Chamberlain University
College of Nursing and Health Care Professions
NR 547 / NR-547
Differential Diagnosis in Psychiatric-Mental Health
across the Lifespan Practicum
Week 3 Midterm Examination
Latest Curriculum Edition
100 Questions | 8 Sections
PMHNP Practicum | DSM-5-TR Aligned
Instructions: Select the BEST answer for each question. Each question has exactly one correct answer marked with [CORRECT]. A detailed rationale
follows each question.
,Chamberlain University | NR 547 Differential Diagnosis in Psychiatric-Mental Health PMHNP Practicum
Section 1: Foundations of Differential Diagnosis (Questions 1-15)
Q1. A PMHNP is evaluating a 34-year-old patient who presents with persistent sadness, anhedonia, and
insomnia following the death of a spouse 8 weeks ago. The patient reports occasional crying spells but continues
to work and care for children. What is the most appropriate initial diagnostic consideration?
A. Major Depressive Disorder, single episode
B. Adjustment Disorder with Depressed Mood
C. Persistent Complex Bereavement Disorder
D. Normal grief reaction requiring clinical monitoring only [CORRECT]
Rationale: At 8 weeks post-loss, this presentation is consistent with normal grief. The patient maintains functional capacity and does
not meet DSM-5-TR criteria for MDD, which requires 5 or more symptoms for at least 2 weeks with clinically significant impairment.
Bereavement exclusion was removed in DSM-5, but the context is essential for differential diagnosis. Persistent Complex Bereavement
Disorder requires symptoms persisting beyond 12 months.
Correct Answer: D
Q2. Which of the following is the MOST critical principle when forming a differential diagnosis in
psychiatric-mental health practice?
A. Ruling out medical conditions that may mimic psychiatric symptoms must always precede assigning a
psychiatric diagnosis [CORRECT]
B. The first diagnosis that fits the presenting symptoms should be accepted without further investigation
C. Laboratory tests should only be ordered when the patient has a known history of medical illness
D. Family history is irrelevant when the patient has no prior psychiatric diagnosis
Rationale: The principle of medical clearance is fundamental in psychiatric assessment. Many medical conditions (thyroid dysfunction,
neurological disorders, infections, metabolic disturbances) can present with psychiatric symptoms. DSM-5-TR emphasizes ruling out
substance-induced and medical conditions before assigning a primary psychiatric diagnosis. This is especially critical in first-episode
presentations.
Correct Answer: A
Q3. A 28-year-old patient presents with auditory hallucinations and disorganized speech. Laboratory results
reveal a serum sodium of 118 mEq/L. What is the priority diagnostic consideration?
A. Schizophrenia spectrum disorder
B. Substance-induced psychotic disorder
C. Psychotic disorder due to another medical condition (hyponatremia) [CORRECT]
D. Brief psychotic disorder
Rationale: Severe hyponatremia (Na less than 120 mEq/L) can cause significant neurological and psychiatric symptoms including
hallucinations, confusion, and disorientation. DSM-5-TR specifies that psychotic disorder due to another medical condition requires
evidence that the disturbance is a direct pathophysiological consequence of the medical condition. The hallucinations should resolve
with correction of the electrolyte imbalance.
Correct Answer: C
Q4. When using the DSM-5-TR differential diagnosis approach, which step should the PMHNP perform
FIRST?
A. Rule out substance/medication-induced conditions
B. Determine whether the presentation meets criteria for a specific disorder
C. Rule out disorders due to another medical condition [CORRECT]
D. Consider the impact of cultural and developmental factors on presentation
Rationale: The DSM-5-TR differential diagnosis decision tree begins with ruling out disorders due to another medical condition.
Medical conditions must be excluded first because many physiological disturbances can produce psychiatric symptoms. The sequence is:
(1) medical condition, (2) substance/medication-induced, (3) specific psychiatric disorder criteria, and (4) cultural and developmental
considerations.
Correct Answer: C
Q5. A 42-year-old woman with no psychiatric history presents with sudden onset of panic attacks, palpitations,
and a sense of impending doom. Thyroid function tests reveal TSH of 0.1 mIU/L and free T4 of 3.2 ng/dL. Which
Page 2
,Chamberlain University | NR 547 Differential Diagnosis in Psychiatric-Mental Health PMHNP Practicum
diagnosis best explains this presentation?
A. Panic Disorder
B. Generalized Anxiety Disorder
C. Anxiety disorder due to hyperthyroidism [CORRECT]
D. Illness Anxiety Disorder
Rationale: The laboratory findings (suppressed TSH and elevated free T4) confirm hyperthyroidism. Hyperthyroidism directly
produces anxiety symptoms, palpitations, and panic-like episodes through increased sympathetic nervous system activation. Per
DSM-5-TR, when anxiety symptoms are attributable to a medical condition, the diagnosis is anxiety disorder due to another medical
condition.
Correct Answer: C
Q6. Which of the following best describes the concept of diagnostic hierarchy in DSM-5-TR?
A. Some diagnoses take precedence over others when symptom criteria overlap [CORRECT]
B. All diagnoses carry equal weight regardless of symptom severity
C. Substance use disorders always supersede mood disorders in the diagnostic hierarchy
D. Personality disorders are always considered the primary diagnosis
Rationale: Diagnostic hierarchy refers to the principle that when a patient meets criteria for multiple disorders, certain diagnoses are
given precedence based on clinical significance and etiological considerations. For example, a substance-induced mood disorder takes
precedence over a primary mood disorder if substances are causally related. Organic conditions are ruled out before functional
psychiatric disorders.
Correct Answer: A
Q7. A PMHNP is assessing a 19-year-old college student who reports difficulty concentrating, occasional
forgetfulness, and feeling overwhelmed since starting college 3 months ago. The student denies sadness,
anhedonia, or sleep disturbance. What is the most appropriate formulation?
A. Attention-Deficit/Hyperactivity Disorder, predominantly inattentive presentation
B. Major Depressive Disorder
C. Adjustment Disorder with Anxiety
D. No psychiatric diagnosis; this represents a normal stress response to life transition [CORRECT]
Rationale: This presentation does not meet threshold for any DSM-5-TR disorder. The symptoms emerged in the context of a
significant life transition (starting college) and are limited in scope. DSM-5-TR emphasizes that distressing experiences that do not meet
full criteria for a disorder should not be automatically pathologized. Normal stress responses must be distinguished from psychiatric
conditions.
Correct Answer: D
Q8. A 55-year-old patient with a 20-year history of recurrent major depressive episodes now presents with
symptoms consistent with a manic episode. Which diagnosis BEST captures this clinical picture?
A. Bipolar I Disorder [CORRECT]
B. Bipolar II Disorder
C. Major Depressive Disorder with atypical features
D. Substance/Medication-Induced Bipolar Disorder
Rationale: The presence of a full manic episode in a patient with a history of major depressive episodes meets criteria for Bipolar I
Disorder. Bipolar I requires at least one lifetime manic episode (which may have been preceded or followed by hypomanic or major
depressive episodes). Bipolar II requires hypomanic episodes but not full mania.
Correct Answer: A
Q9. In the context of cultural formulation interview (CFI) as recommended by DSM-5-TR, which question is
MOST relevant for differential diagnosis?
A. What is your racial and ethnic background?
B. How would you or members of your family describe the problem you are experiencing? [CORRECT]
C. Do you have health insurance that covers psychiatric treatment?
D. Have you ever been hospitalized for a psychiatric condition?
Rationale: The CFI is a set of 16 questions designed to obtain information about the impact of culture on key aspects of an individual’s
clinical presentation and care. Asking how the patient or family describes the problem provides critical cultural context that may
Page 3
, Chamberlain University | NR 547 Differential Diagnosis in Psychiatric-Mental Health PMHNP Practicum
influence whether certain symptoms are normative or pathological within that cultural framework. This directly affects differential
diagnosis.
Correct Answer: B
Q10. A PMHNP is evaluating a patient who reports hearing voices commenting on their behavior. The patient
states the voices have been present for 6 months, occur daily, and are distressing. There are no mood symptoms,
substance use, or medical conditions identified. What is the most likely diagnosis?
A. Schizophrenia [CORRECT]
B. Schizoaffective Disorder
C. Brief Psychotic Disorder
D. Delusional Disorder
Rationale: The patient meets DSM-5-TR criteria for schizophrenia: at least one active-phase symptom (auditory hallucinations) lasting
for at least 6 months (continuous or intermittent), with significant impairment in functioning. The absence of mood episodes
distinguishes this from schizoaffective disorder. Brief psychotic disorder requires symptoms lasting less than 1 month.
Correct Answer: A
Q11. A 65-year-old patient presents with new-onset visual hallucinations of people in the house. Neurological
examination reveals bradykinesia, resting tremor, and rigidity. What is the most likely diagnosis?
A. Schizophrenia, late-onset
B. Psychotic disorder due to Parkinson disease
C. Major Neurocognitive Disorder with behavioral disturbance [CORRECT]
D. Delirium
Rationale: While psychotic disorder due to Parkinson disease is possible, the most comprehensive diagnosis is Major Neurocognitive
Disorder with behavioral disturbance. Parkinson disease is a neurodegenerative condition that commonly leads to neurocognitive
decline. Visual hallucinations are a well-documented neuropsychiatric feature. The DSM-5-TR emphasizes identifying the underlying
neurocognitive disorder when psychotic symptoms occur in this context.
Correct Answer: C
Q12. Which of the following is the MOST important reason for a PMHNP to conduct a thorough medical review
of systems during psychiatric assessment?
A. It is required for insurance billing purposes
B. Medical conditions can mimic or exacerbate psychiatric symptoms and must be ruled out [CORRECT]
C. Patients expect a physical examination during every visit
D. It helps establish rapport with the patient
Rationale: A thorough medical review is essential because numerous medical conditions (endocrine disorders, neurological diseases,
infections, autoimmune conditions, and nutritional deficiencies) can present with psychiatric symptoms. Failing to identify and treat the
underlying medical condition can lead to inappropriate psychiatric treatment, delayed medical intervention, and potential harm to the
patient.
Correct Answer: B
Q13. A 30-year-old patient reports episodic feelings of unreality and detachment from the self lasting several
minutes, occurring multiple times per week for the past 3 months. These episodes cause significant distress.
There is no history of trauma, substance use, or seizure disorder. What is the most likely diagnosis?
A. Depersonalization/Derealization Disorder [CORRECT]
B. Dissociative Amnesia
C. Post-Traumatic Stress Disorder
D. Panic Disorder
Rationale: Depersonalization/Derealization Disorder is characterized by recurrent or persistent episodes of depersonalization
(detachment from self) and/or derealization (detachment from surroundings). DSM-5-TR criteria require that the disturbance causes
clinically significant distress and is not better explained by another disorder, substance use, or medical condition. The absence of
trauma history makes PTSD less likely.
Correct Answer: A
Page 4
College of Nursing and Health Care Professions
NR 547 / NR-547
Differential Diagnosis in Psychiatric-Mental Health
across the Lifespan Practicum
Week 3 Midterm Examination
Latest Curriculum Edition
100 Questions | 8 Sections
PMHNP Practicum | DSM-5-TR Aligned
Instructions: Select the BEST answer for each question. Each question has exactly one correct answer marked with [CORRECT]. A detailed rationale
follows each question.
,Chamberlain University | NR 547 Differential Diagnosis in Psychiatric-Mental Health PMHNP Practicum
Section 1: Foundations of Differential Diagnosis (Questions 1-15)
Q1. A PMHNP is evaluating a 34-year-old patient who presents with persistent sadness, anhedonia, and
insomnia following the death of a spouse 8 weeks ago. The patient reports occasional crying spells but continues
to work and care for children. What is the most appropriate initial diagnostic consideration?
A. Major Depressive Disorder, single episode
B. Adjustment Disorder with Depressed Mood
C. Persistent Complex Bereavement Disorder
D. Normal grief reaction requiring clinical monitoring only [CORRECT]
Rationale: At 8 weeks post-loss, this presentation is consistent with normal grief. The patient maintains functional capacity and does
not meet DSM-5-TR criteria for MDD, which requires 5 or more symptoms for at least 2 weeks with clinically significant impairment.
Bereavement exclusion was removed in DSM-5, but the context is essential for differential diagnosis. Persistent Complex Bereavement
Disorder requires symptoms persisting beyond 12 months.
Correct Answer: D
Q2. Which of the following is the MOST critical principle when forming a differential diagnosis in
psychiatric-mental health practice?
A. Ruling out medical conditions that may mimic psychiatric symptoms must always precede assigning a
psychiatric diagnosis [CORRECT]
B. The first diagnosis that fits the presenting symptoms should be accepted without further investigation
C. Laboratory tests should only be ordered when the patient has a known history of medical illness
D. Family history is irrelevant when the patient has no prior psychiatric diagnosis
Rationale: The principle of medical clearance is fundamental in psychiatric assessment. Many medical conditions (thyroid dysfunction,
neurological disorders, infections, metabolic disturbances) can present with psychiatric symptoms. DSM-5-TR emphasizes ruling out
substance-induced and medical conditions before assigning a primary psychiatric diagnosis. This is especially critical in first-episode
presentations.
Correct Answer: A
Q3. A 28-year-old patient presents with auditory hallucinations and disorganized speech. Laboratory results
reveal a serum sodium of 118 mEq/L. What is the priority diagnostic consideration?
A. Schizophrenia spectrum disorder
B. Substance-induced psychotic disorder
C. Psychotic disorder due to another medical condition (hyponatremia) [CORRECT]
D. Brief psychotic disorder
Rationale: Severe hyponatremia (Na less than 120 mEq/L) can cause significant neurological and psychiatric symptoms including
hallucinations, confusion, and disorientation. DSM-5-TR specifies that psychotic disorder due to another medical condition requires
evidence that the disturbance is a direct pathophysiological consequence of the medical condition. The hallucinations should resolve
with correction of the electrolyte imbalance.
Correct Answer: C
Q4. When using the DSM-5-TR differential diagnosis approach, which step should the PMHNP perform
FIRST?
A. Rule out substance/medication-induced conditions
B. Determine whether the presentation meets criteria for a specific disorder
C. Rule out disorders due to another medical condition [CORRECT]
D. Consider the impact of cultural and developmental factors on presentation
Rationale: The DSM-5-TR differential diagnosis decision tree begins with ruling out disorders due to another medical condition.
Medical conditions must be excluded first because many physiological disturbances can produce psychiatric symptoms. The sequence is:
(1) medical condition, (2) substance/medication-induced, (3) specific psychiatric disorder criteria, and (4) cultural and developmental
considerations.
Correct Answer: C
Q5. A 42-year-old woman with no psychiatric history presents with sudden onset of panic attacks, palpitations,
and a sense of impending doom. Thyroid function tests reveal TSH of 0.1 mIU/L and free T4 of 3.2 ng/dL. Which
Page 2
,Chamberlain University | NR 547 Differential Diagnosis in Psychiatric-Mental Health PMHNP Practicum
diagnosis best explains this presentation?
A. Panic Disorder
B. Generalized Anxiety Disorder
C. Anxiety disorder due to hyperthyroidism [CORRECT]
D. Illness Anxiety Disorder
Rationale: The laboratory findings (suppressed TSH and elevated free T4) confirm hyperthyroidism. Hyperthyroidism directly
produces anxiety symptoms, palpitations, and panic-like episodes through increased sympathetic nervous system activation. Per
DSM-5-TR, when anxiety symptoms are attributable to a medical condition, the diagnosis is anxiety disorder due to another medical
condition.
Correct Answer: C
Q6. Which of the following best describes the concept of diagnostic hierarchy in DSM-5-TR?
A. Some diagnoses take precedence over others when symptom criteria overlap [CORRECT]
B. All diagnoses carry equal weight regardless of symptom severity
C. Substance use disorders always supersede mood disorders in the diagnostic hierarchy
D. Personality disorders are always considered the primary diagnosis
Rationale: Diagnostic hierarchy refers to the principle that when a patient meets criteria for multiple disorders, certain diagnoses are
given precedence based on clinical significance and etiological considerations. For example, a substance-induced mood disorder takes
precedence over a primary mood disorder if substances are causally related. Organic conditions are ruled out before functional
psychiatric disorders.
Correct Answer: A
Q7. A PMHNP is assessing a 19-year-old college student who reports difficulty concentrating, occasional
forgetfulness, and feeling overwhelmed since starting college 3 months ago. The student denies sadness,
anhedonia, or sleep disturbance. What is the most appropriate formulation?
A. Attention-Deficit/Hyperactivity Disorder, predominantly inattentive presentation
B. Major Depressive Disorder
C. Adjustment Disorder with Anxiety
D. No psychiatric diagnosis; this represents a normal stress response to life transition [CORRECT]
Rationale: This presentation does not meet threshold for any DSM-5-TR disorder. The symptoms emerged in the context of a
significant life transition (starting college) and are limited in scope. DSM-5-TR emphasizes that distressing experiences that do not meet
full criteria for a disorder should not be automatically pathologized. Normal stress responses must be distinguished from psychiatric
conditions.
Correct Answer: D
Q8. A 55-year-old patient with a 20-year history of recurrent major depressive episodes now presents with
symptoms consistent with a manic episode. Which diagnosis BEST captures this clinical picture?
A. Bipolar I Disorder [CORRECT]
B. Bipolar II Disorder
C. Major Depressive Disorder with atypical features
D. Substance/Medication-Induced Bipolar Disorder
Rationale: The presence of a full manic episode in a patient with a history of major depressive episodes meets criteria for Bipolar I
Disorder. Bipolar I requires at least one lifetime manic episode (which may have been preceded or followed by hypomanic or major
depressive episodes). Bipolar II requires hypomanic episodes but not full mania.
Correct Answer: A
Q9. In the context of cultural formulation interview (CFI) as recommended by DSM-5-TR, which question is
MOST relevant for differential diagnosis?
A. What is your racial and ethnic background?
B. How would you or members of your family describe the problem you are experiencing? [CORRECT]
C. Do you have health insurance that covers psychiatric treatment?
D. Have you ever been hospitalized for a psychiatric condition?
Rationale: The CFI is a set of 16 questions designed to obtain information about the impact of culture on key aspects of an individual’s
clinical presentation and care. Asking how the patient or family describes the problem provides critical cultural context that may
Page 3
, Chamberlain University | NR 547 Differential Diagnosis in Psychiatric-Mental Health PMHNP Practicum
influence whether certain symptoms are normative or pathological within that cultural framework. This directly affects differential
diagnosis.
Correct Answer: B
Q10. A PMHNP is evaluating a patient who reports hearing voices commenting on their behavior. The patient
states the voices have been present for 6 months, occur daily, and are distressing. There are no mood symptoms,
substance use, or medical conditions identified. What is the most likely diagnosis?
A. Schizophrenia [CORRECT]
B. Schizoaffective Disorder
C. Brief Psychotic Disorder
D. Delusional Disorder
Rationale: The patient meets DSM-5-TR criteria for schizophrenia: at least one active-phase symptom (auditory hallucinations) lasting
for at least 6 months (continuous or intermittent), with significant impairment in functioning. The absence of mood episodes
distinguishes this from schizoaffective disorder. Brief psychotic disorder requires symptoms lasting less than 1 month.
Correct Answer: A
Q11. A 65-year-old patient presents with new-onset visual hallucinations of people in the house. Neurological
examination reveals bradykinesia, resting tremor, and rigidity. What is the most likely diagnosis?
A. Schizophrenia, late-onset
B. Psychotic disorder due to Parkinson disease
C. Major Neurocognitive Disorder with behavioral disturbance [CORRECT]
D. Delirium
Rationale: While psychotic disorder due to Parkinson disease is possible, the most comprehensive diagnosis is Major Neurocognitive
Disorder with behavioral disturbance. Parkinson disease is a neurodegenerative condition that commonly leads to neurocognitive
decline. Visual hallucinations are a well-documented neuropsychiatric feature. The DSM-5-TR emphasizes identifying the underlying
neurocognitive disorder when psychotic symptoms occur in this context.
Correct Answer: C
Q12. Which of the following is the MOST important reason for a PMHNP to conduct a thorough medical review
of systems during psychiatric assessment?
A. It is required for insurance billing purposes
B. Medical conditions can mimic or exacerbate psychiatric symptoms and must be ruled out [CORRECT]
C. Patients expect a physical examination during every visit
D. It helps establish rapport with the patient
Rationale: A thorough medical review is essential because numerous medical conditions (endocrine disorders, neurological diseases,
infections, autoimmune conditions, and nutritional deficiencies) can present with psychiatric symptoms. Failing to identify and treat the
underlying medical condition can lead to inappropriate psychiatric treatment, delayed medical intervention, and potential harm to the
patient.
Correct Answer: B
Q13. A 30-year-old patient reports episodic feelings of unreality and detachment from the self lasting several
minutes, occurring multiple times per week for the past 3 months. These episodes cause significant distress.
There is no history of trauma, substance use, or seizure disorder. What is the most likely diagnosis?
A. Depersonalization/Derealization Disorder [CORRECT]
B. Dissociative Amnesia
C. Post-Traumatic Stress Disorder
D. Panic Disorder
Rationale: Depersonalization/Derealization Disorder is characterized by recurrent or persistent episodes of depersonalization
(detachment from self) and/or derealization (detachment from surroundings). DSM-5-TR criteria require that the disturbance causes
clinically significant distress and is not better explained by another disorder, substance use, or medical condition. The absence of
trauma history makes PTSD less likely.
Correct Answer: A
Page 4
