[PMHNP EXAM] – EXAM-STYLE QUESTIONS AND ANSWERS | VERIFIED AND
WELL DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS | 2026/27
LATEST UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST
1. A 32-year-old male with no prior psychiatric history presents to the
emergency department with acute onset of auditory hallucinations,
persecutory delusions, and disorganized speech. His urine toxicology screen is
positive for cannabis. He reports using cannabis daily for the past year. What is
the most appropriate initial management step?
A. Initiate an atypical antipsychotic and admit to the inpatient psychiatric unit.
B. Observe in the emergency department until cannabis intoxication resolves,
then reassess.
C. Obtain a baseline electroencephalogram to rule out a seizure disorder.
D. Order a lumbar puncture to evaluate for central nervous system infection.
Correct Answer: B. Observe in the emergency department until cannabis
intoxication resolves, then reassess.
Rationale: The acute onset of psychosis in the context of cannabis use requires
differentiation between a primary psychotic disorder and substance-induced
psychosis. The standard of care is to observe the patient until the acute effects of
the substance have cleared, as symptoms of cannabis intoxication can closely
mimic schizophrenia. If psychotic symptoms persist after a period of observation
(e.g., 24-48 hours) and sobriety, then a primary psychiatric etiology is more likely,
and a full workup and treatment can be initiated. Initiating antipsychotic
medication prematurely risks unnecessary treatment and may complicate the
clinical picture. While ruling out organic causes is important, it is not the most
immediate step; observation is the priority. The patient's presentation is not atypical
,for cannabis-induced psychosis, making more invasive tests like an EEG or lumbar
puncture unnecessary at this stage without additional indicators.
2. A 45-year-old female with a history of major depressive disorder is started
on fluoxetine 20 mg daily. She returns for follow-up after 6 weeks and reports
that her mood is unchanged. She denies any adverse effects and states she has
been taking the medication every day as prescribed. Which of the following is
the most appropriate next step?
A. Increase the fluoxetine to 40 mg daily.
B. Discontinue fluoxetine and start bupropion.
C. Add aripiprazole as an adjunctive therapy.
D. Augment with low-dose lithium.
Correct Answer: A. Increase the fluoxetine to 40 mg daily.
Rationale: The standard of care for depression that is unresponsive to an initial
SSRI trial is to first optimize the dose. For fluoxetine, 20 mg is a starting dose, and
increasing to 40 mg is a common and appropriate next step before considering a
switch or augmentation. Patients often require higher doses to achieve a
therapeutic response. Discontinuing the medication for an alternative agent or
adding an augmentation agent is premature at this stage. The patient has had an
adequate trial of at least 6 weeks at the starting dose, but dose optimization is the
next logical step.
3. A 28-year-old female with a diagnosis of bipolar I disorder is maintained on
lithium 900 mg daily. Her serum lithium level is 0.8 mEq/L. She presents with a
new onset of fine hand tremors, increased thirst, and polyuria. What is the
most appropriate initial intervention?
,A. Decrease the lithium dose to 600 mg daily.
B. Check a serum creatinine and BUN.
C. Add propranolol for tremor management.
D. Switch her to divalproex sodium.
Correct Answer: B. Check a serum creatinine and BUN.
Rationale: Lithium’s adverse effects, particularly polyuria and polydipsia, are often
related to its effects on renal function (nephrogenic diabetes insipidus). Before
making a medication change, the patient’s renal status should be assessed. The
tremor is dose-related, but the polyuria suggests a renal effect that requires
evaluation. Decreasing the dose could help, but it would be clinically premature
without knowing the impact on renal function. Adding propranolol is an option for
tremor, but it does not address the underlying renal issue. Switching medications is
a more drastic step that is not the first-line intervention.
4. A 55-year-old patient with treatment-resistant depression has been taking
phenelzine, a monoamine oxidase inhibitor, for 3 months. She reports a
significant improvement in mood but is concerned about dietary restrictions.
She plans to attend a family dinner. Which of the following foods should she be
most strongly counseled to avoid?
A. Roasted chicken.
B. Fresh fruit salad.
C. Aged cheddar cheese.
D. Steamed vegetables.
Correct Answer: C. Aged cheddar cheese.
, Rationale: MAOIs carry a significant risk of hypertensive crisis when combined with
tyramine-rich foods. Tyramine is found in aged, fermented, or cured foods. Aged
cheeses (cheddar, stilton, parmesan) are classic high-tyramine foods and must be
strictly avoided. Roasted chicken, fresh fruit, and steamed vegetables are generally
considered safe and are not associated with a high tyramine content.
5. A 17-year-old male is brought to the clinic by his parents due to concerns
about his behavior. He has a history of significant inattention, impulsivity, and
poor academic performance since early childhood. He has been on
methylphenidate extended-release for 2 years. He now reports that the
medication is "not working as well" and he is struggling to focus. His weight is
at the 15th percentile. What is the most important factor to assess before
altering his medication regimen?
A. Serum medication levels.
B. Blood pressure and heart rate.
C. Sleep patterns and quality.
D. Height and weight since starting treatment.
Correct Answer: D. Height and weight since starting treatment.
Rationale: Stimulant medications are associated with growth suppression in
children and adolescents. When a patient on long-term stimulant therapy presents
with potential treatment failure (e.g., tolerance or inadequate response), a key part
of the assessment is to evaluate the impact on growth. A decrease in expected
growth velocity would be a major concern and would influence the decision to
continue, adjust, or change medication. While blood pressure, sleep, and serum
levels may be relevant, the primary concern with long-term stimulant use in a
WELL DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS | 2026/27
LATEST UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST
1. A 32-year-old male with no prior psychiatric history presents to the
emergency department with acute onset of auditory hallucinations,
persecutory delusions, and disorganized speech. His urine toxicology screen is
positive for cannabis. He reports using cannabis daily for the past year. What is
the most appropriate initial management step?
A. Initiate an atypical antipsychotic and admit to the inpatient psychiatric unit.
B. Observe in the emergency department until cannabis intoxication resolves,
then reassess.
C. Obtain a baseline electroencephalogram to rule out a seizure disorder.
D. Order a lumbar puncture to evaluate for central nervous system infection.
Correct Answer: B. Observe in the emergency department until cannabis
intoxication resolves, then reassess.
Rationale: The acute onset of psychosis in the context of cannabis use requires
differentiation between a primary psychotic disorder and substance-induced
psychosis. The standard of care is to observe the patient until the acute effects of
the substance have cleared, as symptoms of cannabis intoxication can closely
mimic schizophrenia. If psychotic symptoms persist after a period of observation
(e.g., 24-48 hours) and sobriety, then a primary psychiatric etiology is more likely,
and a full workup and treatment can be initiated. Initiating antipsychotic
medication prematurely risks unnecessary treatment and may complicate the
clinical picture. While ruling out organic causes is important, it is not the most
immediate step; observation is the priority. The patient's presentation is not atypical
,for cannabis-induced psychosis, making more invasive tests like an EEG or lumbar
puncture unnecessary at this stage without additional indicators.
2. A 45-year-old female with a history of major depressive disorder is started
on fluoxetine 20 mg daily. She returns for follow-up after 6 weeks and reports
that her mood is unchanged. She denies any adverse effects and states she has
been taking the medication every day as prescribed. Which of the following is
the most appropriate next step?
A. Increase the fluoxetine to 40 mg daily.
B. Discontinue fluoxetine and start bupropion.
C. Add aripiprazole as an adjunctive therapy.
D. Augment with low-dose lithium.
Correct Answer: A. Increase the fluoxetine to 40 mg daily.
Rationale: The standard of care for depression that is unresponsive to an initial
SSRI trial is to first optimize the dose. For fluoxetine, 20 mg is a starting dose, and
increasing to 40 mg is a common and appropriate next step before considering a
switch or augmentation. Patients often require higher doses to achieve a
therapeutic response. Discontinuing the medication for an alternative agent or
adding an augmentation agent is premature at this stage. The patient has had an
adequate trial of at least 6 weeks at the starting dose, but dose optimization is the
next logical step.
3. A 28-year-old female with a diagnosis of bipolar I disorder is maintained on
lithium 900 mg daily. Her serum lithium level is 0.8 mEq/L. She presents with a
new onset of fine hand tremors, increased thirst, and polyuria. What is the
most appropriate initial intervention?
,A. Decrease the lithium dose to 600 mg daily.
B. Check a serum creatinine and BUN.
C. Add propranolol for tremor management.
D. Switch her to divalproex sodium.
Correct Answer: B. Check a serum creatinine and BUN.
Rationale: Lithium’s adverse effects, particularly polyuria and polydipsia, are often
related to its effects on renal function (nephrogenic diabetes insipidus). Before
making a medication change, the patient’s renal status should be assessed. The
tremor is dose-related, but the polyuria suggests a renal effect that requires
evaluation. Decreasing the dose could help, but it would be clinically premature
without knowing the impact on renal function. Adding propranolol is an option for
tremor, but it does not address the underlying renal issue. Switching medications is
a more drastic step that is not the first-line intervention.
4. A 55-year-old patient with treatment-resistant depression has been taking
phenelzine, a monoamine oxidase inhibitor, for 3 months. She reports a
significant improvement in mood but is concerned about dietary restrictions.
She plans to attend a family dinner. Which of the following foods should she be
most strongly counseled to avoid?
A. Roasted chicken.
B. Fresh fruit salad.
C. Aged cheddar cheese.
D. Steamed vegetables.
Correct Answer: C. Aged cheddar cheese.
, Rationale: MAOIs carry a significant risk of hypertensive crisis when combined with
tyramine-rich foods. Tyramine is found in aged, fermented, or cured foods. Aged
cheeses (cheddar, stilton, parmesan) are classic high-tyramine foods and must be
strictly avoided. Roasted chicken, fresh fruit, and steamed vegetables are generally
considered safe and are not associated with a high tyramine content.
5. A 17-year-old male is brought to the clinic by his parents due to concerns
about his behavior. He has a history of significant inattention, impulsivity, and
poor academic performance since early childhood. He has been on
methylphenidate extended-release for 2 years. He now reports that the
medication is "not working as well" and he is struggling to focus. His weight is
at the 15th percentile. What is the most important factor to assess before
altering his medication regimen?
A. Serum medication levels.
B. Blood pressure and heart rate.
C. Sleep patterns and quality.
D. Height and weight since starting treatment.
Correct Answer: D. Height and weight since starting treatment.
Rationale: Stimulant medications are associated with growth suppression in
children and adolescents. When a patient on long-term stimulant therapy presents
with potential treatment failure (e.g., tolerance or inadequate response), a key part
of the assessment is to evaluate the impact on growth. A decrease in expected
growth velocity would be a major concern and would influence the decision to
continue, adjust, or change medication. While blood pressure, sleep, and serum
levels may be relevant, the primary concern with long-term stimulant use in a
