Barkley PMHNP CHaPter Quiz 9 v2.0:
advaNCed PsyCHiatriC-MeNtal HealtH
assessMeNt, PsyCHoPHarMaCology, aNd
CliNiCal deCisioN-MakiNg a well
detailed oNe writteN aNd
graded a+ uPgraded
Question 1
A 28-year-old female with treatment-resistant depression has failed adequate trials of two SSRIs
and one SNRI. She reports significant anhedonia, psychomotor retardation, and early morning
awakening. Which medication combination would be most appropriate as a next-step strategy?
A) Fluoxetine plus olanzapine
B) Bupropion plus trazodone
C) Vortioxetine plus aripiprazole
D) Tranylcypromine plus lithium
Correct Answer: C) Vortioxetine plus aripiprazole
Rationale: Aripiprazole is FDA-approved as an adjunctive treatment for MDD. Vortioxetine has a
multimodal mechanism and may be beneficial in patients who have failed multiple
antidepressants. The combination of an atypical antidepressant with an atypical antipsychotic is
a evidence-based strategy for treatment-resistant depression.
Question 2
,A 52-year-old male with bipolar I disorder is maintained on lithium 900 mg/day. He presents
with tremor, polyuria, and polydipsia. His serum lithium level is 1.4 mEq/L. Which intervention is
most appropriate?
A) Decrease lithium to 600 mg/day and check level in 1 week
B) Add propranolol 20 mg TID for tremor
C) Check serum creatinine and urine osmolality
D) Switch to valproate immediately
Correct Answer: C) Check serum creatinine and urine osmolality
Rationale: Polyuria and polydipsia suggest nephrogenic diabetes insipidus, a known adverse
effect of lithium. Renal function assessment is critical before making medication changes. The
lithium level of 1.4 mEq/L is within therapeutic range (0.6-1.2 mEq/L for maintenance; up to 1.5
mEq/L for acute mania), so the tremor may be related to long-term use rather than toxicity.
Question 3
Which cytochrome P450 enzyme is primarily responsible for the metabolism of fluoxetine?
A) CYP1A2
B) CYP2D6
C) CYP3A4
D) CYP2C19
Correct Answer: B) CYP2D6
Rationale: Fluoxetine is metabolized primarily by CYP2D6 and CYP2C19, but its active
metabolite norfluoxetine is a potent inhibitor of CYP2D6. This contributes to its drug-drug
interaction potential.
Question 4
A 38-year-old patient with schizophrenia has been stable on risperidone 4 mg daily for 2 years.
She now reports amenorrhea and galactorrhea. Her prolactin level is 85 ng/mL (normal: <25).
Which is the most appropriate next step?
A) Continue risperidone and add bromocriptine
B) Switch to aripiprazole
C) Decrease risperidone to 2 mg daily
D) Order a pituitary MRI
,Correct Answer: B) Switch to aripiprazole
Rationale: Risperidone is associated with significant hyperprolactinemia due to potent D2
receptor antagonism. Aripiprazole, a D2 partial agonist, has a lower propensity for
hyperprolactinemia and can normalize prolactin levels when switched.
Question 5
Which of the following is the strongest predictor of antidepressant response in major depressive
disorder?
A) Family history of depression
B) Severity of baseline symptoms
C) Presence of psychotic features
D) Early improvement within 2 weeks of treatment
Correct Answer: D) Early improvement within 2 weeks of treatment
Rationale: Early improvement (≥20-30% reduction in symptoms within 2 weeks) is the strongest
predictor of eventual response and remission in MDD.
Question 6
A 19-year-old college student presents with excessive worry about academic performance,
difficulty concentrating, muscle tension, and insomnia for 8 months. She avoids social situations
due to fear of negative evaluation. What is the most likely diagnosis?
A) Generalized anxiety disorder only
B) Social anxiety disorder only
C) Generalized anxiety disorder with comorbid social anxiety disorder
D) Adjustment disorder with mixed anxiety and depression
Correct Answer: C) Generalized anxiety disorder with comorbid social anxiety disorder
Rationale: She meets criteria for GAD (excessive worry across domains >6 months with physical
symptoms) AND social anxiety disorder (fear of negative evaluation in social situations).
Comorbidity is common.
Question 7
A patient on phenelzine (MAOI) reports severe headache, palpitations, and nausea after eating
aged cheese. What is the most likely diagnosis?
, A) Serotonin syndrome
B) Hypertensive crisis
C) Neuroleptic malignant syndrome
D) Anticholinergic crisis
Correct Answer: B) Hypertensive crisis
Rationale: MAOIs interact with tyramine-rich foods (aged cheese, cured meats) to cause
hypertensive crisis due to norepinephrine release.
Question 8
Which of the following antipsychotics has the lowest risk of QTc prolongation?
A) Ziprasidone
B) Iloperidone
C) Quetiapine
D) Aripiprazole
Correct Answer: D) Aripiprazole
Rationale: Aripiprazole has the lowest risk of QTc prolongation among antipsychotics.
Ziprasidone and iloperidone have higher risk.
Question 9
A 45-year-old with bipolar II disorder presents with hypomania. She is currently on lamotrigine
200 mg/day. What is the most appropriate next step?
A) Increase lamotrigine to 300 mg/day
B) Add quetiapine
C) Add lithium
D) Discontinue lamotrigine
Correct Answer: B) Add quetiapine
Rationale: Lamotrigine is more effective for bipolar depression than for mania. Adding an
atypical antipsychotic like quetiapine is appropriate for acute hypomanic symptoms.
Question 10
advaNCed PsyCHiatriC-MeNtal HealtH
assessMeNt, PsyCHoPHarMaCology, aNd
CliNiCal deCisioN-MakiNg a well
detailed oNe writteN aNd
graded a+ uPgraded
Question 1
A 28-year-old female with treatment-resistant depression has failed adequate trials of two SSRIs
and one SNRI. She reports significant anhedonia, psychomotor retardation, and early morning
awakening. Which medication combination would be most appropriate as a next-step strategy?
A) Fluoxetine plus olanzapine
B) Bupropion plus trazodone
C) Vortioxetine plus aripiprazole
D) Tranylcypromine plus lithium
Correct Answer: C) Vortioxetine plus aripiprazole
Rationale: Aripiprazole is FDA-approved as an adjunctive treatment for MDD. Vortioxetine has a
multimodal mechanism and may be beneficial in patients who have failed multiple
antidepressants. The combination of an atypical antidepressant with an atypical antipsychotic is
a evidence-based strategy for treatment-resistant depression.
Question 2
,A 52-year-old male with bipolar I disorder is maintained on lithium 900 mg/day. He presents
with tremor, polyuria, and polydipsia. His serum lithium level is 1.4 mEq/L. Which intervention is
most appropriate?
A) Decrease lithium to 600 mg/day and check level in 1 week
B) Add propranolol 20 mg TID for tremor
C) Check serum creatinine and urine osmolality
D) Switch to valproate immediately
Correct Answer: C) Check serum creatinine and urine osmolality
Rationale: Polyuria and polydipsia suggest nephrogenic diabetes insipidus, a known adverse
effect of lithium. Renal function assessment is critical before making medication changes. The
lithium level of 1.4 mEq/L is within therapeutic range (0.6-1.2 mEq/L for maintenance; up to 1.5
mEq/L for acute mania), so the tremor may be related to long-term use rather than toxicity.
Question 3
Which cytochrome P450 enzyme is primarily responsible for the metabolism of fluoxetine?
A) CYP1A2
B) CYP2D6
C) CYP3A4
D) CYP2C19
Correct Answer: B) CYP2D6
Rationale: Fluoxetine is metabolized primarily by CYP2D6 and CYP2C19, but its active
metabolite norfluoxetine is a potent inhibitor of CYP2D6. This contributes to its drug-drug
interaction potential.
Question 4
A 38-year-old patient with schizophrenia has been stable on risperidone 4 mg daily for 2 years.
She now reports amenorrhea and galactorrhea. Her prolactin level is 85 ng/mL (normal: <25).
Which is the most appropriate next step?
A) Continue risperidone and add bromocriptine
B) Switch to aripiprazole
C) Decrease risperidone to 2 mg daily
D) Order a pituitary MRI
,Correct Answer: B) Switch to aripiprazole
Rationale: Risperidone is associated with significant hyperprolactinemia due to potent D2
receptor antagonism. Aripiprazole, a D2 partial agonist, has a lower propensity for
hyperprolactinemia and can normalize prolactin levels when switched.
Question 5
Which of the following is the strongest predictor of antidepressant response in major depressive
disorder?
A) Family history of depression
B) Severity of baseline symptoms
C) Presence of psychotic features
D) Early improvement within 2 weeks of treatment
Correct Answer: D) Early improvement within 2 weeks of treatment
Rationale: Early improvement (≥20-30% reduction in symptoms within 2 weeks) is the strongest
predictor of eventual response and remission in MDD.
Question 6
A 19-year-old college student presents with excessive worry about academic performance,
difficulty concentrating, muscle tension, and insomnia for 8 months. She avoids social situations
due to fear of negative evaluation. What is the most likely diagnosis?
A) Generalized anxiety disorder only
B) Social anxiety disorder only
C) Generalized anxiety disorder with comorbid social anxiety disorder
D) Adjustment disorder with mixed anxiety and depression
Correct Answer: C) Generalized anxiety disorder with comorbid social anxiety disorder
Rationale: She meets criteria for GAD (excessive worry across domains >6 months with physical
symptoms) AND social anxiety disorder (fear of negative evaluation in social situations).
Comorbidity is common.
Question 7
A patient on phenelzine (MAOI) reports severe headache, palpitations, and nausea after eating
aged cheese. What is the most likely diagnosis?
, A) Serotonin syndrome
B) Hypertensive crisis
C) Neuroleptic malignant syndrome
D) Anticholinergic crisis
Correct Answer: B) Hypertensive crisis
Rationale: MAOIs interact with tyramine-rich foods (aged cheese, cured meats) to cause
hypertensive crisis due to norepinephrine release.
Question 8
Which of the following antipsychotics has the lowest risk of QTc prolongation?
A) Ziprasidone
B) Iloperidone
C) Quetiapine
D) Aripiprazole
Correct Answer: D) Aripiprazole
Rationale: Aripiprazole has the lowest risk of QTc prolongation among antipsychotics.
Ziprasidone and iloperidone have higher risk.
Question 9
A 45-year-old with bipolar II disorder presents with hypomania. She is currently on lamotrigine
200 mg/day. What is the most appropriate next step?
A) Increase lamotrigine to 300 mg/day
B) Add quetiapine
C) Add lithium
D) Discontinue lamotrigine
Correct Answer: B) Add quetiapine
Rationale: Lamotrigine is more effective for bipolar depression than for mania. Adding an
atypical antipsychotic like quetiapine is appropriate for acute hypomanic symptoms.
Question 10
