AANP PMHNP Certification Practice Exam
120 Multiple-Choice Questions with Answers & Rationales
1. A patient starting fluoxetine asks how long it typically takes to see a full
therapeutic antidepressant effect. What should the PMHNP tell the patient?
A. 1 week
B. 2-4 weeks with full effect by 6-8 weeks
C. 24 hours
D. 3-6 months
Correct Answer: B
Rationale: SSRIs typically require 2-4 weeks before initial improvement is noted, with
full therapeutic benefit often taking 6-8 weeks. Patients should be counseled not to
discontinue prematurely due to perceived lack of efficacy.
2. Which of the following is the most concerning early sign of serotonin
syndrome in a patient recently started on an SSRI plus tramadol?
A. Dry mouth
B. Mild sedation
C. Myoclonus, hyperreflexia, and agitation
D. Weight gain
Correct Answer: C
Rationale: Serotonin syndrome presents with a triad of mental status changes,
autonomic instability, and neuromuscular abnormalities such as myoclonus,
hyperreflexia, clonus, and agitation. Combining an SSRI with tramadol increases
serotonergic risk.
,3. A patient on lithium presents with coarse tremor, ataxia, confusion, and
vomiting. Which lab value is most important to obtain immediately?
A. Serum lithium level
B. Fasting glucose
C. TSH
D. Liver enzymes
Correct Answer: A
Rationale: These findings are classic for lithium toxicity. A serum lithium level should
be obtained emergently to confirm toxicity and guide management, since toxicity can
occur even within or slightly above therapeutic range.
4. Which baseline laboratory tests are recommended before initiating lithium
therapy?
A. Renal function, thyroid function, and pregnancy test
B. Liver function only
C. Lipid panel only
D. CBC with differential only
Correct Answer: A
Rationale: Lithium is renally excreted and affects thyroid function, so renal function
(BUN/creatinine) and TSH should be obtained at baseline, along with a pregnancy test
in women of childbearing age due to teratogenic risk (Ebstein anomaly).
5. A patient prescribed valproic acid for bipolar disorder should have which
baseline and ongoing lab monitoring?
A. Liver function tests and CBC with platelets
B. Renal function only
C. TSH only
D. ECG only
Correct Answer: A
Rationale: Valproic acid carries risk of hepatotoxicity and thrombocytopenia, so LFTs
and CBC with platelet count should be checked at baseline and periodically during
treatment.
,6. Which mood stabilizer requires a slow titration schedule specifically to reduce
the risk of Stevens-Johnson syndrome?
A. Lithium
B. Valproic acid
C. Lamotrigine
D. Gabapentin
Correct Answer: C
Rationale: Lamotrigine carries a black box warning for serious rash including
Stevens-Johnson syndrome; slow titration significantly reduces this risk, especially
when combined with valproate, which inhibits lamotrigine metabolism.
7. A patient on clozapine reports fever and sore throat. What is the priority
nursing action?
A. Reassure the patient this is a common benign side effect
B. Obtain an absolute neutrophil count (ANC) immediately
C. Increase clozapine dose
D. Schedule routine follow-up in one month
Correct Answer: B
Rationale: Clozapine carries a risk of agranulocytosis. Fever and sore throat may
indicate infection secondary to neutropenia, so an ANC must be obtained immediately
per REMS monitoring protocol.
8. Which second-generation antipsychotic carries the highest risk of significant
weight gain and metabolic syndrome?
A. Ziprasidone
B. Aripiprazole
C. Olanzapine
D. Lurasidone
Correct Answer: C
Rationale: Olanzapine and clozapine carry the highest risk among second-generation
antipsychotics for weight gain, dyslipidemia, and new-onset diabetes, requiring regular
metabolic monitoring.
, 9. A patient taking an MAOI develops a hypertensive crisis after eating aged
cheese. What is the mechanism responsible?
A. Excess tyramine unable to be metabolized, causing norepinephrine release
B. Excess serotonin reuptake
C. Dopamine receptor blockade
D. Cholinergic rebound
Correct Answer: A
Rationale: MAOIs inhibit the breakdown of tyramine in the gut and liver. Tyramine-rich
foods can trigger release of excess norepinephrine, precipitating a hypertensive crisis.
10. What is the recommended washout period when switching a patient from
fluoxetine to an MAOI?
A. 24 hours
B. 1 week
C. At least 5 weeks due to fluoxetine's long half-life and active metabolite
D. No washout needed
Correct Answer: C
Rationale: Fluoxetine and its active metabolite norfluoxetine have a long half-life; a
washout of at least 5 weeks is recommended before starting an MAOI to prevent
serotonin syndrome.
11. Which extrapyramidal symptom is characterized by an acute, sustained,
involuntary muscle contraction, often of the neck or eyes, occurring within
hours to days of starting an antipsychotic?
A. Tardive dyskinesia
B. Akathisia
C. Acute dystonia
D. Pseudoparkinsonism
Correct Answer: C
Rationale: Acute dystonic reactions occur early in treatment (hours to days) and
present as sustained involuntary muscle contractions such as torticollis or oculogyric
crisis; treated with anticholinergics or diphenhydramine.
120 Multiple-Choice Questions with Answers & Rationales
1. A patient starting fluoxetine asks how long it typically takes to see a full
therapeutic antidepressant effect. What should the PMHNP tell the patient?
A. 1 week
B. 2-4 weeks with full effect by 6-8 weeks
C. 24 hours
D. 3-6 months
Correct Answer: B
Rationale: SSRIs typically require 2-4 weeks before initial improvement is noted, with
full therapeutic benefit often taking 6-8 weeks. Patients should be counseled not to
discontinue prematurely due to perceived lack of efficacy.
2. Which of the following is the most concerning early sign of serotonin
syndrome in a patient recently started on an SSRI plus tramadol?
A. Dry mouth
B. Mild sedation
C. Myoclonus, hyperreflexia, and agitation
D. Weight gain
Correct Answer: C
Rationale: Serotonin syndrome presents with a triad of mental status changes,
autonomic instability, and neuromuscular abnormalities such as myoclonus,
hyperreflexia, clonus, and agitation. Combining an SSRI with tramadol increases
serotonergic risk.
,3. A patient on lithium presents with coarse tremor, ataxia, confusion, and
vomiting. Which lab value is most important to obtain immediately?
A. Serum lithium level
B. Fasting glucose
C. TSH
D. Liver enzymes
Correct Answer: A
Rationale: These findings are classic for lithium toxicity. A serum lithium level should
be obtained emergently to confirm toxicity and guide management, since toxicity can
occur even within or slightly above therapeutic range.
4. Which baseline laboratory tests are recommended before initiating lithium
therapy?
A. Renal function, thyroid function, and pregnancy test
B. Liver function only
C. Lipid panel only
D. CBC with differential only
Correct Answer: A
Rationale: Lithium is renally excreted and affects thyroid function, so renal function
(BUN/creatinine) and TSH should be obtained at baseline, along with a pregnancy test
in women of childbearing age due to teratogenic risk (Ebstein anomaly).
5. A patient prescribed valproic acid for bipolar disorder should have which
baseline and ongoing lab monitoring?
A. Liver function tests and CBC with platelets
B. Renal function only
C. TSH only
D. ECG only
Correct Answer: A
Rationale: Valproic acid carries risk of hepatotoxicity and thrombocytopenia, so LFTs
and CBC with platelet count should be checked at baseline and periodically during
treatment.
,6. Which mood stabilizer requires a slow titration schedule specifically to reduce
the risk of Stevens-Johnson syndrome?
A. Lithium
B. Valproic acid
C. Lamotrigine
D. Gabapentin
Correct Answer: C
Rationale: Lamotrigine carries a black box warning for serious rash including
Stevens-Johnson syndrome; slow titration significantly reduces this risk, especially
when combined with valproate, which inhibits lamotrigine metabolism.
7. A patient on clozapine reports fever and sore throat. What is the priority
nursing action?
A. Reassure the patient this is a common benign side effect
B. Obtain an absolute neutrophil count (ANC) immediately
C. Increase clozapine dose
D. Schedule routine follow-up in one month
Correct Answer: B
Rationale: Clozapine carries a risk of agranulocytosis. Fever and sore throat may
indicate infection secondary to neutropenia, so an ANC must be obtained immediately
per REMS monitoring protocol.
8. Which second-generation antipsychotic carries the highest risk of significant
weight gain and metabolic syndrome?
A. Ziprasidone
B. Aripiprazole
C. Olanzapine
D. Lurasidone
Correct Answer: C
Rationale: Olanzapine and clozapine carry the highest risk among second-generation
antipsychotics for weight gain, dyslipidemia, and new-onset diabetes, requiring regular
metabolic monitoring.
, 9. A patient taking an MAOI develops a hypertensive crisis after eating aged
cheese. What is the mechanism responsible?
A. Excess tyramine unable to be metabolized, causing norepinephrine release
B. Excess serotonin reuptake
C. Dopamine receptor blockade
D. Cholinergic rebound
Correct Answer: A
Rationale: MAOIs inhibit the breakdown of tyramine in the gut and liver. Tyramine-rich
foods can trigger release of excess norepinephrine, precipitating a hypertensive crisis.
10. What is the recommended washout period when switching a patient from
fluoxetine to an MAOI?
A. 24 hours
B. 1 week
C. At least 5 weeks due to fluoxetine's long half-life and active metabolite
D. No washout needed
Correct Answer: C
Rationale: Fluoxetine and its active metabolite norfluoxetine have a long half-life; a
washout of at least 5 weeks is recommended before starting an MAOI to prevent
serotonin syndrome.
11. Which extrapyramidal symptom is characterized by an acute, sustained,
involuntary muscle contraction, often of the neck or eyes, occurring within
hours to days of starting an antipsychotic?
A. Tardive dyskinesia
B. Akathisia
C. Acute dystonia
D. Pseudoparkinsonism
Correct Answer: C
Rationale: Acute dystonic reactions occur early in treatment (hours to days) and
present as sustained involuntary muscle contractions such as torticollis or oculogyric
crisis; treated with anticholinergics or diphenhydramine.
