1
APEA Psychiatric Mental Health Nurse Practitioner
PMHNP Exam 250 Questions and Correct Answers
Question 1: A 34-year-old female presents to the clinic complaining of a 6-month
history of persistent sadness, anhedonia, significant weight loss of 15 pounds,
insomnia, and feelings of worthlessness. She also reports hearing a voice telling her
she is a burden to her family. She has no history of manic or hypomanic episodes.
What is the most appropriate initial pharmacological treatment for this patient? A.
Lithium monotherapy
B. An SSRI combined with an atypical antipsychotic
C. Benzodiazepine monotherapy
D. Bupropion monotherapy
CORRECT ANSWER: B. An SSRI combined with an atypical antipsychotic
Rationale: The patient meets the DSM-5-TR criteria for Major Depressive Disorder with
psychotic features. The gold standard pharmacological treatment for this condition is the
combination of an antidepressant (such as an SSRI) and an atypical antipsychotic.
Monotherapy with an antidepressant is insufficient for psychotic features, and
electroconvulsive therapy (ECT) is an alternative for severe or treatment-resistant cases.
Question 2: A 45-year-old male with a known history of Bipolar I Disorder is brought to
the emergency department by his wife due to confusion, coarse hand tremors, ataxia,
and severe nausea. His current medication regimen includes lithium carbonate 900
mg daily. A serum lithium level is drawn and returns at 1.8 mEq/L. What is the most
appropriate immediate action?
A. Increase the lithium dose to achieve therapeutic levels.
B. Hold the lithium, administer IV normal saline, and monitor renal function.
C. Administer activated charcoal immediately.
D. Add valproic acid to stabilize his mood.
CORRECT ANSWER: B. Hold the lithium, administer IV normal saline, and monitor
renal function. Rationale: The patient is exhibiting classic signs of moderate to severe
lithium toxicity (levels >1.5 mEq/L), which include neurological symptoms like ataxia,
coarse tremors, and confusion. The immediate intervention is to discontinue lithium, provide
aggressive IV hydration with normal saline to enhance renal excretion, and monitor
electrolytes and renal function. Activated charcoal does not bind lithium.
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Question 3: A 28-year-old male with schizophrenia has been stable on haloperidol for
the past two years but now presents with new-onset, involuntary, repetitive lip-
smacking and tongue protrusions. He is distressed by these movements. What is the
most appropriate next step in management?
A. Increase the dose of haloperidol to suppress the movements.
B. Cross-taper to a second-generation antipsychotic and consider a VMAT2 inhibitor.
C. Add benztropine to the current regimen.
D. Discontinue all antipsychotic medications immediately.
CORRECT ANSWER: B. Cross-taper to a second-generation antipsychotic and consider
a VMAT2 inhibitor.
Rationale: The patient is exhibiting signs of tardive dyskinesia (TD), a potentially
irreversible movement disorder associated with long-term use of first-generation
antipsychotics. The most appropriate management is to gradually cross-taper to a second-
generation antipsychotic (which has a lower risk of TD) and consider adding a vesicular
monoamine transporter 2 (VMAT2) inhibitor, such as valbenazine or deutetrabenazine,
which are FDA-approved for TD. Anticholinergics like benztropine can worsen TD.
Question 4: A 32-year-old female presents with excessive, uncontrollable worry about
her job, health, and family for the past 8 months. She reports muscle tension,
restlessness, and difficulty concentrating, which are impairing her occupational
functioning. She has no history of panic attacks or trauma. What is the first-line
pharmacological treatment for her condition?
A. Alprazolam
B. Escitalopram
C. Quetiapine
D. Propranolol
CORRECT ANSWER: B. Escitalopram
Rationale: The patient meets the criteria for Generalized Anxiety Disorder (GAD). First-line
pharmacological treatment for GAD includes selective serotonin reuptake inhibitors (SSRIs)
like escitalopram or serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine.
Benzodiazepines (e.g., alprazolam) are not recommended for first-line, long-term
management due to the risk of tolerance, dependence, and withdrawal.
Question 5: A 40-year-old male veteran presents with severe, recurrent nightmares
related to his combat experiences, leading to significant sleep avoidance and daytime
,3
fatigue. He is already taking sertraline for his PTSD but continues to experience these
nightmares. Which medication should be added to specifically target his nightmares?
A. Trazodone B. Prazosin C. Clonazepam D. Diphenhydramine
CORRECT ANSWER: B. Prazosin Rationale: Prazosin, an alpha-1 adrenergic receptor
antagonist, is widely used off-label as an adjunctive treatment for PTSD-related nightmares
and sleep disturbances. It works by blocking the central sympathetic nervous system
overactivity that contributes to trauma-related nightmares. While trazodone is used for
insomnia, prazosin specifically targets the noradrenergic hyperarousal of PTSD nightmares.
Question 6: A 9-year-old boy is brought to the clinic for evaluation of inattention,
hyperactivity, and impulsivity that have been present at home and at school for over a
year. He also has a comorbid diagnosis of Tourette’s syndrome with frequent motor
tics. Which medication is the most appropriate first-line choice for his ADHD? A.
Methylphenidate B. Atomoxetine C. Dextroamphetamine D. Guanfacine monotherapy
CORRECT ANSWER: B. Atomoxetine Rationale: While stimulants (like methylphenidate)
are first-line for ADHD, they can sometimes exacerbate tics. Atomoxetine, a selective
norepinephrine reuptake inhibitor (SNRI), is a non-stimulant FDA-approved for ADHD that
does not exacerbate tics and is considered a first-line option for patients with comorbid
ADHD and tic disorders. Alpha-2 agonists (guanfacine, clonidine) can also be used, but
atomoxetine is highly effective for core ADHD symptoms without worsening tics.
Question 7: A 25-year-old female presents with intrusive, ego-dystonic thoughts about
contamination, leading to compulsive hand-washing up to 50 times a day, causing
skin breakdown. She has tried cognitive-behavioral therapy (CBT) with exposure and
response prevention (ERP) with partial success. What is the most appropriate
pharmacological intervention? A. Low-dose alprazolam B. High-dose fluoxetine C.
Bupropion D. Aripiprazole monotherapy
CORRECT ANSWER: B. High-dose fluoxetine Rationale: Obsessive-Compulsive Disorder
(OCD) often requires higher-than-standard doses of SSRIs (e.g., fluoxetine, sertraline,
fluvoxamine) to achieve symptom remission. If CBT with ERP is partially effective, adding or
optimizing a high-dose SSRI is the next best step. Bupropion is ineffective for OCD, and
benzodiazepines do not treat core OCD symptoms.
Question 8: A 22-year-old female with a history of self-harm, intense and unstable
relationships, chronic feelings of emptiness, and frantic efforts to avoid real or
imagined abandonment is diagnosed with Borderline Personality Disorder (BPD).
What is the most evidence-based psychotherapeutic intervention for this patient? A.
Psychoanalysis B. Dialectical Behavior Therapy (DBT) C. Supportive psychotherapy D.
Electroconvulsive therapy (ECT)
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CORRECT ANSWER: B. Dialectical Behavior Therapy (DBT) Rationale: Dialectical
Behavior Therapy (DBT) is the gold-standard, most evidence-based psychotherapeutic
treatment for Borderline Personality Disorder. It focuses on teaching skills in four key areas:
mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness,
significantly reducing self-harm and hospitalization rates.
Question 9: A 50-year-old male with Alcohol Use Disorder expresses a strong desire to
stop drinking. He has mild, stable liver enzyme elevations (AST and ALT are 1.5 times
the upper limit of normal) but no evidence of cirrhosis or acute hepatitis. He also has a
history of chronic opioid use for back pain, for which he takes hydrocodone. Which
medication is contraindicated for this patient? A. Acamprosate B. Naltrexone C.
Topiramate D. Disulfiram
CORRECT ANSWER: B. Naltrexone Rationale: Naltrexone is a mu-opioid receptor
antagonist used to reduce alcohol cravings. However, it is strictly contraindicated in patients
currently taking opioid medications, as it will precipitate acute, severe opioid withdrawal.
While it can be used in mild liver disease, the concurrent opioid use makes it absolutely
contraindicated. Acamprosate is renally cleared and safe in mild liver disease and with
opioid use.
Question 10: A 35-year-old male with Opioid Use Disorder is being inducted on
buprenorphine/naloxone. He last used heroin 10 hours ago. He is given the first dose
and within 30 minutes develops severe agitation, sweating, abdominal cramps, and
nausea. What is the most likely cause of this reaction? A. An allergic reaction to
naloxone B. Precipitated withdrawal C. Buprenorphine overdose D. Serotonin syndrome
CORRECT ANSWER: B. Precipitated withdrawal Rationale: Precipitated withdrawal
occurs when a partial mu-opioid agonist with high receptor affinity (buprenorphine) is
administered before full agonist opioids (like heroin) have sufficiently cleared the
receptors. This abruptly displaces the full agonist, causing an immediate and severe
withdrawal state. Patients must be in mild-to-moderate withdrawal (e.g., COWS score > 8-
12) before induction to prevent this.
Question 11: A 29-year-old female presents with recurrent, unexpected panic attacks
characterized by palpitations, sweating, trembling, shortness of breath, and a fear of
dying. She has begun avoiding driving and crowded places due to fear of having an
attack. What is the most appropriate long-term pharmacological management? A.
Daily alprazolam B. Daily sertraline C. As-needed propranolol D. Daily buspirone
CORRECT ANSWER: B. Daily sertraline Rationale: Panic Disorder with agoraphobia is
best treated long-term with an SSRI, such as sertraline, paroxetine, or fluoxetine. SSRIs
reduce the frequency and severity of panic attacks and the anticipatory anxiety associated
APEA Psychiatric Mental Health Nurse Practitioner
PMHNP Exam 250 Questions and Correct Answers
Question 1: A 34-year-old female presents to the clinic complaining of a 6-month
history of persistent sadness, anhedonia, significant weight loss of 15 pounds,
insomnia, and feelings of worthlessness. She also reports hearing a voice telling her
she is a burden to her family. She has no history of manic or hypomanic episodes.
What is the most appropriate initial pharmacological treatment for this patient? A.
Lithium monotherapy
B. An SSRI combined with an atypical antipsychotic
C. Benzodiazepine monotherapy
D. Bupropion monotherapy
CORRECT ANSWER: B. An SSRI combined with an atypical antipsychotic
Rationale: The patient meets the DSM-5-TR criteria for Major Depressive Disorder with
psychotic features. The gold standard pharmacological treatment for this condition is the
combination of an antidepressant (such as an SSRI) and an atypical antipsychotic.
Monotherapy with an antidepressant is insufficient for psychotic features, and
electroconvulsive therapy (ECT) is an alternative for severe or treatment-resistant cases.
Question 2: A 45-year-old male with a known history of Bipolar I Disorder is brought to
the emergency department by his wife due to confusion, coarse hand tremors, ataxia,
and severe nausea. His current medication regimen includes lithium carbonate 900
mg daily. A serum lithium level is drawn and returns at 1.8 mEq/L. What is the most
appropriate immediate action?
A. Increase the lithium dose to achieve therapeutic levels.
B. Hold the lithium, administer IV normal saline, and monitor renal function.
C. Administer activated charcoal immediately.
D. Add valproic acid to stabilize his mood.
CORRECT ANSWER: B. Hold the lithium, administer IV normal saline, and monitor
renal function. Rationale: The patient is exhibiting classic signs of moderate to severe
lithium toxicity (levels >1.5 mEq/L), which include neurological symptoms like ataxia,
coarse tremors, and confusion. The immediate intervention is to discontinue lithium, provide
aggressive IV hydration with normal saline to enhance renal excretion, and monitor
electrolytes and renal function. Activated charcoal does not bind lithium.
,2
Question 3: A 28-year-old male with schizophrenia has been stable on haloperidol for
the past two years but now presents with new-onset, involuntary, repetitive lip-
smacking and tongue protrusions. He is distressed by these movements. What is the
most appropriate next step in management?
A. Increase the dose of haloperidol to suppress the movements.
B. Cross-taper to a second-generation antipsychotic and consider a VMAT2 inhibitor.
C. Add benztropine to the current regimen.
D. Discontinue all antipsychotic medications immediately.
CORRECT ANSWER: B. Cross-taper to a second-generation antipsychotic and consider
a VMAT2 inhibitor.
Rationale: The patient is exhibiting signs of tardive dyskinesia (TD), a potentially
irreversible movement disorder associated with long-term use of first-generation
antipsychotics. The most appropriate management is to gradually cross-taper to a second-
generation antipsychotic (which has a lower risk of TD) and consider adding a vesicular
monoamine transporter 2 (VMAT2) inhibitor, such as valbenazine or deutetrabenazine,
which are FDA-approved for TD. Anticholinergics like benztropine can worsen TD.
Question 4: A 32-year-old female presents with excessive, uncontrollable worry about
her job, health, and family for the past 8 months. She reports muscle tension,
restlessness, and difficulty concentrating, which are impairing her occupational
functioning. She has no history of panic attacks or trauma. What is the first-line
pharmacological treatment for her condition?
A. Alprazolam
B. Escitalopram
C. Quetiapine
D. Propranolol
CORRECT ANSWER: B. Escitalopram
Rationale: The patient meets the criteria for Generalized Anxiety Disorder (GAD). First-line
pharmacological treatment for GAD includes selective serotonin reuptake inhibitors (SSRIs)
like escitalopram or serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine.
Benzodiazepines (e.g., alprazolam) are not recommended for first-line, long-term
management due to the risk of tolerance, dependence, and withdrawal.
Question 5: A 40-year-old male veteran presents with severe, recurrent nightmares
related to his combat experiences, leading to significant sleep avoidance and daytime
,3
fatigue. He is already taking sertraline for his PTSD but continues to experience these
nightmares. Which medication should be added to specifically target his nightmares?
A. Trazodone B. Prazosin C. Clonazepam D. Diphenhydramine
CORRECT ANSWER: B. Prazosin Rationale: Prazosin, an alpha-1 adrenergic receptor
antagonist, is widely used off-label as an adjunctive treatment for PTSD-related nightmares
and sleep disturbances. It works by blocking the central sympathetic nervous system
overactivity that contributes to trauma-related nightmares. While trazodone is used for
insomnia, prazosin specifically targets the noradrenergic hyperarousal of PTSD nightmares.
Question 6: A 9-year-old boy is brought to the clinic for evaluation of inattention,
hyperactivity, and impulsivity that have been present at home and at school for over a
year. He also has a comorbid diagnosis of Tourette’s syndrome with frequent motor
tics. Which medication is the most appropriate first-line choice for his ADHD? A.
Methylphenidate B. Atomoxetine C. Dextroamphetamine D. Guanfacine monotherapy
CORRECT ANSWER: B. Atomoxetine Rationale: While stimulants (like methylphenidate)
are first-line for ADHD, they can sometimes exacerbate tics. Atomoxetine, a selective
norepinephrine reuptake inhibitor (SNRI), is a non-stimulant FDA-approved for ADHD that
does not exacerbate tics and is considered a first-line option for patients with comorbid
ADHD and tic disorders. Alpha-2 agonists (guanfacine, clonidine) can also be used, but
atomoxetine is highly effective for core ADHD symptoms without worsening tics.
Question 7: A 25-year-old female presents with intrusive, ego-dystonic thoughts about
contamination, leading to compulsive hand-washing up to 50 times a day, causing
skin breakdown. She has tried cognitive-behavioral therapy (CBT) with exposure and
response prevention (ERP) with partial success. What is the most appropriate
pharmacological intervention? A. Low-dose alprazolam B. High-dose fluoxetine C.
Bupropion D. Aripiprazole monotherapy
CORRECT ANSWER: B. High-dose fluoxetine Rationale: Obsessive-Compulsive Disorder
(OCD) often requires higher-than-standard doses of SSRIs (e.g., fluoxetine, sertraline,
fluvoxamine) to achieve symptom remission. If CBT with ERP is partially effective, adding or
optimizing a high-dose SSRI is the next best step. Bupropion is ineffective for OCD, and
benzodiazepines do not treat core OCD symptoms.
Question 8: A 22-year-old female with a history of self-harm, intense and unstable
relationships, chronic feelings of emptiness, and frantic efforts to avoid real or
imagined abandonment is diagnosed with Borderline Personality Disorder (BPD).
What is the most evidence-based psychotherapeutic intervention for this patient? A.
Psychoanalysis B. Dialectical Behavior Therapy (DBT) C. Supportive psychotherapy D.
Electroconvulsive therapy (ECT)
, 4
CORRECT ANSWER: B. Dialectical Behavior Therapy (DBT) Rationale: Dialectical
Behavior Therapy (DBT) is the gold-standard, most evidence-based psychotherapeutic
treatment for Borderline Personality Disorder. It focuses on teaching skills in four key areas:
mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness,
significantly reducing self-harm and hospitalization rates.
Question 9: A 50-year-old male with Alcohol Use Disorder expresses a strong desire to
stop drinking. He has mild, stable liver enzyme elevations (AST and ALT are 1.5 times
the upper limit of normal) but no evidence of cirrhosis or acute hepatitis. He also has a
history of chronic opioid use for back pain, for which he takes hydrocodone. Which
medication is contraindicated for this patient? A. Acamprosate B. Naltrexone C.
Topiramate D. Disulfiram
CORRECT ANSWER: B. Naltrexone Rationale: Naltrexone is a mu-opioid receptor
antagonist used to reduce alcohol cravings. However, it is strictly contraindicated in patients
currently taking opioid medications, as it will precipitate acute, severe opioid withdrawal.
While it can be used in mild liver disease, the concurrent opioid use makes it absolutely
contraindicated. Acamprosate is renally cleared and safe in mild liver disease and with
opioid use.
Question 10: A 35-year-old male with Opioid Use Disorder is being inducted on
buprenorphine/naloxone. He last used heroin 10 hours ago. He is given the first dose
and within 30 minutes develops severe agitation, sweating, abdominal cramps, and
nausea. What is the most likely cause of this reaction? A. An allergic reaction to
naloxone B. Precipitated withdrawal C. Buprenorphine overdose D. Serotonin syndrome
CORRECT ANSWER: B. Precipitated withdrawal Rationale: Precipitated withdrawal
occurs when a partial mu-opioid agonist with high receptor affinity (buprenorphine) is
administered before full agonist opioids (like heroin) have sufficiently cleared the
receptors. This abruptly displaces the full agonist, causing an immediate and severe
withdrawal state. Patients must be in mild-to-moderate withdrawal (e.g., COWS score > 8-
12) before induction to prevent this.
Question 11: A 29-year-old female presents with recurrent, unexpected panic attacks
characterized by palpitations, sweating, trembling, shortness of breath, and a fear of
dying. She has begun avoiding driving and crowded places due to fear of having an
attack. What is the most appropriate long-term pharmacological management? A.
Daily alprazolam B. Daily sertraline C. As-needed propranolol D. Daily buspirone
CORRECT ANSWER: B. Daily sertraline Rationale: Panic Disorder with agoraphobia is
best treated long-term with an SSRI, such as sertraline, paroxetine, or fluoxetine. SSRIs
reduce the frequency and severity of panic attacks and the anticipatory anxiety associated
