APEA PREDICTOR GOLD 200 PMHNP
BOARD REVIEW QUESTIONS AND IN
DEPTH RATIONALES (2024/2025
EDITION)
1. A 42-year-old male with chronic schizophrenia presents
with high fever, "lead-pipe" muscle rigidity, and fluctuating
consciousness. What is the priority intervention?
A. Increase haloperidol dose
B. Administer benztropine
C. Discontinue antipsychotics and initiate hydration and
dantrolene
D. Switch to clozapine
Rationale: These symptoms indicate Neuroleptic Malignant
Syndrome (NMS), a life-threatening emergency. The primary
action is stopping the causative agent and providing
intensive supportive care.
2. Which cardiac defect is specifically associated with Lithium
use during the first trimester?
A. Tetralogy of Fallot
B. Ventricular septal defect
C. Ebstein’s anomaly
D. Coarctation of the aorta
Rationale: Ebstein’s anomaly, involving tricuspid valve
displacement, is a rare but well-documented teratogenic risk
for lithium exposure in utero.
3. What is the only absolute contraindication for
Electroconvulsive Therapy (ECT)?
A. Recent myocardial infarction
B. Increased intracranial pressure (ICP)
C. Advanced pregnancy
D. Osteoporosis
Rationale: ECT causes a transient increase in cerebral blood
flow, which can lead to brain herniation in patients with pre-
existing high ICP.
,4. A patient on Phenelzine (MAOI) reports a pounding
headache after a party where they consumed aged cheese and
wine. What is the likely cause?
A. Serotonin syndrome
B. Hypertensive crisis due to tyramine
C. Anticholinergic toxicity
D. Orthostatic hypotension
Rationale: MAOIs prevent the breakdown of tyramine; its
accumulation causes massive norepinephrine release,
leading to dangerous blood pressure spikes.
5. Which symptoms represent the "negative symptoms"
cluster of Schizophrenia?
A. Delusions and hallucinations
B. Disorganized speech and behavior
C. Affective flattening, alogia, and avolition
D. Ideas of reference
Rationale: Negative symptoms refer to the absence of normal
function, such as reduced emotional expression (flattening)
or lack of speech (alogia).
6. At what Absolute Neutrophil Count (ANC) must Clozapine
be discontinued in the general population?
A. <2,000/mm³
B. <1,500/mm³
C. <1,000/mm³
D. <500/mm³
Rationale: Monitoring is mandated via the Clozapine REMS
program to prevent fatal agranulocytosis; therapy is
withheld if the ANC drops below 1,500. [1, 2]
7. A patient in alcohol withdrawal experiences visual
hallucinations and tachycardia on day three. What is the first-
line treatment?
A. Haloperidol
B. Lorazepam (Benzodiazepines)
C. Valproic acid
D. Thiamine
Rationale: Benzodiazepines are the gold standard for
treating alcohol withdrawal symptoms and preventing
seizures or delirium tremens.
,8. Which TCA is considered the "gold standard" for treating
Obsessive-Compulsive Disorder (OCD)?
A. Amitriptyline
B. Imipramine
C. Clomipramine
D. Nortriptyline
Rationale: Clomipramine is uniquely potent in inhibiting
serotonin reuptake, making it highly effective for OCD,
though often reserved for secondary treatment due to side
effects.
9. A patient shows intense fear of abandonment, unstable
relationships, and self-harm behaviors. Which personality
disorder is most likely?
A. Histrionic
B. Borderline
C. Narcissistic
D. Schizoid
Rationale: Borderline Personality Disorder (BPD) is
characterized by emotional instability, impulsivity, and
turbulent interpersonal relationships. [1, 2]
10. Why is Lamotrigine titrated slowly over several weeks?
A. To prevent weight gain
B. To avoid sedation
C. To minimize the risk of Stevens-Johnson Syndrome (SJS)
D. To prevent lithium toxicity
Rationale: Rapid titration of Lamotrigine is a major risk
factor for life-threatening dermatological reactions like SJS.
11. A 72-year-old patient with mild cognitive impairment is
being evaluated for new-onset depression. The Nurse
Practitioner is concerned about the anticholinergic burden of
medications. Which of the following antidepressants has the
lowest anticholinergic activity and is generally preferred for
the elderly?
A. Amitriptyline.
B. Paroxetine.
C. Sertraline.
D. Imipramine.
Rationale: SSRIs like Sertraline are preferred in the elderly
because they lack the significant anticholinergic side effects
, (confusion, urinary retention, constipation) associated with
TCAs and certain SSRIs like Paroxetine.
12. A patient with Bipolar I disorder has been stable on
Lithium for two years. He recently started taking
Hydrochlorothiazide (HCTZ) for hypertension. He now
presents with nausea, slurred speech, and unsteadiness. What
is the most likely cause of these symptoms?
A. Increased Lithium levels due to decreased renal clearance.
B. A stroke involving the cerebellum.
C. Worsening of his bipolar symptoms.
D. Dehydration from the diuretic causing a hangover effect.
Rationale: Thiazide diuretics cause the kidneys to retain
lithium by depleting sodium, leading to a dangerous rise in
lithium levels and subsequent toxicity.
13. A 25-year-old female reports that she feels "outside of her
body," as if she is observing herself from a distance. She
remains oriented to reality and knows who she is, but the
sensation is distressing. This is best described as:
A. Derealization.
B. Depersonalization.
C. Dissociative Fugue.
D. Visual Hallucination.
Rationale: Depersonalization is an alteration in the
perception or experience of the self so that one feels detached
from, and as if one is an outside observer of, one's mental
processes or body.
14. When treating a patient with ADHD and a co-occurring
History of Substance Use Disorder, which of the following is
the most appropriate first-line pharmacological intervention?
A. Methylphenidate (Ritalin).
B. Dextroamphetamine (Adderall).
C. Atomoxetine (Strattera).
D. Lisdexamfetamine (Vyvanse).
Rationale: Atomoxetine is a non-stimulant with no abuse
potential, making it the safest first-line choice for patients
with a history of addiction.
15. A patient on Clozapine reports a sore throat and a fever of
102°F. The Absolute Neutrophil Count (ANC) is 450/mm³.
BOARD REVIEW QUESTIONS AND IN
DEPTH RATIONALES (2024/2025
EDITION)
1. A 42-year-old male with chronic schizophrenia presents
with high fever, "lead-pipe" muscle rigidity, and fluctuating
consciousness. What is the priority intervention?
A. Increase haloperidol dose
B. Administer benztropine
C. Discontinue antipsychotics and initiate hydration and
dantrolene
D. Switch to clozapine
Rationale: These symptoms indicate Neuroleptic Malignant
Syndrome (NMS), a life-threatening emergency. The primary
action is stopping the causative agent and providing
intensive supportive care.
2. Which cardiac defect is specifically associated with Lithium
use during the first trimester?
A. Tetralogy of Fallot
B. Ventricular septal defect
C. Ebstein’s anomaly
D. Coarctation of the aorta
Rationale: Ebstein’s anomaly, involving tricuspid valve
displacement, is a rare but well-documented teratogenic risk
for lithium exposure in utero.
3. What is the only absolute contraindication for
Electroconvulsive Therapy (ECT)?
A. Recent myocardial infarction
B. Increased intracranial pressure (ICP)
C. Advanced pregnancy
D. Osteoporosis
Rationale: ECT causes a transient increase in cerebral blood
flow, which can lead to brain herniation in patients with pre-
existing high ICP.
,4. A patient on Phenelzine (MAOI) reports a pounding
headache after a party where they consumed aged cheese and
wine. What is the likely cause?
A. Serotonin syndrome
B. Hypertensive crisis due to tyramine
C. Anticholinergic toxicity
D. Orthostatic hypotension
Rationale: MAOIs prevent the breakdown of tyramine; its
accumulation causes massive norepinephrine release,
leading to dangerous blood pressure spikes.
5. Which symptoms represent the "negative symptoms"
cluster of Schizophrenia?
A. Delusions and hallucinations
B. Disorganized speech and behavior
C. Affective flattening, alogia, and avolition
D. Ideas of reference
Rationale: Negative symptoms refer to the absence of normal
function, such as reduced emotional expression (flattening)
or lack of speech (alogia).
6. At what Absolute Neutrophil Count (ANC) must Clozapine
be discontinued in the general population?
A. <2,000/mm³
B. <1,500/mm³
C. <1,000/mm³
D. <500/mm³
Rationale: Monitoring is mandated via the Clozapine REMS
program to prevent fatal agranulocytosis; therapy is
withheld if the ANC drops below 1,500. [1, 2]
7. A patient in alcohol withdrawal experiences visual
hallucinations and tachycardia on day three. What is the first-
line treatment?
A. Haloperidol
B. Lorazepam (Benzodiazepines)
C. Valproic acid
D. Thiamine
Rationale: Benzodiazepines are the gold standard for
treating alcohol withdrawal symptoms and preventing
seizures or delirium tremens.
,8. Which TCA is considered the "gold standard" for treating
Obsessive-Compulsive Disorder (OCD)?
A. Amitriptyline
B. Imipramine
C. Clomipramine
D. Nortriptyline
Rationale: Clomipramine is uniquely potent in inhibiting
serotonin reuptake, making it highly effective for OCD,
though often reserved for secondary treatment due to side
effects.
9. A patient shows intense fear of abandonment, unstable
relationships, and self-harm behaviors. Which personality
disorder is most likely?
A. Histrionic
B. Borderline
C. Narcissistic
D. Schizoid
Rationale: Borderline Personality Disorder (BPD) is
characterized by emotional instability, impulsivity, and
turbulent interpersonal relationships. [1, 2]
10. Why is Lamotrigine titrated slowly over several weeks?
A. To prevent weight gain
B. To avoid sedation
C. To minimize the risk of Stevens-Johnson Syndrome (SJS)
D. To prevent lithium toxicity
Rationale: Rapid titration of Lamotrigine is a major risk
factor for life-threatening dermatological reactions like SJS.
11. A 72-year-old patient with mild cognitive impairment is
being evaluated for new-onset depression. The Nurse
Practitioner is concerned about the anticholinergic burden of
medications. Which of the following antidepressants has the
lowest anticholinergic activity and is generally preferred for
the elderly?
A. Amitriptyline.
B. Paroxetine.
C. Sertraline.
D. Imipramine.
Rationale: SSRIs like Sertraline are preferred in the elderly
because they lack the significant anticholinergic side effects
, (confusion, urinary retention, constipation) associated with
TCAs and certain SSRIs like Paroxetine.
12. A patient with Bipolar I disorder has been stable on
Lithium for two years. He recently started taking
Hydrochlorothiazide (HCTZ) for hypertension. He now
presents with nausea, slurred speech, and unsteadiness. What
is the most likely cause of these symptoms?
A. Increased Lithium levels due to decreased renal clearance.
B. A stroke involving the cerebellum.
C. Worsening of his bipolar symptoms.
D. Dehydration from the diuretic causing a hangover effect.
Rationale: Thiazide diuretics cause the kidneys to retain
lithium by depleting sodium, leading to a dangerous rise in
lithium levels and subsequent toxicity.
13. A 25-year-old female reports that she feels "outside of her
body," as if she is observing herself from a distance. She
remains oriented to reality and knows who she is, but the
sensation is distressing. This is best described as:
A. Derealization.
B. Depersonalization.
C. Dissociative Fugue.
D. Visual Hallucination.
Rationale: Depersonalization is an alteration in the
perception or experience of the self so that one feels detached
from, and as if one is an outside observer of, one's mental
processes or body.
14. When treating a patient with ADHD and a co-occurring
History of Substance Use Disorder, which of the following is
the most appropriate first-line pharmacological intervention?
A. Methylphenidate (Ritalin).
B. Dextroamphetamine (Adderall).
C. Atomoxetine (Strattera).
D. Lisdexamfetamine (Vyvanse).
Rationale: Atomoxetine is a non-stimulant with no abuse
potential, making it the safest first-line choice for patients
with a history of addiction.
15. A patient on Clozapine reports a sore throat and a fever of
102°F. The Absolute Neutrophil Count (ANC) is 450/mm³.
