APEA PMHNP-PSYCHIATRIC-MENTAL HEALTH NURSE
PRACTITIONER EXAM WITH COMPLETE QUESTIONS AND
VERIFIED ANSWERS
Question 1: A 32-year-old female with a history of major depressive
disorder presents to the clinic reporting a two-week history of persistent
low mood, anhedonia, and fatigue. She is currently prescribed sertraline
100 mg daily, which she has been taking consistently for the past six
weeks. She reports partial improvement in her sleep but no significant
change in her mood or energy levels. According to the STAR*D trial and
current psychopharmacological guidelines, what is the most appropriate
next step in her pharmacological management?
A. Increase sertraline to 200 mg daily
B. Augment with aripiprazole 2 mg daily
C. Switch to bupropion XL 150 mg daily
D. Add lithium carbonate 300 mg twice daily
CORRECT ANSWER: C. Switch to bupropion XL 150 mg daily
Rationale: For a patient who has not achieved remission after an adequate
trial (6-8 weeks) of a first-line SSRI, switching to a different class of
antidepressant, such as bupropion, is a standard evidence-based strategy.
Bupropion is particularly useful for addressing residual symptoms like fatigue
and anhedonia, and it avoids the sexual side effects associated with SSRIs.
Augmentation or switching to another SSRI are also options, but switching
classes is highly supported for SSRI non-responders with prominent fatigue.
Question 2: A 45-year-old male with schizophrenia is being transitioned
from oral risperidone to a long-acting injectable (LAI) antipsychotic due to
a history of medication nonadherence. He is prescribed risperidone Consta
25 mg IM. What is the critical clinical consideration regarding the initiation
of this specific LAI formulation?
A. It requires daily oral supplementation for the first 3 weeks.
B. It must be stored at room temperature before administration.
C. It achieves immediate therapeutic blood levels without the need for oral
overlap.
D. It should be administered subcutaneously rather than intramuscularly.
CORRECT ANSWER: A. It requires daily oral supplementation for the first 3
weeks.
Rationale: Risperidone Consta (microspheres) requires a delayed release
period; therefore, oral antipsychotic supplementation is necessary for the
first 3 weeks after the first injection to maintain therapeutic levels and
Page 1 of 50
,prevent relapse. In contrast, some newer LAIs like Invega Sustenna do not
require oral overlap.
Question 3: A 24-year-old college student presents with excessive worry
about academic performance, relationships, and finances. She reports
difficulty concentrating, muscle tension, and restless sleep for the past
eight months. She denies panic attacks, obsessive thoughts, or traumatic
events. Which of the following pharmacological agents is considered a
first-line treatment for her primary diagnosis?
A. Alprazolam
B. Escitalopram
C. Buspirone
D. Diphenhydramine
CORRECT ANSWER: B. Escitalopram
Rationale: The patient's presentation is consistent with Generalized Anxiety
Disorder (GAD). First-line pharmacological treatments for GAD include SSRIs
(such as escitalopram or sertraline) and SNRIs (such as venlafaxine or
duloxetine). Buspirone is a second-line or adjunctive option, while
alprazolam is not recommended for long-term management due to the risk
of dependence.
Question 4: A 60-year-old male with bipolar I disorder is currently
maintained on lithium carbonate 900 mg daily. His recent serum lithium
level is 1.1 mEq/L, and he reports a new onset of a coarse hand tremor,
mild ataxia, and slurred speech. What is the most appropriate immediate
action?
A. Reassure the patient that these are expected side effects of lithium
therapy.
B. Decrease the lithium dose to 600 mg daily and recheck the level in one
week.
C. Discontinue lithium immediately, check a stat serum lithium level, and
evaluate for toxicity.
D. Add propranolol 10 mg twice daily to manage the tremor.
CORRECT ANSWER: C. Discontinue lithium immediately, check a stat serum
lithium level, and evaluate for toxicity.
Rationale: The patient is exhibiting signs of moderate to severe lithium
toxicity (coarse tremor, ataxia, slurred speech), which can occur even at
therapeutic or slightly elevated serum levels, especially in older adults or
those with dehydration/renal changes. Immediate discontinuation and
medical evaluation are critical to prevent permanent neurological damage.
Question 5: A 19-year-old female is diagnosed with anorexia nervosa,
restricting type. She has a BMI of 16.2 and exhibits significant electrolyte
Page 2 of 50
,imbalances. The treatment team is considering pharmacological options to
assist with her psychiatric care. Which of the following medications is most
appropriate to target her comorbid obsessive-compulsive features and
anxiety regarding weight gain, while being mindful of her medical status?
A. Fluoxetine
B. Olanzapine
C. Bupropion
D. Mirtazapine
CORRECT ANSWER: B. Olanzapine
Rationale: Olanzapine has evidence supporting its use in anorexia nervosa to
help promote weight gain and reduce severe anxiety and obsessive
ruminations related to food and weight. Bupropion is strictly contraindicated
in eating disorders due to the lowered seizure threshold. Fluoxetine is not
effective in the acutely malnourished state of anorexia, though it may be
used in bulimia or after weight restoration.
Question 6: A 55-year-old male with treatment-resistant depression is
being evaluated for the initiation of a monoamine oxidase inhibitor
(MAOI). He is currently taking venlafaxine 150 mg daily. What is the
mandatory washout period required before safely initiating an MAOI like
phenelzine?
A. 24 hours
B. 3 days
C. 7 days
D. 14 days
CORRECT ANSWER: D. 14 days
Rationale: A minimum washout period of 14 days is required when switching
from an SNRI (like venlafaxine) or most SSRIs to an MAOI to prevent
serotonin syndrome, a potentially fatal condition caused by excessive
serotonergic activity. (Note: Fluoxetine requires a 5-week washout due to its
long half-life).
Question 7: A 30-year-old female presents with a history of recurrent
major depressive episodes with seasonal patterns, typically occurring in
the late fall and winter. She reports hypersomnia, hyperphagia, leaden
paralysis, and interpersonal rejection sensitivity. Which of the following
interventions is considered a first-line, evidence-based treatment for her
specific presentation?
A. Cognitive Behavioral Therapy (CBT) alone
B. Bright light therapy
C. Tranylcypromine
D. Electroconvulsive therapy (ECT)
Page 3 of 50
, CORRECT ANSWER: B. Bright light therapy
Rationale: The patient's symptoms are classic for Major Depressive Disorder
with a seasonal pattern (Seasonal Affective Disorder). Bright light therapy
(phototherapy) using a 10,000-lux light box for 30-45 minutes shortly after
waking is a well-established, first-line treatment for this specific subtype of
depression.
Question 8: A 42-year-old male with a history of alcohol use disorder is
being started on naltrexone to reduce heavy drinking days. Which of the
following baseline laboratory tests is absolutely essential before initiating
this medication, and why?
A. Complete Blood Count (CBC) to check for macrocytic anemia
B. Liver function tests (LFTs) because naltrexone is hepatotoxic at high doses
C. Thyroid function tests to rule out hypothyroidism
D. Fasting lipid panel to assess cardiovascular risk
CORRECT ANSWER: B. Liver function tests (LFTs) because naltrexone is
hepatotoxic at high doses
Rationale: Naltrexone carries a risk of hepatotoxicity, particularly at doses
exceeding the recommended 50 mg/day. Baseline and periodic monitoring
of liver enzymes (AST, ALT) is required, and the medication is contraindicated
in patients with acute hepatitis or liver failure.
Question 9: A 26-year-old male with schizophrenia presents with a new
onset of severe restlessness, an inability to sit still, and a subjective feeling
of inner tension. He recently had his dose of haloperidol decanoate
increased. He denies suicidal ideation or worsening psychotic symptoms.
What is the most likely diagnosis, and what is the first-line
pharmacological treatment?
A. Tardive dyskinesia; switch to a second-generation antipsychotic
B. Acute dystonia; administer benztropine IM
C. Akathisia; administer propranolol or reduce the antipsychotic dose
D. Parkinsonism; administer diphenhydramine
CORRECT ANSWER: C. Akathisia; administer propranolol or reduce the
antipsychotic dose
Rationale: Akathisia is an extrapyramidal symptom (EPS) characterized by a
subjective feeling of inner restlessness and the urge to move constantly. It is
highly distressing and can be mistaken for worsening psychosis or agitation.
First-line treatments include lowering the antipsychotic dose, switching to an
antipsychotic with lower EPS risk, or adding a beta-blocker like propranolol.
Question 10: A 35-year-old female with borderline personality disorder
frequently engages in non-suicidal self-injury (cutting) during times of
interpersonal stress. She is seeking a therapy that can help her manage
Page 4 of 50
PRACTITIONER EXAM WITH COMPLETE QUESTIONS AND
VERIFIED ANSWERS
Question 1: A 32-year-old female with a history of major depressive
disorder presents to the clinic reporting a two-week history of persistent
low mood, anhedonia, and fatigue. She is currently prescribed sertraline
100 mg daily, which she has been taking consistently for the past six
weeks. She reports partial improvement in her sleep but no significant
change in her mood or energy levels. According to the STAR*D trial and
current psychopharmacological guidelines, what is the most appropriate
next step in her pharmacological management?
A. Increase sertraline to 200 mg daily
B. Augment with aripiprazole 2 mg daily
C. Switch to bupropion XL 150 mg daily
D. Add lithium carbonate 300 mg twice daily
CORRECT ANSWER: C. Switch to bupropion XL 150 mg daily
Rationale: For a patient who has not achieved remission after an adequate
trial (6-8 weeks) of a first-line SSRI, switching to a different class of
antidepressant, such as bupropion, is a standard evidence-based strategy.
Bupropion is particularly useful for addressing residual symptoms like fatigue
and anhedonia, and it avoids the sexual side effects associated with SSRIs.
Augmentation or switching to another SSRI are also options, but switching
classes is highly supported for SSRI non-responders with prominent fatigue.
Question 2: A 45-year-old male with schizophrenia is being transitioned
from oral risperidone to a long-acting injectable (LAI) antipsychotic due to
a history of medication nonadherence. He is prescribed risperidone Consta
25 mg IM. What is the critical clinical consideration regarding the initiation
of this specific LAI formulation?
A. It requires daily oral supplementation for the first 3 weeks.
B. It must be stored at room temperature before administration.
C. It achieves immediate therapeutic blood levels without the need for oral
overlap.
D. It should be administered subcutaneously rather than intramuscularly.
CORRECT ANSWER: A. It requires daily oral supplementation for the first 3
weeks.
Rationale: Risperidone Consta (microspheres) requires a delayed release
period; therefore, oral antipsychotic supplementation is necessary for the
first 3 weeks after the first injection to maintain therapeutic levels and
Page 1 of 50
,prevent relapse. In contrast, some newer LAIs like Invega Sustenna do not
require oral overlap.
Question 3: A 24-year-old college student presents with excessive worry
about academic performance, relationships, and finances. She reports
difficulty concentrating, muscle tension, and restless sleep for the past
eight months. She denies panic attacks, obsessive thoughts, or traumatic
events. Which of the following pharmacological agents is considered a
first-line treatment for her primary diagnosis?
A. Alprazolam
B. Escitalopram
C. Buspirone
D. Diphenhydramine
CORRECT ANSWER: B. Escitalopram
Rationale: The patient's presentation is consistent with Generalized Anxiety
Disorder (GAD). First-line pharmacological treatments for GAD include SSRIs
(such as escitalopram or sertraline) and SNRIs (such as venlafaxine or
duloxetine). Buspirone is a second-line or adjunctive option, while
alprazolam is not recommended for long-term management due to the risk
of dependence.
Question 4: A 60-year-old male with bipolar I disorder is currently
maintained on lithium carbonate 900 mg daily. His recent serum lithium
level is 1.1 mEq/L, and he reports a new onset of a coarse hand tremor,
mild ataxia, and slurred speech. What is the most appropriate immediate
action?
A. Reassure the patient that these are expected side effects of lithium
therapy.
B. Decrease the lithium dose to 600 mg daily and recheck the level in one
week.
C. Discontinue lithium immediately, check a stat serum lithium level, and
evaluate for toxicity.
D. Add propranolol 10 mg twice daily to manage the tremor.
CORRECT ANSWER: C. Discontinue lithium immediately, check a stat serum
lithium level, and evaluate for toxicity.
Rationale: The patient is exhibiting signs of moderate to severe lithium
toxicity (coarse tremor, ataxia, slurred speech), which can occur even at
therapeutic or slightly elevated serum levels, especially in older adults or
those with dehydration/renal changes. Immediate discontinuation and
medical evaluation are critical to prevent permanent neurological damage.
Question 5: A 19-year-old female is diagnosed with anorexia nervosa,
restricting type. She has a BMI of 16.2 and exhibits significant electrolyte
Page 2 of 50
,imbalances. The treatment team is considering pharmacological options to
assist with her psychiatric care. Which of the following medications is most
appropriate to target her comorbid obsessive-compulsive features and
anxiety regarding weight gain, while being mindful of her medical status?
A. Fluoxetine
B. Olanzapine
C. Bupropion
D. Mirtazapine
CORRECT ANSWER: B. Olanzapine
Rationale: Olanzapine has evidence supporting its use in anorexia nervosa to
help promote weight gain and reduce severe anxiety and obsessive
ruminations related to food and weight. Bupropion is strictly contraindicated
in eating disorders due to the lowered seizure threshold. Fluoxetine is not
effective in the acutely malnourished state of anorexia, though it may be
used in bulimia or after weight restoration.
Question 6: A 55-year-old male with treatment-resistant depression is
being evaluated for the initiation of a monoamine oxidase inhibitor
(MAOI). He is currently taking venlafaxine 150 mg daily. What is the
mandatory washout period required before safely initiating an MAOI like
phenelzine?
A. 24 hours
B. 3 days
C. 7 days
D. 14 days
CORRECT ANSWER: D. 14 days
Rationale: A minimum washout period of 14 days is required when switching
from an SNRI (like venlafaxine) or most SSRIs to an MAOI to prevent
serotonin syndrome, a potentially fatal condition caused by excessive
serotonergic activity. (Note: Fluoxetine requires a 5-week washout due to its
long half-life).
Question 7: A 30-year-old female presents with a history of recurrent
major depressive episodes with seasonal patterns, typically occurring in
the late fall and winter. She reports hypersomnia, hyperphagia, leaden
paralysis, and interpersonal rejection sensitivity. Which of the following
interventions is considered a first-line, evidence-based treatment for her
specific presentation?
A. Cognitive Behavioral Therapy (CBT) alone
B. Bright light therapy
C. Tranylcypromine
D. Electroconvulsive therapy (ECT)
Page 3 of 50
, CORRECT ANSWER: B. Bright light therapy
Rationale: The patient's symptoms are classic for Major Depressive Disorder
with a seasonal pattern (Seasonal Affective Disorder). Bright light therapy
(phototherapy) using a 10,000-lux light box for 30-45 minutes shortly after
waking is a well-established, first-line treatment for this specific subtype of
depression.
Question 8: A 42-year-old male with a history of alcohol use disorder is
being started on naltrexone to reduce heavy drinking days. Which of the
following baseline laboratory tests is absolutely essential before initiating
this medication, and why?
A. Complete Blood Count (CBC) to check for macrocytic anemia
B. Liver function tests (LFTs) because naltrexone is hepatotoxic at high doses
C. Thyroid function tests to rule out hypothyroidism
D. Fasting lipid panel to assess cardiovascular risk
CORRECT ANSWER: B. Liver function tests (LFTs) because naltrexone is
hepatotoxic at high doses
Rationale: Naltrexone carries a risk of hepatotoxicity, particularly at doses
exceeding the recommended 50 mg/day. Baseline and periodic monitoring
of liver enzymes (AST, ALT) is required, and the medication is contraindicated
in patients with acute hepatitis or liver failure.
Question 9: A 26-year-old male with schizophrenia presents with a new
onset of severe restlessness, an inability to sit still, and a subjective feeling
of inner tension. He recently had his dose of haloperidol decanoate
increased. He denies suicidal ideation or worsening psychotic symptoms.
What is the most likely diagnosis, and what is the first-line
pharmacological treatment?
A. Tardive dyskinesia; switch to a second-generation antipsychotic
B. Acute dystonia; administer benztropine IM
C. Akathisia; administer propranolol or reduce the antipsychotic dose
D. Parkinsonism; administer diphenhydramine
CORRECT ANSWER: C. Akathisia; administer propranolol or reduce the
antipsychotic dose
Rationale: Akathisia is an extrapyramidal symptom (EPS) characterized by a
subjective feeling of inner restlessness and the urge to move constantly. It is
highly distressing and can be mistaken for worsening psychosis or agitation.
First-line treatments include lowering the antipsychotic dose, switching to an
antipsychotic with lower EPS risk, or adding a beta-blocker like propranolol.
Question 10: A 35-year-old female with borderline personality disorder
frequently engages in non-suicidal self-injury (cutting) during times of
interpersonal stress. She is seeking a therapy that can help her manage
Page 4 of 50
