Barkley PMHNP Mock Certification
Exam III - Version 2.0 Advanced Clinical
Practice and Differential Diagnosis in
Psychiatric-Mental Health Nursing a
well detailed one written
and graded A+ upgraded
Instructions
This comprehensive 150-question examination is designed to assess advanced clinical
knowledge, diagnostic reasoning, and evidence-based prescribing practices required for PMHNP
board certification. Questions reflect current DSM-5-TR criteria, FDA-approved indications, and
standard of care guidelines. Each question has ONE correct answer. Select the best response
based on clinical evidence and safety considerations.
Question 1
A 42-year-old female with major depressive disorder presents with a 3-week history of
anhedonia, psychomotor retardation, and excessive guilt. She reports her symptoms are
,significantly worse in the morning and she awakens at 4:00 AM daily. Which of the following
best describes her symptom presentation?
A. Atypical features
B. Melancholic features
C. Catatonic features
D. Psychotic features
Correct Answer: B
Rationale: Melancholic features include early morning awakening, diurnal mood variation with
worsening in the morning, psychomotor retardation or agitation, significant anorexia, and
excessive guilt. Atypical features include mood reactivity and reversed neurovegetative
symptoms.
Question 2
A 55-year-old male with schizophrenia has been stable on fluphenazine decanoate 25 mg every
2 weeks for 5 years. He now presents with involuntary chewing movements and tongue
protrusion. Which of the following is the most appropriate next step?
A. Increase fluphenazine dose
B. Add benztropine 1 mg BID
C. Switch to clozapine
D. Add valbenazine 40 mg daily
Correct Answer: C
Rationale: The patient is demonstrating tardive dyskinesia. Valbenazine and deutetrabenazine
are FDA-approved for TD, but clozapine is the antipsychotic of choice when TD develops as it has
the lowest risk of worsening TD. Switching to clozapine addresses both psychosis and TD risk.
Question 3
A 28-year-old female with no psychiatric history presents to the emergency department with
acute-onset confusion, visual hallucinations, and fluctuating consciousness. She is febrile and
tachycardic. Her family reports she recently started taking prednisone for asthma. Which
diagnosis is most likely?
A. Schizophrenia
B. Brief psychotic disorder
,C. Delirium
D. Substance-induced psychotic disorder
Correct Answer: C
Rationale: Delirium is characterized by acute onset, fluctuating course, inattention, and altered
consciousness. Corticosteroids are a common cause of medication-induced delirium. The acute
presentation and fluctuating consciousness distinguish it from primary psychiatric disorders.
Question 4
A 62-year-old male with Parkinson's disease and dementia with Lewy bodies is experiencing
visual hallucinations that are distressing. His current medications include carbidopa-levodopa.
Which antipsychotic is most appropriate?
A. Haloperidol 0.5 mg daily
B. Quetiapine 12.5 mg at bedtime
C. Olanzapine 2.5 mg daily
D. Risperidone 0.5 mg BID
Correct Answer: B
Rationale: Quetiapine is preferred in patients with Parkinson's disease and dementia with Lewy
bodies due to its lower risk of extrapyramidal symptoms. Haloperidol carries significant EPS risk.
Olanzapine and risperidone have higher EPS risk than quetiapine.
Question 5
A 34-year-old female with bipolar I disorder is currently experiencing a depressive episode. She
is already on lithium 900 mg daily (level 0.9 mEq/L) and lamotrigine 200 mg daily. Which of the
following is the most appropriate augmentation strategy?
A. Add quetiapine 300 mg daily
B. Add fluoxetine 20 mg daily
C. Increase lithium to 1200 mg daily
D. Add valproic acid 500 mg BID
Correct Answer: A
Rationale: Quetiapine is FDA-approved for bipolar depression and can be added to mood
stabilizers. Fluoxetine carries risk of mood destabilization. Valproic acid is less effective for
bipolar depression than quetiapine.
, Question 6
A 45-year-old male with treatment-resistant depression has failed trials of sertraline,
venlafaxine, and bupropion. He is started on esketamine nasal spray. Which monitoring
parameter is most critical immediately following administration?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Oxygen saturation
Correct Answer: A
Rationale: Esketamine can cause transient blood pressure elevations. Blood pressure must be
monitored for at least 2 hours post-administration. Patients require monitoring in a healthcare
setting.
Question 7
A 19-year-old male with first-episode psychosis is started on risperidone 2 mg daily. He develops
severe neck stiffness and upward eye deviation. Which intervention is most appropriate?
A. Diphenhydramine 50 mg IM
B. Propranolol 20 mg PO
C. Benztropine 2 mg IM
D. A or C
Correct Answer: D
Rationale: Acute dystonia is a medical emergency requiring anticholinergic treatment. Both
diphenhydramine and benztropine are appropriate. Propranolol is for akathisia.
Question 8
A 58-year-old female with generalized anxiety disorder has been on alprazolam 0.5 mg TID for 6
months. She reports needing to increase her dose for the same effect. This phenomenon is best
described as:
A. Tolerance
B. Dependence
Exam III - Version 2.0 Advanced Clinical
Practice and Differential Diagnosis in
Psychiatric-Mental Health Nursing a
well detailed one written
and graded A+ upgraded
Instructions
This comprehensive 150-question examination is designed to assess advanced clinical
knowledge, diagnostic reasoning, and evidence-based prescribing practices required for PMHNP
board certification. Questions reflect current DSM-5-TR criteria, FDA-approved indications, and
standard of care guidelines. Each question has ONE correct answer. Select the best response
based on clinical evidence and safety considerations.
Question 1
A 42-year-old female with major depressive disorder presents with a 3-week history of
anhedonia, psychomotor retardation, and excessive guilt. She reports her symptoms are
,significantly worse in the morning and she awakens at 4:00 AM daily. Which of the following
best describes her symptom presentation?
A. Atypical features
B. Melancholic features
C. Catatonic features
D. Psychotic features
Correct Answer: B
Rationale: Melancholic features include early morning awakening, diurnal mood variation with
worsening in the morning, psychomotor retardation or agitation, significant anorexia, and
excessive guilt. Atypical features include mood reactivity and reversed neurovegetative
symptoms.
Question 2
A 55-year-old male with schizophrenia has been stable on fluphenazine decanoate 25 mg every
2 weeks for 5 years. He now presents with involuntary chewing movements and tongue
protrusion. Which of the following is the most appropriate next step?
A. Increase fluphenazine dose
B. Add benztropine 1 mg BID
C. Switch to clozapine
D. Add valbenazine 40 mg daily
Correct Answer: C
Rationale: The patient is demonstrating tardive dyskinesia. Valbenazine and deutetrabenazine
are FDA-approved for TD, but clozapine is the antipsychotic of choice when TD develops as it has
the lowest risk of worsening TD. Switching to clozapine addresses both psychosis and TD risk.
Question 3
A 28-year-old female with no psychiatric history presents to the emergency department with
acute-onset confusion, visual hallucinations, and fluctuating consciousness. She is febrile and
tachycardic. Her family reports she recently started taking prednisone for asthma. Which
diagnosis is most likely?
A. Schizophrenia
B. Brief psychotic disorder
,C. Delirium
D. Substance-induced psychotic disorder
Correct Answer: C
Rationale: Delirium is characterized by acute onset, fluctuating course, inattention, and altered
consciousness. Corticosteroids are a common cause of medication-induced delirium. The acute
presentation and fluctuating consciousness distinguish it from primary psychiatric disorders.
Question 4
A 62-year-old male with Parkinson's disease and dementia with Lewy bodies is experiencing
visual hallucinations that are distressing. His current medications include carbidopa-levodopa.
Which antipsychotic is most appropriate?
A. Haloperidol 0.5 mg daily
B. Quetiapine 12.5 mg at bedtime
C. Olanzapine 2.5 mg daily
D. Risperidone 0.5 mg BID
Correct Answer: B
Rationale: Quetiapine is preferred in patients with Parkinson's disease and dementia with Lewy
bodies due to its lower risk of extrapyramidal symptoms. Haloperidol carries significant EPS risk.
Olanzapine and risperidone have higher EPS risk than quetiapine.
Question 5
A 34-year-old female with bipolar I disorder is currently experiencing a depressive episode. She
is already on lithium 900 mg daily (level 0.9 mEq/L) and lamotrigine 200 mg daily. Which of the
following is the most appropriate augmentation strategy?
A. Add quetiapine 300 mg daily
B. Add fluoxetine 20 mg daily
C. Increase lithium to 1200 mg daily
D. Add valproic acid 500 mg BID
Correct Answer: A
Rationale: Quetiapine is FDA-approved for bipolar depression and can be added to mood
stabilizers. Fluoxetine carries risk of mood destabilization. Valproic acid is less effective for
bipolar depression than quetiapine.
, Question 6
A 45-year-old male with treatment-resistant depression has failed trials of sertraline,
venlafaxine, and bupropion. He is started on esketamine nasal spray. Which monitoring
parameter is most critical immediately following administration?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Oxygen saturation
Correct Answer: A
Rationale: Esketamine can cause transient blood pressure elevations. Blood pressure must be
monitored for at least 2 hours post-administration. Patients require monitoring in a healthcare
setting.
Question 7
A 19-year-old male with first-episode psychosis is started on risperidone 2 mg daily. He develops
severe neck stiffness and upward eye deviation. Which intervention is most appropriate?
A. Diphenhydramine 50 mg IM
B. Propranolol 20 mg PO
C. Benztropine 2 mg IM
D. A or C
Correct Answer: D
Rationale: Acute dystonia is a medical emergency requiring anticholinergic treatment. Both
diphenhydramine and benztropine are appropriate. Propranolol is for akathisia.
Question 8
A 58-year-old female with generalized anxiety disorder has been on alprazolam 0.5 mg TID for 6
months. She reports needing to increase her dose for the same effect. This phenomenon is best
described as:
A. Tolerance
B. Dependence
