NRNP 6665-01, Week 11 Final Exam Solutions 2026/2027 Advanced
PMHNP Care Across the Lifespan | Complex & Evolving Case Studies|
Actual Questions & Verified Solutions | Advanced Psychiatric-Mental
Health Nurse Practitioner | Pass Guarantee
CASE BLOCK 1 – "JORDAN" (Questions 1-11)
Patient Background:
Jordan, 19-year-old college freshman (they/them), assigned female at birth, presents to campus
psychiatry with 4-month history of low mood, social withdrawal, 12-lb weight gain, hypersomnia,
and "brain fog." Premenstrual worsening. No past psych meds. Family history: maternal PTSD,
paternal alcohol use. Born at 29 weeks; developmental milestones on time. Medical: asthma
(albuterol PRN), migraines (sumatriptan PRN). Recreational: vape cannabis nightly "to sleep."
GAD-7 = 14, PHQ-9 = 16.
Initial Differential – Part A
Which two DSM-5-TR diagnoses must be ruled-in first given the temporal pattern?
A. Major depressive disorder & bulimia nervosa
B. Persistent depressive disorder & cannabis-induced sleep disorder
C. Premenstrual dysphoric disorder (PMDD) & major depressive disorder
D. ADHD-inattentive & primary hypersomnia
Correct Answer: C
Rationale: Clear premenstrual cyclicity + mood symptoms; cannabis use may be secondary
self-medication. APA guidelines (2023) recommend tracking two symptomatic cycles to confirm
PMDD.
Initial Differential – Part B
Which single screening tool should be administered today to clarify Jordan’s gender-related
stress?
A. GIDYQ-AA
B. Gender Identity Interview
C. Gender Minority Stress & Resilience Measure (GMSR)
D. Utrecht Gender Dysphoria Scale
Correct Answer: C
Rationale: GMSR captures distal/proximal stressors and buffers; essential for biopsychosocial
formulation in gender-diverse youth (Russell, 2022).
Labs & Work-up
Which one laboratory test is most likely to change management today?
A. Serum ferritin
B. 25-OH vitamin D
C. Serum hCG
D. TSH
Correct Answer: D
,Rationale: Hypothyroidism can mimic or worsen depressive symptoms; TSH is
guideline-recommended before antidepressant initiation (CANMAT, 2024).
New Information (Week 2): Daily mood ratings × 14 days show 3-fold symptom spike luteal
phase. Cannabis unchanged. Sleep study negative. TSH 1.2 mIU/L.
Precision Psychopharmacology
Jordan wishes to avoid oral contraceptives. Which first-line agent has the strongest evidence for
PMDD and lowest risk of weight gain?
A. Sertraline 50 mg daily
B. Escitalopram 10 mg luteal-phase only
C. Bupropion XL 150 mg daily
D. Lamotrigine 25 mg daily
Correct Answer: B
Rationale: APA guidelines (2023) rate luteal-phase SSRIs (escitalopram, sertraline) as Level 1
for PMDD; escitalopram has favorable weight-profile meta-analysis (Zhang, 2021).
Pharmacogenomic Check
CYP2C19 genotype = *2/*17 (intermediate). Which adjustment is indicated for escitalopram?
A. Reduce dose 50 %
B. No adjustment
C. Switch to sertraline
D. Increase dose 25 %
Correct Answer: A
Rationale: *2 loss-of-function allele lowers clearance → ↑ serum levels; FDA table recommends
50 % dose reduction to minimize QTc prolongation.
New Information (Week 6): On escitalopram 5 mg luteal-phase, PHQ-9 drops to 8, but Jordan
develops tension headaches, mild akathisia, and suicidality 2 days after each start.
Adverse Event Analysis
The most likely pharmacodynamic explanation is:
A. 5-HT2C antagonism → dopamine release
B. Rapid 5-HT1A partial agonism → emotional blunting
C. Excessive serotonergic burst in amygdala (hyperbolic SSRI curve)
D. Noradrenergic rebound due to NET inhibition
Correct Answer: C
Rationale: Ultra-rapid change in 5-HT tone in sensitive individuals can transiently worsen
anxiety/suicidality; luteal-phase dosing accentuates peak-trough variability (Harmer, 2022).
Switch Strategy
Next best step:
A. Increase escitalopram to 10 mg daily
B. Cross-taper to duloxetine 30 mg
C. Trial of calcium 600 mg BID luteal-phase
D. Add aripiprazole 2 mg
Correct Answer: C
Rationale: Calcium carbonate Level-2 evidence for PMDD, no serotonergic adverse effects;
safer given previous SSRI sensitivity (CANMAT, 2024).
Integrated Psychotherapy
, Jordan prefers non-pharmacologic relapse prevention. Which evidence-based manualized
therapy targets both mood reactivity and cannabis use?
A. Cognitive Processing Therapy (CPT)
B. Dialectical Behavior Therapy for Adolescents (DBT-A)
C. Acceptance & Commitment Therapy (ACT)
D. Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST)
Correct Answer: C
Rationale: ACT shows efficacy for co-occurring depression and cannabis misuse by increasing
psychological flexibility (Hayes, 2023).
Risk Assessment – Part A
During a Skype session Jordan discloses, "I’ve thought about driving into oncoming traffic, but
I’d never do it—I don’t want to hurt anyone." Which element best lowers acute risk estimate?
A. Presence of protective THC use
B. Stated moral objection
C. Passive suicidal ideation only
D. Age <25 years
**Correct Answer: B
Rationale: Strong internalized moral barrier is a robust protective factor (CAMS framework).
Risk Assessment – Part B
Using the Columbia Classification Algorithm, Jordan’s ideation is best coded:
A. Active / non-specific
B. Active / method but no intent
C. Passive
D. Self-harm / no intent to die
**Correct Answer: B
Rationale: Specific method (oncoming traffic) without intent or plan → "method but no intent."
Documentation & Ethics
University policy requires notifying parents for "high-risk" students. Jordan asks that parents not
be told due to unsupportive environment. Which action aligns with ethical and legal standards?
A. Invoke duty to warn and notify parents
B. Document protective factors, maintain confidentiality, create safety plan
C. Obtain written release before any further sessions
D. Refer to campus counseling only
**Correct Answer: B
Rationale: FERPA permits disclosure only when imminent danger and no less-restrictive means;
current risk is moderate with clear protections—confidentiality should be preserved (NASW,
2023).
CASE BLOCK 2 – "MR. CASTILLO" (Questions 12-22)
Patient Background:
Carlos Castillo, 54-year-old Latino construction foreman, brought by wife after 3-week history of
insomnia, irritability, and "talking to himself." Wife notes 6-month decline in memory and
balance. Past medical: HTN (amlodipine), hyperlipidemia (atorvastatin), carpal-tunnel release
last year. No prior psych. Father died 62 with "shaking and dementia." Urine tox negative. Vital
signs WNL. MMSE 22/30 (impaired recall, attention). CBC, CMP normal, TSH 1.0.
PMHNP Care Across the Lifespan | Complex & Evolving Case Studies|
Actual Questions & Verified Solutions | Advanced Psychiatric-Mental
Health Nurse Practitioner | Pass Guarantee
CASE BLOCK 1 – "JORDAN" (Questions 1-11)
Patient Background:
Jordan, 19-year-old college freshman (they/them), assigned female at birth, presents to campus
psychiatry with 4-month history of low mood, social withdrawal, 12-lb weight gain, hypersomnia,
and "brain fog." Premenstrual worsening. No past psych meds. Family history: maternal PTSD,
paternal alcohol use. Born at 29 weeks; developmental milestones on time. Medical: asthma
(albuterol PRN), migraines (sumatriptan PRN). Recreational: vape cannabis nightly "to sleep."
GAD-7 = 14, PHQ-9 = 16.
Initial Differential – Part A
Which two DSM-5-TR diagnoses must be ruled-in first given the temporal pattern?
A. Major depressive disorder & bulimia nervosa
B. Persistent depressive disorder & cannabis-induced sleep disorder
C. Premenstrual dysphoric disorder (PMDD) & major depressive disorder
D. ADHD-inattentive & primary hypersomnia
Correct Answer: C
Rationale: Clear premenstrual cyclicity + mood symptoms; cannabis use may be secondary
self-medication. APA guidelines (2023) recommend tracking two symptomatic cycles to confirm
PMDD.
Initial Differential – Part B
Which single screening tool should be administered today to clarify Jordan’s gender-related
stress?
A. GIDYQ-AA
B. Gender Identity Interview
C. Gender Minority Stress & Resilience Measure (GMSR)
D. Utrecht Gender Dysphoria Scale
Correct Answer: C
Rationale: GMSR captures distal/proximal stressors and buffers; essential for biopsychosocial
formulation in gender-diverse youth (Russell, 2022).
Labs & Work-up
Which one laboratory test is most likely to change management today?
A. Serum ferritin
B. 25-OH vitamin D
C. Serum hCG
D. TSH
Correct Answer: D
,Rationale: Hypothyroidism can mimic or worsen depressive symptoms; TSH is
guideline-recommended before antidepressant initiation (CANMAT, 2024).
New Information (Week 2): Daily mood ratings × 14 days show 3-fold symptom spike luteal
phase. Cannabis unchanged. Sleep study negative. TSH 1.2 mIU/L.
Precision Psychopharmacology
Jordan wishes to avoid oral contraceptives. Which first-line agent has the strongest evidence for
PMDD and lowest risk of weight gain?
A. Sertraline 50 mg daily
B. Escitalopram 10 mg luteal-phase only
C. Bupropion XL 150 mg daily
D. Lamotrigine 25 mg daily
Correct Answer: B
Rationale: APA guidelines (2023) rate luteal-phase SSRIs (escitalopram, sertraline) as Level 1
for PMDD; escitalopram has favorable weight-profile meta-analysis (Zhang, 2021).
Pharmacogenomic Check
CYP2C19 genotype = *2/*17 (intermediate). Which adjustment is indicated for escitalopram?
A. Reduce dose 50 %
B. No adjustment
C. Switch to sertraline
D. Increase dose 25 %
Correct Answer: A
Rationale: *2 loss-of-function allele lowers clearance → ↑ serum levels; FDA table recommends
50 % dose reduction to minimize QTc prolongation.
New Information (Week 6): On escitalopram 5 mg luteal-phase, PHQ-9 drops to 8, but Jordan
develops tension headaches, mild akathisia, and suicidality 2 days after each start.
Adverse Event Analysis
The most likely pharmacodynamic explanation is:
A. 5-HT2C antagonism → dopamine release
B. Rapid 5-HT1A partial agonism → emotional blunting
C. Excessive serotonergic burst in amygdala (hyperbolic SSRI curve)
D. Noradrenergic rebound due to NET inhibition
Correct Answer: C
Rationale: Ultra-rapid change in 5-HT tone in sensitive individuals can transiently worsen
anxiety/suicidality; luteal-phase dosing accentuates peak-trough variability (Harmer, 2022).
Switch Strategy
Next best step:
A. Increase escitalopram to 10 mg daily
B. Cross-taper to duloxetine 30 mg
C. Trial of calcium 600 mg BID luteal-phase
D. Add aripiprazole 2 mg
Correct Answer: C
Rationale: Calcium carbonate Level-2 evidence for PMDD, no serotonergic adverse effects;
safer given previous SSRI sensitivity (CANMAT, 2024).
Integrated Psychotherapy
, Jordan prefers non-pharmacologic relapse prevention. Which evidence-based manualized
therapy targets both mood reactivity and cannabis use?
A. Cognitive Processing Therapy (CPT)
B. Dialectical Behavior Therapy for Adolescents (DBT-A)
C. Acceptance & Commitment Therapy (ACT)
D. Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST)
Correct Answer: C
Rationale: ACT shows efficacy for co-occurring depression and cannabis misuse by increasing
psychological flexibility (Hayes, 2023).
Risk Assessment – Part A
During a Skype session Jordan discloses, "I’ve thought about driving into oncoming traffic, but
I’d never do it—I don’t want to hurt anyone." Which element best lowers acute risk estimate?
A. Presence of protective THC use
B. Stated moral objection
C. Passive suicidal ideation only
D. Age <25 years
**Correct Answer: B
Rationale: Strong internalized moral barrier is a robust protective factor (CAMS framework).
Risk Assessment – Part B
Using the Columbia Classification Algorithm, Jordan’s ideation is best coded:
A. Active / non-specific
B. Active / method but no intent
C. Passive
D. Self-harm / no intent to die
**Correct Answer: B
Rationale: Specific method (oncoming traffic) without intent or plan → "method but no intent."
Documentation & Ethics
University policy requires notifying parents for "high-risk" students. Jordan asks that parents not
be told due to unsupportive environment. Which action aligns with ethical and legal standards?
A. Invoke duty to warn and notify parents
B. Document protective factors, maintain confidentiality, create safety plan
C. Obtain written release before any further sessions
D. Refer to campus counseling only
**Correct Answer: B
Rationale: FERPA permits disclosure only when imminent danger and no less-restrictive means;
current risk is moderate with clear protections—confidentiality should be preserved (NASW,
2023).
CASE BLOCK 2 – "MR. CASTILLO" (Questions 12-22)
Patient Background:
Carlos Castillo, 54-year-old Latino construction foreman, brought by wife after 3-week history of
insomnia, irritability, and "talking to himself." Wife notes 6-month decline in memory and
balance. Past medical: HTN (amlodipine), hyperlipidemia (atorvastatin), carpal-tunnel release
last year. No prior psych. Father died 62 with "shaking and dementia." Urine tox negative. Vital
signs WNL. MMSE 22/30 (impaired recall, attention). CBC, CMP normal, TSH 1.0.
