
At any point in the first year postpartum
During pregnancy or within 4 weeks after delivery (Correct answer)

Correct answer: During pregnancy or within 4 weeks after delivery

DSM-5 changed the specifier from 'postpartum' to 'peripartum onset,' applying it to episodes beginning during pregnancy or within 4 weeks of delivery.

Question 48: A patient with major depressive disorder has not responded to two adequate SSRI trials. The PMHNP considers augmentation. Which agent is FDA-approved for adjunctive treatment of MDD?

Clonazepam
Aripiprazole (Correct answer)
Hydroxyzine
Gabapentin

Correct answer: Aripiprazole

Aripiprazole is FDA-approved as an adjunctive therapy to antidepressants in adults with major depressive disorder who have had an inadequate response.

Question 49: A PMHNP prescribes lithium for a patient with bipolar I disorder. Which patient statement indicates a need for additional teaching?

I can skip blood levels once I feel stable on lithium. (Correct answer)
I should maintain consistent fluid and sodium intake.
I will avoid NSAIDs and use acetaminophen for pain.
I will call if I experience tremor, nausea, or confusion.

Correct answer: I can skip blood levels once I feel stable on lithium.

Lithium has a narrow therapeutic index and requires ongoing serum level monitoring even when the patient feels stable to prevent toxicity.

Question 50: Which nursing diagnosis best fits the needs of a patient who is away from home for the first time in a year, arrives at the mental in-patient unit wearing a surgical mask and white gloves, and cries, "The germs in here are going to kill me."

Ineffective coping AEB dysfunctional isolation R /T unrealistic fear of germs.
Social isolation R /T fear of germs AEB continually refusing to leave the home. (Correct answer)
Anxiety R /T the inability to leave home, resulting in dysfunctional fear of germs.
Fear of germs R /T obsessive-compulsive disorder, resulting in dysfunctional isolation.

Correct answer: Social isolation R /T fear of germs AEB continually refusing to leave the home.

The North American Nursing Diagnosis Association (NANDA) states that the nursing diagnosis format must include three key elements: (1) identification of the health problem; (2) presentation of the etiology (or cause) of the problem; and (3) description of a group of symptoms known as "defining characteristics." The correct response includes all three elements in the proper order: health problem/NANDA stem (social isolation); etiology/cause, or R /T Due to a fear of germs, this client has been unable to leave the house for a year. As a result, the client's behaviors fit the description of social isolation.

Question 51: The Mini-Mental State Examination (MMSE) is used primarily to assess which domain?

Cognitive functioning (Correct answer)
Psychotic symptom severity
Depressive symptom severity
Personality pathology

Correct answer: Cognitive functioning

The MMSE screens for cognitive impairment across orientation, memory, attention, language, and visuospatial domains.

Question 52: A PMHNP applying trauma-informed care (TIC) principles encounters a patient who becomes suddenly fearful and dissociates during an assessment. The priority intervention is:

Proceed quickly with the assessment to minimize disruption
Gently reorient the patient using grounding techniques and pause the assessment (Correct answer)
Administer a PRN benzodiazepine immediately
Document the behavior and continue when the patient is calmer without acknowledging it

Correct answer: Gently reorient the patient using grounding techniques and pause the assessment

Trauma-informed care prioritizes safety; grounding techniques help restore present-moment awareness and demonstrate respect for the patient's response to trauma cues.

Question 53: A patient taking lithium presents with coarse tremor, ataxia, slurred speech, and confusion. Serum lithium is 2.4 mEq/L. What is the priority nursing action?

Prepare the patient for hemodialysis and ensure IV access (Correct answer)
Administer activated charcoal
Administer sodium bicarbonate to alkalinize the urine
Hold the next dose and recheck level in 6 hours

Correct answer: Prepare the patient for hemodialysis and ensure IV access

A lithium level above 2.0 mEq/L with neurological symptoms is a life-threatening emergency; hemodialysis is the definitive treatment to rapidly remove lithium.

Question 54: A patient with PTSD is treated with Prolonged Exposure (PE) therapy. What is the core mechanism of this treatment?

Teaching relaxation skills to manage physiological arousal
Replacing traumatic memories with positive ones through EMDR
Restructuring maladaptive core beliefs through Socratic questioning
Reducing avoidance by systematically confronting trauma-related stimuli (Correct answer)

Correct answer: Reducing avoidance by systematically confronting trauma-related stimuli

PE works through extinction learning by having patients repeatedly confront avoided trauma cues, reducing fear responses over time.

Question 55: Which documentation standard is most critical for the PMHNP to follow when managing a suicidal patient in an outpatient setting?

Documentation is only required for inpatient settings
Document only the patient's verbal statements about suicidality
Document only the interventions performed
Document the risk assessment, clinical reasoning, safety plan, and rationale for treatment decisions (Correct answer)

Correct answer: Document the risk assessment, clinical reasoning, safety plan, and rationale for treatment decisions

Thorough documentation of risk assessment findings, clinical reasoning, safety planning, and the rationale for level-of-care decisions is essential for both patient safety and professional liability protection.

Question 56: Which psychotherapy is based on the idea that improving interpersonal relationships and role functioning reduces psychiatric symptoms?

Interpersonal therapy (IPT) (Correct answer)
Existential therapy
Cognitive processing therapy
Behavioral activation

Correct answer: Interpersonal therapy (IPT)

IPT focuses on grief, role disputes, role transitions, and interpersonal deficits as key areas contributing to depression and other disorders.

Question 57: Which instrument is the gold standard for measuring the severity of alcohol withdrawal?

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) (Correct answer)
PHQ-9
CAGE questionnaire
Addiction Severity Index (ASI)

Correct answer: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

The CIWA-Ar is the validated tool for assessing and guiding pharmacological management of alcohol withdrawal severity.

Question 58: A patient with schizophrenia believes that a television news anchor is sending personal messages specifically to them. This is an example of:

Grandiose delusion
Ideas of reference (Correct answer)
Thought broadcasting
Persecutory delusion

Correct answer: Ideas of reference

Ideas of reference involve the belief that external events, objects, or people have special personal significance directed specifically at oneself.

Question 59: Which of the following medications should Nurse Rose get ready to give to a patient who has dangerous levels of acetaminophen (Tylenol)?

Acetylcysteine (Mucomyst) (Correct answer)
Succimer (Chemet)
Deferoxamine mesylate (Desferal)
Flumazenil (Romazicon)

Correct answer: Acetylcysteine (Mucomyst)

Acetylcysteine is the remedy for acetaminophen poisoning. It speeds up the transition from harmful to nontoxic metabolites. The fact that acetaminophen (N-acetyl-para-aminophenol, also known as paracetamol or APAP) is widely available and widely believed to be safe is a major contributing factor to its frequent toxicity. Every week, more than 60 million Americans take acetaminophen. N-acetyl-cysteine (NAC) therapy is required for all individuals with excessive acetaminophen levels. If administered within eight hours of consumption, this medication offers complete protection against liver damage.

Question 60: When prescribing SSRIs for children and adolescents, the FDA black box warning requires informing families about increased risk of:

Suicidal ideation and behavior in patients under 25 (Correct answer)
QTc prolongation
Serotonin syndrome in all pediatric patients
Tardive dyskinesia

Correct answer: Suicidal ideation and behavior in patients under 25

The FDA black box warning on antidepressants requires clinicians to monitor for increased suicidal ideation and behavior in children, adolescents, and young adults.

Question 61: Which therapy is most evidence-based for treating borderline personality disorder (BPD)?

Rational emotive behavior therapy
Dialectical Behavior Therapy (DBT) (Correct answer)
Solution-focused therapy
Psychoanalysis

Correct answer: Dialectical Behavior Therapy (DBT)

DBT was specifically developed by Marsha Linehan for BPD and has the strongest evidence base for this population.

Question 62: A patient experiencing acute dystonia after receiving haloperidol is best treated with:

Diphenhydramine IM or benztropine IM (Correct answer)
Dantrolene IV
Propranolol PO
Lorazepam IV

Correct answer: Diphenhydramine IM or benztropine IM

Acute dystonia is treated with anticholinergic agents such as benztropine or antihistamines such as diphenhydramine, which rapidly reverse muscle spasms.

Question 63: During a manic crisis, a patient refuses medication and is destroying property. Which intervention is the MOST appropriate next step?

Initiate a least restrictive intervention and document behaviors (Correct answer)
Discharge the patient immediately
Wait for the episode to resolve naturally
Ignore the behavior to avoid reinforcing it

Correct answer: Initiate a least restrictive intervention and document behaviors

Least restrictive intervention with thorough documentation is required before escalating to more coercive measures.

Question 64: A PMHNP using the SLAP mnemonic to assess lethality of a suicide plan is assessing which four elements?

Suicidal thoughts, Lethality, Attempt history, Plan specificity
Severity, Location, Availability, Proximity to rescue
Seriousness, Lethality, Availability, Proximity (Correct answer)
Severity, Likelihood, Agitation, Plan

Correct answer: Seriousness, Lethality, Availability, Proximity

The SLAP mnemonic assesses the Seriousness of intent, Lethality of the chosen method, Availability of the means, and Proximity of rescue.

Question 65: A PMHNP is considering prescribing naltrexone for alcohol use disorder. Which condition is an ABSOLUTE contraindication?

Current physiological opioid dependence or acute opioid use (Correct answer)
Concurrent use of ibuprofen
Mildly elevated liver enzymes (3x ULN)
Active depression with suicidal ideation

Correct answer: Current physiological opioid dependence or acute opioid use

Naltrexone is an opioid antagonist and will precipitate severe acute opioid withdrawal in patients who are physiologically dependent on opioids, making current opioid dependence an absolute contraindication.

Question 66: A patient discloses in an outpatient session that they molested a child two years ago but claim it will never happen again. The PMHNP is legally required to:

Report the disclosed past abuse to child protective services per mandatory reporting laws (Correct answer)
Refer the patient to a specialized therapist and transfer care
Only report if there is evidence of ongoing or current abuse
Maintain confidentiality since the abuse occurred in the past

Correct answer: Report the disclosed past abuse to child protective services per mandatory reporting laws

Mandatory reporting laws in most states require clinicians to report known or reasonably suspected child abuse regardless of when it occurred, as a child may still be at risk or other children could be in danger.

Question 67: Which DSM-5 specifier distinguishes a manic episode with flight of ideas, decreased need for sleep, and grandiosity lasting 4 days without hospitalization?

Mixed features specifier
Cyclothymic disorder
Manic episode
Hypomanic episode (Correct answer)

Correct answer: Hypomanic episode

Hypomanic episodes last at least 4 days, are not severe enough to require hospitalization, and do not cause marked functional impairment.

Question 68: A PMHNP is assessing negative symptoms of schizophrenia. Which symptom cluster is classified as 'negative'?

Thought insertion and broadcasting
Alogia, anhedonia, avolition, and flat affect (Correct answer)
Hallucinations and delusions
Disorganized speech and behavior

Correct answer: Alogia, anhedonia, avolition, and flat affect

Negative symptoms represent a diminution of normal functions, including restricted speech (alogia), lack of pleasure (anhedonia), lack of motivation (avolition), and flattened affect.

Question 69: A nurse practitioner is evaluating a 16-year-old who self-harms by cutting. Which therapeutic approach has the strongest evidence base for this population?

Dialectical Behavior Therapy adapted for adolescents (DBT-A) (Correct answer)
Trauma-focused cognitive behavioral therapy (TF-CBT)
Psychodynamic therapy with weekly sessions
Motivational interviewing focused on harm reduction

Correct answer: Dialectical Behavior Therapy adapted for adolescents (DBT-A)

DBT-A is specifically designed for suicidal and self-harming adolescents and has the strongest RCT evidence for reducing non-suicidal self-injury in this age group.

Question 70: Under HIPAA, which situation allows a PMHNP to disclose psychiatric records without patient authorization?

A patient's employer requests information to assess fitness for duty
Law enforcement requests records to investigate a minor traffic violation
A patient's spouse requests information out of concern
Disclosure is necessary to avert a serious and imminent threat to the patient or others (Correct answer)

Correct answer: Disclosure is necessary to avert a serious and imminent threat to the patient or others

HIPAA permits disclosure without authorization when necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Question 71: Behavioral activation therapy for depression primarily works by:

Increasing engagement in rewarding activities to improve mood (Correct answer)
Teaching breathing relaxation techniques
Analyzing dream content
Exploring childhood trauma

Correct answer: Increasing engagement in rewarding activities to improve mood

Behavioral activation breaks the cycle of depression and avoidance by scheduling and increasing participation in pleasurable or meaningful activities.

Question 72: A PMHNP is treating a patient with intellectual disability (ID) and severe self-injurious behavior. Pharmacotherapy should:

Be avoided entirely in patients with ID
Always begin with antipsychotics regardless of diagnosis
Be used adjunctively with behavioral interventions after identifying the function of the behavior (Correct answer)
Be the first and only treatment modality

Correct answer: Be used adjunctively with behavioral interventions after identifying the function of the behavior

In ID, behavioral analysis to identify the function of self-injury is essential before or alongside pharmacotherapy, as medications address symptoms rather than causes.

Question 73: A PMHNP is evaluating a patient who reports 'hearing voices telling me to hurt myself.' What is the priority intervention?

Administer a PRN antipsychotic
Teach the patient to distract from the voices
Assess the nature, frequency, and command quality of the hallucinations (Correct answer)
Immediately initiate involuntary hospitalization

Correct answer: Assess the nature, frequency, and command quality of the hallucinations

A thorough assessment of command hallucinations—including content, frequency, and the patient's intent to act—is the priority before determining next steps.

Question 74: A PMHNP is assessing a patient using motivational interviewing. Which technique best exemplifies the 'rolling with resistance' strategy?

Arguing against the patient's denial of a substance problem
Providing direct advice about stopping substance use immediately
Confronting the patient about the consequences of their behavior
Reflecting the patient's ambivalence without challenging it directly (Correct answer)

Correct answer: Reflecting the patient's ambivalence without challenging it directly

Rolling with resistance in motivational interviewing involves acknowledging ambivalence and reflecting it back rather than confronting or arguing, reducing defensiveness.

Question 75: A patient on clozapine develops a fever, sore throat, and absolute neutrophil count (ANC) of 400 cells/mm³. What is the appropriate action?

Administer prophylactic antibiotics and continue clozapine
Reduce the clozapine dose by 50%
Discontinue clozapine immediately and notify the prescriber (Correct answer)
Recheck the ANC in 48 hours before making changes

Correct answer: Discontinue clozapine immediately and notify the prescriber

An ANC below 500 cells/mm³ indicates severe neutropenia (agranulocytosis), requiring immediate discontinuation of clozapine to prevent fatal infection.

Question 76: A PMHNP treating a patient with anorexia nervosa should monitor MOST closely for which life-threatening electrolyte complication?

Hypernatremia
Hypercalcemia
Hypokalemia and hypophosphatemia (Correct answer)
Hypermagnesemia

Correct answer: Hypokalemia and hypophosphatemia

Hypokalemia and hypophosphatemia (especially refeeding syndrome) in anorexia nervosa can cause fatal cardiac arrhythmias and require vigilant electrolyte monitoring.

Question 77: A patient with bipolar I disorder is prescribed lithium. Which laboratory value requires the most immediate intervention?

TSH of 3.2 mIU/L
Serum lithium level of 1.8 mEq/L (Correct answer)
Serum lithium level of 0.8 mEq/L
Serum creatinine of 0.9 mg/dL

Correct answer: Serum lithium level of 1.8 mEq/L

A serum lithium level of 1.8 mEq/L is above the therapeutic range (0.6–1.2 mEq/L) and indicates toxicity requiring immediate intervention.

Question 78: A patient with ADHD and comorbid bipolar disorder requires pharmacological treatment. Which approach is MOST appropriate?

Stabilize the bipolar disorder with a mood stabilizer before treating ADHD (Correct answer)
Avoid all pharmacotherapy due to the complexity of comorbidity
Use an MAOI to address both conditions simultaneously
Start a stimulant immediately to address ADHD as the primary diagnosis

Correct answer: Stabilize the bipolar disorder with a mood stabilizer before treating ADHD

In ADHD-bipolar comorbidity, the bipolar disorder must be stabilized first with a mood stabilizer to prevent stimulants from triggering mania or rapid cycling.

Question 79: Which educational requirement is crucial when buspirone (BuSpar) 5 mg tid is first prescribed to a patient?

Encourage the patient to be compliant with monthly lab tests to monitor for medication toxicity.
Encourage the patient to avoid drinking alcohol while taking this medication because of the additive central nervous system depressant effects.
Encourage the patient to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks. (Correct answer)
Encourage the patient to monitor for signs and symptoms of anxiety to determine need for additional buspirone (BuSpar) PRN.

Correct answer: Encourage the patient to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks.

Unlike benzodiazepines, which depress the central nervous system, buspirone (BuSpar) is an anti-anxiety drug. The drug's exact mechanism of action is unknown, however it is thought to interact with serotonin, dopamine, and other neurotransmitter receptors to achieve the intended effects. It is crucial to inform the client that buspirone (BuSpar) takes 2–3 weeks to start working. Because of the benzodiazepine's early beginning of action, the nurse may frequently observe the prescription of clonazepam before the buspirone starts to take effect.

Question 80: In motivational interviewing, what does the acronym OARS stand for?

Objectives, Actions, Reflections, Solutions
Open questions, Affirmations, Reflections, Summaries (Correct answer)
Outcomes, Assessments, Referrals, Support
Open questions, Alternatives, Reasoning, Strategies

Correct answer: Open questions, Affirmations, Reflections, Summaries

OARS represents the core communication techniques used in motivational interviewing to build rapport and elicit change talk.

Question 81: A PMHNP is treating an adolescent with depression and learns the patient disclosed abuse by a family member. The PMHNP's FIRST legal and ethical obligation is to:

Consult a colleague before making any report
Maintain confidentiality to preserve the therapeutic alliance
Discuss the disclosure with the patient's parents before acting
Report the suspected abuse to the appropriate child protective services (Correct answer)

Correct answer: Report the suspected abuse to the appropriate child protective services

As a mandated reporter, the PMHNP must immediately report suspected child abuse to child protective services regardless of the therapeutic relationship or parental consent.

Question 82: Which axis of the former DSM-IV multiaxial system was designated for personality disorders and intellectual disabilities?

Axis I
Axis II (Correct answer)
Axis IV
Axis III

Correct answer: Axis II

DSM-IV Axis II was designated for personality disorders and intellectual developmental disorders, distinguishing them from Axis I clinical syndromes.

Question 83: A PMHNP assessing insight asks a patient, 'Do you think you have a mental illness?' A patient who denies having any illness despite clear evidence demonstrates:

Poor insight (Correct answer)
Nihilistic delusions
Anosognosia
Concrete thinking

Correct answer: Poor insight

Poor insight refers to a patient's limited awareness or acknowledgment of their mental illness, which often impacts medication adherence.

Question 84: Which protective factor most strongly reduces suicide risk during crisis assessment?

Reasons for living and strong social support (Correct answer)
Current antidepressant use
Financial stability
Previous psychiatric hospitalizations

Correct answer: Reasons for living and strong social support

Strong reasons for living and robust social support networks are among the most consistently identified protective factors against suicide.

Question 85: A woman of childbearing potential is being started on valproate for bipolar disorder. What is the most critical counseling point?

Valproate carries a high risk of neural tube defects and requires reliable contraception (Correct answer)
Valproate is preferred over lithium in pregnancy
Folate supplementation eliminates valproate's teratogenic risk
Valproate is safe during the first trimester only

Correct answer: Valproate carries a high risk of neural tube defects and requires reliable contraception

Valproate is a major teratogen associated with neural tube defects (spina bifida), cognitive impairment in offspring, and requires a REMS program with mandatory contraception.

Question 86: A PMHNP documents 'loosening of associations' in a patient. This thought process abnormality means:

The patient shifts topic in response to sound rather than meaning
The patient abruptly stops mid-sentence
The patient's thinking shifts between topics with tenuous connections (Correct answer)
The patient repeats words or phrases involuntarily

Correct answer: The patient's thinking shifts between topics with tenuous connections

Loosening of associations describes fragmented, illogical thinking where ideas shift with weak or absent logical connections.

Question 87: A PMHNP using Acceptance and Commitment Therapy (ACT) would primarily help patients to:

Practice progressive muscle relaxation
Accept difficult emotions and commit to value-driven actions (Correct answer)
Eliminate all negative thoughts
Analyze childhood experiences

Correct answer: Accept difficult emotions and commit to value-driven actions

ACT promotes psychological flexibility by accepting internal experiences and aligning behavior with personal values.

Question 88: Which long-acting injectable antipsychotic formulation has the longest dosing interval, allowing once-every-3-month administration?

Paliperidone palmitate 3-month (Invega Trinza) (Correct answer)
Paliperidone palmitate 1-month (Invega Sustenna)
Risperidone microspheres (Risperdal Consta)
Aripiprazole monohydrate (Abilify Maintena)

Correct answer: Paliperidone palmitate 3-month (Invega Trinza)

Paliperidone palmitate 3-month (Invega Trinza) is the only LAI antipsychotic approved for once-every-3-month dosing, improving adherence in stabilized patients.

Question 89: Which psychotherapy modality uses homework assignments, Socratic questioning, and thought records as core techniques?

Cognitive-behavioral therapy (CBT) (Correct answer)
Narrative therapy
Psychodynamic therapy
Gestalt therapy

Correct answer: Cognitive-behavioral therapy (CBT)

CBT uses structured tools like thought records, behavioral experiments, and Socratic questioning to challenge cognitive distortions.

Question 90: Which benzodiazepine is preferred in elderly patients due to its lack of active metabolites and shorter half-life?

Chlordiazepoxide
Diazepam
Lorazepam (Correct answer)
Clonazepam

Correct answer: Lorazepam

Lorazepam undergoes direct glucuronidation without active metabolites and has a shorter half-life, reducing cumulative CNS depression in elderly patients (LOT = Lorazepam, Oxazepam, Temazepam preferred).

Question 91: A patient with posttraumatic stress disorder is almost ready to be released. Which client comment would suggest that the effectiveness of education about the psychosocial causes of posttraumatic stress disorder?

“Because of the trauma, I have a negative perception of the world and feel hopeless."
“So, natural opioid release during the trauma caused my body to become ‘addicted.’”
“I understand that the event I experienced, and how I deal with it, and my support system, all affect my disease process.” (Correct answer)
“I have learned to avoid stressful situations as a way to decrease emotional pain.”

Correct answer: “I understand that the event I experienced, and how I deal with it, and my support system, all affect my disease process.”

The patient shows a solid awareness of the psychosocial causes of posttraumatic stress disorder (PTSD) when they express understanding of how the experienced event, personal characteristics, and available support networks affect their diagnosis.

Question 92: A teenager presents with sudden onset of paralysis in one arm with no neurological findings on MRI. The patient recently witnessed a traumatic accident. The PMHNP suspects which condition?

Somatic symptom disorder
Malingering disorder
Factitious disorder
Conversion disorder (Functional Neurological Symptom Disorder) (Correct answer)

Correct answer: Conversion disorder (Functional Neurological Symptom Disorder)

Conversion disorder presents with neurological symptoms (paralysis, blindness, seizures) incompatible with neurological disease, often triggered by psychological stress.

Question 93: Which professional standard best defines the PMHNP's scope of practice?

Set only by the employing institution
Defined by the ANA/APNA Psychiatric-Mental Health Nursing: Scope and Standards of Practice, state nurse practice acts, and institutional policies (Correct answer)
Limited to what Medicare and Medicaid reimburse
Determined solely by the individual PMHNP's personal skills and comfort level

Correct answer: Defined by the ANA/APNA Psychiatric-Mental Health Nursing: Scope and Standards of Practice, state nurse practice acts, and institutional policies

PMHNP scope of practice is governed by the ANA/APNA Scope and Standards of Practice, state nurse practice acts and regulations, and facility-level policies and credentialing.

Question 94: Which of the following describes the appropriate use of flumazenil in benzodiazepine overdose?

It is the first-line treatment and should be given to all benzodiazepine overdose patients
It should be avoided in patients with chronic benzodiazepine use due to risk of precipitating seizures (Correct answer)
It provides sustained reversal lasting 8-12 hours, eliminating need for monitoring
It reverses opioid co-ingestion as well, making it useful in mixed overdoses

Correct answer: It should be avoided in patients with chronic benzodiazepine use due to risk of precipitating seizures

Flumazenil can precipitate life-threatening withdrawal seizures in benzodiazepine-dependent patients and should be used cautiously; it is not routinely recommended in chronic users.

Question 95: A female client who poses a serious suicide risk requires strict surveillance. In order to best guarantee the client's safety, Nurse Shenny ought to?

Check the client frequently at irregular intervals throughout the night. (Correct answer)
Repeatedly discuss previous suicide attempts with the client.
Disregard decreased communication by the client because this is common with suicidal clients.
Assure the client that the nurse will hold in confidence anything the client says.

Correct answer: Check the client frequently at irregular intervals throughout the night.

The patient cannot predict when an observation will occur and change behavior in a misleading way at these times if they are checked often but at unpredictable intervals. When the patient is determined to be at risk of suicide, immediate intervention measures must be taken. The person cannot be left alone. While at home, enlist the assistance of a support person. The suicidal person has to be treated in a secure setting. The area also has to be watched over.

Question 96: Which psychotherapy approach focuses on identifying and modifying distorted thought patterns that contribute to emotional distress?

Psychoanalytic therapy
Gestalt therapy
Cognitive-behavioral therapy (CBT) (Correct answer)
Interpersonal therapy

Correct answer: Cognitive-behavioral therapy (CBT)

CBT targets maladaptive cognitive distortions and behaviors to reduce psychological symptoms.

Question 97: A male patient who overdosed on oxazepam (Serax) has been prescribed flumazenil (Romazicon). Which typical side effect should nurse Gina be ready for before to delivering the medication?

Shivering
Seizures (Correct answer)
Chest pain
Anxiety

Correct answer: Seizures

The most frequent significant side effect of administering flumazenil to treat benzodiazepine overdose is seizures. If the client overdoses on both benzodiazepines and tricyclic antidepressants, the damage is amplified. Seizures and benzodiazepine reversal are related. Patients who have used benzodiazepines for prolonged sedation or who are exhibiting symptoms of severe tricyclic antidepressant overdose may experience seizures more frequently. To treat seizures, doctors should measure and prepare the appropriate dosage of Flumazenil. In patients who depend on a benzodiazepine for seizure control, flumazenil use needs to be cautious.

Question 98: A patient on disulfiram for alcohol use disorder inadvertently uses an aftershave containing 70% ethanol. What reaction is expected and what is the mechanism?

Severe respiratory depression from combined CNS depressant effects
Mild euphoria due to disulfiram potentiating ethanol's CNS effects
No reaction because skin absorption of ethanol is insufficient to cause a disulfiram reaction
Flushing, nausea, tachycardia, and hypotension due to acetaldehyde accumulation from ALDH inhibition (Correct answer)

Correct answer: Flushing, nausea, tachycardia, and hypotension due to acetaldehyde accumulation from ALDH inhibition

Disulfiram inhibits aldehyde dehydrogenase (ALDH), causing acetaldehyde to accumulate when any ethanol source is absorbed, producing the aversive disulfiram-ethanol reaction even from topical exposures.

Question 99: A PMHNP discovers that a colleague is prescribing controlled substances to patients without appropriate clinical indications. The PMHNP's ethical obligation is to:

Report the behavior through appropriate institutional or regulatory channels (Correct answer)
Ignore the situation as it involves a colleague
Confront the colleague publicly at a staff meeting
Only act if a patient files a formal complaint

Correct answer: Report the behavior through appropriate institutional or regulatory channels

Ethical and legal obligations require PMHNPs to report unsafe or illegal prescribing practices through appropriate channels such as hospital administration, the state board of nursing, or the DEA.

Question 100: The psychiatric and mental health nurse is followed by a patient who has been really angry because his girlfriend dumped him while he was in the hospital. He insults the nurse and claims that she is trying to thwart his therapy. This is probably an illustration of:

Transference (Correct answer)
Displacement
Obsession
Countertransference

Correct answer: Transference

When a patient starts to follow the psychiatric and mental health nurse, criticizing her and implying that she is attempting to sabotage his therapy, he is displaying transference. This patient has been really unhappy because his girlfriend dumped him while he was in the hospital. Affection or anger can be transferred from one person to another due to unconscious identification, which is known as transference. A nurse's or therapist's emotional response to the patient is called countertransference.

Question 101: A patient in an inpatient psychiatric unit is placed in seclusion. According to CMS regulations, how frequently must the patient be assessed by a qualified clinician?

Within 1 hour of initiation and then per state/facility policy with physician oversight (Correct answer)
Every 15 minutes by a registered nurse only
Every 1 hour by a physician or licensed independent practitioner
Every 4 hours by any staff member

Correct answer: Within 1 hour of initiation and then per state/facility policy with physician oversight

CMS Conditions of Participation require that a licensed independent practitioner (LIP) conduct an in-person evaluation within 1 hour of initiating seclusion or restraint, with ongoing monitoring per policy.

Question 102: When a patient meets criteria for involuntary psychiatric hospitalization, which legal standard most commonly applies in the US?

Physician agreement with family
Preponderance of evidence
Court order required in all cases
Imminent danger to self or others due to mental illness (Correct answer)

Correct answer: Imminent danger to self or others due to mental illness

Involuntary holds in the US require evidence of a mental illness causing imminent risk of harm to self or others.

Question 103: Which cognitive distortion does a patient demonstrate when they say, 'I failed one exam, so I'll never pass any test and I'm a total failure'?

Overgeneralization (Correct answer)
Magnification
Mind reading
Personalization

Correct answer: Overgeneralization

Overgeneralization involves drawing sweeping negative conclusions from a single event and applying them broadly across situations.

Question 104: In psychiatric advanced practice nursing, competency refers to:

A clinical judgment made by the PMHNP at the bedside
Whether a patient can perform activities of daily living independently
A legal determination made by a court regarding a person's ability to make decisions (Correct answer)
The patient's score on a cognitive screening tool

Correct answer: A legal determination made by a court regarding a person's ability to make decisions

Competency is a legal determination made by a court or judge, whereas decision-making capacity is a clinical assessment performed by the treating clinician.

Question 105: According to the DSM-5, how long must symptoms of generalized anxiety disorder (GAD) persist to meet diagnostic criteria?

At least 1 month
At least 6 months (Correct answer)
At least 2 weeks
At least 1 year

Correct answer: At least 6 months

DSM-5 requires excessive anxiety and worry occurring more days than not for at least 6 months to diagnose GAD.

Question 106: The Montreal Cognitive Assessment (MoCA) differs from the MMSE in that it:

Focuses exclusively on memory
Is more sensitive to mild cognitive impairment (MCI) (Correct answer)
Takes longer to administer
Assesses psychotic symptoms

Correct answer: Is more sensitive to mild cognitive impairment (MCI)

The MoCA has greater sensitivity than the MMSE for detecting mild cognitive impairment, particularly in executive functioning and attention.

Question 107: A PMHNP is implementing Dialectical Behavior Therapy (DBT). Which skill module teaches patients to tolerate painful emotions without acting impulsively?

Distress tolerance (Correct answer)
Mindfulness
Interpersonal effectiveness
Emotion regulation

Correct answer: Distress tolerance

Distress tolerance skills help patients endure crisis situations without making them worse.

Question 108: When a PMHNP experiences strong emotional reactions to a patient based on their own unresolved issues, this is called:

Vicarious traumatization
Empathic resonance
Countertransference (Correct answer)
Transference

Correct answer: Countertransference

Countertransference refers to the clinician's emotional reactions to the patient that are rooted in the clinician's own history and conflicts.

Question 109: A patient with opioid use disorder is being considered for medication-assisted treatment (MAT). Which medication can be prescribed by a PMHNP in an office-based setting without a specialized DEA waiver?

Heroin-assisted treatment
Methadone for opioid use disorder
Buprenorphine/naloxone (Suboxone)
Injectable naltrexone (Vivitrol) (Correct answer)

Correct answer: Injectable naltrexone (Vivitrol)

Naltrexone (oral or injectable) does not require a DEA waiver and can be prescribed in any outpatient setting by a licensed prescriber for opioid use disorder.

Question 110: A PMHNP notes that a patient consistently misinterprets neutral facial expressions as hostile. This cognitive distortion is best described as:

Mind reading (Correct answer)
Emotional reasoning
Personalization
Catastrophizing

Correct answer: Mind reading

Mind reading is the distortion of assuming one knows what others are thinking, often in a negative direction, without actual evidence.

Question 111: Which validated tool is commonly used by PMHNPs to assess suicide risk in emergency settings?

CAGE questionnaire
GAD-7
PHQ-9
Columbia Suicide Severity Rating Scale (C-SSRS) (Correct answer)

Correct answer: Columbia Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a standardized, evidence-based tool that quantifies suicidal ideation and behavior severity.

Question 112: Male client being treated by nurse Mench has erroneous sensory sensations that have no rational justification. This impression is referred to as:

Neologisms
Delusions
Loose associations
Hallucinations (Correct answer)

Correct answer: Hallucinations

Hallucinations are unfounded sensory sensations, such as those that are visual, aural, gustatory, tactile, or olfactory. Hallucinations are defined as "sensory experiences that are not caused by stimulation of the relevant sensory organs" and the "perception of a nonexistent object or event" Hallucinations are common in people with psychiatric conditions, such as schizophrenia and bipolar disorder, but you don't necessarily need to have a mental illness to experience them.

Question 113: A PMHNP evaluates a 70-year-old patient with new-onset paranoid delusions and visual hallucinations. Which assessment finding would most strongly suggest a medical etiology rather than a primary psychiatric disorder?

Social withdrawal over the past year
Family history of schizophrenia
Acute onset with fluctuating consciousness and disorientation (Correct answer)
Auditory hallucinations with command features

Correct answer: Acute onset with fluctuating consciousness and disorientation

Acute onset, fluctuating consciousness, and disorientation are hallmarks of delirium—a medical emergency—rather than a primary psychiatric illness like schizophrenia.

Question 114: Which antidepressant is most appropriate for a patient with major depressive disorder who also has significant insomnia but cannot tolerate anticholinergic side effects?

Amitriptyline
Paroxetine
Mirtazapine (Correct answer)
Doxepin

Correct answer: Mirtazapine

Mirtazapine is highly sedating via H1 antagonism and has minimal anticholinergic activity, making it suitable for patients needing sleep aid without anticholinergic burden.

Question 115: Which of the following is a black box warning associated with atomoxetine (Strattera)?

Increased suicidal ideation in children and adolescents (Correct answer)
Sudden cardiac death in adults
Risk of agranulocytosis
Severe hepatotoxicity leading to liver failure

Correct answer: Increased suicidal ideation in children and adolescents

Atomoxetine carries a black box warning for increased suicidal ideation in pediatric patients, requiring close monitoring especially during dose initiation and adjustment.

Question 116: A PMHNP applies the Recovery Model when working with patients with serious mental illness. Which principle is MOST central to this model?

Self-determination and building a meaningful life despite illness (Correct answer)
Symptom elimination as the primary treatment goal
Medication adherence as the only evidence-based intervention
Clinician-directed care planning to optimize outcomes

Correct answer: Self-determination and building a meaningful life despite illness

The Recovery Model emphasizes self-determination, hope, and building a meaningful, satisfying life even in the presence of ongoing psychiatric symptoms.

Question 117: An outpatient with generalized anxiety disorder (GAD) has a cat as an emotional support animal, and when she resumes work, she wants to bring the cat with her. An emotional support animal is defined by Titles II and III of the Americans with Disabilities Act as:

Must be accommodated by employers as a service animal
Can be certified as a service animal only if it is a dog
Is certified as a service animal only on special request
Does not qualify as a service animal (Correct answer)

Correct answer: Does not qualify as a service animal

Although special requests can be made to include miniature ponies as service animals, service animals must really do some type of active duty and must be canines. On the other hand, psychiatric service dogs are qualified and may be trained to recognize impending mental episodes, remind the patient to take their meds, stop self-harming behavior, or safeguard confused patients from danger.

Question 118: A patient recently started on lithium complains of a coarse tremor, confusion, and vomiting. Lithium level is 2.4 mEq/L. What is the PRIORITY intervention?

Reduce the lithium dose by half and recheck level in 24 hours
Administer activated charcoal and hold the next dose
Administer IV normal saline and arrange urgent hemodialysis consultation (Correct answer)
Add propranolol to manage the tremor and observe inpatient

Correct answer: Administer IV normal saline and arrange urgent hemodialysis consultation

A lithium level above 2.0 mEq/L with neurological and GI toxicity signs constitutes severe lithium toxicity; IV hydration restores renal clearance and hemodialysis may be needed to rapidly reduce levels.

Question 119: A patient presents to the ED after a suicide attempt by overdose. After medical stabilization, the PMHNP's priority assessment is:

Level of suicidal intent before, during, and after the attempt (Correct answer)
Insurance coverage for inpatient care
Marital status and living situation only
Cognitive functioning

Correct answer: Level of suicidal intent before, during, and after the attempt

Assessing the intent level before, during, and after the attempt provides critical information about ongoing suicide risk.

Question 120: A patient with bipolar depression is prescribed quetiapine. At which dose range does quetiapine primarily exert antidepressant effects versus antipsychotic effects?

Low doses (25-100 mg) for antipsychotic; high doses (400-800 mg) for antidepressant
Low doses (50-150 mg) for antidepressant via H1/5-HT2 blockade; higher doses for antipsychotic via D2 blockade (Correct answer)
Equal antidepressant and antipsychotic effects at all doses above 200 mg
Antidepressant effects only occur at plasma levels above 800 ng/mL regardless of dose

Correct answer: Low doses (50-150 mg) for antidepressant via H1/5-HT2 blockade; higher doses for antipsychotic via D2 blockade

At lower doses, quetiapine preferentially blocks H1 and 5-HT2A receptors (contributing to antidepressant/sedating effects); D2 blockade (antipsychotic effect) predominates at higher doses.

Question 121: A patient in acute psychotic crisis is agitated and threatening violence. What is the PMHNP's safest first intervention?

Verbal de-escalation in a calm, low-stimulation environment (Correct answer)
Call police first
Administer IM antipsychotic without consent
Physical restraint immediately

Correct answer: Verbal de-escalation in a calm, low-stimulation environment

Verbal de-escalation is the least restrictive, safest first-line intervention for agitated patients.

Question 122: A PMHNP suspects factitious disorder in a patient who fabricates symptoms. How does factitious disorder differ from malingering?

Factitious disorder involves unconscious symptom production
Factitious disorder has external incentives; malingering does not
Malingering has external incentives; factitious disorder is driven by psychological need to assume the sick role (Correct answer)
They are the same disorder with different names

Correct answer: Malingering has external incentives; factitious disorder is driven by psychological need to assume the sick role

In factitious disorder, symptom falsification is motivated by a psychological need to assume the sick role, with no external gains; malingering involves intentional feigning for external rewards.

Question 123: According to DSM-5, a major depressive episode requires at least how many symptoms persisting for a minimum of how many weeks?

5 symptoms for 2 weeks (Correct answer)
7 symptoms for 1 month
4 symptoms for 3 weeks
3 symptoms for 1 week

Correct answer: 5 symptoms for 2 weeks

DSM-5 requires at least 5 of 9 specified symptoms present for a minimum of 2 weeks, with at least one being depressed mood or anhedonia.

Question 124: A PMHNP receives a subpoena for a patient's psychotherapy records. The most appropriate initial action is to:

Notify the patient and consult with legal counsel before releasing any records (Correct answer)
Release a summary but not the complete record
Refuse to release any records under all circumstances
Immediately release all records to comply with the subpoena

Correct answer: Notify the patient and consult with legal counsel before releasing any records

A subpoena for psychotherapy records requires notification of the patient and consultation with legal counsel, as therapist-patient privilege may protect the records from disclosure depending on jurisdiction and circumstances.

Question 125: Which pharmacological property of quetiapine at lower doses (25–100 mg) is primarily responsible for its sedating effects used in sleep or anxiety?

5-HT2A antagonism
D2 receptor antagonism
H1 (histamine) receptor antagonism (Correct answer)
Alpha-1 adrenergic agonism

Correct answer: H1 (histamine) receptor antagonism

At low doses, quetiapine's sedating effects are primarily driven by potent H1 histamine receptor antagonism before significant D2 or 5-HT2A blockade occurs.

Question 126: A psychiatric patient in crisis states, 'I have a plan and I have the means.' According to risk stratification, this patient is best classified as:

Low risk
High risk (Correct answer)
Moderate risk
Indeterminate risk

Correct answer: High risk

Having a specific plan with access to the means significantly elevates suicide risk to high, warranting immediate intervention.

Question 127: Under the Olmstead v. L.C. Supreme Court decision, states are required to:

Eliminate all inpatient psychiatric facilities
Provide community-based mental health services to qualified individuals with disabilities who do not oppose such placement (Correct answer)
Provide inpatient psychiatric beds for all individuals with mental illness
Require all individuals with mental illness to live in supervised housing

Correct answer: Provide community-based mental health services to qualified individuals with disabilities who do not oppose such placement

The Olmstead decision (1999) held that unjustified institutionalization of persons with disabilities constitutes discrimination under the ADA and requires states to provide integrated, community-based services when clinically appropriate and desired by the patient.

Question 128: In group therapy, the therapeutic factor where patients realize they are not alone in their struggles is called:

Cohesiveness
Altruism
Catharsis
Universality (Correct answer)

Correct answer: Universality

Universality, identified by Yalom, is the therapeutic factor in which group members recognize that others share similar problems.

Question 129: A patient with treatment-resistant depression is started on ketamine infusions. Which mechanism best explains its rapid antidepressant effect?

D2 receptor partial agonism stabilizing dopamine circuits
NMDA receptor antagonism followed by AMPA receptor upregulation and BDNF release (Correct answer)
Blockade of 5-HT3 receptors in the limbic system
Potent MAO-A inhibition leading to serotonin accumulation

Correct answer: NMDA receptor antagonism followed by AMPA receptor upregulation and BDNF release

Ketamine blocks NMDA receptors, causing a glutamate surge that activates AMPA receptors, releasing BDNF and promoting rapid synaptogenesis in the prefrontal cortex and hippocampus.

Question 130: A PMHNP screens a patient using the GAD-7 and obtains a score of 15. This score indicates:

Severe anxiety (Correct answer)
Moderate anxiety
Minimal anxiety
Mild anxiety

Correct answer: Severe anxiety

GAD-7 scores of 15–21 indicate severe anxiety, prompting urgent clinical attention and treatment.

Question 131: The patient has had schizophrenia for a very long time, and it has been treated with haloperidol (Haldol). The nurse observes persistent restlessness and fidgeting during an entrance exam brought on by a worsening of the condition. Which drug would the nurse anticipate the doctor to recommend for this patient?

Haloperidol (Haldol).
Clozapine (Clozaril).
Benztropine mesylate (Cogentin) (Correct answer)
Fluphenazine decanoate (Prolixin Decanoate).

Correct answer: Benztropine mesylate (Cogentin)

An anticholinergic drug called benztropine mesylate (Cogentin) is used to treat extrapyramidal symptoms like akathisia. The client's complaints of restlessness and fidgeting would lead the nurse to anticipate that the doctor would prescribe this medication.

Question 132: Which symptom cluster in a trauma patient indicates acute stress disorder (ASD) rather than acute PTSD?

Absence of avoidance symptoms
Symptoms occurring within one month of the traumatic event (Correct answer)
Presence of psychosis
Symptoms lasting more than one month

Correct answer: Symptoms occurring within one month of the traumatic event

ASD is diagnosed when PTSD-like symptoms occur within 3 days to 1 month following trauma; PTSD is diagnosed when symptoms persist beyond 1 month.

Question 133: A patient on venlafaxine for 2 years abruptly stops the medication. Which symptom cluster is most characteristic of what will occur within 24-48 hours?

Rebound hypertension, diaphoresis, and fever consistent with adrenergic storm
Acute psychosis, hallucinations, and severe insomnia
Bradycardia, hypotension, and somnolence consistent with cholinergic excess
Dizziness, electric shock sensations ('brain zaps'), nausea, and irritability (Correct answer)

Correct answer: Dizziness, electric shock sensations ('brain zaps'), nausea, and irritability

Venlafaxine has a short half-life and discontinuation syndrome (FINISH mnemonic) is common, characterized by flu-like symptoms, insomnia, nausea, sensory disturbances, and hyperarousal.

Question 134: A patient describes feeling detached from their own body and observing themselves from the outside during periods of stress. This symptom is BEST described as:

Déjà vu
Derealization
Dissociative amnesia
Depersonalization (Correct answer)

Correct answer: Depersonalization

Depersonalization is the subjective experience of feeling detached from or outside of one's own body, thoughts, or feelings.

Question 135: Which medication combination is considered first-line for rapid tranquilization of an acutely agitated patient in the ED?

Quetiapine + lamotrigine
Clozapine + olanzapine
Lithium + valproate
Haloperidol + lorazepam (or diphenhydramine) (Correct answer)

Correct answer: Haloperidol + lorazepam (or diphenhydramine)

Haloperidol combined with lorazepam (or diphenhydramine to prevent EPS) is a widely used, evidence-supported rapid tranquilization regimen.

Question 136: A PMHNP is evaluating a patient for autism spectrum disorder (ASD) in adulthood. Which presentation is MOST characteristic of ASD that may have been missed in childhood?

Auditory hallucinations and flat affect
Rigid routines, difficulty with social reciprocity, and sensory sensitivities (Correct answer)
Fluctuating cognitive performance across domains
Episodic mood swings tied to interpersonal conflicts

Correct answer: Rigid routines, difficulty with social reciprocity, and sensory sensitivities

Core features of ASD include persistent deficits in social communication, restricted/repetitive behaviors, and sensory processing differences that may be 'masked' in high-functioning individuals until adulthood.

Question 137: Which of the following is the best way to respond to a male patient who has been brought to the psychiatric ward for drug misuse therapy when he says to the nurse, "It felt so wonderful to get high?"

“Tell me more about how it felt to get high.”
“If you continue to talk like that, I’m going to stop speaking to you.”
“Don’t you know it’s illegal to use drugs?”
“You told me you got fired from your last job for missing too many days after taking drugs all night.” (Correct answer)

Correct answer: “You told me you got fired from your last job for missing too many days after taking drugs all night.”

Removing the client's denial requires confronting them with the negative effects of substance addiction. Since your physical presence is the reality, present reality to the customer by spending time with them to encourage reality orientation. When speaking to the client, be clear, concise, and easy to understand. Avoid ideological or theoretical conversations when speaking with the client and instead focus on concrete or known topics. The client has trouble processing abstractions or complexity.

Question 138: A PMHNP in private practice begins dating a former patient who terminated therapy 6 months ago. This behavior is best described as:

A boundary violation that is ethically prohibited (Correct answer)
Acceptable given the therapeutic relationship has ended
Permissible after a waiting period specified in state law
Acceptable only if both parties freely consent

Correct answer: A boundary violation that is ethically prohibited

Sexual or romantic relationships with former patients are considered boundary violations and are prohibited by professional ethics codes due to the power differential inherent in the therapeutic relationship, which persists after termination.

Question 139: Which medication is considered first-line pharmacotherapy for PTSD according to current evidence-based guidelines?

Lorazepam
Buspirone
Haloperidol
Sertraline (Correct answer)

Correct answer: Sertraline

Sertraline (and paroxetine) are FDA-approved SSRIs for PTSD and are recommended as first-line pharmacotherapy by VA/DoD and APA guidelines.

Question 140: Which ethical principle is most directly supported when a PMHNP provides a patient with complete information about treatment options and risks before obtaining consent?

Autonomy (Correct answer)
Justice
Beneficence
Nonmaleficence

Correct answer: Autonomy

Informed consent is a direct application of the principle of autonomy, which respects the patient's right to make informed decisions about their own care.

Question 141: A PMHNP is conducting a risk assessment using the Columbia Suicide Severity Rating Scale (C-SSRS). Which finding indicates the highest level of suicidal ideation?

Active ideation with a specific plan and intent to act (Correct answer)
Ideation that occurs less than once per week
Ideation present only in response to an interpersonal stressor
Passive ideation without intent to act

Correct answer: Active ideation with a specific plan and intent to act

On the C-SSRS, ideation with a specific plan AND intent to act represents the most severe and clinically urgent category requiring immediate intervention.

Question 142: Which of the following is the mechanism of action of aripiprazole that differentiates it from most other second-generation antipsychotics?

D1 receptor full agonism
D2 receptor partial agonism (Correct answer)
Selective serotonin reuptake inhibition
Full D2 receptor antagonism

Correct answer: D2 receptor partial agonism

Aripiprazole acts as a partial agonist at D2 and D3 receptors, stabilizing dopamine activity rather than fully blocking it, which reduces EPS risk.

Question 143: A PMHNP is applying Dialectical Behavior Therapy (DBT). Which skill module teaches patients to tolerate distress without making a crisis worse?

Mindfulness
Interpersonal effectiveness
Emotion regulation
Distress tolerance (Correct answer)

Correct answer: Distress tolerance

Distress tolerance skills in DBT teach patients to survive crisis moments without engaging in behaviors that worsen the situation, using techniques like TIPP and ACCEPTS.

Question 144: A PMHNP is conducting a safety planning intervention. Which element should be placed FIRST on the safety plan?

Emergency contact numbers
Names of mental health professionals to contact
Warning signs that a crisis may be developing (Correct answer)
Reasons for living

Correct answer: Warning signs that a crisis may be developing

Warning signs are placed first on safety plans so patients can recognize early signals and activate coping strategies before reaching crisis level.

Question 145: A patient on clozapine has an ANC of 1,200 cells/mm³. What is the PMHNP's priority action?

Continue clozapine and recheck ANC in one week
Add lithium augmentation to support bone marrow function
Reduce the clozapine dose by 50% and monitor closely
Immediately discontinue clozapine and notify the prescriber (Correct answer)

Correct answer: Immediately discontinue clozapine and notify the prescriber

An ANC below 1,500 cells/mm³ (severe neutropenia threshold) requires immediate discontinuation of clozapine to prevent life-threatening agranulocytosis.

Question 146: A patient who is voluntarily admitted to an inpatient psychiatric unit states they want to leave. What is the PMHNP's first action?

Initiate involuntary commitment proceedings without assessment
Contact the patient's family before doing anything else
Assess the patient's current mental status and risk to self or others (Correct answer)
Immediately discharge the patient

Correct answer: Assess the patient's current mental status and risk to self or others

The PMHNP must first assess the patient's mental status and risk level to determine whether voluntary discharge is safe or whether involuntary hold criteria are met.

Question 147: A patient with schizophrenia is prescribed clozapine. Which laboratory monitoring is MOST critical due to the risk of agranulocytosis?

Serum creatinine monthly
Absolute neutrophil count (ANC) per REMS protocol (Correct answer)
Thyroid function tests quarterly
Liver function tests weekly

Correct answer: Absolute neutrophil count (ANC) per REMS protocol

Clozapine carries a black box warning for agranulocytosis, requiring ANC monitoring through the Clozapine REMS program before dispensing.

Question 148: Which mood stabilizer has the most evidence for suicide prevention in patients with bipolar disorder?

Valproate
Carbamazepine
Lithium (Correct answer)
Lamotrigine

Correct answer: Lithium

Lithium has robust long-term evidence for reducing suicide and suicidal behavior in patients with mood disorders, likely through serotonergic and neuroprotective mechanisms.

Question 149: Alic approached Nurse April to seek guidance on how to handle his alcoholism. The patient should be informed by nurse April that there is only one proven method for treating alcoholism:

Total abstinence (Correct answer)
Alcoholics Anonymous (A.A.)
Aversion Therapy
Psychotherapy

Correct answer: Total abstinence

The only effective treatment for alcoholism is complete abstinence. Some problem drinkers might be persuaded to seek treatment before suffering harsh effects if they are given counseling on moderation. According to studies on moderate or "controlled" drinking, this approach can be effective for people who have not yet established a systemic pattern of alcohol addiction or who have only sometimes suffered harmful effects from drinking. Being young, female, employed, in a secure social environment, and self-assured about limiting consumption are also advantages. Before they cross the line into dependence, patients are supposed to be assisted in setting objectives and drinking restrictions.

Question 150: A female patient of Nurse Ashy's is being treated because she has suicidal thoughts. Nurse Ashy should go with the client to the bathroom.

Open the window and allow her to get some fresh air.
Give her privacy.
Allow her to urinate.
Observe her. (Correct answer)

Correct answer: Observe her.

The acutely suicidal patient must be continuously observed by the nurse. The nurse should keep an eye out for warning signs, such as talking about dying, stockpiling drugs, and conveying suicidal thoughts and messages. The intervention is to first and foremost ensure the patient's safety. The application of risk variables along with a clinical investigation form the basis of intervention.

Question 151: Which intervention, according to psychodynamic theory, would be suitable for a patient with a panic disorder?

Ask the patient to include his or her family in scheduled therapy sessions.
Teach the client about the effect of blood lactate level as it relates to the patient’s panic attacks.
Discuss the overuse of ego defense mechanisms and their impact on anxiety. (Correct answer)
Encourage the patient to evaluate the power of distorted thinking.

Correct answer: Discuss the overuse of ego defense mechanisms and their impact on anxiety.

The nurse's discussion of the patient's overuse of ego defense mechanisms serves as an example of a psychodynamic approach to treating the client's panic disorder-related behaviors.

Question 152: A patient reports racing thoughts, decreased need for sleep, grandiosity, and increased goal-directed activity for 5 days without hospitalization. The PMHNP should document this episode as:

Major depressive episode with mixed features
Cyclothymic episode
Manic episode (Correct answer)
Hypomanic episode

Correct answer: Manic episode

A manic episode requires at least 7 days (or any duration if hospitalization is needed) of elevated/expansive/irritable mood with 3+ symptoms; 5 days with functional impairment severe enough to describe meets manic criteria.

Question 153: The PMHNP role as a patient advocate is best demonstrated when the PMHNP:

Ensures the patient's rights, preferences, and needs are communicated and represented in care planning (Correct answer)
Advocates only for medication-based treatments
Agrees with all treatment decisions made by the attending physician without question
Limits advocacy to patients who are verbally able to express their own preferences

Correct answer: Ensures the patient's rights, preferences, and needs are communicated and represented in care planning

Patient advocacy in psychiatric advanced practice nursing involves ensuring that the patient's rights, values, and preferences are articulated, respected, and incorporated into all aspects of care planning regardless of the patient's communication ability.

Question 154: Which eating disorder is characterized by recurrent binge eating without compensatory behaviors and is the most prevalent eating disorder in the US?

Avoidant/restrictive food intake disorder
Bulimia nervosa
Binge-eating disorder (BED) (Correct answer)
Anorexia nervosa

Correct answer: Binge-eating disorder (BED)

Binge-eating disorder is the most prevalent eating disorder in the US and is distinguished from bulimia nervosa by the absence of compensatory behaviors.

Question 155: A nurse practitioner is using the Columbia Suicide Severity Rating Scale (C-SSRS). Which item would place a patient at the HIGHEST level of suicide ideation on this scale?

Active ideation with intent but no specific plan
Passive death wish ('I wish I were dead')
Active ideation without plan or intent
Active ideation with a specific plan and intent to act (Correct answer)

Correct answer: Active ideation with a specific plan and intent to act

The C-SSRS categorizes ideation from passive wish to die up to active ideation with a specific plan and intent, with the latter representing the highest and most critical risk level.

Question 156: Which antidote is given for benzodiazepine overdose in a psychiatric emergency?

N-acetylcysteine
Physostigmine
Naloxone
Flumazenil (Correct answer)

Correct answer: Flumazenil

Flumazenil is a competitive GABA-A receptor antagonist that reverses benzodiazepine sedation and respiratory depression.

Question 157: Which brief, structured therapy is specifically designed for suicidal patients and focuses on reasons for living and building safety plans?

Cognitive processing therapy
Schema therapy
Mentalization-based therapy
Collaborative Assessment and Management of Suicidality (CAMS) (Correct answer)

Correct answer: Collaborative Assessment and Management of Suicidality (CAMS)

CAMS is an evidence-based framework for assessing and treating suicidal patients through collaborative goal-setting and safety planning.

Question 158: Which criterion differentiates schizophrenia from schizoaffective disorder?

Schizoaffective disorder has a shorter duration requirement
Presence of hallucinations
In schizoaffective disorder, mood episodes are present for the majority of the illness duration (Correct answer)
Schizophrenia always includes negative symptoms

Correct answer: In schizoaffective disorder, mood episodes are present for the majority of the illness duration

Schizoaffective disorder requires that mood episodes (manic or depressive) are present for the majority of the total illness duration alongside psychotic symptoms.

Question 159: The AUDIT-C is a brief screening tool used to detect which condition?

Tobacco use disorder
Stimulant use disorder
Opioid use disorder
Alcohol use disorder (Correct answer)

Correct answer: Alcohol use disorder

The AUDIT-C is a validated 3-item alcohol screening tool derived from the full Alcohol Use Disorders Identification Test.

Question 160: Eye Movement Desensitization and Reprocessing (EMDR) is the first-line evidence-based treatment for which condition?

Post-traumatic stress disorder (PTSD) (Correct answer)
Bipolar I disorder
Obsessive-compulsive disorder
Schizophrenia

Correct answer: Post-traumatic stress disorder (PTSD)

EMDR is a well-established, evidence-based treatment specifically validated for PTSD.

Question 161: Which rating scale is used specifically to assess extrapyramidal side effects (EPS) in patients taking antipsychotics?

Young Mania Rating Scale (YMRS)
Positive and Negative Syndrome Scale (PANSS)
Columbia Suicide Severity Rating Scale (C-SSRS)
Simpson-Angus Scale (SAS) (Correct answer)

Correct answer: Simpson-Angus Scale (SAS)

The Simpson-Angus Scale assesses drug-induced parkinsonism and other extrapyramidal side effects associated with antipsychotic use.

Question 162: A PMHNP documents that a patient with schizophrenia sits motionless for hours, maintains an unusual posture when repositioned, and does not speak. These symptoms best describe:

Tardive dyskinesia
Catatonia (Correct answer)
Akathisia
Negative symptom avolition

Correct answer: Catatonia

Catatonia is characterized by motor immobility, posturing (waxy flexibility), mutism, and negativism, which can occur in schizophrenia, mood disorders, and medical conditions.

Question 163: What legal standard is used to evaluate whether a PMHNP's conduct met the expected level of care in a malpractice case?

What a reasonably prudent PMHNP with similar training and in similar circumstances would have done (Correct answer)
What the individual PMHNP personally believed was appropriate
What is listed in any textbook on psychiatric nursing
What the most skilled specialist in the field would have done

Correct answer: What a reasonably prudent PMHNP with similar training and in similar circumstances would have done

The legal standard of care in malpractice cases is what a reasonably prudent practitioner with similar education, training, and experience would have done under the same or similar circumstances.

Question 164: Which structured clinical assessment instrument is considered the gold standard for diagnosing DSM-5 disorders in research settings?

PHQ-9
Hamilton Anxiety Rating Scale (HAM-A)
Structured Clinical Interview for DSM Disorders (SCID) (Correct answer)
Beck Depression Inventory (BDI)

Correct answer: Structured Clinical Interview for DSM Disorders (SCID)

The SCID is a semi-structured diagnostic interview conducted by trained clinicians and is considered the gold standard for establishing DSM diagnoses.

Question 165: Which medication for ADHD is a non-stimulant and is preferred when there is comorbid anxiety or substance use disorder?

Amphetamine salts
Atomoxetine (Correct answer)
Lisdexamfetamine
Methylphenidate

Correct answer: Atomoxetine

Atomoxetine (Strattera) is a non-stimulant SNRI approved for ADHD that does not carry abuse potential, making it preferred in patients with comorbid anxiety or SUD.

Question 166: A PMHNP is conducting psychoeducation. Which statement best describes its primary goal?

To provide in-depth psychoanalytic insight
To eliminate the need for ongoing therapy
To replace pharmacotherapy
To help patients and families understand the illness and treatment (Correct answer)

Correct answer: To help patients and families understand the illness and treatment

Psychoeducation improves treatment adherence and outcomes by informing patients and families about the illness, medications, and coping strategies.

Question 167: Which DSM-5 neurodevelopmental disorder requires persistent deficits in social communication across multiple contexts AND restricted, repetitive behaviors for diagnosis?

Intellectual disability
ADHD
Specific learning disorder
Autism spectrum disorder (ASD) (Correct answer)

Correct answer: Autism spectrum disorder (ASD)

ASD requires both persistent social communication deficits AND restricted, repetitive behaviors present in early development per DSM-5 criteria.

Question 168: Which psychiatric disorder is most prevalent among incarcerated individuals in the US, highlighting a major gap in mental health care access?

Specific phobia
Autism spectrum disorder
Eating disorders
Substance use disorder comorbid with serious mental illness (Correct answer)

Correct answer: Substance use disorder comorbid with serious mental illness

The US prison system has become a de facto psychiatric care setting, with very high prevalence of co-occurring substance use and serious mental illness.

Question 169: A patient with bipolar I disorder who is stabilized on lithium becomes pregnant. The PMHNP knows that lithium carries a risk for which fetal cardiac defect?

Tetralogy of Fallot
Ventricular septal defect
Patent ductus arteriosus
Ebstein's anomaly (Correct answer)

Correct answer: Ebstein's anomaly

Lithium exposure in the first trimester has been associated with Ebstein's anomaly, a rare tricuspid valve malformation, though the absolute risk is low.

Question 170: Dependent personality disorder was identified in a patient who is 20 years old. Which conduct is least likely to be indicative of inadequate personal coping?

Inability to make choices and decisions without advice. (Correct answer)
Avoiding relationships.
Recurrent self-destructive behavior.
Showing interest in solitary activities.

Correct answer: Inability to make choices and decisions without advice.

To get others to make decisions with them, people with dependent personality disorder frequently exhibit indecisiveness, submission, and clinging behaviors. Anxious personality disorders include dependent personality disorder (DPD). People with DPD frequently experience feelings of helplessness, submission, or impotence. They could struggle to come to easy judgments. However, a person with a dependent personality can develop self-confidence and independence with assistance.

Question 171: A patient with GAD has not responded to two trials of SSRIs. Which medication class is FDA-approved as a second-line option for GAD?

SNRIs such as venlafaxine (Correct answer)
Atypical antipsychotics as monotherapy
Benzodiazepines
Tricyclic antidepressants

Correct answer: SNRIs such as venlafaxine

SNRIs such as venlafaxine (Effexor XR) and duloxetine are FDA-approved for GAD and represent a first- or second-line alternative to SSRIs.

Question 172: A PMHNP working with veterans notes that moral injury differs from PTSD in that moral injury primarily involves:

Hyperarousal and startle response
Intrusive flashbacks and nightmares
Avoidance of trauma reminders
Guilt, shame, and spiritual distress from actions violating personal moral code (Correct answer)

Correct answer: Guilt, shame, and spiritual distress from actions violating personal moral code

Moral injury results from witnessing or participating in events that transgress deeply held moral beliefs, leading to guilt, shame, and loss of meaning rather than fear-based PTSD responses.

Question 173: The PMHNP is initiating bupropion in a patient with a history of anorexia nervosa. What is the primary contraindication?

Increased risk of lithium toxicity
Lowered seizure threshold in patients with eating disorders (Correct answer)
QTc prolongation risk
Risk of serotonin syndrome

Correct answer: Lowered seizure threshold in patients with eating disorders

Bupropion is contraindicated in eating disorders because electrolyte imbalances and low body weight significantly increase seizure risk.

Question 174: Which element is NOT required to establish malpractice in psychiatric nursing practice?

A duty of care existed between the PMHNP and patient
The PMHNP breached the standard of care
The patient experienced harm or damages
The PMHNP intended to harm the patient (Correct answer)

Correct answer: The PMHNP intended to harm the patient

Malpractice (negligence) requires duty, breach of duty, causation, and damages — intent to harm is not an element, distinguishing negligence from intentional torts.

Question 175: Which condition is characterized by at least 6 months of inattention and/or hyperactivity-impulsivity before age 12 with impairment in two or more settings?

Autism spectrum disorder
Attention-deficit/hyperactivity disorder (ADHD) (Correct answer)
Conduct disorder
Bipolar disorder

Correct answer: Attention-deficit/hyperactivity disorder (ADHD)

DSM-5 ADHD criteria require symptom onset before age 12 and impairment across multiple settings, such as home and school.

Question 176: A PMHNP learns during therapy that a patient is being physically abused by a caregiver. What is the PMHNP's legal obligation?

Report the suspected abuse to appropriate authorities as a mandatory reporter (Correct answer)
Maintain confidentiality because the patient is an adult
Consult with the patient about whether they want the abuse reported
Refer the patient to a social worker to handle the report

Correct answer: Report the suspected abuse to appropriate authorities as a mandatory reporter

PMHNPs are mandatory reporters in all U.S. states and are legally required to report suspected abuse of vulnerable individuals, including adults who may be incapacitated, to protective services.

Question 177: A patient with schizophrenia refuses antipsychotic medication. What must be established before medication can be administered involuntarily?

The PMHNP believes treatment is in the patient's best interest
A psychiatric diagnosis alone is sufficient justification
The patient's family has given consent
The patient has been determined to lack decision-making capacity by appropriate legal or clinical process (Correct answer)

Correct answer: The patient has been determined to lack decision-making capacity by appropriate legal or clinical process

A psychiatric diagnosis does not automatically remove a patient's right to refuse treatment; lack of decision-making capacity must be formally established through clinical and/or legal processes before involuntary medication.

ANCC Psychiatric-Mental Health Nurse Practitioner (PMHNP) board certification exam

This exam certifies the knowledge and skills of advanced practice registered nurses specializing in psychiatric-mental health care across the lifespan.

175

Questions

210 min

Time Limit

70%

To Pass

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