Barkley PMHNP CHaPter 6 Quiz v2.0:
advaNCed PsyCHiatriC assessMeNt,
differeNtial diagNosis,
PsyCHoPHarMaCology, aNd CliNiCal
deCisioN-MakiNg for tHe PsyCHiatriC-
MeNtal HealtH Nurse PraCtitioNer a
well detailed oNe writteN
aNd graded a+ uPgraded
QUESTION 1
A 32-year-old female with no prior psychiatric history presents to the emergency department
with acute-onset confusion, hallucinations, and fluctuating consciousness. Her family reports
she recently started taking a new medication for a urinary tract infection. Which medication
class is most likely responsible for her symptoms?
A. Fluoroquinolones
B. Macrolides
C. Cephalosporins
D. Tetracyclines
Correct Answer: A
,Rationale: Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) are associated with acute
delirium, particularly in older adults and those with underlying CNS compromise. The acute
onset of confusion with fluctuating consciousness is characteristic of delirium, which can be
medication-induced.
QUESTION 2
A 68-year-old male with Parkinson's disease develops visual hallucinations of small animals and
children in his home. He has no other psychotic symptoms and retains insight that these are not
real. Which medication adjustment is most appropriate?
A. Increase his carbidopa-levodopa dose
B. Add quetiapine 25 mg at bedtime
C. Reduce his carbidopa-levodopa dose
D. Add risperidone 1 mg daily
Correct Answer: C
Rationale: Visual hallucinations in Parkinson's disease are often medication-induced,
particularly by dopaminergic agents. The first step is to reduce the carbidopa-levodopa dose.
Quetiapine is sometimes used but should not be first-line without attempting dose reduction.
Risperidone can worsen Parkinsonian symptoms.
QUESTION 3
A 45-year-old male with schizoaffective disorder is on clozapine 400 mg daily. His ANC drops
from 2,500 to 1,200 cells/mm³. According to the clozapine REMS program, what is the
appropriate next step?
A. Continue clozapine with increased monitoring
B. Hold clozapine and restart when ANC returns to >1,500
C. Discontinue clozapine permanently
D. Add lithium to boost white blood cell count
Correct Answer: B
Rationale: According to clozapine REMS guidelines, if ANC drops below 1,500 (or 1,000 in
patients with benign ethnic neutropenia), clozapine should be held, and monitoring should be
increased. Once ANC returns to >1,500, clozapine may be restarted. Permanent discontinuation
is required if ANC drops below 500.
,QUESTION 4
Which of the following is the most sensitive neuroimaging finding in a patient with early-stage
Alzheimer's disease?
A. White matter hyperintensities on T2-weighted MRI
B. Hippocampal atrophy on MRI
C. Reduced cerebral blood flow on SPECT
D. Increased ventricular size on CT
Correct Answer: B
Rationale: Hippocampal atrophy on MRI is the most sensitive neuroimaging finding in early
Alzheimer's disease. While SPECT and PET may show reduced metabolism, hippocampal atrophy
is an early and specific finding. White matter hyperintensities are more common in vascular
dementia.
QUESTION 5
A 22-year-old female with borderline personality disorder presents with chronic emptiness,
unstable relationships, and self-harm behaviors. She reports that she often feels like she doesn't
know who she is. Which defense mechanism is she most likely using?
A. Splitting
B. Identity diffusion
C. Projective identification
D. Idealization
Correct Answer: B
Rationale: Identity diffusion is a core feature of borderline personality disorder characterized by
a persistent and unstable sense of self. While splitting (viewing others as all-good or all-bad) is
also common, identity diffusion specifically describes the patient's lack of self-concept.
QUESTION 6
A 55-year-old male with treatment-resistant depression is started on a monoamine oxidase
inhibitor (MAOI). His wife calls stating he is confused and agitated after eating at a restaurant.
Which food most likely triggered this reaction?
, A. Grilled chicken
B. Aged cheese and red wine
C. Fresh vegetables
D. Pasta with tomato sauce
Correct Answer: B
Rationale: Aged cheese and red wine contain tyramine, which can cause a hypertensive crisis in
patients taking MAOIs. Symptoms include severe headache, hypertension, confusion, and
agitation. Patients on MAOIs must adhere to a tyramine-restricted diet.
QUESTION 7
Which of the following is the primary mechanism of action of ketamine in treating treatment-
resistant depression?
A. SSRI activity
B. NMDA receptor antagonism and AMPA receptor stimulation
C. Dopamine receptor blockade
D. GABA receptor agonism
Correct Answer: B
Rationale: Ketamine's antidepressant effect is primarily mediated through NMDA receptor
antagonism, leading to downstream effects on AMPA receptors. This triggers a cascade that
results in increased synaptic plasticity and rapid antidepressant effects.
QUESTION 8
A 30-year-old female with generalized anxiety disorder is prescribed buspirone. She returns
after 4 weeks reporting no improvement. Which of the following factors is most likely
responsible?
A. The dose was too high
B. She is taking the medication as needed rather than daily
C. She is taking it with food
D. The medication has not yet reached therapeutic effect
Correct Answer: B
advaNCed PsyCHiatriC assessMeNt,
differeNtial diagNosis,
PsyCHoPHarMaCology, aNd CliNiCal
deCisioN-MakiNg for tHe PsyCHiatriC-
MeNtal HealtH Nurse PraCtitioNer a
well detailed oNe writteN
aNd graded a+ uPgraded
QUESTION 1
A 32-year-old female with no prior psychiatric history presents to the emergency department
with acute-onset confusion, hallucinations, and fluctuating consciousness. Her family reports
she recently started taking a new medication for a urinary tract infection. Which medication
class is most likely responsible for her symptoms?
A. Fluoroquinolones
B. Macrolides
C. Cephalosporins
D. Tetracyclines
Correct Answer: A
,Rationale: Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) are associated with acute
delirium, particularly in older adults and those with underlying CNS compromise. The acute
onset of confusion with fluctuating consciousness is characteristic of delirium, which can be
medication-induced.
QUESTION 2
A 68-year-old male with Parkinson's disease develops visual hallucinations of small animals and
children in his home. He has no other psychotic symptoms and retains insight that these are not
real. Which medication adjustment is most appropriate?
A. Increase his carbidopa-levodopa dose
B. Add quetiapine 25 mg at bedtime
C. Reduce his carbidopa-levodopa dose
D. Add risperidone 1 mg daily
Correct Answer: C
Rationale: Visual hallucinations in Parkinson's disease are often medication-induced,
particularly by dopaminergic agents. The first step is to reduce the carbidopa-levodopa dose.
Quetiapine is sometimes used but should not be first-line without attempting dose reduction.
Risperidone can worsen Parkinsonian symptoms.
QUESTION 3
A 45-year-old male with schizoaffective disorder is on clozapine 400 mg daily. His ANC drops
from 2,500 to 1,200 cells/mm³. According to the clozapine REMS program, what is the
appropriate next step?
A. Continue clozapine with increased monitoring
B. Hold clozapine and restart when ANC returns to >1,500
C. Discontinue clozapine permanently
D. Add lithium to boost white blood cell count
Correct Answer: B
Rationale: According to clozapine REMS guidelines, if ANC drops below 1,500 (or 1,000 in
patients with benign ethnic neutropenia), clozapine should be held, and monitoring should be
increased. Once ANC returns to >1,500, clozapine may be restarted. Permanent discontinuation
is required if ANC drops below 500.
,QUESTION 4
Which of the following is the most sensitive neuroimaging finding in a patient with early-stage
Alzheimer's disease?
A. White matter hyperintensities on T2-weighted MRI
B. Hippocampal atrophy on MRI
C. Reduced cerebral blood flow on SPECT
D. Increased ventricular size on CT
Correct Answer: B
Rationale: Hippocampal atrophy on MRI is the most sensitive neuroimaging finding in early
Alzheimer's disease. While SPECT and PET may show reduced metabolism, hippocampal atrophy
is an early and specific finding. White matter hyperintensities are more common in vascular
dementia.
QUESTION 5
A 22-year-old female with borderline personality disorder presents with chronic emptiness,
unstable relationships, and self-harm behaviors. She reports that she often feels like she doesn't
know who she is. Which defense mechanism is she most likely using?
A. Splitting
B. Identity diffusion
C. Projective identification
D. Idealization
Correct Answer: B
Rationale: Identity diffusion is a core feature of borderline personality disorder characterized by
a persistent and unstable sense of self. While splitting (viewing others as all-good or all-bad) is
also common, identity diffusion specifically describes the patient's lack of self-concept.
QUESTION 6
A 55-year-old male with treatment-resistant depression is started on a monoamine oxidase
inhibitor (MAOI). His wife calls stating he is confused and agitated after eating at a restaurant.
Which food most likely triggered this reaction?
, A. Grilled chicken
B. Aged cheese and red wine
C. Fresh vegetables
D. Pasta with tomato sauce
Correct Answer: B
Rationale: Aged cheese and red wine contain tyramine, which can cause a hypertensive crisis in
patients taking MAOIs. Symptoms include severe headache, hypertension, confusion, and
agitation. Patients on MAOIs must adhere to a tyramine-restricted diet.
QUESTION 7
Which of the following is the primary mechanism of action of ketamine in treating treatment-
resistant depression?
A. SSRI activity
B. NMDA receptor antagonism and AMPA receptor stimulation
C. Dopamine receptor blockade
D. GABA receptor agonism
Correct Answer: B
Rationale: Ketamine's antidepressant effect is primarily mediated through NMDA receptor
antagonism, leading to downstream effects on AMPA receptors. This triggers a cascade that
results in increased synaptic plasticity and rapid antidepressant effects.
QUESTION 8
A 30-year-old female with generalized anxiety disorder is prescribed buspirone. She returns
after 4 weeks reporting no improvement. Which of the following factors is most likely
responsible?
A. The dose was too high
B. She is taking the medication as needed rather than daily
C. She is taking it with food
D. The medication has not yet reached therapeutic effect
Correct Answer: B
