NR 548 Exam 3 (VersionAdvanced
2.0) Psychiatric
-Mental Health Nursing Practice
—A
Comprehensive, High
-Complexity Examination Covering Differential Diagnosis,
Psychopharmacology, Comorbid Conditions, and Clinical
-Making
Decision
for the PMHNP
Table of Contents
Question
Domain
Numbers
I. Advanced Differential Diagnosis & Diagnostic Formulation 1–18
II. Comorbid Psychiatric & Medical Conditions 19–32
III. Psychopharmacology: Mechanisms, Interactions, & Adverse
33–52
Effects
IV. Mood Disorders: Complex Presentations & Treatment Resistance 53–68
V. Psychotic Disorders: Schizophrenia Spectrum & Other Psychotic
69–82
Disorders
VI. Trauma, Dissociation, & Somatic Symptom Disorders 83–94
VII. Substance Use Disorders: Complex Withdrawal & Medication-
95–108
Assisted Treatment
VIII. Neurocognitive Disorders & Delirium 109–120
IX. Personality Disorders: Assessment & Management Strategies 121–132
X. Suicide Risk Assessment: Advanced Clinical Scenarios 133–142
, Question
Domain
Numbers
XI. Ethical Dilemmas, Legal Standards, & Boundary Complexities 143–150
SECTION I: ADVANCED DIFFERENTIAL DIAGNOSIS & DIAGNOSTIC FORMULATION
• 1. A 42-year-old female presents with a 6-month history of progressive fatigue, cognitive
slowing, and depressed mood. She reports that her symptoms began after a viral illness and
have not responded to two adequate trials of SSRIs. Laboratory studies reveal elevated TSH and
positive anti-thyroid peroxidase antibodies. Which of the following is the most appropriate next
step in management?
• A. Increase the SSRI dose to maximum
• B. Add levothyroxine and reassess psychiatric symptoms
• C. Switch to an SNRI
• D. Refer for electroconvulsive therapy
.. CorreCt Answer: B
Rationale: This patient has laboratory-confirmed hypothyroidism (Hashimoto's
thyroiditis), which can present with depressive symptoms that are often refractory to
antidepressants alone. Levothyroxine replacement is the primary treatment, and
psychiatric symptoms typically improve with thyroid hormone normalization. Continuing
to escalate antidepressant therapy without addressing the underlying endocrine
condition would be inappropriate.
• 2. A 58-year-old male with a 20-year history of alcohol use disorder presents with confusion,
ataxia, and ophthalmoplegia. He reports that he has not eaten well for several weeks. What is
the most likely diagnosis, and what is the emergent treatment?
• A. Wernicke's encephalopathy; treat with intravenous thiamine
• B. Hepatic encephalopathy; treat with lactulose
• C. Alcohol withdrawal delirium; treat with benzodiazepines
• D. Korsakoff syndrome; treat with oral multivitamins
.. CorreCt Answer: A
, Rationale: The classic triad of Wernicke's encephalopathy (confusion, ataxia,
ophthalmoplegia) in the context of chronic alcohol use and poor nutrition indicates
thiamine deficiency. This is a medical emergency requiring immediate high-dose IV
thiamine administration to prevent progression to Korsakoff syndrome or death.
• 3. A 34-year-old patient presents with a 3-month history of excessive worry about having a
serious illness despite multiple normal medical evaluations. The patient spends hours
researching symptoms online and repeatedly visits different specialists. The most likely
diagnosis is:
• A. Somatic Symptom Disorder
• B. Illness Anxiety Disorder
• C. Obsessive-Compulsive Disorder
• D. Generalized Anxiety Disorder
.. CorreCt Answer: B
Rationale: Illness Anxiety Disorder is characterized by preoccupation with having or
acquiring a serious illness, with minimal or no somatic symptoms. The patient is
distressed by health concerns, performs excessive health-related behaviors (online
research, seeking reassurance), and remains preoccupied despite normal evaluations.
Somatic Symptom Disorder requires prominent somatic symptoms.
• 4. A 27-year-old patient with no prior psychiatric history presents with sudden onset of
bizarre behavior, disorganized speech, and auditory hallucinations over the past 10 days. The
patient has been using cannabis daily for the past year but reports no other substance use. Vital
signs are normal, and urine toxicology is positive only for cannabis. What is the most
appropriate next step?
• A. Diagnose schizophrenia and start antipsychotic
• B. Diagnose brief psychotic disorder and observe
• C. Consider cannabis-induced psychotic disorder and monitor for resolution with
abstinence
• D. Diagnose schizophreniform disorder and start antipsychotic
.. CorreCt Answer: C
Rationale: Cannabis use can precipitate psychotic symptoms, especially with heavy use.
Cannabis-induced psychotic disorder requires that the symptoms are not better
explained by another psychotic disorder and that they resolve with cessation of cannabis
, use. Given the acute onset and lack of prior psychiatric history, a period of observation
with cannabis abstinence is warranted before committing to a primary psychotic
disorder diagnosis.
• 5. A 45-year-old female presents with a 1-year history of progressive memory loss,
personality changes, and difficulty with complex tasks. She reports that her mother had
"dementia" in her 50s. Neurological examination reveals choreiform movements. What is the
most likely diagnosis?
• A. Alzheimer's disease
• B. Vascular dementia
• C. Huntington's disease
• D. Frontotemporal dementia
.. CorreCt Answer: C
Rationale: Huntington's disease is an autosomal dominant neurodegenerative disorder
characterized by progressive cognitive decline, psychiatric symptoms (personality
changes, depression), and choreiform movements. Onset is typically in mid-adulthood
(30s-50s), and a positive family history is present. Alzheimer's disease typically presents
with more prominent memory impairment and lacks chorea; vascular dementia has a
stepwise progression.
• 6. A patient with bipolar I disorder has been stable on lithium for 5 years. He presents with a
2-week history of progressively worsening tremors, nausea, vomiting, and confusion. He reports
that he has been drinking more fluids due to hot weather and has been taking ibuprofen for
knee pain. His lithium level is 2.1 mEq/L. What is the most appropriate immediate
management?
• A. Increase the lithium dose to achieve therapeutic level
• B. Discontinue lithium and start valproic acid
• C. Hold lithium, provide IV fluids, and monitor for signs of toxicity
• D. Start haloperidol for agitation
.. CorreCt Answer: C
Rationale: Lithium levels >1.5 mEq/L represent toxicity. This patient's level of 2.1 mEq/L
with symptoms of toxicity (tremor, nausea, vomiting, confusion) requires immediate
discontinuation of lithium, IV fluid hydration to enhance renal clearance, and close
2.0) Psychiatric
-Mental Health Nursing Practice
—A
Comprehensive, High
-Complexity Examination Covering Differential Diagnosis,
Psychopharmacology, Comorbid Conditions, and Clinical
-Making
Decision
for the PMHNP
Table of Contents
Question
Domain
Numbers
I. Advanced Differential Diagnosis & Diagnostic Formulation 1–18
II. Comorbid Psychiatric & Medical Conditions 19–32
III. Psychopharmacology: Mechanisms, Interactions, & Adverse
33–52
Effects
IV. Mood Disorders: Complex Presentations & Treatment Resistance 53–68
V. Psychotic Disorders: Schizophrenia Spectrum & Other Psychotic
69–82
Disorders
VI. Trauma, Dissociation, & Somatic Symptom Disorders 83–94
VII. Substance Use Disorders: Complex Withdrawal & Medication-
95–108
Assisted Treatment
VIII. Neurocognitive Disorders & Delirium 109–120
IX. Personality Disorders: Assessment & Management Strategies 121–132
X. Suicide Risk Assessment: Advanced Clinical Scenarios 133–142
, Question
Domain
Numbers
XI. Ethical Dilemmas, Legal Standards, & Boundary Complexities 143–150
SECTION I: ADVANCED DIFFERENTIAL DIAGNOSIS & DIAGNOSTIC FORMULATION
• 1. A 42-year-old female presents with a 6-month history of progressive fatigue, cognitive
slowing, and depressed mood. She reports that her symptoms began after a viral illness and
have not responded to two adequate trials of SSRIs. Laboratory studies reveal elevated TSH and
positive anti-thyroid peroxidase antibodies. Which of the following is the most appropriate next
step in management?
• A. Increase the SSRI dose to maximum
• B. Add levothyroxine and reassess psychiatric symptoms
• C. Switch to an SNRI
• D. Refer for electroconvulsive therapy
.. CorreCt Answer: B
Rationale: This patient has laboratory-confirmed hypothyroidism (Hashimoto's
thyroiditis), which can present with depressive symptoms that are often refractory to
antidepressants alone. Levothyroxine replacement is the primary treatment, and
psychiatric symptoms typically improve with thyroid hormone normalization. Continuing
to escalate antidepressant therapy without addressing the underlying endocrine
condition would be inappropriate.
• 2. A 58-year-old male with a 20-year history of alcohol use disorder presents with confusion,
ataxia, and ophthalmoplegia. He reports that he has not eaten well for several weeks. What is
the most likely diagnosis, and what is the emergent treatment?
• A. Wernicke's encephalopathy; treat with intravenous thiamine
• B. Hepatic encephalopathy; treat with lactulose
• C. Alcohol withdrawal delirium; treat with benzodiazepines
• D. Korsakoff syndrome; treat with oral multivitamins
.. CorreCt Answer: A
, Rationale: The classic triad of Wernicke's encephalopathy (confusion, ataxia,
ophthalmoplegia) in the context of chronic alcohol use and poor nutrition indicates
thiamine deficiency. This is a medical emergency requiring immediate high-dose IV
thiamine administration to prevent progression to Korsakoff syndrome or death.
• 3. A 34-year-old patient presents with a 3-month history of excessive worry about having a
serious illness despite multiple normal medical evaluations. The patient spends hours
researching symptoms online and repeatedly visits different specialists. The most likely
diagnosis is:
• A. Somatic Symptom Disorder
• B. Illness Anxiety Disorder
• C. Obsessive-Compulsive Disorder
• D. Generalized Anxiety Disorder
.. CorreCt Answer: B
Rationale: Illness Anxiety Disorder is characterized by preoccupation with having or
acquiring a serious illness, with minimal or no somatic symptoms. The patient is
distressed by health concerns, performs excessive health-related behaviors (online
research, seeking reassurance), and remains preoccupied despite normal evaluations.
Somatic Symptom Disorder requires prominent somatic symptoms.
• 4. A 27-year-old patient with no prior psychiatric history presents with sudden onset of
bizarre behavior, disorganized speech, and auditory hallucinations over the past 10 days. The
patient has been using cannabis daily for the past year but reports no other substance use. Vital
signs are normal, and urine toxicology is positive only for cannabis. What is the most
appropriate next step?
• A. Diagnose schizophrenia and start antipsychotic
• B. Diagnose brief psychotic disorder and observe
• C. Consider cannabis-induced psychotic disorder and monitor for resolution with
abstinence
• D. Diagnose schizophreniform disorder and start antipsychotic
.. CorreCt Answer: C
Rationale: Cannabis use can precipitate psychotic symptoms, especially with heavy use.
Cannabis-induced psychotic disorder requires that the symptoms are not better
explained by another psychotic disorder and that they resolve with cessation of cannabis
, use. Given the acute onset and lack of prior psychiatric history, a period of observation
with cannabis abstinence is warranted before committing to a primary psychotic
disorder diagnosis.
• 5. A 45-year-old female presents with a 1-year history of progressive memory loss,
personality changes, and difficulty with complex tasks. She reports that her mother had
"dementia" in her 50s. Neurological examination reveals choreiform movements. What is the
most likely diagnosis?
• A. Alzheimer's disease
• B. Vascular dementia
• C. Huntington's disease
• D. Frontotemporal dementia
.. CorreCt Answer: C
Rationale: Huntington's disease is an autosomal dominant neurodegenerative disorder
characterized by progressive cognitive decline, psychiatric symptoms (personality
changes, depression), and choreiform movements. Onset is typically in mid-adulthood
(30s-50s), and a positive family history is present. Alzheimer's disease typically presents
with more prominent memory impairment and lacks chorea; vascular dementia has a
stepwise progression.
• 6. A patient with bipolar I disorder has been stable on lithium for 5 years. He presents with a
2-week history of progressively worsening tremors, nausea, vomiting, and confusion. He reports
that he has been drinking more fluids due to hot weather and has been taking ibuprofen for
knee pain. His lithium level is 2.1 mEq/L. What is the most appropriate immediate
management?
• A. Increase the lithium dose to achieve therapeutic level
• B. Discontinue lithium and start valproic acid
• C. Hold lithium, provide IV fluids, and monitor for signs of toxicity
• D. Start haloperidol for agitation
.. CorreCt Answer: C
Rationale: Lithium levels >1.5 mEq/L represent toxicity. This patient's level of 2.1 mEq/L
with symptoms of toxicity (tremor, nausea, vomiting, confusion) requires immediate
discontinuation of lithium, IV fluid hydration to enhance renal clearance, and close
