NRNP 6665-01 PMHNP Final Exam | Week 11 Solutions
2026/2027 Complete Final Examination | Actual Questions &
Verified Solutions | Comprehensive Lifespan Psychiatry |
Advanced Clinical Scenarios | Pass Guarantee
1. A 7-year-old boy is brought by his mother for “constant fidgeting and poor
listening.” Teachers report he blurts answers, loses assignments, and climbs
furniture. Symptoms began at age 4, occur in two settings, and ADHD-RS-5 score
= 45. Mother has bipolar I; grandfather died by suicide. Which initial diagnosis is
most accurate?
A. ADHD, combined presentation
B. Bipolar disorder NOS
C. Disruptive mood dysregulation disorder (DMDD)
D. Autism spectrum disorder without intellectual impairment
Correct Answer: A
Rationale: DSM-5-TR requires ≥6 inattention and/or hyperactivity-impulsivity
items before age 12, cross-situational, and clear impairment. ADHD-RS-5 ≥40
supports combined presentation. No evidence of distinct manic episodes (ruling
out B), severe chronic irritability with hyperarousal >1 year (ruling out C), or
restricted/repetitive behaviors (ruling out D). Family history of BD flags future
mood-watch but does not override current ADHD criteria.
2. For the child in Q1, which first-line pharmacotherapy and dose best reflects 2024
AACAP guidelines?
A. Methylphenidate extended-release 18 mg every morning
B. Atomoxetine 40 mg daily
C. Clonidine 0.1 mg BID
D. Risperidone 0.25 mg daily
Correct Answer: A
Rationale: AACAP and AAP endorse stimulants as first-line; methylphenidate-ER
has the largest effect size (≈1.0) and once-daily dosing improves adherence.
Starting 18 mg permits titration every 1–2 weeks by 9–18 mg to max 54 mg.
Atomoxetine is second-line, slower onset (4–6 weeks), and less robust effect.
, Alpha-agonists are adjunctive for tics or insomnia. Risperidone targets
aggression, not core ADHD.
3. A 15-year-old girl presents with 3-week history of decreased sleep (3 h/night),
pressured speech, buying $800 of makeup, and hypersexuality with a 22-year-old
man. She had MDD treated with sertraline 100 mg × 8 weeks, switched to
escitalopram 4 weeks ago. YMRS = 28. Urine THC (−). Which is the most
accurate next step?
A. Increase escitalopram to 20 mg for treatment-resistant depression
B. Discontinue SSRI, start lithium 300 mg BID, obtain level in 5 days
C. Add amphetamine for suspected ADHD
D. Refer for dialectical-behavior therapy (DBT) only
Correct Answer: B
Rationale: Antidepressant-associated mania necessitates immediate
discontinuation; YMRS ≥20 confirms manic episode. Lithium remains first-line for
bipolar I manic episode per APA 2025 guidelines; low starting dose (300 mg BID)
with renal monitoring is safe in adolescents. Increasing SSRI (A) risks worsening
mania. Amphetamine (C) can precipitate psychosis. DBT (D) is adjunctive, not
monotherapy for mania.
4. A 6-year-old boy repeatedly bangs his head, lines up cars, and speaks in single
words. ADOS-2 score = 18. Which additional assessment is required before
confirming autism spectrum diagnosis?
A. EEG during sleep
B. Lead level
C. Functional behavior analysis
D. Comprehensive cognitive & language testing
Correct Answer: D
Rationale: DSM-5-TR mandates specification of intellectual/language ability for
ASD; ADOS-2 alone cannot determine level of support. Cognitive testing (e.g.,
Stanford-Binet-5) guides individualized education plan (IEP). EEG (A) only if
regression or seizures; lead (B) is universal screening but not diagnostic; FBA (C)
follows diagnosis for behavior plan.
5. The same 6-year-old (Q4) has severe tantrums when routines change. Which
evidence-based psychosocial intervention is first-line?
A. Applied behavior analysis (ABA) 25 h/week
B. Parent-child interaction therapy (PCIT)
C. Cognitive-behavioral therapy (CBT)
D. Family-focused therapy (FFT)
Correct Answer: A
Rationale: ABA has Grade A evidence for improving core ASD symptoms and
, adaptive function; intensity 20–30 h/week before age 8 yields largest gains. PCIT
targets oppositionality, not ASD core. CBT requires verbal age >7 years. FFT is for
bipolar disorder.
6. A 12-year-old girl with IQ 65 presents with daily tearfulness, weight loss 4 kg,
insomnia, and self-blame after sexual abuse 4 months ago. CDI-2 = 18. Which
diagnosis best explains her symptoms?
A. Adjustment disorder with depressed mood
B. Major depressive disorder, moderate, with intellectual disability
C. PTSD, preschool subtype
D. Acute stress disorder
Correct Answer: B
Rationale: Symptoms >2 weeks, 5+ neurovegetative signs, and functional decline
meet MDD criteria regardless of IQ; self-blame is mood-congruent. CDI-2 ≥16
supports moderate severity. Abuse is a precipitant, but symptom constellation
exceeds PTSD (requires intrusion, avoidance, arousal, duration >1 month) and
ASD (<1 month).
7. For the girl in Q6, which FDA-approved medication and dose should be initiated?
A. Sertraline 12.5 mg daily
B. Escitalopram 10 mg daily
C. Fluoxetine 5 mg daily
D. Paroxetine 20 mg daily
Correct Answer: A
Rationale: Sertraline is FDA-approved (age ≥6); start 12.5 mg (lowest split tab) to
minimize activation in youth with ID. Escitalopram approved ≥12 y at 10 mg but
may cause more SI in girls per 2023 network meta-analysis. Fluoxetine 5 mg
acceptable but longer half-life complicates withdrawal if SI emerges. Paroxetine
has anticholinergic effects and is not pediatric-approved.
8. A 9-year-old boy with ADHD on methylphenidate ER 36 mg develops new onset
tachycardia (HR 118 bpm) and BP 118/76 (95th percentile). ECG normal. Which
action is best?
A. Switch to atomoxetine 0.5 mg/kg
B. Add propranolol 10 mg BID
C. Hold dose for 1 week then re-challenge at 27 mg
D. Continue current dose and recheck vitals in 3 months
Correct Answer: C
Rationale: AHA 2025 statement recommends withholding stimulant 5–7 days to
establish baseline; if HR/BP normalize, resume at 75% dose with monthly
monitoring. Atomoxetine (A) is reasonable but not first action. Propranolol (B)
unlicensed for this indication. Ignoring (D) risks masked hypertension.
2026/2027 Complete Final Examination | Actual Questions &
Verified Solutions | Comprehensive Lifespan Psychiatry |
Advanced Clinical Scenarios | Pass Guarantee
1. A 7-year-old boy is brought by his mother for “constant fidgeting and poor
listening.” Teachers report he blurts answers, loses assignments, and climbs
furniture. Symptoms began at age 4, occur in two settings, and ADHD-RS-5 score
= 45. Mother has bipolar I; grandfather died by suicide. Which initial diagnosis is
most accurate?
A. ADHD, combined presentation
B. Bipolar disorder NOS
C. Disruptive mood dysregulation disorder (DMDD)
D. Autism spectrum disorder without intellectual impairment
Correct Answer: A
Rationale: DSM-5-TR requires ≥6 inattention and/or hyperactivity-impulsivity
items before age 12, cross-situational, and clear impairment. ADHD-RS-5 ≥40
supports combined presentation. No evidence of distinct manic episodes (ruling
out B), severe chronic irritability with hyperarousal >1 year (ruling out C), or
restricted/repetitive behaviors (ruling out D). Family history of BD flags future
mood-watch but does not override current ADHD criteria.
2. For the child in Q1, which first-line pharmacotherapy and dose best reflects 2024
AACAP guidelines?
A. Methylphenidate extended-release 18 mg every morning
B. Atomoxetine 40 mg daily
C. Clonidine 0.1 mg BID
D. Risperidone 0.25 mg daily
Correct Answer: A
Rationale: AACAP and AAP endorse stimulants as first-line; methylphenidate-ER
has the largest effect size (≈1.0) and once-daily dosing improves adherence.
Starting 18 mg permits titration every 1–2 weeks by 9–18 mg to max 54 mg.
Atomoxetine is second-line, slower onset (4–6 weeks), and less robust effect.
, Alpha-agonists are adjunctive for tics or insomnia. Risperidone targets
aggression, not core ADHD.
3. A 15-year-old girl presents with 3-week history of decreased sleep (3 h/night),
pressured speech, buying $800 of makeup, and hypersexuality with a 22-year-old
man. She had MDD treated with sertraline 100 mg × 8 weeks, switched to
escitalopram 4 weeks ago. YMRS = 28. Urine THC (−). Which is the most
accurate next step?
A. Increase escitalopram to 20 mg for treatment-resistant depression
B. Discontinue SSRI, start lithium 300 mg BID, obtain level in 5 days
C. Add amphetamine for suspected ADHD
D. Refer for dialectical-behavior therapy (DBT) only
Correct Answer: B
Rationale: Antidepressant-associated mania necessitates immediate
discontinuation; YMRS ≥20 confirms manic episode. Lithium remains first-line for
bipolar I manic episode per APA 2025 guidelines; low starting dose (300 mg BID)
with renal monitoring is safe in adolescents. Increasing SSRI (A) risks worsening
mania. Amphetamine (C) can precipitate psychosis. DBT (D) is adjunctive, not
monotherapy for mania.
4. A 6-year-old boy repeatedly bangs his head, lines up cars, and speaks in single
words. ADOS-2 score = 18. Which additional assessment is required before
confirming autism spectrum diagnosis?
A. EEG during sleep
B. Lead level
C. Functional behavior analysis
D. Comprehensive cognitive & language testing
Correct Answer: D
Rationale: DSM-5-TR mandates specification of intellectual/language ability for
ASD; ADOS-2 alone cannot determine level of support. Cognitive testing (e.g.,
Stanford-Binet-5) guides individualized education plan (IEP). EEG (A) only if
regression or seizures; lead (B) is universal screening but not diagnostic; FBA (C)
follows diagnosis for behavior plan.
5. The same 6-year-old (Q4) has severe tantrums when routines change. Which
evidence-based psychosocial intervention is first-line?
A. Applied behavior analysis (ABA) 25 h/week
B. Parent-child interaction therapy (PCIT)
C. Cognitive-behavioral therapy (CBT)
D. Family-focused therapy (FFT)
Correct Answer: A
Rationale: ABA has Grade A evidence for improving core ASD symptoms and
, adaptive function; intensity 20–30 h/week before age 8 yields largest gains. PCIT
targets oppositionality, not ASD core. CBT requires verbal age >7 years. FFT is for
bipolar disorder.
6. A 12-year-old girl with IQ 65 presents with daily tearfulness, weight loss 4 kg,
insomnia, and self-blame after sexual abuse 4 months ago. CDI-2 = 18. Which
diagnosis best explains her symptoms?
A. Adjustment disorder with depressed mood
B. Major depressive disorder, moderate, with intellectual disability
C. PTSD, preschool subtype
D. Acute stress disorder
Correct Answer: B
Rationale: Symptoms >2 weeks, 5+ neurovegetative signs, and functional decline
meet MDD criteria regardless of IQ; self-blame is mood-congruent. CDI-2 ≥16
supports moderate severity. Abuse is a precipitant, but symptom constellation
exceeds PTSD (requires intrusion, avoidance, arousal, duration >1 month) and
ASD (<1 month).
7. For the girl in Q6, which FDA-approved medication and dose should be initiated?
A. Sertraline 12.5 mg daily
B. Escitalopram 10 mg daily
C. Fluoxetine 5 mg daily
D. Paroxetine 20 mg daily
Correct Answer: A
Rationale: Sertraline is FDA-approved (age ≥6); start 12.5 mg (lowest split tab) to
minimize activation in youth with ID. Escitalopram approved ≥12 y at 10 mg but
may cause more SI in girls per 2023 network meta-analysis. Fluoxetine 5 mg
acceptable but longer half-life complicates withdrawal if SI emerges. Paroxetine
has anticholinergic effects and is not pediatric-approved.
8. A 9-year-old boy with ADHD on methylphenidate ER 36 mg develops new onset
tachycardia (HR 118 bpm) and BP 118/76 (95th percentile). ECG normal. Which
action is best?
A. Switch to atomoxetine 0.5 mg/kg
B. Add propranolol 10 mg BID
C. Hold dose for 1 week then re-challenge at 27 mg
D. Continue current dose and recheck vitals in 3 months
Correct Answer: C
Rationale: AHA 2025 statement recommends withholding stimulant 5–7 days to
establish baseline; if HR/BP normalize, resume at 75% dose with monthly
monitoring. Atomoxetine (A) is reasonable but not first action. Propranolol (B)
unlicensed for this indication. Ignoring (D) risks masked hypertension.
