**The PMHNP Edge: Advanced Psychiatric-Mental
Health Nursing Certification**
1. A patient with schizophrenia has been stable on paliperidone palmitate 156 mg IM monthly for 6
months. The patient now presents with muscle rigidity, fever of 39.4°C (103°F), and elevated creatine
kinase (CK) of 4,500 U/L. What is the priority action?
A) Administer diphenhydramine 50 mg IM
B) Give bromocriptine 2.5 mg PO
C) Hold the next paliperidone dose and transfer to medical unit
D) Increase the paliperidone dose to 234 mg
💫RATIONALE✔️✔️: Fever, rigidity, and elevated CK indicate neuroleptic malignant syndrome (NMS), a
life-threatening emergency. Stop the antipsychotic, transfer to ICU for supportive care, and consider
dantrolene or bromocriptine.
💫ANSWER✔️✔️: C) Hold the next paliperidone dose and transfer to medical unit
---
2. A patient with bipolar I disorder is being discharged on lithium 900 mg daily. Which statement by the
patient indicates adequate understanding?
A) "I will drink at least 2-3 liters of water every day."
B) "I can take ibuprofen for headaches as needed."
C) "I will have my blood drawn every 6 months."
D) "A sudden weight gain means the medication is working."
💫RATIONALE✔️✔️: Lithium requires adequate hydration to prevent toxicity. NSAIDs (ibuprofen) increase
lithium levels. Levels should be checked every 1-3 months, not 6 months. Weight gain is a side effect,
not a therapeutic indicator.
💫ANSWER✔️✔️: A) "I will drink at least 2-3 liters of water every day."
---
,3. A patient with major depressive disorder has failed two SSRIs. The nurse practitioner prescribes
phenelzine (MAOI). Which dietary instruction is most critical?
A) "Avoid aged cheeses, cured meats, and tap beer."
B) "Increase your intake of leafy green vegetables."
C) "Limit caffeine to one cup of coffee per day."
D) "Take this medication with a high-protein meal."
💫RATIONALE✔️✔️: MAOIs require tyramine restriction to prevent hypertensive crisis. Aged cheese,
cured meats, fermented foods, and tap beer are high in tyramine. Fresh meats and vegetables are safe.
💫ANSWER✔️✔️: A) "Avoid aged cheeses, cured meats, and tap beer."
---
4. A patient with borderline personality disorder is admitted after a wrist-cutting episode. The patient
demands to see the provider immediately and threatens to "do it again" if not seen. What is the most
therapeutic response?
A) "If you threaten self-harm again, I will place you in restraints."
B) "I will notify the provider, but you must wait calmly. Self-harm will result in safety precautions."
C) "You are being manipulative; I will talk to you when you are calm."
D) "Here is a PRN dose of lorazepam to help you relax."
💫RATIONALE✔️✔️: Set firm but compassionate limits: address the behavior without reinforcing
manipulation. Acknowledge the request, state the expectation, and outline the consequence of self-
harm without anger.
💫ANSWER✔️✔️: B) "I will notify the provider, but you must wait calmly. Self-harm will result in safety
precautions."
---
5. A patient with generalized anxiety disorder has been on alprazolam 1 mg TID for 2 years. The provider
plans to taper the medication. Which withdrawal symptom is most concerning?
A) Rebound anxiety
B) Insomnia
C) Seizure activity
D) Tremors
,💫RATIONALE✔️✔️: Benzodiazepine withdrawal can cause seizures, which is life-threatening. A slow taper
over weeks to months is essential. Rebound anxiety, insomnia, and tremors are expected but less
severe.
💫ANSWER✔️✔️: C) Seizure activity
---
6. A patient with schizophrenia tells the nurse, "The radio is sending me messages to kill the president."
Which term best describes this symptom?
A) Illusion
B) Delusion of reference
C) Thought broadcasting
D) Auditory hallucination
💫RATIONALE✔️✔️: Delusion of reference is the belief that external stimuli (radio, TV) are specifically
directed at oneself. This differs from an auditory hallucination, which involves hearing voices not
present.
💫ANSWER✔️✔️: B) Delusion of reference
---
7. A patient with post-traumatic stress disorder (PTSD) reports recurrent nightmares and hypervigilance.
Which medication is FDA-approved for PTSD?
A) Paroxetine
B) Propranolol
C) Prazosin
D) Quetiapine
💫RATIONALE✔️✔️: Paroxetine and sertraline are FDA-approved for PTSD. Prazosin is used off-label for
nightmares. Propranolol is studied for prophylaxis but not approved.
💫ANSWER✔️✔️: A) Paroxetine
---
8. A patient with anorexia nervosa has a BMI of 15.5 kg/m² and a heart rate of 38 bpm. What is the
priority intervention?
, A) Initiate a behavioral contract for weight gain
B) Start a refeeding protocol at 1,200 calories/day
C) Transfer to a medical unit for cardiac monitoring
D) Begin fluoxetine 20 mg daily
💫RATIONALE✔️✔️: Bradycardia (HR <40) in anorexia nervosa indicates severe medical instability and risk
of cardiac arrest. The patient requires immediate medical admission for cardiac monitoring. Refeeding
syndrome is also a risk but cardiac stability is first.
💫ANSWER✔️✔️: C) Transfer to a medical unit for cardiac monitoring
---
9. A patient with alcohol use disorder is admitted for detoxification. The nurse implements the Clinical
Institute Withdrawal Assessment for Alcohol (CIWA-Ar) protocol. Which finding indicates severe
withdrawal?
A) Heart rate 98 bpm
B) Blood pressure 140/90 mmHg
C) Tremors rated 4/7
D) Seizure activity observed
💫RATIONALE✔️✔️: Seizure activity indicates severe withdrawal (delirium tremens), which is a medical
emergency requiring ICU transfer. CIWA-Ar scores guide treatment, but seizures are an absolute
indicator of severe withdrawal.
💫ANSWER✔️✔️: D) Seizure activity observed
---
10. A patient with major depressive disorder is started on venlafaxine 75 mg daily. The nurse should
monitor for which common adverse effect?
A) Weight gain
B) Sexual dysfunction
C) Hypertension at higher doses
D) Sedation
💫RATIONALE✔️✔️: Venlafaxine (SNRI) is associated with dose-dependent hypertension due to
norepinephrine reuptake inhibition. Blood pressure should be monitored regularly. Sexual dysfunction
occurs but hypertension is unique to higher doses.
Health Nursing Certification**
1. A patient with schizophrenia has been stable on paliperidone palmitate 156 mg IM monthly for 6
months. The patient now presents with muscle rigidity, fever of 39.4°C (103°F), and elevated creatine
kinase (CK) of 4,500 U/L. What is the priority action?
A) Administer diphenhydramine 50 mg IM
B) Give bromocriptine 2.5 mg PO
C) Hold the next paliperidone dose and transfer to medical unit
D) Increase the paliperidone dose to 234 mg
💫RATIONALE✔️✔️: Fever, rigidity, and elevated CK indicate neuroleptic malignant syndrome (NMS), a
life-threatening emergency. Stop the antipsychotic, transfer to ICU for supportive care, and consider
dantrolene or bromocriptine.
💫ANSWER✔️✔️: C) Hold the next paliperidone dose and transfer to medical unit
---
2. A patient with bipolar I disorder is being discharged on lithium 900 mg daily. Which statement by the
patient indicates adequate understanding?
A) "I will drink at least 2-3 liters of water every day."
B) "I can take ibuprofen for headaches as needed."
C) "I will have my blood drawn every 6 months."
D) "A sudden weight gain means the medication is working."
💫RATIONALE✔️✔️: Lithium requires adequate hydration to prevent toxicity. NSAIDs (ibuprofen) increase
lithium levels. Levels should be checked every 1-3 months, not 6 months. Weight gain is a side effect,
not a therapeutic indicator.
💫ANSWER✔️✔️: A) "I will drink at least 2-3 liters of water every day."
---
,3. A patient with major depressive disorder has failed two SSRIs. The nurse practitioner prescribes
phenelzine (MAOI). Which dietary instruction is most critical?
A) "Avoid aged cheeses, cured meats, and tap beer."
B) "Increase your intake of leafy green vegetables."
C) "Limit caffeine to one cup of coffee per day."
D) "Take this medication with a high-protein meal."
💫RATIONALE✔️✔️: MAOIs require tyramine restriction to prevent hypertensive crisis. Aged cheese,
cured meats, fermented foods, and tap beer are high in tyramine. Fresh meats and vegetables are safe.
💫ANSWER✔️✔️: A) "Avoid aged cheeses, cured meats, and tap beer."
---
4. A patient with borderline personality disorder is admitted after a wrist-cutting episode. The patient
demands to see the provider immediately and threatens to "do it again" if not seen. What is the most
therapeutic response?
A) "If you threaten self-harm again, I will place you in restraints."
B) "I will notify the provider, but you must wait calmly. Self-harm will result in safety precautions."
C) "You are being manipulative; I will talk to you when you are calm."
D) "Here is a PRN dose of lorazepam to help you relax."
💫RATIONALE✔️✔️: Set firm but compassionate limits: address the behavior without reinforcing
manipulation. Acknowledge the request, state the expectation, and outline the consequence of self-
harm without anger.
💫ANSWER✔️✔️: B) "I will notify the provider, but you must wait calmly. Self-harm will result in safety
precautions."
---
5. A patient with generalized anxiety disorder has been on alprazolam 1 mg TID for 2 years. The provider
plans to taper the medication. Which withdrawal symptom is most concerning?
A) Rebound anxiety
B) Insomnia
C) Seizure activity
D) Tremors
,💫RATIONALE✔️✔️: Benzodiazepine withdrawal can cause seizures, which is life-threatening. A slow taper
over weeks to months is essential. Rebound anxiety, insomnia, and tremors are expected but less
severe.
💫ANSWER✔️✔️: C) Seizure activity
---
6. A patient with schizophrenia tells the nurse, "The radio is sending me messages to kill the president."
Which term best describes this symptom?
A) Illusion
B) Delusion of reference
C) Thought broadcasting
D) Auditory hallucination
💫RATIONALE✔️✔️: Delusion of reference is the belief that external stimuli (radio, TV) are specifically
directed at oneself. This differs from an auditory hallucination, which involves hearing voices not
present.
💫ANSWER✔️✔️: B) Delusion of reference
---
7. A patient with post-traumatic stress disorder (PTSD) reports recurrent nightmares and hypervigilance.
Which medication is FDA-approved for PTSD?
A) Paroxetine
B) Propranolol
C) Prazosin
D) Quetiapine
💫RATIONALE✔️✔️: Paroxetine and sertraline are FDA-approved for PTSD. Prazosin is used off-label for
nightmares. Propranolol is studied for prophylaxis but not approved.
💫ANSWER✔️✔️: A) Paroxetine
---
8. A patient with anorexia nervosa has a BMI of 15.5 kg/m² and a heart rate of 38 bpm. What is the
priority intervention?
, A) Initiate a behavioral contract for weight gain
B) Start a refeeding protocol at 1,200 calories/day
C) Transfer to a medical unit for cardiac monitoring
D) Begin fluoxetine 20 mg daily
💫RATIONALE✔️✔️: Bradycardia (HR <40) in anorexia nervosa indicates severe medical instability and risk
of cardiac arrest. The patient requires immediate medical admission for cardiac monitoring. Refeeding
syndrome is also a risk but cardiac stability is first.
💫ANSWER✔️✔️: C) Transfer to a medical unit for cardiac monitoring
---
9. A patient with alcohol use disorder is admitted for detoxification. The nurse implements the Clinical
Institute Withdrawal Assessment for Alcohol (CIWA-Ar) protocol. Which finding indicates severe
withdrawal?
A) Heart rate 98 bpm
B) Blood pressure 140/90 mmHg
C) Tremors rated 4/7
D) Seizure activity observed
💫RATIONALE✔️✔️: Seizure activity indicates severe withdrawal (delirium tremens), which is a medical
emergency requiring ICU transfer. CIWA-Ar scores guide treatment, but seizures are an absolute
indicator of severe withdrawal.
💫ANSWER✔️✔️: D) Seizure activity observed
---
10. A patient with major depressive disorder is started on venlafaxine 75 mg daily. The nurse should
monitor for which common adverse effect?
A) Weight gain
B) Sexual dysfunction
C) Hypertension at higher doses
D) Sedation
💫RATIONALE✔️✔️: Venlafaxine (SNRI) is associated with dose-dependent hypertension due to
norepinephrine reuptake inhibition. Blood pressure should be monitored regularly. Sexual dysfunction
occurs but hypertension is unique to higher doses.
