WALDEN UNIVERSITY NRNP 6675 MIDTERM EXAM
PRACTICE 2026-2027 – 100+ ADVANCED
PSYCHIATRIC-MENTAL HEALTH NURSING
QUESTIONS WITH RATIONALES
QUESTION 1.
A 32-year-old patient presents with a 4-month history of depressed mood,
anhedonia, insomnia, diminished appetite, impaired concentration, psychomotor
slowing, and recurrent thoughts that life is not worth living. The patient denies
hallucinations, delusions, or periods of elevated mood. During the interview, the
patient states, “I have thought about taking all the pills in my medicine cabinet, but I
have not decided when.” Which action should the psychiatric mental health nurse
practitioner prioritize?
A. Schedule the patient for routine psychotherapy within one week
B. Complete an immediate suicide risk assessment, including intent, plan, access
to means, and protective factors
C. Initiate an antidepressant and reassess suicidal ideation at the next appointment
D. Ask the patient's family to monitor the patient without further assessment
Answer: B. Complete an immediate suicide risk assessment, including intent,
plan, access to means, and protective factors
Rationale: The disclosure of a potential method and suicidal thinking requires
immediate, structured assessment of intent, planning, access to lethal means,
previous attempts, protective factors, and the patient's ability to maintain safety.
Treatment planning should follow determination of acute risk and the appropriate
level of care. Initiating medication or arranging routine follow-up without first
determining imminent risk could inadequately address a potentially life-threatening
situation. Family involvement may be appropriate with appropriate consideration of
confidentiality and safety, but it does not replace the clinician's risk assessment.
QUESTION 2.
A 41-year-old patient reports episodic periods lasting approximately 5 days during
which the patient sleeps 3 hours nightly without fatigue, speaks rapidly, develops
numerous business ideas, becomes unusually sociable, and spends substantially
more money than usual. The patient denies psychotic symptoms and has never
required hospitalization. Between episodes, mood and functioning return to baseline.
Which diagnosis is most consistent with this presentation?
A. Bipolar II disorder
B. Cyclothymic disorder
C. Bipolar I disorder
D. Major depressive disorder with mixed features
Answer: A. Bipolar II disorder
Rationale: Bipolar II disorder is characterized by hypomanic episodes and major
depressive episodes without a history of full mania. The described episode involves
,a distinct period of elevated or expansive functioning with decreased need for sleep
and increased goal-directed behavior but no evidence of marked impairment,
hospitalization, or psychosis required for mania. Bipolar I requires at least one
manic episode. Cyclothymic disorder involves numerous fluctuating hypomanic and
depressive symptoms that do not meet full episode criteria.
QUESTION 3.
A patient with generalized anxiety disorder has been taking a therapeutic dose of an
SSRI for 10 weeks with partial improvement. The patient reports persistent excessive
worry, muscle tension, and difficulty concentrating but denies suicidal ideation,
mania, psychosis, or substance misuse. The patient asks whether medication should
immediately be discontinued because symptoms remain. What is the most
appropriate clinical reasoning?
A. Discontinue the SSRI because persistent symptoms establish treatment failure
B. Replace the SSRI immediately with a benzodiazepine
C. Reassess adherence, dose adequacy, adverse effects, comorbidities, and
psychotherapy participation before modifying treatment
D. Increase the SSRI to the maximum dose regardless of tolerability
Answer: C. Reassess adherence, dose adequacy, adverse effects,
comorbidities, and psychotherapy participation before modifying treatment
Rationale: Partial response should prompt systematic reassessment rather than an
automatic medication switch or discontinuation. The clinician should determine
whether the medication has been taken consistently at an adequate therapeutic
dose and duration and assess comorbid depression, substance use, medical
contributors, and engagement in evidence-based psychotherapy. A dose
adjustment or medication change may ultimately be appropriate, but it should be
based on this assessment. Benzodiazepines are not automatically preferred for
persistent generalized anxiety symptoms.
QUESTION 4.
A 27-year-old patient presents with auditory hallucinations and paranoid beliefs that
coworkers are transmitting threatening messages through office computers. The
patient has been experiencing progressive social withdrawal, diminished
occupational functioning, and disorganized speech for approximately 8 months.
Which finding would most strongly support schizophrenia rather than
schizophreniform disorder?
A. Presence of auditory hallucinations
B. Presence of persecutory delusions
C. Social withdrawal before psychotic symptoms
D. Continuous disturbance lasting at least 6 months with functional deterioration
Answer: D. Continuous disturbance lasting at least 6 months with functional
deterioration
Rationale: Duration and functional decline are critical in differentiating schizophrenia
from schizophreniform disorder. Schizophrenia requires a continuous disturbance for
at least 6 months, including at least 1 month of active-phase symptoms, with
,associated functional impairment. Hallucinations, delusions, and disorganized
speech can occur in both disorders and therefore do not establish the distinction by
themselves. The patient's prolonged course and deterioration strongly support
schizophrenia.
QUESTION 5.
A patient with recurrent major depressive episodes reports periods of markedly
increased energy, decreased need for sleep, impulsive spending, and unusually
rapid speech. During the current evaluation, the patient is euthymic and denies any
history of hospitalization or psychosis. Which additional historical question is most
important before initiating antidepressant monotherapy?
A. “Have you ever experienced a sustained period of elevated or unusually
irritable mood accompanied by increased goal-directed activity?”
B. “Do you prefer individual or group therapy?”
C. “Have you ever experienced a mild headache after taking medication?”
D. “Do depressive symptoms occur more frequently during winter?”
Answer: A. “Have you ever experienced a sustained period of elevated or
unusually irritable mood accompanied by increased goal-directed activity?”
Rationale: A history suggestive of hypomania or mania can substantially change the
diagnostic formulation and treatment strategy. Antidepressant monotherapy in an
individual with bipolar-spectrum illness may worsen mood instability or precipitate
mania or hypomania. The clinician should obtain a detailed longitudinal mood
history, including duration, functional changes, impulsivity, decreased need for sleep,
psychosis, and consequences. The other questions may contribute to assessment
but are less immediately important to determining whether bipolarity is present.
QUESTION 6.
A 19-year-old college student presents after several weeks of worsening social
withdrawal, declining academic performance, suspiciousness, and hearing a voice
commenting on behavior. The patient's parents report that the patient has also begun
neglecting hygiene. The patient has no known medical illness and denies substance
use. Which assessment is most important before concluding that the symptoms
represent a primary psychotic disorder?
A. Determine whether the patient has ever received psychotherapy
B. Establish the patient's preferred learning style
C. Evaluate for substance-induced, medical, neurologic, and medication-related
causes of psychosis
D. Determine whether the patient has experienced childhood separation anxiety
Answer: C. Evaluate for substance-induced, medical, neurologic, and
medication-related causes of psychosis
Rationale: New-onset psychosis requires consideration of secondary causes before
assigning a primary psychotic diagnosis. Substances, medications, endocrine
abnormalities, neurologic disorders, infections, metabolic disturbances, and other
medical conditions can produce psychotic symptoms. The clinician should obtain a
detailed history, physical assessment, medication and substance review, and
appropriate diagnostic testing based on the presentation. Psychosocial history
, remains important but does not replace evaluation for potentially reversible causes.
QUESTION 7.
A patient with panic disorder reports sudden episodes of intense fear accompanied
by palpitations, dyspnea, trembling, chest discomfort, and fear of dying. Cardiac
evaluation has been unrevealing. The patient now avoids exercise and crowded
places because of concern about having another attack. Which treatment approach
most directly targets the behavioral mechanism maintaining the patient's symptoms?
A. Long-term avoidance of situations associated with panic
B. Exposure-based cognitive behavioral therapy combined with cognitive
restructuring
C. Reassurance that panic symptoms can never cause physical discomfort
D. Continuous use of short-acting sedative medication before leaving home
Answer: B. Exposure-based cognitive behavioral therapy combined with
cognitive restructuring
Rationale: Panic disorder is often maintained by catastrophic interpretation of bodily
sensations and avoidance of feared situations. Cognitive restructuring helps
challenge maladaptive interpretations, while gradual exposure reduces avoidance
and fear conditioning. Avoidance reinforces the patient's belief that the situations are
dangerous and can progressively restrict functioning. Medication may be useful, but
reliance on immediate sedation does not directly address the behavioral
maintenance cycle.
QUESTION 8.
A 36-year-old patient with bipolar disorder presents with markedly decreased sleep,
pressured speech, grandiose plans, impulsive financial decisions, and increasing
irritability. The patient is difficult to redirect but denies suicidal ideation. Which
clinical feature most strongly indicates that this episode has progressed beyond
hypomania?
A. Increased sociability
B. Reduced need for sleep
C. Increased goal-directed activity
D. Marked impairment requiring urgent intervention
Answer: D. Marked impairment requiring urgent intervention
Rationale: Mania is distinguished from hypomania by greater severity and functional
impairment and may involve hospitalization or psychotic features. Decreased need
for sleep, increased activity, and elevated or irritable mood can occur in both states.
The degree of impairment and behavioral dyscontrol is therefore central to the
distinction. The patient's escalating impulsivity, inability to be redirected, and
significant deterioration indicate a manic syndrome requiring urgent intervention.
QUESTION 9.
A patient with posttraumatic stress disorder reports recurrent nightmares, intrusive
memories, avoidance of reminders, hypervigilance, exaggerated startle response,
and persistent negative beliefs about safety. The patient asks why repeatedly
PRACTICE 2026-2027 – 100+ ADVANCED
PSYCHIATRIC-MENTAL HEALTH NURSING
QUESTIONS WITH RATIONALES
QUESTION 1.
A 32-year-old patient presents with a 4-month history of depressed mood,
anhedonia, insomnia, diminished appetite, impaired concentration, psychomotor
slowing, and recurrent thoughts that life is not worth living. The patient denies
hallucinations, delusions, or periods of elevated mood. During the interview, the
patient states, “I have thought about taking all the pills in my medicine cabinet, but I
have not decided when.” Which action should the psychiatric mental health nurse
practitioner prioritize?
A. Schedule the patient for routine psychotherapy within one week
B. Complete an immediate suicide risk assessment, including intent, plan, access
to means, and protective factors
C. Initiate an antidepressant and reassess suicidal ideation at the next appointment
D. Ask the patient's family to monitor the patient without further assessment
Answer: B. Complete an immediate suicide risk assessment, including intent,
plan, access to means, and protective factors
Rationale: The disclosure of a potential method and suicidal thinking requires
immediate, structured assessment of intent, planning, access to lethal means,
previous attempts, protective factors, and the patient's ability to maintain safety.
Treatment planning should follow determination of acute risk and the appropriate
level of care. Initiating medication or arranging routine follow-up without first
determining imminent risk could inadequately address a potentially life-threatening
situation. Family involvement may be appropriate with appropriate consideration of
confidentiality and safety, but it does not replace the clinician's risk assessment.
QUESTION 2.
A 41-year-old patient reports episodic periods lasting approximately 5 days during
which the patient sleeps 3 hours nightly without fatigue, speaks rapidly, develops
numerous business ideas, becomes unusually sociable, and spends substantially
more money than usual. The patient denies psychotic symptoms and has never
required hospitalization. Between episodes, mood and functioning return to baseline.
Which diagnosis is most consistent with this presentation?
A. Bipolar II disorder
B. Cyclothymic disorder
C. Bipolar I disorder
D. Major depressive disorder with mixed features
Answer: A. Bipolar II disorder
Rationale: Bipolar II disorder is characterized by hypomanic episodes and major
depressive episodes without a history of full mania. The described episode involves
,a distinct period of elevated or expansive functioning with decreased need for sleep
and increased goal-directed behavior but no evidence of marked impairment,
hospitalization, or psychosis required for mania. Bipolar I requires at least one
manic episode. Cyclothymic disorder involves numerous fluctuating hypomanic and
depressive symptoms that do not meet full episode criteria.
QUESTION 3.
A patient with generalized anxiety disorder has been taking a therapeutic dose of an
SSRI for 10 weeks with partial improvement. The patient reports persistent excessive
worry, muscle tension, and difficulty concentrating but denies suicidal ideation,
mania, psychosis, or substance misuse. The patient asks whether medication should
immediately be discontinued because symptoms remain. What is the most
appropriate clinical reasoning?
A. Discontinue the SSRI because persistent symptoms establish treatment failure
B. Replace the SSRI immediately with a benzodiazepine
C. Reassess adherence, dose adequacy, adverse effects, comorbidities, and
psychotherapy participation before modifying treatment
D. Increase the SSRI to the maximum dose regardless of tolerability
Answer: C. Reassess adherence, dose adequacy, adverse effects,
comorbidities, and psychotherapy participation before modifying treatment
Rationale: Partial response should prompt systematic reassessment rather than an
automatic medication switch or discontinuation. The clinician should determine
whether the medication has been taken consistently at an adequate therapeutic
dose and duration and assess comorbid depression, substance use, medical
contributors, and engagement in evidence-based psychotherapy. A dose
adjustment or medication change may ultimately be appropriate, but it should be
based on this assessment. Benzodiazepines are not automatically preferred for
persistent generalized anxiety symptoms.
QUESTION 4.
A 27-year-old patient presents with auditory hallucinations and paranoid beliefs that
coworkers are transmitting threatening messages through office computers. The
patient has been experiencing progressive social withdrawal, diminished
occupational functioning, and disorganized speech for approximately 8 months.
Which finding would most strongly support schizophrenia rather than
schizophreniform disorder?
A. Presence of auditory hallucinations
B. Presence of persecutory delusions
C. Social withdrawal before psychotic symptoms
D. Continuous disturbance lasting at least 6 months with functional deterioration
Answer: D. Continuous disturbance lasting at least 6 months with functional
deterioration
Rationale: Duration and functional decline are critical in differentiating schizophrenia
from schizophreniform disorder. Schizophrenia requires a continuous disturbance for
at least 6 months, including at least 1 month of active-phase symptoms, with
,associated functional impairment. Hallucinations, delusions, and disorganized
speech can occur in both disorders and therefore do not establish the distinction by
themselves. The patient's prolonged course and deterioration strongly support
schizophrenia.
QUESTION 5.
A patient with recurrent major depressive episodes reports periods of markedly
increased energy, decreased need for sleep, impulsive spending, and unusually
rapid speech. During the current evaluation, the patient is euthymic and denies any
history of hospitalization or psychosis. Which additional historical question is most
important before initiating antidepressant monotherapy?
A. “Have you ever experienced a sustained period of elevated or unusually
irritable mood accompanied by increased goal-directed activity?”
B. “Do you prefer individual or group therapy?”
C. “Have you ever experienced a mild headache after taking medication?”
D. “Do depressive symptoms occur more frequently during winter?”
Answer: A. “Have you ever experienced a sustained period of elevated or
unusually irritable mood accompanied by increased goal-directed activity?”
Rationale: A history suggestive of hypomania or mania can substantially change the
diagnostic formulation and treatment strategy. Antidepressant monotherapy in an
individual with bipolar-spectrum illness may worsen mood instability or precipitate
mania or hypomania. The clinician should obtain a detailed longitudinal mood
history, including duration, functional changes, impulsivity, decreased need for sleep,
psychosis, and consequences. The other questions may contribute to assessment
but are less immediately important to determining whether bipolarity is present.
QUESTION 6.
A 19-year-old college student presents after several weeks of worsening social
withdrawal, declining academic performance, suspiciousness, and hearing a voice
commenting on behavior. The patient's parents report that the patient has also begun
neglecting hygiene. The patient has no known medical illness and denies substance
use. Which assessment is most important before concluding that the symptoms
represent a primary psychotic disorder?
A. Determine whether the patient has ever received psychotherapy
B. Establish the patient's preferred learning style
C. Evaluate for substance-induced, medical, neurologic, and medication-related
causes of psychosis
D. Determine whether the patient has experienced childhood separation anxiety
Answer: C. Evaluate for substance-induced, medical, neurologic, and
medication-related causes of psychosis
Rationale: New-onset psychosis requires consideration of secondary causes before
assigning a primary psychotic diagnosis. Substances, medications, endocrine
abnormalities, neurologic disorders, infections, metabolic disturbances, and other
medical conditions can produce psychotic symptoms. The clinician should obtain a
detailed history, physical assessment, medication and substance review, and
appropriate diagnostic testing based on the presentation. Psychosocial history
, remains important but does not replace evaluation for potentially reversible causes.
QUESTION 7.
A patient with panic disorder reports sudden episodes of intense fear accompanied
by palpitations, dyspnea, trembling, chest discomfort, and fear of dying. Cardiac
evaluation has been unrevealing. The patient now avoids exercise and crowded
places because of concern about having another attack. Which treatment approach
most directly targets the behavioral mechanism maintaining the patient's symptoms?
A. Long-term avoidance of situations associated with panic
B. Exposure-based cognitive behavioral therapy combined with cognitive
restructuring
C. Reassurance that panic symptoms can never cause physical discomfort
D. Continuous use of short-acting sedative medication before leaving home
Answer: B. Exposure-based cognitive behavioral therapy combined with
cognitive restructuring
Rationale: Panic disorder is often maintained by catastrophic interpretation of bodily
sensations and avoidance of feared situations. Cognitive restructuring helps
challenge maladaptive interpretations, while gradual exposure reduces avoidance
and fear conditioning. Avoidance reinforces the patient's belief that the situations are
dangerous and can progressively restrict functioning. Medication may be useful, but
reliance on immediate sedation does not directly address the behavioral
maintenance cycle.
QUESTION 8.
A 36-year-old patient with bipolar disorder presents with markedly decreased sleep,
pressured speech, grandiose plans, impulsive financial decisions, and increasing
irritability. The patient is difficult to redirect but denies suicidal ideation. Which
clinical feature most strongly indicates that this episode has progressed beyond
hypomania?
A. Increased sociability
B. Reduced need for sleep
C. Increased goal-directed activity
D. Marked impairment requiring urgent intervention
Answer: D. Marked impairment requiring urgent intervention
Rationale: Mania is distinguished from hypomania by greater severity and functional
impairment and may involve hospitalization or psychotic features. Decreased need
for sleep, increased activity, and elevated or irritable mood can occur in both states.
The degree of impairment and behavioral dyscontrol is therefore central to the
distinction. The patient's escalating impulsivity, inability to be redirected, and
significant deterioration indicate a manic syndrome requiring urgent intervention.
QUESTION 9.
A patient with posttraumatic stress disorder reports recurrent nightmares, intrusive
memories, avoidance of reminders, hypervigilance, exaggerated startle response,
and persistent negative beliefs about safety. The patient asks why repeatedly
