NR 547 MIDTERM EXAM 2026-2027
ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS
A 52-year-old client presents to the emergency department following a car
accident. The emergency department (ED) physician is concerned that the client
may have intentionally crashed her car and requests a stat PMHNP consult. In
speaking with the PMHNP, the client describes persistent feelings of sadness and
hopelessness. She states that she often wonders if her husband would be
happier if she wasn't around anymore since she's never happy and sometimes
thinks about what it would be like to just take a handful of sleeping pills and go to
sleep forever. The client reports a previous suicide attempt when she was 16 but
denies that she is considering killing herself right now.
Based on the client's ASQ score, what is the most appropriate response?
No action is necessary as the client is not currently considering suicide.
Provide a brief suicide safety assessment.
Alert the client's primary care physician.
Provide a ST
Rationale: While the client's responses do not indicate a need for a stat full safety and
mental health evaluation, the client requires a brief suicide safety assessment to
determine whether a full mental health evaluation in necessary. It is also important to
notify the client's physician or the clinician responsible for the client's care.
Differential diagnosis
The provider's initial hypothesis
-a working list of potential problems that can be associated with the initial or chief
complaint
-Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)
• provides guidance for identifying psychiatric diagnoses
Psychiatric assessment: History taking
-History of Present Illness
-How long have you been feeling this way?
-Did something happen in your life that may have triggered these emotions?
-How is this current situation impacting your life?
The Psychiatric History
,-Have you ever been hospitalized for any mental health issues?
-Have you ever had counseling or psychotherapy?
-Have you ever taken medications for your mental health in the past?
-Are you currently on any medications for mental health or sleep?
Medical History/Screening for General Medical Conditions
-Do you have a primary care provider?
-Do you have any medical illnesses?
-Are you currently taking any medications or herbal supplements?
-Do you have any allergies to medications?
-Have you ever been hospitalized for any reason?
-Have you ever had surgery?
Family Psychiatric History
-Has any relative of yours ever been hospitalized for a mental health issue?
-Has any blood relative of yours ever been diagnosed with a mental health issue?
-Has any blood relative of yours had a history of seizures or dementia/Alzheimer's?
Social and Developmental History
-Tell me a little bit about your childhood and how you grew up.
-How was your experience in school when you were younger? Did you enjoy school?
-How do you support yourself with your finances?
-Do you have a good support system? Are you currently in a relationship? Where do
you live? Who do you live with?
-What do you do in your free time? What activities do you enjoy?
Screening and Psychiatric Rating Scales
Evidence-based screening tools and psychiatric rating scales
-can help the provider identify symptoms and assess their severity and can assist with
the evaluation of response to treatment
Diagnostic Testing when diagnosing mental health disorders
-Diagnostic tests and labs are most used to rule out physical conditions that may cause
psychiatric symptoms and to evaluate the effects of treatment
Basic Laboratory Interpretation
Complete Blood Count
Comprehensive Metabolic Panel (CMP)
Thyroid Function Tests
Vitamin B12 Level
Vitamin D Level
Toxicology Screen
Urinalysis (UA)
,Basic Laboratory Interpretation: Complete Blood Count
-measures RBCs, WBCs, hemoglobin, hematocrit, and platelets
-includes a differential of the WBCs
-In mental health, the CBC is used to rule out medical conditions that may present with
symptoms that can be attributed to both medical and psychiatric diagnoses
• Ex: rule out anemia as a cause for depressive symptoms and fatigue
• Ex: rule out infection as a cause of acute mental status changes
RBCs: 4.5-6.0 million/microliter
Hemoglobin: 12-18 grams/100 mL
Hematocrit: 38%-48%
Reticulocytes: 0%-1.5%
WBCs (total): 5000-10,000/microliter
Neutrophils: 55%-70%
Eosinophils: 1%-3%
Basophils: 0.5%-1%
Lymphocytes: 20%-35%
Monocytes: 3%-8%
Platelets: 150,000-300,000/microliter
Basic Laboratory Interpretation: Comprehensive Metabolic Panel (CMP)
common blood test used to determine general health status
-fluid and electrolyte balance, status of the body's metabolism, liver function, and kidney
function
-used to monitor the effects of medications, such as antipsychotics, on liver function and
glucose levels
-rule out medical conditions that could cause symptoms
• Ex: changes in mood or cognition
Sodium (Na+): 136-145 mEq/L
Postassium (K+): 3.5-5.0 mEq/L
Chloride (Cl-): 95-105 mEq/L
Bicarbonate (HCO3-): 22-28 mEq/L
Calcium, serum (Ca 2+) 8.4-10.2 mg/dl
Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl
Cholesterol, serum: REC<200 mg/dl
Total Protein 6.0-7.8 g/dl
Albumin 3.5-5.5 g/dl
-Kidney Tests
• Creatinine, serum 0.6-1.2mg/dl
• Urea nitrogen, serum (BUN) 7-18mg/dl
-Liver Tests
• Alanine aminotransferase (ALT), serum: 8-20 U/L
• Aspartate aminotransferase (AST), serum: 8-20 U/L
, • Bilirubin, serum (adult) Total//Direct: 0.1-1.0 mg/dl // 0.0-0.3 mg/dl
• Phosphatase (alkaline), serum: 20-70 U/L
Basic Laboratory Interpretation: Thyroid Function Tests (TFTs)
used to rule out thyroid disorders as a cause for symptoms
• symptoms related to thyroid disorders include anxiety, restlessness, depression, mood
swings, sleeping difficulties, difficulties with concentration, short-term memory lapses,
and lack of mental alertness
Normal TFT levels
TSH: 0.4-4.5 mIU/L
T3: 100-200 ng/dL
T4: 5-11 ug/dL
Basic Laboratory Interpretation: Vitamin B12 Level
Deficiency of vitamin B12 can affect mood and other brain functions
-psychiatric symptoms associated with B12 deficiency include depression, mania,
psychotic symptoms, and cognitive impairment
normal: 190-950 picograms/mL
• 200-300/mL indicates a borderline level with a possible need for additional testing
Basic Laboratory Interpretation: Vitamin D Level
affects functions such as neurotransmission, neuroprotection, &
neuroimmunomodulation
-high prevalence of vitamin D deficiency in clients with psychiatric disorders such as
schizophrenia, depression, seasonal affective disorder, and cognitive impairment
-Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis,
and poor brain development
25-hydroxy vitamin D blood test: normal 20-50 ng/mL, less than 12 ng/mL indicates a
deficiency
Basic Laboratory Interpretation: Toxicology Screen
-rule out substance use as a cause for symptoms
-used before starting therapy involving controlled substances
-used to monitor medication adherence
-used in the diagnosis of substance use disorder
Basic Laboratory Interpretation: Urinalysis (UA)
Urinary tract infections are associated with a variety of neuropsychiatric symptoms
-acute mental status changes
• UA may be used to rule out a UTI as the cause.
Treat or Refer:
Toni is a 58-year-old who presents with fatigue. Her TSH is 6.3 mIU/L.
Refer
Rationale: A TSH level >4.0 is indicative of hypothyroidism, which is associated with
fatigue. A referral for treatment of hypothyroidism is required. Client can be reevaluated
for fatigue if symptoms persist after hypothyroid treatment has been initiated, TSH
levels are within normal limits.
ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS
A 52-year-old client presents to the emergency department following a car
accident. The emergency department (ED) physician is concerned that the client
may have intentionally crashed her car and requests a stat PMHNP consult. In
speaking with the PMHNP, the client describes persistent feelings of sadness and
hopelessness. She states that she often wonders if her husband would be
happier if she wasn't around anymore since she's never happy and sometimes
thinks about what it would be like to just take a handful of sleeping pills and go to
sleep forever. The client reports a previous suicide attempt when she was 16 but
denies that she is considering killing herself right now.
Based on the client's ASQ score, what is the most appropriate response?
No action is necessary as the client is not currently considering suicide.
Provide a brief suicide safety assessment.
Alert the client's primary care physician.
Provide a ST
Rationale: While the client's responses do not indicate a need for a stat full safety and
mental health evaluation, the client requires a brief suicide safety assessment to
determine whether a full mental health evaluation in necessary. It is also important to
notify the client's physician or the clinician responsible for the client's care.
Differential diagnosis
The provider's initial hypothesis
-a working list of potential problems that can be associated with the initial or chief
complaint
-Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)
• provides guidance for identifying psychiatric diagnoses
Psychiatric assessment: History taking
-History of Present Illness
-How long have you been feeling this way?
-Did something happen in your life that may have triggered these emotions?
-How is this current situation impacting your life?
The Psychiatric History
,-Have you ever been hospitalized for any mental health issues?
-Have you ever had counseling or psychotherapy?
-Have you ever taken medications for your mental health in the past?
-Are you currently on any medications for mental health or sleep?
Medical History/Screening for General Medical Conditions
-Do you have a primary care provider?
-Do you have any medical illnesses?
-Are you currently taking any medications or herbal supplements?
-Do you have any allergies to medications?
-Have you ever been hospitalized for any reason?
-Have you ever had surgery?
Family Psychiatric History
-Has any relative of yours ever been hospitalized for a mental health issue?
-Has any blood relative of yours ever been diagnosed with a mental health issue?
-Has any blood relative of yours had a history of seizures or dementia/Alzheimer's?
Social and Developmental History
-Tell me a little bit about your childhood and how you grew up.
-How was your experience in school when you were younger? Did you enjoy school?
-How do you support yourself with your finances?
-Do you have a good support system? Are you currently in a relationship? Where do
you live? Who do you live with?
-What do you do in your free time? What activities do you enjoy?
Screening and Psychiatric Rating Scales
Evidence-based screening tools and psychiatric rating scales
-can help the provider identify symptoms and assess their severity and can assist with
the evaluation of response to treatment
Diagnostic Testing when diagnosing mental health disorders
-Diagnostic tests and labs are most used to rule out physical conditions that may cause
psychiatric symptoms and to evaluate the effects of treatment
Basic Laboratory Interpretation
Complete Blood Count
Comprehensive Metabolic Panel (CMP)
Thyroid Function Tests
Vitamin B12 Level
Vitamin D Level
Toxicology Screen
Urinalysis (UA)
,Basic Laboratory Interpretation: Complete Blood Count
-measures RBCs, WBCs, hemoglobin, hematocrit, and platelets
-includes a differential of the WBCs
-In mental health, the CBC is used to rule out medical conditions that may present with
symptoms that can be attributed to both medical and psychiatric diagnoses
• Ex: rule out anemia as a cause for depressive symptoms and fatigue
• Ex: rule out infection as a cause of acute mental status changes
RBCs: 4.5-6.0 million/microliter
Hemoglobin: 12-18 grams/100 mL
Hematocrit: 38%-48%
Reticulocytes: 0%-1.5%
WBCs (total): 5000-10,000/microliter
Neutrophils: 55%-70%
Eosinophils: 1%-3%
Basophils: 0.5%-1%
Lymphocytes: 20%-35%
Monocytes: 3%-8%
Platelets: 150,000-300,000/microliter
Basic Laboratory Interpretation: Comprehensive Metabolic Panel (CMP)
common blood test used to determine general health status
-fluid and electrolyte balance, status of the body's metabolism, liver function, and kidney
function
-used to monitor the effects of medications, such as antipsychotics, on liver function and
glucose levels
-rule out medical conditions that could cause symptoms
• Ex: changes in mood or cognition
Sodium (Na+): 136-145 mEq/L
Postassium (K+): 3.5-5.0 mEq/L
Chloride (Cl-): 95-105 mEq/L
Bicarbonate (HCO3-): 22-28 mEq/L
Calcium, serum (Ca 2+) 8.4-10.2 mg/dl
Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl
Cholesterol, serum: REC<200 mg/dl
Total Protein 6.0-7.8 g/dl
Albumin 3.5-5.5 g/dl
-Kidney Tests
• Creatinine, serum 0.6-1.2mg/dl
• Urea nitrogen, serum (BUN) 7-18mg/dl
-Liver Tests
• Alanine aminotransferase (ALT), serum: 8-20 U/L
• Aspartate aminotransferase (AST), serum: 8-20 U/L
, • Bilirubin, serum (adult) Total//Direct: 0.1-1.0 mg/dl // 0.0-0.3 mg/dl
• Phosphatase (alkaline), serum: 20-70 U/L
Basic Laboratory Interpretation: Thyroid Function Tests (TFTs)
used to rule out thyroid disorders as a cause for symptoms
• symptoms related to thyroid disorders include anxiety, restlessness, depression, mood
swings, sleeping difficulties, difficulties with concentration, short-term memory lapses,
and lack of mental alertness
Normal TFT levels
TSH: 0.4-4.5 mIU/L
T3: 100-200 ng/dL
T4: 5-11 ug/dL
Basic Laboratory Interpretation: Vitamin B12 Level
Deficiency of vitamin B12 can affect mood and other brain functions
-psychiatric symptoms associated with B12 deficiency include depression, mania,
psychotic symptoms, and cognitive impairment
normal: 190-950 picograms/mL
• 200-300/mL indicates a borderline level with a possible need for additional testing
Basic Laboratory Interpretation: Vitamin D Level
affects functions such as neurotransmission, neuroprotection, &
neuroimmunomodulation
-high prevalence of vitamin D deficiency in clients with psychiatric disorders such as
schizophrenia, depression, seasonal affective disorder, and cognitive impairment
-Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis,
and poor brain development
25-hydroxy vitamin D blood test: normal 20-50 ng/mL, less than 12 ng/mL indicates a
deficiency
Basic Laboratory Interpretation: Toxicology Screen
-rule out substance use as a cause for symptoms
-used before starting therapy involving controlled substances
-used to monitor medication adherence
-used in the diagnosis of substance use disorder
Basic Laboratory Interpretation: Urinalysis (UA)
Urinary tract infections are associated with a variety of neuropsychiatric symptoms
-acute mental status changes
• UA may be used to rule out a UTI as the cause.
Treat or Refer:
Toni is a 58-year-old who presents with fatigue. Her TSH is 6.3 mIU/L.
Refer
Rationale: A TSH level >4.0 is indicative of hypothyroidism, which is associated with
fatigue. A referral for treatment of hypothyroidism is required. Client can be reevaluated
for fatigue if symptoms persist after hypothyroid treatment has been initiated, TSH
levels are within normal limits.
