NRNP 6665-01 Week 11 Final Exam Solutions 2026/2027
Complete Final Exam Guide | Actual Questions & Verified
Solutions | PMHNP Lifespan Psychiatry | Pass Guarantee
1. A 17-year-old presents with 4 months of insomnia, irritability, and 6 lb weight
loss. Parents report 3 weeks of pressured speech, starting 4 projects, and
staying up until 3 a.m. playing guitar. PHQ-9: 6, GAD-7: 8, MDQ: 7/13 positive.
Urine tox negative. Past meds: sertraline (no benefit). What is the most accurate
diagnosis?
A. Major depressive disorder
B. ADHD, combined presentation
C. Bipolar I disorder, manic episode
D. Cannabis-induced mood disorder
Correct Answer: C
Rationale: Clear manic syndrome (>3 weeks, decreased need for sleep, pressured
speech, multiple projects, functional change) plus MDQ screen positive; sertraline
non-response supports bipolar spectrum. ADHD does not explain acute sleepless
hyperactivity. Tox screen negative rules out substance-induced.
2. A 62-year-old woman with HTN, T2DM, and CKD (eGFR 35) has had two prior
depressive episodes; now PHQ-9: 19. Current meds: metformin, lisinopril. Which
first-line antidepressant best balances efficacy and safety?
A. Duloxetine 30 mg daily
B. Sertraline 50 mg daily
C. Bupropion XL 150 mg daily
D. Nortriptyline 25 mg nightly
Correct Answer: B
Rationale: Sertraline has strong evidence, minimal renal adjustment, low
drug-drug interaction. Duloxetine can raise BP and requires dose reduction in
CKD. Bupropion lowers seizure threshold and is renally cleared. Nortriptyline has
anticholinergic/cardiac risk.
3. A 9-year-old boy (weight 32 kg) is diagnosed with ADHD, combined type. No
cardiac symptoms. BP 98/60, HR 82, ECG normal. Which FDA-approved stimulant
and dose is most appropriate to initiate?
A. Methylphenidate ER 18 mg qAM
, B. Amphetamine/dextroamphetamine mixed salts 5 mg BID
C. Atomoxetine 40 mg daily
D. Clonidine ER 0.1 mg nightly
Correct Answer: A
Rationale: MPH-ER 18 mg ≈ 0.56 mg/kg—middle of guideline starting range
(0.3–1 mg/kg/day). BID amphetamine may cause afternoon rebound.
Atomoxetine is second-line, slower onset. Clonidine monotherapy is for tics or
insomnia, not first-line for core ADHD.
4. A 24-year-old Army veteran reports nightmares, hypervigilance, and emotional
numbing since return 18 months ago. Nightmares occur 5×/week, causing
daytime fatigue. Prazosin 1 mg qHS tried × 4 weeks without benefit. BP 118/74.
Which next step is best?
A. Increase prazosin gradually to 6–10 mg qHS
B. Switch to clonidine 0.1 mg BID
C. Start risperidone 1 mg BID
D. Begin sertraline 50 mg daily
Correct Answer: A
Rationale: APA PTSD guidelines: titrate prazosin for trauma nightmares to 6–10
mg (max 15 mg). Studies show dose-response. Clonidine lacks nightmare
evidence. Risperidone is not first-line for PTSD without psychosis. SSRIs help
global PTSD but specific nightmare often requires prazosin.
5. A 35-year-old woman with bipolar I (last manic episode 2 years ago) on lithium
900 mg qHS reports 3 weeks of sadness, fatigue, hypersomnia, and 8 lb weight
gain. Lithium level 0.9 mEq/L, TSH 4.8 µIU/mL (high-normal), creatinine 0.9.
PHQ-9: 17. Which is the best next step?
A. Increase lithium to achieve level 1.2 mEq/L
B. Add bupropion XL 150 mg qAM
C. Add lamotrigine 25 mg daily, titrate upward
D. Switch lithium to valproate
Correct Answer: C
Rationale: Lithium-induced hypothyroidism can present with depressive
symptoms; adding lamotrigine is evidence-based for bipolar depression without
increasing mania risk. Increasing lithium may worsen hypothyroidism. Bupropion
carries mania risk without mood stabilizer. Switching lithium loses long-term
mania prophylaxis.
6. A 78-year-old man with Alzheimer’s (MMSE 18) develops agitation, hitting staff
during care. Medical work-up negative. He is on donepezil 10 mg, memantine 10
mg BID. Which pharmacologic option is best?
A. Start risperidone 0.25 mg BID
, B. Start sertraline 50 mg daily
C. Start lorazepam 0.5 mg PRN
D. Increase memantine to 15 mg BID
Correct Answer: A
Rationale: APA/AAGP: low-dose risperidone (0.25–0.5 mg) is first-line for severe
physical aggression in dementia when non-pharmacologic failed. Black-box
warning for mortality; use lowest dose shortest time. SSRIs ineffective for
agitation. Benzodiazepine increases falls, confusion. Memantine max already 20
mg/day.
7. A 16-year-old female reports 6 months of restrictive eating, 15 % weight loss,
amenorrhea, and marked body-image distortion. BMI 16.5. Vital signs stable.
Which medication is contraindicated?
A. Fluoxetine 20 mg daily
B. Olanzapine 2.5 mg nightly
C. Bupropion XL 150 mg daily
D. Escitalopram 10 mg daily
Correct Answer: C
Rationale: Bupropion lowers seizure threshold and is contraindicated in anorexia
nervosa due to seizure risk with low weight. Fluoxetine is first-line for comorbid
depression after weight restoration. Olanzapine can aid weight gain and
obsessional thinking.
8. A 42-year-old man with OCD has persistent contamination fears despite CBT and
fluoxetine 80 mg × 12 weeks (Y-BOCS 26). Level is therapeutic. Which
augmentation strategy is best supported?
A. Add risperidone 1 mg daily
B. Add aripiprazole 5 mg daily
C. Add clomipramine 50 mg daily
D. Add memantine 10 mg BID
Correct Answer: B
Rationale: APA OCD guidelines: low-dose aripiprazole (5–10 mg) has strongest
RCT evidence for SSRI-refractory OCD. Risperidone data weaker. Clomipramine
augmentation limited by SRI overlap and cardiac risk. Memantine evidence is
preliminary.
9. A 29-year-old woman 28 weeks pregnant with recurrent MDD (PHQ-9 18).
Previous response to sertraline. She is medication-naive this pregnancy. Which
treatment is best?
A. Start sertraline 50 mg daily
B. Start paroxetine 20 mg daily
C. Start nortriptyline 75 mg daily
Complete Final Exam Guide | Actual Questions & Verified
Solutions | PMHNP Lifespan Psychiatry | Pass Guarantee
1. A 17-year-old presents with 4 months of insomnia, irritability, and 6 lb weight
loss. Parents report 3 weeks of pressured speech, starting 4 projects, and
staying up until 3 a.m. playing guitar. PHQ-9: 6, GAD-7: 8, MDQ: 7/13 positive.
Urine tox negative. Past meds: sertraline (no benefit). What is the most accurate
diagnosis?
A. Major depressive disorder
B. ADHD, combined presentation
C. Bipolar I disorder, manic episode
D. Cannabis-induced mood disorder
Correct Answer: C
Rationale: Clear manic syndrome (>3 weeks, decreased need for sleep, pressured
speech, multiple projects, functional change) plus MDQ screen positive; sertraline
non-response supports bipolar spectrum. ADHD does not explain acute sleepless
hyperactivity. Tox screen negative rules out substance-induced.
2. A 62-year-old woman with HTN, T2DM, and CKD (eGFR 35) has had two prior
depressive episodes; now PHQ-9: 19. Current meds: metformin, lisinopril. Which
first-line antidepressant best balances efficacy and safety?
A. Duloxetine 30 mg daily
B. Sertraline 50 mg daily
C. Bupropion XL 150 mg daily
D. Nortriptyline 25 mg nightly
Correct Answer: B
Rationale: Sertraline has strong evidence, minimal renal adjustment, low
drug-drug interaction. Duloxetine can raise BP and requires dose reduction in
CKD. Bupropion lowers seizure threshold and is renally cleared. Nortriptyline has
anticholinergic/cardiac risk.
3. A 9-year-old boy (weight 32 kg) is diagnosed with ADHD, combined type. No
cardiac symptoms. BP 98/60, HR 82, ECG normal. Which FDA-approved stimulant
and dose is most appropriate to initiate?
A. Methylphenidate ER 18 mg qAM
, B. Amphetamine/dextroamphetamine mixed salts 5 mg BID
C. Atomoxetine 40 mg daily
D. Clonidine ER 0.1 mg nightly
Correct Answer: A
Rationale: MPH-ER 18 mg ≈ 0.56 mg/kg—middle of guideline starting range
(0.3–1 mg/kg/day). BID amphetamine may cause afternoon rebound.
Atomoxetine is second-line, slower onset. Clonidine monotherapy is for tics or
insomnia, not first-line for core ADHD.
4. A 24-year-old Army veteran reports nightmares, hypervigilance, and emotional
numbing since return 18 months ago. Nightmares occur 5×/week, causing
daytime fatigue. Prazosin 1 mg qHS tried × 4 weeks without benefit. BP 118/74.
Which next step is best?
A. Increase prazosin gradually to 6–10 mg qHS
B. Switch to clonidine 0.1 mg BID
C. Start risperidone 1 mg BID
D. Begin sertraline 50 mg daily
Correct Answer: A
Rationale: APA PTSD guidelines: titrate prazosin for trauma nightmares to 6–10
mg (max 15 mg). Studies show dose-response. Clonidine lacks nightmare
evidence. Risperidone is not first-line for PTSD without psychosis. SSRIs help
global PTSD but specific nightmare often requires prazosin.
5. A 35-year-old woman with bipolar I (last manic episode 2 years ago) on lithium
900 mg qHS reports 3 weeks of sadness, fatigue, hypersomnia, and 8 lb weight
gain. Lithium level 0.9 mEq/L, TSH 4.8 µIU/mL (high-normal), creatinine 0.9.
PHQ-9: 17. Which is the best next step?
A. Increase lithium to achieve level 1.2 mEq/L
B. Add bupropion XL 150 mg qAM
C. Add lamotrigine 25 mg daily, titrate upward
D. Switch lithium to valproate
Correct Answer: C
Rationale: Lithium-induced hypothyroidism can present with depressive
symptoms; adding lamotrigine is evidence-based for bipolar depression without
increasing mania risk. Increasing lithium may worsen hypothyroidism. Bupropion
carries mania risk without mood stabilizer. Switching lithium loses long-term
mania prophylaxis.
6. A 78-year-old man with Alzheimer’s (MMSE 18) develops agitation, hitting staff
during care. Medical work-up negative. He is on donepezil 10 mg, memantine 10
mg BID. Which pharmacologic option is best?
A. Start risperidone 0.25 mg BID
, B. Start sertraline 50 mg daily
C. Start lorazepam 0.5 mg PRN
D. Increase memantine to 15 mg BID
Correct Answer: A
Rationale: APA/AAGP: low-dose risperidone (0.25–0.5 mg) is first-line for severe
physical aggression in dementia when non-pharmacologic failed. Black-box
warning for mortality; use lowest dose shortest time. SSRIs ineffective for
agitation. Benzodiazepine increases falls, confusion. Memantine max already 20
mg/day.
7. A 16-year-old female reports 6 months of restrictive eating, 15 % weight loss,
amenorrhea, and marked body-image distortion. BMI 16.5. Vital signs stable.
Which medication is contraindicated?
A. Fluoxetine 20 mg daily
B. Olanzapine 2.5 mg nightly
C. Bupropion XL 150 mg daily
D. Escitalopram 10 mg daily
Correct Answer: C
Rationale: Bupropion lowers seizure threshold and is contraindicated in anorexia
nervosa due to seizure risk with low weight. Fluoxetine is first-line for comorbid
depression after weight restoration. Olanzapine can aid weight gain and
obsessional thinking.
8. A 42-year-old man with OCD has persistent contamination fears despite CBT and
fluoxetine 80 mg × 12 weeks (Y-BOCS 26). Level is therapeutic. Which
augmentation strategy is best supported?
A. Add risperidone 1 mg daily
B. Add aripiprazole 5 mg daily
C. Add clomipramine 50 mg daily
D. Add memantine 10 mg BID
Correct Answer: B
Rationale: APA OCD guidelines: low-dose aripiprazole (5–10 mg) has strongest
RCT evidence for SSRI-refractory OCD. Risperidone data weaker. Clomipramine
augmentation limited by SRI overlap and cardiac risk. Memantine evidence is
preliminary.
9. A 29-year-old woman 28 weeks pregnant with recurrent MDD (PHQ-9 18).
Previous response to sertraline. She is medication-naive this pregnancy. Which
treatment is best?
A. Start sertraline 50 mg daily
B. Start paroxetine 20 mg daily
C. Start nortriptyline 75 mg daily
