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 – “Maya” (16 y F) – Adolescent Outpatient
Case Background
Maya, a 16-year-old Black cis-gender female, presents with 8-week worsening mood,
irritability, insomnia, and new self-cutting (superficial, forearms). Academic decline,
increased social-media conflict. Parents report 3-year history of “mood swings”
beginning with menarche. No past psych meds. PMH: asthma (fluticasone PRN). FH:
maternal bipolar-1, paternal alcohol use disorder. Toxicology: + Δ9-THC 120 ng/mL.
Vitals normal. PHQ-A 17, GAD-7 14, MDQ “yes” to 4 items (symptoms clustered 2 weeks,
not continuous).
1. Given the current data, the MOST accurate working diagnosis is:
A. Major depressive disorder, moderate, with anxious distress
B. Bipolar II disorder, current hypomanic
C. Bipolar I disorder, most recent episode depressed
D. ADHD, combined presentation, with mood dysregulation
Correct Answer: C
Rationale: MDQ positivity, clear 2-week+ depressed mood plus historical 4-day
hypomanic periods meet DSM-5-TR bipolar-I “most recent episode depressed.” THC can
mimic hypomania but does not invalidate history.
, 2. Before initiating any psychotropic, which laboratory test is MOST critical?
A. Serum 25-OH vitamin D
B. TSH & free T4
C. Liver panel
D. Serum pregnancy test
Correct Answer: D
Rationale: All are reasonable, but pregnancy status must precede teratogenic agents
(e.g., valproate, lithium).
3. Maya’s mother requests fluoxetine “because it helped me.” Which gene–drug pair
BEST predicts SSRI response in adolescents?
A. CYP2D6 – fluoxetine metabolism
B. SLC6A4 – serotonin-transporter-linked polymorphic region (5-HTTLPR)
C. COMT Val158Met – dopamine catabolism
D. ANK3 – ankyrin-G variant
Correct Answer: B
Rationale: Meta-analysis shows 5-HTTLPR short-allele carriers have modestly lower
SSRI response and higher suicidality in youth.
4. You decide to start lamotrigine. Which counseling point is MOST essential?
A. Discontinue if rash appears, then call clinician within 24 h
B. Take with high-fat meal to reduce AUC
C. Expect therapeutic benefit by week 2
D. Swallow tablets whole only
Correct Answer: A
Rationale: Risk of Stevens-Johnson; prompt action required.
5. After 4 weeks (lamotrigine 25 mg → 50 mg), Maya reports “I still feel numb; cuts
are deeper.” She denies active SI today. Next BEST step:
A. Increase lamotrigine to 100 mg daily
B. Add dialectical behavior therapy (DBT) adolescent skills group
, C. Switch to lithium monotherapy
D. Obtain EEG to rule out epilepsy
Correct Answer: B
Rationale: Partial mood response + ongoing self-injury → DBT-skills targets emotional
dysregulation and is first-line for adolescent NSSI per AACAP 2023.
6. During session 3 of DBT, Maya’s father asks to see diary cards to “monitor her
better.” Father is custodial; Maya objects. Your ETHICAL obligation is:
A. Release records because father is legal guardian
B. Refuse entirely to protect minor confidentiality
C. Negotiate a collaborative agreement balancing confidentiality and safety,
documenting risk
D. Wait until Maya turns 18
Correct Answer: C
Rationale: APA ethics encourage adolescent autonomy while involving guardians in
safety; document clinical reasoning.
Case Block 2 – “Mr. Alvarez” (72 y M) – Geriatric Primary-Care Embedded Consult
Case Background
Mr. Alvarez, 72-y/o Latino veteran, retired mechanic, is referred by PCP for “depression
and memory complaints.” Wife notes 1-year cognitive slowing, apathy, 10-lb weight loss.
PHQ-9 15, MoCA 22 (visuospatial –2, delayed recall –3). Meds: metformin 1 g BID,
atorvastatin 20 mg, omeprazole 20 mg, tamsulosin 0.4 mg. No alcohol. FH: father
late-onset AD.
7. Which screening tool BEST differentiates late-life depression vs. early
neurocognitive disorder?
A. GDS-15
B. MoCA
, C. HDRS-17
D. Cornell Dementia Scale for Depression
Correct Answer: D
Rationale: Cornell integrates informant report & cognitive signs; validated in NCD.
8. Initial labs reveal B12 180 pg/mL (low), TSH 5.8 mIU/L (high). Which abnormality
MOST likely explains his apathy?
A. Low B12
B. High TSH
C. Atorvastatin-induced cognitive change
D. Omeprazole-induced B12 deficiency
Correct Answer: B
Rationale: Hypothyroidism directly causes apathy & pseudodementia; B12 low but rarely
symptomatic until <150.
9. After levothyroxine initiation, repeat TSH normal, but PHQ-9 remains 14. You
consider sertraline. Which pharmacokinetic change in Mr. Alvarez INCREASES
risk of hyponatremia?
A. ↑ CYP2C19 activity
B. ↓ Renal blood flow
C. ↑ Albumin
D. ↓ Gastric pH
Correct Answer: B
Rationale: Age-related ↓ renal perfusion potentiates SIADH-like SSRI effect.
10. Starting sertraline 25 mg, you schedule follow-up in 2 weeks primarily to monitor:
A. QTc prolongation
B. SIADH / serum sodium
C. Bleeding time
D. Intraocular pressure
Correct Answer: B
PMHNP Care Across the Lifespan | Complex & Evolving Case Studies|
Actual Questions & Verified Solutions | Advanced Psychiatric-Mental
Health Nurse Practitioner | Pass Guarantee
Case Block 1 – “Maya” (16 y F) – Adolescent Outpatient
Case Background
Maya, a 16-year-old Black cis-gender female, presents with 8-week worsening mood,
irritability, insomnia, and new self-cutting (superficial, forearms). Academic decline,
increased social-media conflict. Parents report 3-year history of “mood swings”
beginning with menarche. No past psych meds. PMH: asthma (fluticasone PRN). FH:
maternal bipolar-1, paternal alcohol use disorder. Toxicology: + Δ9-THC 120 ng/mL.
Vitals normal. PHQ-A 17, GAD-7 14, MDQ “yes” to 4 items (symptoms clustered 2 weeks,
not continuous).
1. Given the current data, the MOST accurate working diagnosis is:
A. Major depressive disorder, moderate, with anxious distress
B. Bipolar II disorder, current hypomanic
C. Bipolar I disorder, most recent episode depressed
D. ADHD, combined presentation, with mood dysregulation
Correct Answer: C
Rationale: MDQ positivity, clear 2-week+ depressed mood plus historical 4-day
hypomanic periods meet DSM-5-TR bipolar-I “most recent episode depressed.” THC can
mimic hypomania but does not invalidate history.
, 2. Before initiating any psychotropic, which laboratory test is MOST critical?
A. Serum 25-OH vitamin D
B. TSH & free T4
C. Liver panel
D. Serum pregnancy test
Correct Answer: D
Rationale: All are reasonable, but pregnancy status must precede teratogenic agents
(e.g., valproate, lithium).
3. Maya’s mother requests fluoxetine “because it helped me.” Which gene–drug pair
BEST predicts SSRI response in adolescents?
A. CYP2D6 – fluoxetine metabolism
B. SLC6A4 – serotonin-transporter-linked polymorphic region (5-HTTLPR)
C. COMT Val158Met – dopamine catabolism
D. ANK3 – ankyrin-G variant
Correct Answer: B
Rationale: Meta-analysis shows 5-HTTLPR short-allele carriers have modestly lower
SSRI response and higher suicidality in youth.
4. You decide to start lamotrigine. Which counseling point is MOST essential?
A. Discontinue if rash appears, then call clinician within 24 h
B. Take with high-fat meal to reduce AUC
C. Expect therapeutic benefit by week 2
D. Swallow tablets whole only
Correct Answer: A
Rationale: Risk of Stevens-Johnson; prompt action required.
5. After 4 weeks (lamotrigine 25 mg → 50 mg), Maya reports “I still feel numb; cuts
are deeper.” She denies active SI today. Next BEST step:
A. Increase lamotrigine to 100 mg daily
B. Add dialectical behavior therapy (DBT) adolescent skills group
, C. Switch to lithium monotherapy
D. Obtain EEG to rule out epilepsy
Correct Answer: B
Rationale: Partial mood response + ongoing self-injury → DBT-skills targets emotional
dysregulation and is first-line for adolescent NSSI per AACAP 2023.
6. During session 3 of DBT, Maya’s father asks to see diary cards to “monitor her
better.” Father is custodial; Maya objects. Your ETHICAL obligation is:
A. Release records because father is legal guardian
B. Refuse entirely to protect minor confidentiality
C. Negotiate a collaborative agreement balancing confidentiality and safety,
documenting risk
D. Wait until Maya turns 18
Correct Answer: C
Rationale: APA ethics encourage adolescent autonomy while involving guardians in
safety; document clinical reasoning.
Case Block 2 – “Mr. Alvarez” (72 y M) – Geriatric Primary-Care Embedded Consult
Case Background
Mr. Alvarez, 72-y/o Latino veteran, retired mechanic, is referred by PCP for “depression
and memory complaints.” Wife notes 1-year cognitive slowing, apathy, 10-lb weight loss.
PHQ-9 15, MoCA 22 (visuospatial –2, delayed recall –3). Meds: metformin 1 g BID,
atorvastatin 20 mg, omeprazole 20 mg, tamsulosin 0.4 mg. No alcohol. FH: father
late-onset AD.
7. Which screening tool BEST differentiates late-life depression vs. early
neurocognitive disorder?
A. GDS-15
B. MoCA
, C. HDRS-17
D. Cornell Dementia Scale for Depression
Correct Answer: D
Rationale: Cornell integrates informant report & cognitive signs; validated in NCD.
8. Initial labs reveal B12 180 pg/mL (low), TSH 5.8 mIU/L (high). Which abnormality
MOST likely explains his apathy?
A. Low B12
B. High TSH
C. Atorvastatin-induced cognitive change
D. Omeprazole-induced B12 deficiency
Correct Answer: B
Rationale: Hypothyroidism directly causes apathy & pseudodementia; B12 low but rarely
symptomatic until <150.
9. After levothyroxine initiation, repeat TSH normal, but PHQ-9 remains 14. You
consider sertraline. Which pharmacokinetic change in Mr. Alvarez INCREASES
risk of hyponatremia?
A. ↑ CYP2C19 activity
B. ↓ Renal blood flow
C. ↑ Albumin
D. ↓ Gastric pH
Correct Answer: B
Rationale: Age-related ↓ renal perfusion potentiates SIADH-like SSRI effect.
10. Starting sertraline 25 mg, you schedule follow-up in 2 weeks primarily to monitor:
A. QTc prolongation
B. SIADH / serum sodium
C. Bleeding time
D. Intraocular pressure
Correct Answer: B
