Barkley PMHNP Mock
certificatioN exaM iii
coMPreHeNsive 150-QuestioN
Practice exaMiNatioN for
PsycHiatric-MeNtal HealtH
Nurse PractitioNer Board
certificatioN a well detailed
oNe writteN aNd
graded a+ uPgraded
Exam Domains Covered: Psychopharmacology, Neurobiology & Pathophysiology, Differential
Diagnosis & Psychiatric Assessment, Psychotherapy & Therapeutic Interventions, Ethics & Legal
Issues, Crisis Management, and Evidence-Based Practice Across the Lifespan
,Instructions
This examination consists of 150 multiple-choice questions designed to assess advanced clinical
knowledge and decision-making skills required for PMHNP board certification. Each question
has one correct answer. Select the best response based on current evidence-based practice,
DSM-5-TR criteria, and standard psychiatric nursing guidelines. Questions range from
foundational knowledge to complex clinical scenarios requiring synthesis of multiple domains.
Question 1
A 28-year-old female with a history of bipolar I disorder presents with a 4-day history of
escalating mood, decreased need for sleep, racing thoughts, and reckless spending. She is
currently taking lithium 900 mg daily with a serum level of 0.8 mEq/L. Which of the following is
the most appropriate next step?
A. Increase lithium to 1200 mg daily
B. Add olanzapine 5 mg daily
C. Add lamotrigine 25 mg daily
D. Transition to valproic acid 500 mg BID
Correct Answer: B
Rationale: The patient is experiencing a manic episode despite therapeutic lithium levels (0.6-
1.2 mEq/L). Adding an atypical antipsychotic such as olanzapine is the recommended approach
for acute mania management when lithium alone is insufficient. Increasing lithium without
addressing the acute episode would be insufficient. Lamotrigine is not effective for acute mania.
Valproic acid is an alternative but not the first add-on choice.
Question 2
A 45-year-old male with major depressive disorder has failed trials of fluoxetine, sertraline, and
venlafaxine. He reports increased appetite, hypersomnia, and extreme fatigue. Which
medication would be most appropriate as an adjunctive treatment?
A. Bupropion
B. Mirtazapine
C. Aripiprazole
D. Lithium
Correct Answer: C
Rationale: This patient exhibits atypical features of depression (increased appetite,
,hypersomnia, fatigue) and has failed multiple antidepressant trials. Aripiprazole is FDA-
approved as an adjunctive treatment for treatment-resistant depression. Bupropion is activating
but may worsen anxiety. Mirtazapine would increase appetite and sedation, exacerbating
symptoms. Lithium is less commonly used as a first-line adjunctive for depression without
bipolar features.
Question 3
Which neurotransmitter system is primarily implicated in the pathophysiology of positive
symptoms of schizophrenia?
A. Serotonin (5-HT2A)
B. Dopamine (D2)
C. Gamma-aminobutyric acid (GABA)
D. Glutamate (NMDA)
Correct Answer: B
Rationale: Hyperactivity of dopaminergic pathways, particularly the mesolimbic pathway, is
associated with positive psychotic symptoms including hallucinations and delusions. Serotonin
dysregulation is more implicated in mood and negative symptoms. GABA and glutamate
abnormalities are associated with cognitive symptoms and the neurodevelopmental model of
schizophrenia.
Question 4
A 72-year-old male with Parkinson's disease develops visual hallucinations of people in his
home. He has no prior psychiatric history. His current medications include carbidopa-levodopa
and pramipexole. What is the most appropriate initial management strategy?
A. Initiate quetiapine 25 mg at bedtime
B. Add rivastigmine 1.5 mg BID
C. Reduce or discontinue pramipexole
D. Start haloperidol 0.5 mg daily
Correct Answer: C
Rationale: Dopamine agonists like pramipexole are common causes of hallucinations in
Parkinson's disease. The first step is to reduce or discontinue the dopamine agonist. Quetiapine
may be used if symptoms persist but is not first-line. Rivastigmine is for dementia-related
, psychosis. Haloperidol should be avoided in Parkinson's disease due to extrapyramidal side
effects.
Question 5
A 16-year-old female is brought to the clinic by her parents for excessive worry, difficulty
concentrating, and sleep disturbance for the past 8 months. She reports feeling "on edge" most
days and avoids social situations due to fear of embarrassment. Which of the following is the
most appropriate first-line pharmacological treatment?
A. Fluoxetine 10 mg daily
B. Alprazolam 0.25 mg PRN
C. Buspirone 5 mg BID
D. Sertraline 25 mg daily
Correct Answer: D
Rationale: For generalized anxiety disorder in adolescents, SSRIs such as sertraline are first-line
pharmacotherapy. Fluoxetine is also an option but sertraline is often preferred for anxiety
disorders. Benzodiazepines are not first-line in adolescents due to dependence risk. Buspirone
has limited evidence in pediatric populations.
Question 6
A 34-year-old female with PTSD reports recurrent nightmares, hypervigilance, and avoidance of
reminders of a traumatic event that occurred 18 months ago. She has tried paroxetine without
significant improvement. Which medication has the strongest evidence for PTSD-related
nightmares?
A. Prazosin
B. Trazodone
C. Clonidine
D. Hydroxyzine
Correct Answer: A
Rationale: Prazosin, an alpha-1 adrenergic antagonist, has demonstrated efficacy in reducing
trauma-related nightmares and improving sleep quality in PTSD. Trazodone is used for insomnia
but has less specific evidence for PTSD nightmares. Clonidine and hydroxyzine are not first-line
for this indication.
certificatioN exaM iii
coMPreHeNsive 150-QuestioN
Practice exaMiNatioN for
PsycHiatric-MeNtal HealtH
Nurse PractitioNer Board
certificatioN a well detailed
oNe writteN aNd
graded a+ uPgraded
Exam Domains Covered: Psychopharmacology, Neurobiology & Pathophysiology, Differential
Diagnosis & Psychiatric Assessment, Psychotherapy & Therapeutic Interventions, Ethics & Legal
Issues, Crisis Management, and Evidence-Based Practice Across the Lifespan
,Instructions
This examination consists of 150 multiple-choice questions designed to assess advanced clinical
knowledge and decision-making skills required for PMHNP board certification. Each question
has one correct answer. Select the best response based on current evidence-based practice,
DSM-5-TR criteria, and standard psychiatric nursing guidelines. Questions range from
foundational knowledge to complex clinical scenarios requiring synthesis of multiple domains.
Question 1
A 28-year-old female with a history of bipolar I disorder presents with a 4-day history of
escalating mood, decreased need for sleep, racing thoughts, and reckless spending. She is
currently taking lithium 900 mg daily with a serum level of 0.8 mEq/L. Which of the following is
the most appropriate next step?
A. Increase lithium to 1200 mg daily
B. Add olanzapine 5 mg daily
C. Add lamotrigine 25 mg daily
D. Transition to valproic acid 500 mg BID
Correct Answer: B
Rationale: The patient is experiencing a manic episode despite therapeutic lithium levels (0.6-
1.2 mEq/L). Adding an atypical antipsychotic such as olanzapine is the recommended approach
for acute mania management when lithium alone is insufficient. Increasing lithium without
addressing the acute episode would be insufficient. Lamotrigine is not effective for acute mania.
Valproic acid is an alternative but not the first add-on choice.
Question 2
A 45-year-old male with major depressive disorder has failed trials of fluoxetine, sertraline, and
venlafaxine. He reports increased appetite, hypersomnia, and extreme fatigue. Which
medication would be most appropriate as an adjunctive treatment?
A. Bupropion
B. Mirtazapine
C. Aripiprazole
D. Lithium
Correct Answer: C
Rationale: This patient exhibits atypical features of depression (increased appetite,
,hypersomnia, fatigue) and has failed multiple antidepressant trials. Aripiprazole is FDA-
approved as an adjunctive treatment for treatment-resistant depression. Bupropion is activating
but may worsen anxiety. Mirtazapine would increase appetite and sedation, exacerbating
symptoms. Lithium is less commonly used as a first-line adjunctive for depression without
bipolar features.
Question 3
Which neurotransmitter system is primarily implicated in the pathophysiology of positive
symptoms of schizophrenia?
A. Serotonin (5-HT2A)
B. Dopamine (D2)
C. Gamma-aminobutyric acid (GABA)
D. Glutamate (NMDA)
Correct Answer: B
Rationale: Hyperactivity of dopaminergic pathways, particularly the mesolimbic pathway, is
associated with positive psychotic symptoms including hallucinations and delusions. Serotonin
dysregulation is more implicated in mood and negative symptoms. GABA and glutamate
abnormalities are associated with cognitive symptoms and the neurodevelopmental model of
schizophrenia.
Question 4
A 72-year-old male with Parkinson's disease develops visual hallucinations of people in his
home. He has no prior psychiatric history. His current medications include carbidopa-levodopa
and pramipexole. What is the most appropriate initial management strategy?
A. Initiate quetiapine 25 mg at bedtime
B. Add rivastigmine 1.5 mg BID
C. Reduce or discontinue pramipexole
D. Start haloperidol 0.5 mg daily
Correct Answer: C
Rationale: Dopamine agonists like pramipexole are common causes of hallucinations in
Parkinson's disease. The first step is to reduce or discontinue the dopamine agonist. Quetiapine
may be used if symptoms persist but is not first-line. Rivastigmine is for dementia-related
, psychosis. Haloperidol should be avoided in Parkinson's disease due to extrapyramidal side
effects.
Question 5
A 16-year-old female is brought to the clinic by her parents for excessive worry, difficulty
concentrating, and sleep disturbance for the past 8 months. She reports feeling "on edge" most
days and avoids social situations due to fear of embarrassment. Which of the following is the
most appropriate first-line pharmacological treatment?
A. Fluoxetine 10 mg daily
B. Alprazolam 0.25 mg PRN
C. Buspirone 5 mg BID
D. Sertraline 25 mg daily
Correct Answer: D
Rationale: For generalized anxiety disorder in adolescents, SSRIs such as sertraline are first-line
pharmacotherapy. Fluoxetine is also an option but sertraline is often preferred for anxiety
disorders. Benzodiazepines are not first-line in adolescents due to dependence risk. Buspirone
has limited evidence in pediatric populations.
Question 6
A 34-year-old female with PTSD reports recurrent nightmares, hypervigilance, and avoidance of
reminders of a traumatic event that occurred 18 months ago. She has tried paroxetine without
significant improvement. Which medication has the strongest evidence for PTSD-related
nightmares?
A. Prazosin
B. Trazodone
C. Clonidine
D. Hydroxyzine
Correct Answer: A
Rationale: Prazosin, an alpha-1 adrenergic antagonist, has demonstrated efficacy in reducing
trauma-related nightmares and improving sleep quality in PTSD. Trazodone is used for insomnia
but has less specific evidence for PTSD nightmares. Clonidine and hydroxyzine are not first-line
for this indication.
