GEORGETTE PMHNP Review – Actual Exam Test Bank A+
(Newest 2026/2027) – Complete Verified Questions, Correct
Answers & Detailed Rationales
Question 1
A 28-year-old patient with bipolar I disorder is stabilized on lithium 1200 mg daily
with a level of 0.9 mEq/L. The patient develops acne and reports "shakes." The
PMHNP considers a medication change. Which agent is MOST appropriate for
maintenance treatment in bipolar disorder?
A) Lamotrigine monotherapy
B) Valproate monotherapy
C) Aripiprazole monotherapy
D) All of the above are FDA-approved for maintenance
Correct Answer :- D
Explanation: Lithium, valproate, lamotrigine (for bipolar depression
maintenance), aripiprazole, olanzapine, quetiapine, risperidone, and others are
FDA-approved for maintenance in bipolar disorder. Choice depends on patient
factors, side effect profile, and phase of illness.
Question 1
A 32-year-old patient with major depressive disorder has failed trials of two SSRIs
and one SNRI. The PMHNP is considering augmentation with a second-generation
antipsychotic. Which receptor affinity profile would be MOST beneficial for
augmentation in treatment-resistant depression?
,A) High D2 receptor antagonism with low 5-HT2A affinity
B) High 5-HT2A antagonism with weak D2 antagonism
C) Pure D2 partial agonism with no serotonergic activity
D) High muscarinic M1 antagonism with D2 antagonism
Correct Answer :- B
Explanation: Second-generation antipsychotics with high 5-HT2A antagonism
relative to D2 antagonism (like aripiprazole, brexpiprazole, quetiapine) are FDA-
approved for adjunctive treatment in MDD. The 5-HT2A antagonism enhances
serotonergic transmission in prefrontal cortex. High D2 antagonism (A) increases
EPS risk. Pure D2 partial agonism (C) without 5-HT2A effects is less effective for
depression. M1 antagonism (D) causes anticholinergic side effects.
Question 2
A patient with schizophrenia is started on risperidone 4 mg daily. After 2 weeks,
the patient develops muscle stiffness, fever, and altered mental status. CPK is
12,000 IU/L. Which mechanism BEST explains this reaction?
A) D2 receptor blockade in nigrostriatal pathway causing EPS
B) 5-HT2A antagonism causing serotonin syndrome
C) D2 receptor blockade in hypothalamus leading to impaired thermoregulation
and muscle rigidity
D) Alpha-1 adrenergic blockade causing hypotension and compensatory
tachycardia
Correct Answer :- C
Explanation: This describes neuroleptic malignant syndrome (NMS). D2 blockade
in the hypothalamus impairs thermoregulation; nigrostriatal blockade causes
rigidity; autonomic dysfunction causes instability. Option A describes EPS
(dystonia, parkinsonism) without fever or autonomic instability. Option B
(serotonin syndrome) would involve hyperreflexia, clonus, and GI symptoms.
Option D describes orthostatic hypotension.
Question 3
,A PMHNP is prescribing lamotrigine for a patient with bipolar I disorder. Which
instruction about dosing is MOST critical?
A) "Take this medication with food to prevent GI upset."
B) "The dose will be increased slowly over several weeks to reduce rash risk."
C) "You may experience weight gain; monitor your diet."
D) "This medication may cause sedation; take it at bedtime."
Correct Answer :- B
Explanation: Lamotrigine requires slow titration to reduce risk of Stevens-Johnson
syndrome (life-threatening rash). Typical titration increases by 25 mg every 2
weeks. Option A (food) is not critical. Weight gain (C) is minimal with lamotrigine.
Sedation (D) is less common; some patients take it in morning.
Question 4
A 24-year-old patient with panic disorder is started on paroxetine 20 mg daily.
Three days later, the patient reports increased anxiety, jitteriness, and insomnia.
What is the MOST likely explanation?
A) The dose is too high and should be reduced
B) This is a sign of serotonin syndrome
C) This is an initial paradoxical effect of SSRIs that usually resolves
D) The patient is having an allergic reaction
Correct Answer :- C
Explanation: SSRIs can cause initial activation/jitteriness, especially in panic
disorder, due to increased serotonin in raphe nuclei before autoreceptor
downregulation. This typically resolves in 1-2 weeks. Serotonin syndrome (B)
would include fever, clonus, hyperreflexia. Dose reduction (A) may be considered
if severe, but explanation is correct.
Question 5
, A patient with bipolar I disorder is stabilized on lithium 900 mg daily. The lithium
level is 0.8 mEq/L. The patient reports new-onset tremors, polyuria, and
polydipsia. What is the MOST appropriate action?
A) Increase lithium dose to achieve level of 1.0-1.2 mEq/L
B) Switch to valproate due to lithium intolerance
C) Check thyroid and renal function; consider adding propranolol for tremor
D) Discontinue lithium immediately due to toxicity
Correct Answer :- C
Explanation: Lithium level 0.8 is therapeutic (0.6-1.2). Tremor is a common side
effect (can use propranolol). Polyuria/polydipsia may indicate nephrogenic
diabetes insipidus or early renal impairment. Check renal and thyroid function
(lithium can cause hypothyroidism). Level is not toxic (D). Increasing dose (A)
would worsen symptoms. Switching (B) may be needed if renal impairment, but
assess first.
Question 6
A 68-year-old patient with Parkinson's disease develops psychosis. Which
antipsychotic is MOST appropriate?
A) Haloperidol
B) Risperidone
C) Quetiapine
D) Aripiprazole
Correct Answer :- C
Explanation: Quetiapine has the lowest D2 affinity among SGAs and is least likely
to worsen Parkinson's symptoms. Pimavanserin (5-HT2A inverse agonist) is FDA-
approved for Parkinson's psychosis but not listed. Haloperidol (A) is high-potency
D2 antagonist—contraindicated. Risperidone (B) and aripiprazole (D) can worsen
motor symptoms.
Question 7
(Newest 2026/2027) – Complete Verified Questions, Correct
Answers & Detailed Rationales
Question 1
A 28-year-old patient with bipolar I disorder is stabilized on lithium 1200 mg daily
with a level of 0.9 mEq/L. The patient develops acne and reports "shakes." The
PMHNP considers a medication change. Which agent is MOST appropriate for
maintenance treatment in bipolar disorder?
A) Lamotrigine monotherapy
B) Valproate monotherapy
C) Aripiprazole monotherapy
D) All of the above are FDA-approved for maintenance
Correct Answer :- D
Explanation: Lithium, valproate, lamotrigine (for bipolar depression
maintenance), aripiprazole, olanzapine, quetiapine, risperidone, and others are
FDA-approved for maintenance in bipolar disorder. Choice depends on patient
factors, side effect profile, and phase of illness.
Question 1
A 32-year-old patient with major depressive disorder has failed trials of two SSRIs
and one SNRI. The PMHNP is considering augmentation with a second-generation
antipsychotic. Which receptor affinity profile would be MOST beneficial for
augmentation in treatment-resistant depression?
,A) High D2 receptor antagonism with low 5-HT2A affinity
B) High 5-HT2A antagonism with weak D2 antagonism
C) Pure D2 partial agonism with no serotonergic activity
D) High muscarinic M1 antagonism with D2 antagonism
Correct Answer :- B
Explanation: Second-generation antipsychotics with high 5-HT2A antagonism
relative to D2 antagonism (like aripiprazole, brexpiprazole, quetiapine) are FDA-
approved for adjunctive treatment in MDD. The 5-HT2A antagonism enhances
serotonergic transmission in prefrontal cortex. High D2 antagonism (A) increases
EPS risk. Pure D2 partial agonism (C) without 5-HT2A effects is less effective for
depression. M1 antagonism (D) causes anticholinergic side effects.
Question 2
A patient with schizophrenia is started on risperidone 4 mg daily. After 2 weeks,
the patient develops muscle stiffness, fever, and altered mental status. CPK is
12,000 IU/L. Which mechanism BEST explains this reaction?
A) D2 receptor blockade in nigrostriatal pathway causing EPS
B) 5-HT2A antagonism causing serotonin syndrome
C) D2 receptor blockade in hypothalamus leading to impaired thermoregulation
and muscle rigidity
D) Alpha-1 adrenergic blockade causing hypotension and compensatory
tachycardia
Correct Answer :- C
Explanation: This describes neuroleptic malignant syndrome (NMS). D2 blockade
in the hypothalamus impairs thermoregulation; nigrostriatal blockade causes
rigidity; autonomic dysfunction causes instability. Option A describes EPS
(dystonia, parkinsonism) without fever or autonomic instability. Option B
(serotonin syndrome) would involve hyperreflexia, clonus, and GI symptoms.
Option D describes orthostatic hypotension.
Question 3
,A PMHNP is prescribing lamotrigine for a patient with bipolar I disorder. Which
instruction about dosing is MOST critical?
A) "Take this medication with food to prevent GI upset."
B) "The dose will be increased slowly over several weeks to reduce rash risk."
C) "You may experience weight gain; monitor your diet."
D) "This medication may cause sedation; take it at bedtime."
Correct Answer :- B
Explanation: Lamotrigine requires slow titration to reduce risk of Stevens-Johnson
syndrome (life-threatening rash). Typical titration increases by 25 mg every 2
weeks. Option A (food) is not critical. Weight gain (C) is minimal with lamotrigine.
Sedation (D) is less common; some patients take it in morning.
Question 4
A 24-year-old patient with panic disorder is started on paroxetine 20 mg daily.
Three days later, the patient reports increased anxiety, jitteriness, and insomnia.
What is the MOST likely explanation?
A) The dose is too high and should be reduced
B) This is a sign of serotonin syndrome
C) This is an initial paradoxical effect of SSRIs that usually resolves
D) The patient is having an allergic reaction
Correct Answer :- C
Explanation: SSRIs can cause initial activation/jitteriness, especially in panic
disorder, due to increased serotonin in raphe nuclei before autoreceptor
downregulation. This typically resolves in 1-2 weeks. Serotonin syndrome (B)
would include fever, clonus, hyperreflexia. Dose reduction (A) may be considered
if severe, but explanation is correct.
Question 5
, A patient with bipolar I disorder is stabilized on lithium 900 mg daily. The lithium
level is 0.8 mEq/L. The patient reports new-onset tremors, polyuria, and
polydipsia. What is the MOST appropriate action?
A) Increase lithium dose to achieve level of 1.0-1.2 mEq/L
B) Switch to valproate due to lithium intolerance
C) Check thyroid and renal function; consider adding propranolol for tremor
D) Discontinue lithium immediately due to toxicity
Correct Answer :- C
Explanation: Lithium level 0.8 is therapeutic (0.6-1.2). Tremor is a common side
effect (can use propranolol). Polyuria/polydipsia may indicate nephrogenic
diabetes insipidus or early renal impairment. Check renal and thyroid function
(lithium can cause hypothyroidism). Level is not toxic (D). Increasing dose (A)
would worsen symptoms. Switching (B) may be needed if renal impairment, but
assess first.
Question 6
A 68-year-old patient with Parkinson's disease develops psychosis. Which
antipsychotic is MOST appropriate?
A) Haloperidol
B) Risperidone
C) Quetiapine
D) Aripiprazole
Correct Answer :- C
Explanation: Quetiapine has the lowest D2 affinity among SGAs and is least likely
to worsen Parkinson's symptoms. Pimavanserin (5-HT2A inverse agonist) is FDA-
approved for Parkinson's psychosis but not listed. Haloperidol (A) is high-potency
D2 antagonist—contraindicated. Risperidone (B) and aripiprazole (D) can worsen
motor symptoms.
Question 7
