NRNP 6665 Final Exam Question and Answers 2026/2027 - WALDEN UNIVERSITY
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SECTION I: COMPLEX DIFFERENTIAL DIAGNOSIS ACROSS LIFESPAN (Questions 1-30)
A 17-year-old cis-female presents with 6 weeks of declining academic performance,
social withdrawal, and "hearing my name called when no one is there." She reports these
experiences occur when falling asleep and during high-stress periods. She denies mood
elevation, substance use, or functional decline. Her maternal aunt has schizophrenia.
Mental status exam reveals anxious affect, linear thought process, and intact insight.
PSYRATS-AH = 8. Which diagnosis is most accurate?
A. Schizophreniform disorder
B. Attenuated psychosis syndrome (prodromal)
C. Brief psychotic disorder
1. D. Anxiety disorder with dissociative features
Correct Answer: B
Rationale: Subthreshold psychotic symptoms (frequency, distress, but preserved
functioning and insight) in adolescence meet criteria for attenuated psychosis
syndrome in DSM-5-TR Section III. Schizophreniform requires functional decline and 1-6
months of symptoms. Brief psychotic disorder requires full psychotic symptoms <1
month with return to baseline. Anxiety disorder alone does not account for auditory
perceptual abnormalities.
A 24-year-old graduate student presents with 3 months of fatigue, difficulty
concentrating, and "feeling empty." She reports increased appetite, hypersomnia, and
leaden paralysis. She had similar episode at age 19 lasting 5 months. PHQ-9 = 14. No
mania history, normal TSH. Which diagnosis best fits?
A. Major depressive disorder, single episode
B. Persistent depressive disorder (dysthymia)
C. Major depressive disorder with atypical features
2. D. Adjustment disorder with depressed mood
Correct Answer: C
,Rationale: Mood reactivity preserved with reversed neurovegetative symptoms
(hypersomnia, hyperphagia, leaden paralysis) defines atypical depression. Episodic
nature with full remission excludes dysthymia. Severity and duration exceed adjustment
disorder.
A 68-year-old retired attorney is referred for "personality change." His wife notes 18
months of progressive apathy, disinhibition (inappropriate comments), and compulsive
eating. He has lost empathy and shows diminished concern for others. MRI shows
frontal and temporal atrophy. MoCA = 24/30. Which diagnosis is most accurate?
A. Major neurocognitive disorder due to Alzheimer’s disease
B. Major neurocognitive disorder with behavioral variant frontotemporal dementia
C. Late-onset bipolar disorder
3. D. Major depressive disorder, pseudodementia type
Correct Answer: B
Rationale: Early behavioral disinhibition, apathy, hyperorality, and loss of empathy with
relative sparing of memory are hallmark of bvFTD. Alzheimer’s presents with amnestic
syndrome. No mood elevation or family history suggests bipolar unlikely.
An 8-year-old boy is evaluated for "constant motion." Teacher reports he cannot sit still,
blurts answers, interrupts peers, but completes work when redirected. At home, he plays
video games for hours without moving. Symptoms present >6 months, all settings. No
tics, no mood swings. Which diagnosis is most accurate?
A. ADHD, predominantly hyperactive-impulsive presentation
B. ADHD, combined presentation
C. Disruptive mood dysregulation disorder
4. D. Normal boyhood behavior
Correct Answer: A
Rationale: Situational variability (symptoms worse in structured settings) is
characteristic of ADHD. The child meets criteria for hyperactive-impulsive symptoms
without prominent inattention in preferred activities. DMDD requires severe temper
outbursts and persistent irritability between episodes.
A 42-year-old woman presents with 2 years of pervasive distrust, reading hidden
meanings into benign remarks, and reluctance to confide in her husband. She has no
,friends outside work, suspects coworkers sabotage her, but functions adequately as
accountant. No hallucinations or formal thought disorder. Which diagnosis is most
accurate?
A. Paranoid schizophrenia
B. Delusional disorder, persecutory type
C. Paranoid personality disorder
5. D. Schizotypal personality disorder
Correct Answer: C
Rationale: Pervasive pattern of distrust and suspiciousness beginning in early
adulthood, without frank delusions or psychosis, meets criteria for paranoid personality
disorder. Delusional disorder requires non-bizarre delusions held with certainty.
Schizotypal includes magical thinking and perceptual distortions.
A 15-year-old cis-male presents with 4 months of severe anxiety about vomiting in
public, resulting in restricted eating and 12 lb weight loss. He checks expiration dates
excessively, washes hands 30× daily, and has intrusive images of contamination.
Y-BOCS = 22. Which comorbid diagnosis must be ruled out first?
A. Anorexia nervosa
B. Avoidant-restrictive food intake disorder
C. Obsessive-compulsive disorder
6. D. Social anxiety disorder
Correct Answer: A
Rationale: Significant weight loss and food restriction in adolescence requires careful
assessment for anorexia nervosa, even when preceded by anxiety. The OCD symptoms
may be secondary to or comorbid with eating disorder. ARFID lacks body image
distortion but weight loss severity requires eating disorder workup.
A 55-year-old man presents with 6 months of resting tremor, rigidity, and bradykinesia.
His wife notes he has become "a different person"—apathetic, irritable, and experiencing
visual hallucinations of "children in the yard." He has insight into hallucinations. Which
psychiatric diagnosis is most likely?
A. Major neurocognitive disorder with Lewy bodies
B. Parkinson’s disease psychosis
C. Delirium
7. D. Schizophrenia, late-onset
, Correct Answer: B
Rationale: Psychotic symptoms occurring after established Parkinson’s disease
diagnosis, with preserved insight and visual hallucinations, represent Parkinson’s
disease psychosis. DLB requires dementia preceding or concurrent with parkinsonism
within 1 year. No acute fluctuation or medical cause suggests delirium unlikely.
A 33-year-old woman presents with sudden onset of paralysis in both legs after learning
of her husband’s infidelity. Neurological exam is non-physiologic; she appears
unconcerned ("la belle indifference"). CT/MRI normal. Which diagnosis is most
accurate?
A. Conversion disorder (functional neurological symptom disorder)
B. Factitious disorder
C. Malingering
8. D. Somatic symptom disorder
Correct Answer: A
Rationale: Neurological symptom incompatible with recognized disease, preceded by
psychological stressor, with la belle indifference, meets conversion disorder criteria.
Factitious disorder requires deception and internal gain. Malingering requires external
incentive. Somatic symptom disorder requires predominant pain or multiple symptoms
with excessive thoughts.
A 19-year-old college student presents with 2 weeks of elevated mood, decreased need
for sleep, grandiose plans for business empire, and hypersexuality. She spent $8,000 on
credit cards. She has no prior psychiatric history. Urine tox positive for THC. Which is
the most appropriate initial diagnostic approach?
A. Diagnose bipolar I disorder, manic episode
B. Observe 2 weeks, repeat tox screen, obtain collateral
C. Diagnose substance-induced bipolar disorder
9. D. Begin lithium carbonate 600 mg BID immediately
Correct Answer: B
Rationale: Cannabis can induce manic-like symptoms; APA guidelines recommend
observing beyond acute intoxication and obtaining collateral to establish clear change
from baseline. Premature diagnosis risks unnecessary long-term medication.
PMHNP Care Across the Lifespan | Comprehensive Clinical Competency Assessment |
Actual Questions & Verified Answers | | Pass Guarantee
SECTION I: COMPLEX DIFFERENTIAL DIAGNOSIS ACROSS LIFESPAN (Questions 1-30)
A 17-year-old cis-female presents with 6 weeks of declining academic performance,
social withdrawal, and "hearing my name called when no one is there." She reports these
experiences occur when falling asleep and during high-stress periods. She denies mood
elevation, substance use, or functional decline. Her maternal aunt has schizophrenia.
Mental status exam reveals anxious affect, linear thought process, and intact insight.
PSYRATS-AH = 8. Which diagnosis is most accurate?
A. Schizophreniform disorder
B. Attenuated psychosis syndrome (prodromal)
C. Brief psychotic disorder
1. D. Anxiety disorder with dissociative features
Correct Answer: B
Rationale: Subthreshold psychotic symptoms (frequency, distress, but preserved
functioning and insight) in adolescence meet criteria for attenuated psychosis
syndrome in DSM-5-TR Section III. Schizophreniform requires functional decline and 1-6
months of symptoms. Brief psychotic disorder requires full psychotic symptoms <1
month with return to baseline. Anxiety disorder alone does not account for auditory
perceptual abnormalities.
A 24-year-old graduate student presents with 3 months of fatigue, difficulty
concentrating, and "feeling empty." She reports increased appetite, hypersomnia, and
leaden paralysis. She had similar episode at age 19 lasting 5 months. PHQ-9 = 14. No
mania history, normal TSH. Which diagnosis best fits?
A. Major depressive disorder, single episode
B. Persistent depressive disorder (dysthymia)
C. Major depressive disorder with atypical features
2. D. Adjustment disorder with depressed mood
Correct Answer: C
,Rationale: Mood reactivity preserved with reversed neurovegetative symptoms
(hypersomnia, hyperphagia, leaden paralysis) defines atypical depression. Episodic
nature with full remission excludes dysthymia. Severity and duration exceed adjustment
disorder.
A 68-year-old retired attorney is referred for "personality change." His wife notes 18
months of progressive apathy, disinhibition (inappropriate comments), and compulsive
eating. He has lost empathy and shows diminished concern for others. MRI shows
frontal and temporal atrophy. MoCA = 24/30. Which diagnosis is most accurate?
A. Major neurocognitive disorder due to Alzheimer’s disease
B. Major neurocognitive disorder with behavioral variant frontotemporal dementia
C. Late-onset bipolar disorder
3. D. Major depressive disorder, pseudodementia type
Correct Answer: B
Rationale: Early behavioral disinhibition, apathy, hyperorality, and loss of empathy with
relative sparing of memory are hallmark of bvFTD. Alzheimer’s presents with amnestic
syndrome. No mood elevation or family history suggests bipolar unlikely.
An 8-year-old boy is evaluated for "constant motion." Teacher reports he cannot sit still,
blurts answers, interrupts peers, but completes work when redirected. At home, he plays
video games for hours without moving. Symptoms present >6 months, all settings. No
tics, no mood swings. Which diagnosis is most accurate?
A. ADHD, predominantly hyperactive-impulsive presentation
B. ADHD, combined presentation
C. Disruptive mood dysregulation disorder
4. D. Normal boyhood behavior
Correct Answer: A
Rationale: Situational variability (symptoms worse in structured settings) is
characteristic of ADHD. The child meets criteria for hyperactive-impulsive symptoms
without prominent inattention in preferred activities. DMDD requires severe temper
outbursts and persistent irritability between episodes.
A 42-year-old woman presents with 2 years of pervasive distrust, reading hidden
meanings into benign remarks, and reluctance to confide in her husband. She has no
,friends outside work, suspects coworkers sabotage her, but functions adequately as
accountant. No hallucinations or formal thought disorder. Which diagnosis is most
accurate?
A. Paranoid schizophrenia
B. Delusional disorder, persecutory type
C. Paranoid personality disorder
5. D. Schizotypal personality disorder
Correct Answer: C
Rationale: Pervasive pattern of distrust and suspiciousness beginning in early
adulthood, without frank delusions or psychosis, meets criteria for paranoid personality
disorder. Delusional disorder requires non-bizarre delusions held with certainty.
Schizotypal includes magical thinking and perceptual distortions.
A 15-year-old cis-male presents with 4 months of severe anxiety about vomiting in
public, resulting in restricted eating and 12 lb weight loss. He checks expiration dates
excessively, washes hands 30× daily, and has intrusive images of contamination.
Y-BOCS = 22. Which comorbid diagnosis must be ruled out first?
A. Anorexia nervosa
B. Avoidant-restrictive food intake disorder
C. Obsessive-compulsive disorder
6. D. Social anxiety disorder
Correct Answer: A
Rationale: Significant weight loss and food restriction in adolescence requires careful
assessment for anorexia nervosa, even when preceded by anxiety. The OCD symptoms
may be secondary to or comorbid with eating disorder. ARFID lacks body image
distortion but weight loss severity requires eating disorder workup.
A 55-year-old man presents with 6 months of resting tremor, rigidity, and bradykinesia.
His wife notes he has become "a different person"—apathetic, irritable, and experiencing
visual hallucinations of "children in the yard." He has insight into hallucinations. Which
psychiatric diagnosis is most likely?
A. Major neurocognitive disorder with Lewy bodies
B. Parkinson’s disease psychosis
C. Delirium
7. D. Schizophrenia, late-onset
, Correct Answer: B
Rationale: Psychotic symptoms occurring after established Parkinson’s disease
diagnosis, with preserved insight and visual hallucinations, represent Parkinson’s
disease psychosis. DLB requires dementia preceding or concurrent with parkinsonism
within 1 year. No acute fluctuation or medical cause suggests delirium unlikely.
A 33-year-old woman presents with sudden onset of paralysis in both legs after learning
of her husband’s infidelity. Neurological exam is non-physiologic; she appears
unconcerned ("la belle indifference"). CT/MRI normal. Which diagnosis is most
accurate?
A. Conversion disorder (functional neurological symptom disorder)
B. Factitious disorder
C. Malingering
8. D. Somatic symptom disorder
Correct Answer: A
Rationale: Neurological symptom incompatible with recognized disease, preceded by
psychological stressor, with la belle indifference, meets conversion disorder criteria.
Factitious disorder requires deception and internal gain. Malingering requires external
incentive. Somatic symptom disorder requires predominant pain or multiple symptoms
with excessive thoughts.
A 19-year-old college student presents with 2 weeks of elevated mood, decreased need
for sleep, grandiose plans for business empire, and hypersexuality. She spent $8,000 on
credit cards. She has no prior psychiatric history. Urine tox positive for THC. Which is
the most appropriate initial diagnostic approach?
A. Diagnose bipolar I disorder, manic episode
B. Observe 2 weeks, repeat tox screen, obtain collateral
C. Diagnose substance-induced bipolar disorder
9. D. Begin lithium carbonate 600 mg BID immediately
Correct Answer: B
Rationale: Cannabis can induce manic-like symptoms; APA guidelines recommend
observing beyond acute intoxication and obtaining collateral to establish clear change
from baseline. Premature diagnosis risks unnecessary long-term medication.
