NRNP 6665 Final Exam Question and Answers 2026/2027 - WALDEN
UNIVERSITY PMHNP Care Across the Lifespan | Comprehensive
Clinical Competency Assessment | Actual Questions & Verified
Answers | | Pass Guarantee
1. A 16-year-old presents with 5 months of irritable mood, decreased sleep (4-5
hrs), GPA drop from 3.8 to 2.9, and 4-day episodes of racing thoughts &
hypersexual texts. Episodes alternate with 2-week periods of fatigue & poor
concentration. Mother has bipolar I. PHQ-9: 8, MDQ: 8/13 positive. UDS negative.
Which is the most accurate diagnosis?
A. Major depressive disorder
B. ADHD, combined presentation
C. Bipolar I disorder, manic episode
D. Borderline personality disorder
Correct Answer: C
Rationale: Clear hypomanic/manic episodes (>4 days, hypersexuality, racing
thoughts) alternating with sub-syndromal depression plus strong family history
meets DSM-5-TR criteria for bipolar I. MDQ screen positive supports this. ADHD
does not explain discrete mood episodes. BPD traits overlap but episodicity and
family history favor bipolar.
2. A 72-year-old man with HTN, DM2, CKD (eGFR 38) and new PHQ-9: 17. He failed
sertraline 100 mg × 8 weeks in past. Which first-line agent best balances efficacy
and safety?
A. Duloxetine 30 mg daily
B. Bupropion XL 150 mg daily
C. Venlafaxine XR 37.5 mg daily
D. Mirtazapine 15 mg nightly
Correct Answer: D
Rationale: Mirtazapine is renally cleared, improves appetite/sleep, and has
minimal drug-drug interactions. Duloxetine requires dose reduction in CKD and
may raise BP. Bupropion lowers seizure threshold and is renally cleared.
Venlafaxine also requires renal dose adjustment.
3. A 9-year-old (weight 30 kg) is diagnosed with ADHD, combined type. Vitals
normal, ECG normal. Which FDA-approved stimulant and starting dose is most
appropriate?
A. Methylphenidate ER 18 mg qAM
, B. Lisdexamfetamine 30 mg qAM
C. Atomoxetine 40 mg daily
D. Clonidine ER 0.1 mg nightly
Correct Answer: A
Rationale: Methylphenidate ER 18 mg ≈ 0.6 mg/kg—middle of guideline starting
range (0.3-1 mg/kg/day). Lisdexamfetamine 30 mg is adult starting dose and ≈ 1
mg/kg—too high. Atomoxetine is second-line and slower onset. Clonidine
monotherapy is for tics or insomnia, not first-line for core ADHD.
4. A 27-year-old Army veteran reports 4 months of nightmares, hypervigilance, and
emotional numbing since return from deployment. Prazosin 1 mg qHS × 4 weeks
no change in nightmares. BP 118/74. Which next step is best?
A. Increase prazosin to 5 mg qHS
B. Add risperidone 1 mg BID
C. Start sertraline 50 mg daily
D. Start trauma-focused CBT (TF-CBT)
Correct Answer: A
Rationale: APA PTSD guidelines: titrate prazosin for trauma nightmares to 6-10
mg qHS (max 15 mg). Studies show dose-response. Adding antipsychotic is not
indicated without psychosis. SSRIs help global PTSD but nightmares often
require prazosin. TF-CBT is effective but pharmacologic escalation comes first
for specific symptom.
5. A 34-year-old woman with bipolar II (last hypomania 18 months ago) on lithium
900 mg qHS (level 0.9) reports 3 weeks of fatigue, hypersomnia, 10 lb weight
gain, and PHQ-9: 18. TSH 4.9 µIU/mL (high-normal), creatinine 0.8. Which is the
best next step?
A. Increase lithium to achieve level 1.2
B. Add bupropion XL 150 mg
C. Add lamotrigine 25 mg daily, titrate up
D. Switch lithium to valproate
Correct Answer: C
Rationale: Lithium-induced subclinical 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 mood stabilization.
6. A 77-year-old man with Alzheimer’s (MMSE 16) develops agitation, hitting staff
during bathing. Medical work-up negative. He is on donepezil 10 mg, memantine
10 mg BID. Which first-line pharmacologic option?
A. Sertraline 50 mg daily
, B. Lorazepam 0.5 mg PRN
C. Risperidone 0.25 mg BID
D. Trazodone 50 mg nightly
Correct Answer: C
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 and confusion. Trazodone is for sleep,
not agitation.
7. A 14-year-old girl reports 5 months of restrictive eating, 18 % weight loss,
amenorrhea, and marked body-image distortion. BMI 16.2. 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 at low weight. Olanzapine can aid weight gain and
obsessive thinking. SSRIs are used after weight restoration.
8. A 37-year-old man with OCD has contamination fears and washing rituals
(Y-BOCS 25) despite fluoxetine 80 mg × 10 weeks and ERP. He is adherent. Which
augmentation is best supported?
A. Add risperidone 2 mg daily
B. Add aripiprazole 10 mg daily
C. Add topiramate 100 mg BID
D. Add clomipramine 50 mg daily
Correct Answer: B
Rationale: APA OCD guidelines: low-dose aripiprazole has strongest RCT
evidence for SSRI-refractory OCD. Risperidone data weaker. Topiramate has
negative studies. Adding clomipramine to fluoxetine risks serotonin syndrome
and cardiac toxicity.
9. A 31-year-old woman 26 weeks pregnant with recurrent MDD (PHQ-9 19) had
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
D. Recommend IPT only
UNIVERSITY PMHNP Care Across the Lifespan | Comprehensive
Clinical Competency Assessment | Actual Questions & Verified
Answers | | Pass Guarantee
1. A 16-year-old presents with 5 months of irritable mood, decreased sleep (4-5
hrs), GPA drop from 3.8 to 2.9, and 4-day episodes of racing thoughts &
hypersexual texts. Episodes alternate with 2-week periods of fatigue & poor
concentration. Mother has bipolar I. PHQ-9: 8, MDQ: 8/13 positive. UDS negative.
Which is the most accurate diagnosis?
A. Major depressive disorder
B. ADHD, combined presentation
C. Bipolar I disorder, manic episode
D. Borderline personality disorder
Correct Answer: C
Rationale: Clear hypomanic/manic episodes (>4 days, hypersexuality, racing
thoughts) alternating with sub-syndromal depression plus strong family history
meets DSM-5-TR criteria for bipolar I. MDQ screen positive supports this. ADHD
does not explain discrete mood episodes. BPD traits overlap but episodicity and
family history favor bipolar.
2. A 72-year-old man with HTN, DM2, CKD (eGFR 38) and new PHQ-9: 17. He failed
sertraline 100 mg × 8 weeks in past. Which first-line agent best balances efficacy
and safety?
A. Duloxetine 30 mg daily
B. Bupropion XL 150 mg daily
C. Venlafaxine XR 37.5 mg daily
D. Mirtazapine 15 mg nightly
Correct Answer: D
Rationale: Mirtazapine is renally cleared, improves appetite/sleep, and has
minimal drug-drug interactions. Duloxetine requires dose reduction in CKD and
may raise BP. Bupropion lowers seizure threshold and is renally cleared.
Venlafaxine also requires renal dose adjustment.
3. A 9-year-old (weight 30 kg) is diagnosed with ADHD, combined type. Vitals
normal, ECG normal. Which FDA-approved stimulant and starting dose is most
appropriate?
A. Methylphenidate ER 18 mg qAM
, B. Lisdexamfetamine 30 mg qAM
C. Atomoxetine 40 mg daily
D. Clonidine ER 0.1 mg nightly
Correct Answer: A
Rationale: Methylphenidate ER 18 mg ≈ 0.6 mg/kg—middle of guideline starting
range (0.3-1 mg/kg/day). Lisdexamfetamine 30 mg is adult starting dose and ≈ 1
mg/kg—too high. Atomoxetine is second-line and slower onset. Clonidine
monotherapy is for tics or insomnia, not first-line for core ADHD.
4. A 27-year-old Army veteran reports 4 months of nightmares, hypervigilance, and
emotional numbing since return from deployment. Prazosin 1 mg qHS × 4 weeks
no change in nightmares. BP 118/74. Which next step is best?
A. Increase prazosin to 5 mg qHS
B. Add risperidone 1 mg BID
C. Start sertraline 50 mg daily
D. Start trauma-focused CBT (TF-CBT)
Correct Answer: A
Rationale: APA PTSD guidelines: titrate prazosin for trauma nightmares to 6-10
mg qHS (max 15 mg). Studies show dose-response. Adding antipsychotic is not
indicated without psychosis. SSRIs help global PTSD but nightmares often
require prazosin. TF-CBT is effective but pharmacologic escalation comes first
for specific symptom.
5. A 34-year-old woman with bipolar II (last hypomania 18 months ago) on lithium
900 mg qHS (level 0.9) reports 3 weeks of fatigue, hypersomnia, 10 lb weight
gain, and PHQ-9: 18. TSH 4.9 µIU/mL (high-normal), creatinine 0.8. Which is the
best next step?
A. Increase lithium to achieve level 1.2
B. Add bupropion XL 150 mg
C. Add lamotrigine 25 mg daily, titrate up
D. Switch lithium to valproate
Correct Answer: C
Rationale: Lithium-induced subclinical 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 mood stabilization.
6. A 77-year-old man with Alzheimer’s (MMSE 16) develops agitation, hitting staff
during bathing. Medical work-up negative. He is on donepezil 10 mg, memantine
10 mg BID. Which first-line pharmacologic option?
A. Sertraline 50 mg daily
, B. Lorazepam 0.5 mg PRN
C. Risperidone 0.25 mg BID
D. Trazodone 50 mg nightly
Correct Answer: C
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 and confusion. Trazodone is for sleep,
not agitation.
7. A 14-year-old girl reports 5 months of restrictive eating, 18 % weight loss,
amenorrhea, and marked body-image distortion. BMI 16.2. 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 at low weight. Olanzapine can aid weight gain and
obsessive thinking. SSRIs are used after weight restoration.
8. A 37-year-old man with OCD has contamination fears and washing rituals
(Y-BOCS 25) despite fluoxetine 80 mg × 10 weeks and ERP. He is adherent. Which
augmentation is best supported?
A. Add risperidone 2 mg daily
B. Add aripiprazole 10 mg daily
C. Add topiramate 100 mg BID
D. Add clomipramine 50 mg daily
Correct Answer: B
Rationale: APA OCD guidelines: low-dose aripiprazole has strongest RCT
evidence for SSRI-refractory OCD. Risperidone data weaker. Topiramate has
negative studies. Adding clomipramine to fluoxetine risks serotonin syndrome
and cardiac toxicity.
9. A 31-year-old woman 26 weeks pregnant with recurrent MDD (PHQ-9 19) had
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
D. Recommend IPT only
