BARKLEY PMHNP COMPREHENSIVE
CERTIFICATION EXAMINATION: 350
VERIFIED QUESTIONS WITH ANSWER
RATIONALES FOR THE 2026/2027
ACADEMIC YEAR || ALREADY GRADED
A+ || NEWEST
Question 1
A 28-year-old female with a history of PTSD presents with flashbacks, hypervigilance,
and nightmares. She reports using alcohol to help her sleep. What is the most
appropriate first-line pharmacologic intervention for her nightmares?
A. Quetiapine 25 mg at bedtime
B. Prazosin 1 mg at bedtime
C. Trazodone 50 mg at bedtime
D. Zolpidem 10 mg at bedtime
Correct Answer: B. Prazosin 1 mg at bedtime
Rationale: Prazosin is an alpha-1 antagonist with robust evidence for reducing
trauma-related nightmares in PTSD. It is the guideline-supported first-line agent
specifically for this condition. While trazodone and quetiapine are sometimes used
for sleep, they are not the first-line, evidence-based choice for PTSD-associated
nightmares. Zolpidem is a non-benzodiazepine hypnotic that does not specifically
target trauma-related nightmares and carries risks of dependence and cognitive
impairment .
Question 2
A PMHNP is reviewing a patient's chart and notes the phrase "blunted affect." Which
clinical presentation best correlates with this documentation?
,A. A complete lack of emotional expression
B. A wide range of emotional expression with rapid shifts
C. A significant reduction in the intensity of emotional expression
D. Emotional expression that is incongruent with the situation
Correct Answer: C. A significant reduction in the intensity of emotional
expression
Rationale: Blunted affect is defined as a marked reduction in the intensity of
emotional expression. It is important to distinguish this from flat affect, which is a
complete absence of emotional expression. Labile affect refers to rapid shifts in
emotional expression, while inappropriate affect refers to emotional expression that
does not match the content of the discussion .
Question 3
A 45-year-old male with major depressive disorder (MDD) has been on fluoxetine 40
mg for 8 weeks with partial response. He reports anorgasmia. What is the best next
step?
A. Add bupropion 150 mg daily
B. Switch to sertraline
C. Increase fluoxetine to 60 mg
D. Add trazodone 50 mg at bedtime
Correct Answer: A. Add bupropion 150 mg daily
Rationale: Bupropion is often added to SSRIs like fluoxetine to counteract sexual
side effects such as anorgasmia. Switching to another SSRI would likely not resolve
the issue because sexual dysfunction is a class effect of SSRIs. Increasing the SSRI
dose would likely worsen the side effect. Adding trazodone would address potential
insomnia but would not resolve sexual dysfunction .
Question 4
According to the Barkley DRT, which of the following is a critical element in the
"Assessment" section of a psychiatric note?
,A. The patient's vital signs
B. A detailed list of all medications with dosages
C. A formulation integrating biopsychosocial factors and a differential diagnosis
D. The exact start and stop times of the previous therapy session
Correct Answer: C. A formulation integrating biopsychosocial factors and a
differential diagnosis
Rationale: The Assessment section must include a clinical formulation, differential
diagnoses, and a synthesis of clinical data to support medical necessity. Vital signs
and medication lists belong in the objective or plan sections. Therapy session times
are not a required critical element for establishing medical necessity .
Question 5
A patient with bipolar I disorder is stabilized on lithium 900 mg/day. Their current
lithium level is 1.2 mEq/L. They present with coarse tremor, nausea, and confusion.
What is the priority intervention?
A. Increase lithium to 1200 mg/day
B. Add propranolol for tremor
C. Hold lithium and assess renal function
D. Add ondansetron for nausea
Correct Answer: C. Hold lithium and assess renal function
Rationale: The symptoms of coarse tremor, nausea, and confusion, especially with a
level at the upper end of the therapeutic range (1.2 mEq/L), indicate early lithium
toxicity. Lithium should be held, and renal function and level should be rechecked
immediately. Increasing the dose would worsen toxicity, and simply treating the
symptoms without addressing the underlying toxicity is inappropriate .
Question 6
Which of the following best describes the concept of "medical necessity" as required
for insurance reimbursement in psychiatric practice?
, A. The treatment is convenient for the patient's schedule
B. The treatment is intended to prevent, diagnose, or treat a condition that leads to
significant impairment in functioning
C. The treatment is requested by the patient's family
D. The treatment is the most expensive option available to ensure quality
Correct Answer: B. The treatment is intended to prevent, diagnose, or treat a
condition that leads to significant impairment in functioning
Rationale: Medical necessity requires that services are essential for diagnosing or
treating a medical condition and are not for convenience. The treatment must be
provided to prevent, diagnose, or treat a condition that causes significant
impairment in functioning. Patient or family preference alone does not establish
medical necessity .
Question 7
A patient on long-term haloperidol presents with parkinsonism, including
bradykinesia and rigidity. Which intervention is most appropriate?
A. Add benztropine
B. Increase haloperidol dose
C. Switch to aripiprazole
D. Add propranolol
Correct Answer: A. Add benztropine
Rationale: Benztropine is an anticholinergic medication that treats antipsychotic-
induced extrapyramidal symptoms (EPS) by restoring the dopamine-acetylcholine
balance in the basal ganglia. Increasing the haloperidol dose would worsen EPS.
While switching to aripiprazole may be a long-term strategy, it is not first-line for
acute EPS management, as aripiprazole can also cause EPS. Propranolol treats tremor
but not rigidity or bradykinesia .
Question 8
Which neurotransmitter is primarily implicated in the pathophysiology of obsessive-
compulsive disorder (OCD)?
CERTIFICATION EXAMINATION: 350
VERIFIED QUESTIONS WITH ANSWER
RATIONALES FOR THE 2026/2027
ACADEMIC YEAR || ALREADY GRADED
A+ || NEWEST
Question 1
A 28-year-old female with a history of PTSD presents with flashbacks, hypervigilance,
and nightmares. She reports using alcohol to help her sleep. What is the most
appropriate first-line pharmacologic intervention for her nightmares?
A. Quetiapine 25 mg at bedtime
B. Prazosin 1 mg at bedtime
C. Trazodone 50 mg at bedtime
D. Zolpidem 10 mg at bedtime
Correct Answer: B. Prazosin 1 mg at bedtime
Rationale: Prazosin is an alpha-1 antagonist with robust evidence for reducing
trauma-related nightmares in PTSD. It is the guideline-supported first-line agent
specifically for this condition. While trazodone and quetiapine are sometimes used
for sleep, they are not the first-line, evidence-based choice for PTSD-associated
nightmares. Zolpidem is a non-benzodiazepine hypnotic that does not specifically
target trauma-related nightmares and carries risks of dependence and cognitive
impairment .
Question 2
A PMHNP is reviewing a patient's chart and notes the phrase "blunted affect." Which
clinical presentation best correlates with this documentation?
,A. A complete lack of emotional expression
B. A wide range of emotional expression with rapid shifts
C. A significant reduction in the intensity of emotional expression
D. Emotional expression that is incongruent with the situation
Correct Answer: C. A significant reduction in the intensity of emotional
expression
Rationale: Blunted affect is defined as a marked reduction in the intensity of
emotional expression. It is important to distinguish this from flat affect, which is a
complete absence of emotional expression. Labile affect refers to rapid shifts in
emotional expression, while inappropriate affect refers to emotional expression that
does not match the content of the discussion .
Question 3
A 45-year-old male with major depressive disorder (MDD) has been on fluoxetine 40
mg for 8 weeks with partial response. He reports anorgasmia. What is the best next
step?
A. Add bupropion 150 mg daily
B. Switch to sertraline
C. Increase fluoxetine to 60 mg
D. Add trazodone 50 mg at bedtime
Correct Answer: A. Add bupropion 150 mg daily
Rationale: Bupropion is often added to SSRIs like fluoxetine to counteract sexual
side effects such as anorgasmia. Switching to another SSRI would likely not resolve
the issue because sexual dysfunction is a class effect of SSRIs. Increasing the SSRI
dose would likely worsen the side effect. Adding trazodone would address potential
insomnia but would not resolve sexual dysfunction .
Question 4
According to the Barkley DRT, which of the following is a critical element in the
"Assessment" section of a psychiatric note?
,A. The patient's vital signs
B. A detailed list of all medications with dosages
C. A formulation integrating biopsychosocial factors and a differential diagnosis
D. The exact start and stop times of the previous therapy session
Correct Answer: C. A formulation integrating biopsychosocial factors and a
differential diagnosis
Rationale: The Assessment section must include a clinical formulation, differential
diagnoses, and a synthesis of clinical data to support medical necessity. Vital signs
and medication lists belong in the objective or plan sections. Therapy session times
are not a required critical element for establishing medical necessity .
Question 5
A patient with bipolar I disorder is stabilized on lithium 900 mg/day. Their current
lithium level is 1.2 mEq/L. They present with coarse tremor, nausea, and confusion.
What is the priority intervention?
A. Increase lithium to 1200 mg/day
B. Add propranolol for tremor
C. Hold lithium and assess renal function
D. Add ondansetron for nausea
Correct Answer: C. Hold lithium and assess renal function
Rationale: The symptoms of coarse tremor, nausea, and confusion, especially with a
level at the upper end of the therapeutic range (1.2 mEq/L), indicate early lithium
toxicity. Lithium should be held, and renal function and level should be rechecked
immediately. Increasing the dose would worsen toxicity, and simply treating the
symptoms without addressing the underlying toxicity is inappropriate .
Question 6
Which of the following best describes the concept of "medical necessity" as required
for insurance reimbursement in psychiatric practice?
, A. The treatment is convenient for the patient's schedule
B. The treatment is intended to prevent, diagnose, or treat a condition that leads to
significant impairment in functioning
C. The treatment is requested by the patient's family
D. The treatment is the most expensive option available to ensure quality
Correct Answer: B. The treatment is intended to prevent, diagnose, or treat a
condition that leads to significant impairment in functioning
Rationale: Medical necessity requires that services are essential for diagnosing or
treating a medical condition and are not for convenience. The treatment must be
provided to prevent, diagnose, or treat a condition that causes significant
impairment in functioning. Patient or family preference alone does not establish
medical necessity .
Question 7
A patient on long-term haloperidol presents with parkinsonism, including
bradykinesia and rigidity. Which intervention is most appropriate?
A. Add benztropine
B. Increase haloperidol dose
C. Switch to aripiprazole
D. Add propranolol
Correct Answer: A. Add benztropine
Rationale: Benztropine is an anticholinergic medication that treats antipsychotic-
induced extrapyramidal symptoms (EPS) by restoring the dopamine-acetylcholine
balance in the basal ganglia. Increasing the haloperidol dose would worsen EPS.
While switching to aripiprazole may be a long-term strategy, it is not first-line for
acute EPS management, as aripiprazole can also cause EPS. Propranolol treats tremor
but not rigidity or bradykinesia .
Question 8
Which neurotransmitter is primarily implicated in the pathophysiology of obsessive-
compulsive disorder (OCD)?
