NR607 FINAL EXAM ACTUAL 2026/2027 | Diagnosis &
Management in PMHNP III | Weeks 5-8 Complete Review |
Verified Answers | Chamberlain | Pass Guaranteed - A+
Graded
Section 1: Complex Mood Disorders & Treatment Resistance (Week 5) (Q1-18)
Q1. A 42-year-old patient with major depressive disorder has failed trials of sertraline
200 mg x 12 weeks and venlafaxine 225 mg x 10 weeks at adequate doses. The patient
reports partial response with improved sleep but persistent anhedonia and fatigue.
Which augmentation strategy is most appropriate based on current evidence?
A. Discontinue antidepressant and switch to phenelzine
B. Add aripiprazole 2-5 mg daily to current antidepressant
C. Add bupropion XL 300 mg daily to current antidepressant
D. Discontinue antidepressant and start ECT immediately
Correct format: B. Add aripiprazole 2-5 mg daily to current antidepressant [CORRECT]
Rationale: Aripiprazole is FDA-approved for adjunctive treatment of MDD with
inadequate response. Adding it to an existing antidepressant is evidence-based for TRD.
Switching to an MAOI or ECT is reserved for more refractory cases or intolerance, and
bupropion is generally used earlier in treatment or for sexual side effects rather than as
a second-line augmentation after two failed SSRI/SNRI trials.
Correct Answer: B
Q2. A 28-year-old patient with bipolar I disorder reports four distinct mood episodes in
the past 10 months: two manic episodes requiring hospitalization and two depressive
episodes. The patient is currently euthymic on lithium 1200 mg/day with a level of 0.6
mEq/L. What is the next best step in management?
A. Add an antidepressant to prevent future depressive episodes
B. Increase lithium to achieve a serum level of 1.0-1.2 mEq/L
,C. Add valproate or optimize lithium to 0.8-1.0 mEq/L
D. Discontinue lithium and switch to carbamazepine monotherapy
Correct format: C. Add valproate or optimize lithium to 0.8-1.0 mEq/L [CORRECT]
Rationale: Rapid cycling (≥4 mood episodes/year) often requires higher target serum
levels or combination mood stabilizer therapy. Antidepressants are contraindicated as
they can induce mania and worsen cycling. Discontinuing lithium entirely is not
indicated when the patient is partially responsive.
Correct Answer: C
Q3. A 35-year-old patient presents with elevated mood, decreased need for sleep, racing
thoughts, and pressured speech concurrent with severe irritability, suicidal ideation, and
psychomotor agitation. The patient meets full criteria for a manic episode and major
depressive episode simultaneously. Which treatment approach is most appropriate?
A. Start fluoxetine to address the depressive symptoms
B. Start lithium plus an atypical antipsychotic such as quetiapine or olanzapine
C. Start lamotrigine monotherapy to stabilize mood
D. Start divalproex alone and reassess in 4 weeks
Correct format: B. Start lithium plus an atypical antipsychotic such as quetiapine or
olanzapine [CORRECT]
Rationale: Mixed features in bipolar disorder require mood stabilizers and/or atypical
antipsychotics; antidepressants are contraindicated due to risk of worsening mania and
increasing suicidality. Lamotrigine is primarily for maintenance and bipolar depression,
not acute mixed states. Monotherapy with valproate may be insufficient for severe
mixed presentations.
Correct Answer: B
Q4. Which dietary restriction is essential for patients taking phenelzine or
tranylcypromine?
A. Complete avoidance of all dairy products
B. Avoidance of tyramine-rich foods such as aged cheeses, cured meats, and fermented
products
C. Restriction of all protein sources to prevent hypertensive crisis
,D. Limitation of carbohydrate intake to prevent serotonin syndrome
Correct format: B. Avoidance of tyramine-rich foods such as aged cheeses, cured
meats, and fermented products [CORRECT]
Rationale: MAOIs inhibit the breakdown of tyramine, which can accumulate and cause
hypertensive crisis. Tyramine-rich foods must be strictly avoided. Dairy, protein, and
carbohydrates do not pose the same risk.
Correct Answer: B
Q5. A 24-year-old patient presents with mood lability, intense fear of abandonment,
chronic emptiness, and recurrent suicidal gestures. Episodes of "depression" last hours
to days and are triggered by interpersonal conflict. There is no history of discrete manic
or hypomanic episodes lasting 4+ days. Which diagnosis best fits this presentation?
A. Bipolar II disorder with rapid cycling
B. Borderline personality disorder
C. Cyclothymic disorder
D. Major depressive disorder with atypical features
Correct format: B. Borderline personality disorder [CORRECT]
Rationale: BPD is characterized by affective instability triggered by interpersonal
stressors, chronic emptiness, fear of abandonment, and transient suicidal ideation
without discrete mood episodes. Bipolar disorders require distinct episodes of
mania/hypomania or depression lasting days to weeks, not hours. The longitudinal
pattern and trigger specificity distinguish BPD from bipolar spectrum disorders.
Correct Answer: B
Q6. A 58-year-old patient with severe, treatment-resistant depression has failed trials of
sertraline, venlafaxine, bupropion, and augmentation with aripiprazole. The patient has
catatonic features, psychotic symptoms, and refuses oral medications. What is the
most appropriate next intervention?
A. Start transcranial magnetic stimulation (TMS) five times weekly
B. Initiate a course of electroconvulsive therapy (ECT)
C. Switch to tranylcypromine 30 mg daily
, D. Add lithium augmentation to the current antidepressant
Correct format: B. Initiate a course of electroconvulsive therapy (ECT) [CORRECT]
Rationale: ECT is indicated for severe TRD, especially with catatonic features, psychotic
symptoms, or acute suicidality. TMS is generally for less severe TRD without psychotic
features. MAOIs and lithium augmentation are pharmacologic options but less
appropriate when the patient refuses oral medications and has catatonia.
Correct Answer: B
Q7. A patient with TRD is considering transcranial magnetic stimulation (TMS). The
patient has no history of psychosis and no implanted metallic devices. Which statement
accurately describes TMS compared to ECT?
A. TMS requires general anesthesia and produces seizures
B. TMS is administered daily for 4-6 weeks and has minimal cognitive side effects
C. TMS is first-line for depression with psychotic features
D. ECT and TMS have identical remission rates in all populations
Correct format: B. TMS is administered daily for 4-6 weeks and has minimal cognitive
side effects [CORRECT]
Rationale: TMS involves daily sessions (typically 5 days/week for 4-6 weeks) without
anesthesia and does not cause significant cognitive impairment. ECT requires
anesthesia and may cause transient memory issues. TMS is not indicated for psychotic
depression, and remission rates differ between modalities.
Correct Answer: B
Q8. A 45-year-old patient with severe TRD and passive suicidal ideation is being
evaluated for esketamine. Which statement regarding esketamine administration is
correct?
A. It is administered orally once daily in the primary care setting
B. It requires supervised administration in a certified clinic with post-dose monitoring
for dissociation and blood pressure
C. It is restricted to patients who have failed only one antidepressant
D. It is contraindicated in patients with any history of substance use
Management in PMHNP III | Weeks 5-8 Complete Review |
Verified Answers | Chamberlain | Pass Guaranteed - A+
Graded
Section 1: Complex Mood Disorders & Treatment Resistance (Week 5) (Q1-18)
Q1. A 42-year-old patient with major depressive disorder has failed trials of sertraline
200 mg x 12 weeks and venlafaxine 225 mg x 10 weeks at adequate doses. The patient
reports partial response with improved sleep but persistent anhedonia and fatigue.
Which augmentation strategy is most appropriate based on current evidence?
A. Discontinue antidepressant and switch to phenelzine
B. Add aripiprazole 2-5 mg daily to current antidepressant
C. Add bupropion XL 300 mg daily to current antidepressant
D. Discontinue antidepressant and start ECT immediately
Correct format: B. Add aripiprazole 2-5 mg daily to current antidepressant [CORRECT]
Rationale: Aripiprazole is FDA-approved for adjunctive treatment of MDD with
inadequate response. Adding it to an existing antidepressant is evidence-based for TRD.
Switching to an MAOI or ECT is reserved for more refractory cases or intolerance, and
bupropion is generally used earlier in treatment or for sexual side effects rather than as
a second-line augmentation after two failed SSRI/SNRI trials.
Correct Answer: B
Q2. A 28-year-old patient with bipolar I disorder reports four distinct mood episodes in
the past 10 months: two manic episodes requiring hospitalization and two depressive
episodes. The patient is currently euthymic on lithium 1200 mg/day with a level of 0.6
mEq/L. What is the next best step in management?
A. Add an antidepressant to prevent future depressive episodes
B. Increase lithium to achieve a serum level of 1.0-1.2 mEq/L
,C. Add valproate or optimize lithium to 0.8-1.0 mEq/L
D. Discontinue lithium and switch to carbamazepine monotherapy
Correct format: C. Add valproate or optimize lithium to 0.8-1.0 mEq/L [CORRECT]
Rationale: Rapid cycling (≥4 mood episodes/year) often requires higher target serum
levels or combination mood stabilizer therapy. Antidepressants are contraindicated as
they can induce mania and worsen cycling. Discontinuing lithium entirely is not
indicated when the patient is partially responsive.
Correct Answer: C
Q3. A 35-year-old patient presents with elevated mood, decreased need for sleep, racing
thoughts, and pressured speech concurrent with severe irritability, suicidal ideation, and
psychomotor agitation. The patient meets full criteria for a manic episode and major
depressive episode simultaneously. Which treatment approach is most appropriate?
A. Start fluoxetine to address the depressive symptoms
B. Start lithium plus an atypical antipsychotic such as quetiapine or olanzapine
C. Start lamotrigine monotherapy to stabilize mood
D. Start divalproex alone and reassess in 4 weeks
Correct format: B. Start lithium plus an atypical antipsychotic such as quetiapine or
olanzapine [CORRECT]
Rationale: Mixed features in bipolar disorder require mood stabilizers and/or atypical
antipsychotics; antidepressants are contraindicated due to risk of worsening mania and
increasing suicidality. Lamotrigine is primarily for maintenance and bipolar depression,
not acute mixed states. Monotherapy with valproate may be insufficient for severe
mixed presentations.
Correct Answer: B
Q4. Which dietary restriction is essential for patients taking phenelzine or
tranylcypromine?
A. Complete avoidance of all dairy products
B. Avoidance of tyramine-rich foods such as aged cheeses, cured meats, and fermented
products
C. Restriction of all protein sources to prevent hypertensive crisis
,D. Limitation of carbohydrate intake to prevent serotonin syndrome
Correct format: B. Avoidance of tyramine-rich foods such as aged cheeses, cured
meats, and fermented products [CORRECT]
Rationale: MAOIs inhibit the breakdown of tyramine, which can accumulate and cause
hypertensive crisis. Tyramine-rich foods must be strictly avoided. Dairy, protein, and
carbohydrates do not pose the same risk.
Correct Answer: B
Q5. A 24-year-old patient presents with mood lability, intense fear of abandonment,
chronic emptiness, and recurrent suicidal gestures. Episodes of "depression" last hours
to days and are triggered by interpersonal conflict. There is no history of discrete manic
or hypomanic episodes lasting 4+ days. Which diagnosis best fits this presentation?
A. Bipolar II disorder with rapid cycling
B. Borderline personality disorder
C. Cyclothymic disorder
D. Major depressive disorder with atypical features
Correct format: B. Borderline personality disorder [CORRECT]
Rationale: BPD is characterized by affective instability triggered by interpersonal
stressors, chronic emptiness, fear of abandonment, and transient suicidal ideation
without discrete mood episodes. Bipolar disorders require distinct episodes of
mania/hypomania or depression lasting days to weeks, not hours. The longitudinal
pattern and trigger specificity distinguish BPD from bipolar spectrum disorders.
Correct Answer: B
Q6. A 58-year-old patient with severe, treatment-resistant depression has failed trials of
sertraline, venlafaxine, bupropion, and augmentation with aripiprazole. The patient has
catatonic features, psychotic symptoms, and refuses oral medications. What is the
most appropriate next intervention?
A. Start transcranial magnetic stimulation (TMS) five times weekly
B. Initiate a course of electroconvulsive therapy (ECT)
C. Switch to tranylcypromine 30 mg daily
, D. Add lithium augmentation to the current antidepressant
Correct format: B. Initiate a course of electroconvulsive therapy (ECT) [CORRECT]
Rationale: ECT is indicated for severe TRD, especially with catatonic features, psychotic
symptoms, or acute suicidality. TMS is generally for less severe TRD without psychotic
features. MAOIs and lithium augmentation are pharmacologic options but less
appropriate when the patient refuses oral medications and has catatonia.
Correct Answer: B
Q7. A patient with TRD is considering transcranial magnetic stimulation (TMS). The
patient has no history of psychosis and no implanted metallic devices. Which statement
accurately describes TMS compared to ECT?
A. TMS requires general anesthesia and produces seizures
B. TMS is administered daily for 4-6 weeks and has minimal cognitive side effects
C. TMS is first-line for depression with psychotic features
D. ECT and TMS have identical remission rates in all populations
Correct format: B. TMS is administered daily for 4-6 weeks and has minimal cognitive
side effects [CORRECT]
Rationale: TMS involves daily sessions (typically 5 days/week for 4-6 weeks) without
anesthesia and does not cause significant cognitive impairment. ECT requires
anesthesia and may cause transient memory issues. TMS is not indicated for psychotic
depression, and remission rates differ between modalities.
Correct Answer: B
Q8. A 45-year-old patient with severe TRD and passive suicidal ideation is being
evaluated for esketamine. Which statement regarding esketamine administration is
correct?
A. It is administered orally once daily in the primary care setting
B. It requires supervised administration in a certified clinic with post-dose monitoring
for dissociation and blood pressure
C. It is restricted to patients who have failed only one antidepressant
D. It is contraindicated in patients with any history of substance use
