PMHNP Board Certification 2026:
Practice Questions with Evidence-
Based Rationales
1. A 25-year-old patient presents with depressed mood, anhedonia,
and insomnia for 3 weeks. The best initial pharmacologic treatment is:
A. Sertraline
B. Lithium
C. Haloperidol
D. Buspirone
Answer: A. Sertraline
Rationale: Sertraline is a first-line SSRI for major depressive disorder. SSRIs
are preferred due to their favorable side-effect profile and efficacy. Lithium
is a mood stabilizer primarily for bipolar disorder, haloperidol is an
antipsychotic, and buspirone is for anxiety disorders.
2. Which medication is considered first-line for generalized anxiety
disorder?
A. Lorazepam
B. Paroxetine
C. Imipramine
D. Risperidone
,Answer: B. Paroxetine
Rationale: Paroxetine (an SSRI) is a first-line treatment for GAD, along with
other SSRIs and SNRIs. Lorazepam (benzodiazepine) is used for short-term
relief but not first-line due to dependence risk. Imipramine (TCA) and
risperidone (antipsychotic) are not first-line for GAD.
3. A patient on fluoxetine develops serotonin syndrome. Which
symptom is NOT typical?
A. Agitation
B. Hyperreflexia
C. Bradycardia
D. Diaphoresis
Answer: C. Bradycardia
Rationale: Serotonin syndrome presents with agitation, hyperreflexia,
diaphoresis, tachycardia (not bradycardia), tremor, and confusion.
Bradycardia is not characteristic; tachycardia and hypertension are more
common.
4. The primary indication for lithium therapy is:
A. Schizophrenia
B. Bipolar disorder
C. Major depressive disorder
D. Panic disorder
,Answer: B. Bipolar disorder
Rationale: Lithium is the gold standard mood stabilizer for bipolar
disorder, particularly for acute mania and maintenance. It is not first-line for
schizophrenia, unipolar depression, or panic disorder.
5. A patient on lithium presents with tremor, nausea, and polyuria. The
next step is:
A. Increase the dose
B. Check serum lithium level
C. Start a diuretic
D. Switch to valproate
Answer: B. Check serum lithium level
Rationale: Tremor, nausea, and polyuria are signs of possible lithium
toxicity. The serum lithium level must be checked immediately to guide
management. Increasing the dose would worsen toxicity; diuretics can
increase lithium levels; switching prematurely is not the first step.
6. Which antipsychotic has the lowest risk of metabolic syndrome?
A. Olanzapine
B. Clozapine
C. Ziprasidone
D. Quetiapine
, Answer: C. Ziprasidone
Rationale: Ziprasidone and aripiprazole have the lowest metabolic side-
effect profiles among atypical antipsychotics. Olanzapine and clozapine
carry the highest risk of weight gain, diabetes, and dyslipidemia; quetiapine
has moderate risk.
7. Clozapine therapy requires monitoring of:
A. Liver enzymes
B. White blood cell count
C. Serum sodium
D. Blood glucose only
Answer: B. White blood cell count
Rationale: Clozapine carries a risk of agranulocytosis, necessitating regular
monitoring of absolute neutrophil count (ANC) via the REMS program. Liver
enzymes, sodium, and glucose are not the primary required monitoring
parameters for clozapine.
8. Which SSRI is preferred in pregnancy?
A. Paroxetine
B. Fluoxetine
C. Sertraline
D. Citalopram
Practice Questions with Evidence-
Based Rationales
1. A 25-year-old patient presents with depressed mood, anhedonia,
and insomnia for 3 weeks. The best initial pharmacologic treatment is:
A. Sertraline
B. Lithium
C. Haloperidol
D. Buspirone
Answer: A. Sertraline
Rationale: Sertraline is a first-line SSRI for major depressive disorder. SSRIs
are preferred due to their favorable side-effect profile and efficacy. Lithium
is a mood stabilizer primarily for bipolar disorder, haloperidol is an
antipsychotic, and buspirone is for anxiety disorders.
2. Which medication is considered first-line for generalized anxiety
disorder?
A. Lorazepam
B. Paroxetine
C. Imipramine
D. Risperidone
,Answer: B. Paroxetine
Rationale: Paroxetine (an SSRI) is a first-line treatment for GAD, along with
other SSRIs and SNRIs. Lorazepam (benzodiazepine) is used for short-term
relief but not first-line due to dependence risk. Imipramine (TCA) and
risperidone (antipsychotic) are not first-line for GAD.
3. A patient on fluoxetine develops serotonin syndrome. Which
symptom is NOT typical?
A. Agitation
B. Hyperreflexia
C. Bradycardia
D. Diaphoresis
Answer: C. Bradycardia
Rationale: Serotonin syndrome presents with agitation, hyperreflexia,
diaphoresis, tachycardia (not bradycardia), tremor, and confusion.
Bradycardia is not characteristic; tachycardia and hypertension are more
common.
4. The primary indication for lithium therapy is:
A. Schizophrenia
B. Bipolar disorder
C. Major depressive disorder
D. Panic disorder
,Answer: B. Bipolar disorder
Rationale: Lithium is the gold standard mood stabilizer for bipolar
disorder, particularly for acute mania and maintenance. It is not first-line for
schizophrenia, unipolar depression, or panic disorder.
5. A patient on lithium presents with tremor, nausea, and polyuria. The
next step is:
A. Increase the dose
B. Check serum lithium level
C. Start a diuretic
D. Switch to valproate
Answer: B. Check serum lithium level
Rationale: Tremor, nausea, and polyuria are signs of possible lithium
toxicity. The serum lithium level must be checked immediately to guide
management. Increasing the dose would worsen toxicity; diuretics can
increase lithium levels; switching prematurely is not the first step.
6. Which antipsychotic has the lowest risk of metabolic syndrome?
A. Olanzapine
B. Clozapine
C. Ziprasidone
D. Quetiapine
, Answer: C. Ziprasidone
Rationale: Ziprasidone and aripiprazole have the lowest metabolic side-
effect profiles among atypical antipsychotics. Olanzapine and clozapine
carry the highest risk of weight gain, diabetes, and dyslipidemia; quetiapine
has moderate risk.
7. Clozapine therapy requires monitoring of:
A. Liver enzymes
B. White blood cell count
C. Serum sodium
D. Blood glucose only
Answer: B. White blood cell count
Rationale: Clozapine carries a risk of agranulocytosis, necessitating regular
monitoring of absolute neutrophil count (ANC) via the REMS program. Liver
enzymes, sodium, and glucose are not the primary required monitoring
parameters for clozapine.
8. Which SSRI is preferred in pregnancy?
A. Paroxetine
B. Fluoxetine
C. Sertraline
D. Citalopram
