PMHNP Clinical Judgment Exam: 150 Case-Based
Questions for Skill Mastery Answers And Rationale
Included
2025/2026
1. A 28-year-old woman presents with persistent sadness, fatigue, and
loss of interest in activities she previously enjoyed. She has difficulty
sleeping and poor appetite. Which is the most appropriate first-line
pharmacologic treatment?
A. Bupropion
B. Haloperidol
C. Lithium
D. Buspirone
Answer: A. Bupropion
Rationale: Bupropion is an effective first-line antidepressant for major
depressive disorder, especially in patients experiencing fatigue and
decreased energy. It has a lower risk of sexual side effects compared
to SSRIs.
2. A 16-year-old male reports frequent mood swings, irritability, and
insomnia. He denies suicidal ideation. He has no prior psychiatric
history. Which is the most appropriate next step?
A. Start fluoxetine immediately
B. Conduct a thorough psychiatric assessment including family history
and screen for substance use
C. Prescribe lorazepam for sleep
D. Recommend strict sleep hygiene only
Answer: B. Conduct a thorough psychiatric assessment including
family history and screen for substance use
,Rationale: Adolescents with mood changes should be carefully
assessed for psychiatric disorders, substance use, and family history
before initiating pharmacotherapy.
3. A 45-year-old patient with generalized anxiety disorder reports
persistent worry for most of the day, muscle tension, and difficulty
concentrating. Which medication is first-line?
A. Quetiapine
B. Hydroxyzine
C. Sertraline
D. Diazepam
Answer: C. Sertraline
Rationale: SSRIs, such as sertraline, are considered first-line
pharmacologic therapy for generalized anxiety disorder due to
efficacy and safety profile.
4. A 32-year-old patient with bipolar I disorder presents with acute
mania. Which of the following is the most appropriate first-line
treatment?
A. Fluoxetine
B. Lithium
C. Citalopram
D. Buspirone
Answer: B. Lithium
Rationale: Lithium is a first-line mood stabilizer for acute manic
episodes in bipolar I disorder. Antidepressants are contraindicated in
acute mania due to risk of mood switching.
5. A 22-year-old college student reports hearing voices that others do
not hear and believes people are plotting against him. Symptoms have
been present for 3 months. Which is the most likely diagnosis?
,A. Major depressive disorder
B. Generalized anxiety disorder
C. Schizophrenia
D. Bipolar II disorder
Answer: C. Schizophrenia
Rationale: Schizophrenia is characterized by positive symptoms
(hallucinations, delusions) lasting at least 6 months, but early
psychotic symptoms persisting for ≥1 month may indicate a first
episode. Prompt evaluation and treatment are essential.
6. A patient with major depressive disorder has not responded to two
trials of SSRIs. Which is the next best treatment option?
A. Continue current SSRI indefinitely
B. Start low-dose benzodiazepine
C. Switch to an SNRI such as venlafaxine
D. Start haloperidol
Answer: C. Switch to an SNRI such as venlafaxine
Rationale: For treatment-resistant depression, switching to a different
class of antidepressant (e.g., SNRI) is recommended.
7. A 29-year-old patient with PTSD reports nightmares, flashbacks, and
hypervigilance. First-line pharmacologic treatment is:
A. Risperidone
B. Lorazepam
C. Sertraline
D. Hydroxyzine
Answer: C. Sertraline
Rationale: SSRIs such as sertraline are first-line for PTSD.
Benzodiazepines are not recommended due to risk of dependence.
, 8. A 40-year-old patient with schizophrenia is stabilized on risperidone
but complains of galactorrhea and menstrual irregularities. What is the
most appropriate action?
A. Increase risperidone dose
B. Switch to aripiprazole
C. Add haloperidol
D. Start propranolol
Answer: B. Switch to aripiprazole
Rationale: Risperidone can elevate prolactin, leading to galactorrhea
and menstrual changes. Aripiprazole has minimal effect on prolactin
and is an appropriate alternative.
9. A 65-year-old patient presents with agitation, confusion, and
hallucinations after recent hospitalization. Which condition should be
considered first?
A. Major depressive disorder
B. Delirium
C. Schizophrenia
D. PTSD
Answer: B. Delirium
Rationale: Acute onset of confusion and hallucinations in older adults
often indicates delirium. Rapid identification and treatment of the
underlying cause are critical.
10. A patient with OCD spends 3–4 hours a day washing hands due to
contamination fears. First-line treatment is:
A. Lorazepam
B. Fluoxetine
C. Lithium
D. Olanzapine
Questions for Skill Mastery Answers And Rationale
Included
2025/2026
1. A 28-year-old woman presents with persistent sadness, fatigue, and
loss of interest in activities she previously enjoyed. She has difficulty
sleeping and poor appetite. Which is the most appropriate first-line
pharmacologic treatment?
A. Bupropion
B. Haloperidol
C. Lithium
D. Buspirone
Answer: A. Bupropion
Rationale: Bupropion is an effective first-line antidepressant for major
depressive disorder, especially in patients experiencing fatigue and
decreased energy. It has a lower risk of sexual side effects compared
to SSRIs.
2. A 16-year-old male reports frequent mood swings, irritability, and
insomnia. He denies suicidal ideation. He has no prior psychiatric
history. Which is the most appropriate next step?
A. Start fluoxetine immediately
B. Conduct a thorough psychiatric assessment including family history
and screen for substance use
C. Prescribe lorazepam for sleep
D. Recommend strict sleep hygiene only
Answer: B. Conduct a thorough psychiatric assessment including
family history and screen for substance use
,Rationale: Adolescents with mood changes should be carefully
assessed for psychiatric disorders, substance use, and family history
before initiating pharmacotherapy.
3. A 45-year-old patient with generalized anxiety disorder reports
persistent worry for most of the day, muscle tension, and difficulty
concentrating. Which medication is first-line?
A. Quetiapine
B. Hydroxyzine
C. Sertraline
D. Diazepam
Answer: C. Sertraline
Rationale: SSRIs, such as sertraline, are considered first-line
pharmacologic therapy for generalized anxiety disorder due to
efficacy and safety profile.
4. A 32-year-old patient with bipolar I disorder presents with acute
mania. Which of the following is the most appropriate first-line
treatment?
A. Fluoxetine
B. Lithium
C. Citalopram
D. Buspirone
Answer: B. Lithium
Rationale: Lithium is a first-line mood stabilizer for acute manic
episodes in bipolar I disorder. Antidepressants are contraindicated in
acute mania due to risk of mood switching.
5. A 22-year-old college student reports hearing voices that others do
not hear and believes people are plotting against him. Symptoms have
been present for 3 months. Which is the most likely diagnosis?
,A. Major depressive disorder
B. Generalized anxiety disorder
C. Schizophrenia
D. Bipolar II disorder
Answer: C. Schizophrenia
Rationale: Schizophrenia is characterized by positive symptoms
(hallucinations, delusions) lasting at least 6 months, but early
psychotic symptoms persisting for ≥1 month may indicate a first
episode. Prompt evaluation and treatment are essential.
6. A patient with major depressive disorder has not responded to two
trials of SSRIs. Which is the next best treatment option?
A. Continue current SSRI indefinitely
B. Start low-dose benzodiazepine
C. Switch to an SNRI such as venlafaxine
D. Start haloperidol
Answer: C. Switch to an SNRI such as venlafaxine
Rationale: For treatment-resistant depression, switching to a different
class of antidepressant (e.g., SNRI) is recommended.
7. A 29-year-old patient with PTSD reports nightmares, flashbacks, and
hypervigilance. First-line pharmacologic treatment is:
A. Risperidone
B. Lorazepam
C. Sertraline
D. Hydroxyzine
Answer: C. Sertraline
Rationale: SSRIs such as sertraline are first-line for PTSD.
Benzodiazepines are not recommended due to risk of dependence.
, 8. A 40-year-old patient with schizophrenia is stabilized on risperidone
but complains of galactorrhea and menstrual irregularities. What is the
most appropriate action?
A. Increase risperidone dose
B. Switch to aripiprazole
C. Add haloperidol
D. Start propranolol
Answer: B. Switch to aripiprazole
Rationale: Risperidone can elevate prolactin, leading to galactorrhea
and menstrual changes. Aripiprazole has minimal effect on prolactin
and is an appropriate alternative.
9. A 65-year-old patient presents with agitation, confusion, and
hallucinations after recent hospitalization. Which condition should be
considered first?
A. Major depressive disorder
B. Delirium
C. Schizophrenia
D. PTSD
Answer: B. Delirium
Rationale: Acute onset of confusion and hallucinations in older adults
often indicates delirium. Rapid identification and treatment of the
underlying cause are critical.
10. A patient with OCD spends 3–4 hours a day washing hands due to
contamination fears. First-line treatment is:
A. Lorazepam
B. Fluoxetine
C. Lithium
D. Olanzapine
