NR 546 PRACTICE QUESTIONS AND ANSWERS
Original PMHNP Board/Course Review Set · 65 Questions with Rationales · Covers Mood Disorders,
Anxiety/OCD/Trauma, Psychotic Disorders, Substance Use, Child/Adolescent, Geriatric, and Legal/Ethical
Topics
Note: These are original practice questions written for study purposes and are not sourced from any specific exam or
test bank. Use them to check your understanding of core PMHNP concepts.
Section 1: Mood Disorders and Neurobiology
1. A patient reports at least two years of chronic low-grade depressive symptoms that never
fully remit for more than two months at a time, without ever meeting full criteria for a major
depressive episode. Which diagnosis fits best?
A) Major depressive disorder, recurrent
B) Persistent depressive disorder (dysthymia)
C) Cyclothymic disorder
D) Adjustment disorder with depressed mood
Correct Answer: Persistent depressive disorder (dysthymia)
Rationale: Persistent depressive disorder is defined by chronic depressed mood lasting at least two years
in adults (one year in children/adolescents), with symptom-free intervals no longer than two months. It may
or may not include periods that meet full major depressive episode criteria, distinguishing it from
adjustment disorder, which requires a clear precipitating stressor and resolves within six months of
stressor removal.
2. Which brain structure's dysregulation is most consistently implicated in the impaired
hypothalamic-pituitary-adrenal (HPA) axis feedback seen in major depression?
A) Cerebellum
B) Hippocampus
C) Occipital lobe
D) Basal ganglia only
Correct Answer: Hippocampus
Rationale: Chronic hypercortisolism in depression is linked to reduced hippocampal glucocorticoid receptor
sensitivity, impairing negative feedback on the HPA axis. This contributes to sustained cortisol elevation
and is associated with the reduced hippocampal volume seen in some depressed patients.
3. A patient with bipolar I disorder describes past episodes of decreased need for sleep,
grandiosity, and rapid speech lasting most of the day for over a week, with significant
occupational impairment. What best characterizes this presentation?
A) Hypomanic episode
B) Mixed anxiety-depression
C) Manic episode
D) Cyclothymic pattern
Correct Answer: Manic episode
Rationale: A manic episode requires abnormally elevated, expansive, or irritable mood and increased
energy for at least one week (or any duration if hospitalization is required), with associated symptoms
causing marked functional impairment — distinguishing it from hypomania, which by definition does not
,cause marked impairment.
4. Which of the following most strongly increases suspicion of bipolar disorder in a patient
initially diagnosed with unipolar depression?
A) Onset of depression at age 45
B) Depression that improved with cognitive behavioral therapy
C) A family history of bipolar disorder and early-onset, recurrent depressive episodes
D) Depression accompanied by generalized anxiety
Correct Answer: A family history of bipolar disorder and early-onset, recurrent depressive
episodes
Rationale: Family history of bipolar disorder, early age of onset, high recurrence, atypical features, and
psychotic features in depression are all recognized red flags that raise suspicion for an underlying bipolar
diathesis, prompting caution with antidepressant monotherapy.
5. What is the primary neurobiological rationale for augmenting an antidepressant with an
atypical antipsychotic in treatment-resistant depression?
A) Atypical antipsychotics have no receptor activity relevant to mood
B) Partial dopamine and serotonin receptor modulation may enhance monoaminergic
antidepressant effects
C) They eliminate the need for psychotherapy
D) They work exclusively through anticholinergic blockade
Correct Answer: Partial dopamine and serotonin receptor modulation may enhance
monoaminergic antidepressant effects
Rationale: Several atypical antipsychotics (e.g., aripiprazole, quetiapine) have FDA-approved
augmentation indications in treatment-resistant depression. Their serotonin-dopamine receptor activity is
thought to complement monoaminergic antidepressant mechanisms, improving response in patients with
inadequate benefit from an antidepressant alone.
6. A patient describes recurrent depressive episodes only during fall and winter months, with
full remission in spring and summer. Which specifier applies?
A) Melancholic features
B) Atypical features
C) Seasonal pattern
D) Peripartum onset
Correct Answer: Seasonal pattern
Rationale: The seasonal pattern specifier applies when there is a regular temporal relationship between
the onset of major depressive episodes and a particular time of year, most classically fall/winter onset with
remission in spring, and is thought to relate to circadian and light-related mechanisms.
7. Which finding is most characteristic of melancholic features in major depressive disorder?
A) Mood reactivity to positive events
B) Increased appetite and weight gain
C) Anhedonia with lack of mood reactivity and worse mood in the morning
D) Leaden paralysis of the limbs
Correct Answer: Anhedonia with lack of mood reactivity and worse mood in the morning
, Rationale: Melancholic features include profound anhedonia, mood that does not brighten even
temporarily in response to positive events, distinct quality of depressed mood, worse mood in the morning,
early morning awakening, and psychomotor changes — contrasting with atypical features (mood reactivity,
hyperphagia, hypersomnia, leaden paralysis).
8. A postpartum patient develops depressive symptoms with onset during pregnancy through
four weeks postpartum, per DSM-5 criteria. What specifier is used?
A) Postpartum psychosis
B) Peripartum onset
C) Baby blues
D) Seasonal pattern
Correct Answer: Peripartum onset
Rationale: DSM-5 uses the peripartum onset specifier for a major depressive episode with onset during
pregnancy or within four weeks after delivery, distinguishing it clinically from the much more common and
self-limited 'baby blues,' which resolves within two weeks without treatment.
9. Which of the following is the best description of the monoamine hypothesis of depression's
major limitation?
A) It has never been supported by any clinical evidence
B) It cannot explain the delayed onset of antidepressant therapeutic effect despite immediate
neurotransmitter changes
C) It only applies to bipolar disorder
D) It excludes serotonin from any role in mood
Correct Answer: It cannot explain the delayed onset of antidepressant therapeutic effect
despite immediate neurotransmitter changes
Rationale: A key criticism of the monoamine hypothesis is the mismatch between the rapid pharmacologic
increase in synaptic monoamines after starting an antidepressant and the typical two-to-four-week delay
before clinical improvement, suggesting downstream neuroplastic and receptor-adaptation changes are
more central to therapeutic effect.
10. A patient with a two-year history of hypomanic and mild depressive symptoms that never
meet full episode criteria, without symptom-free periods longer than two months, most likely
has which condition?
A) Bipolar II disorder
B) Cyclothymic disorder
C) Bipolar I disorder
D) Persistent depressive disorder
Correct Answer: Cyclothymic disorder
Rationale: Cyclothymic disorder involves numerous periods of hypomanic and depressive symptoms that
do not meet full criteria for hypomanic or major depressive episodes, present for at least two years in
adults, with no symptom-free interval exceeding two months.
Section 2: Antidepressants and Mood Stabilizers
11. A patient taking an SSRI develops agitation, diaphoresis, hyperreflexia, and tremor shortly
after a tramadol prescription is added. What is the most likely explanation?
Original PMHNP Board/Course Review Set · 65 Questions with Rationales · Covers Mood Disorders,
Anxiety/OCD/Trauma, Psychotic Disorders, Substance Use, Child/Adolescent, Geriatric, and Legal/Ethical
Topics
Note: These are original practice questions written for study purposes and are not sourced from any specific exam or
test bank. Use them to check your understanding of core PMHNP concepts.
Section 1: Mood Disorders and Neurobiology
1. A patient reports at least two years of chronic low-grade depressive symptoms that never
fully remit for more than two months at a time, without ever meeting full criteria for a major
depressive episode. Which diagnosis fits best?
A) Major depressive disorder, recurrent
B) Persistent depressive disorder (dysthymia)
C) Cyclothymic disorder
D) Adjustment disorder with depressed mood
Correct Answer: Persistent depressive disorder (dysthymia)
Rationale: Persistent depressive disorder is defined by chronic depressed mood lasting at least two years
in adults (one year in children/adolescents), with symptom-free intervals no longer than two months. It may
or may not include periods that meet full major depressive episode criteria, distinguishing it from
adjustment disorder, which requires a clear precipitating stressor and resolves within six months of
stressor removal.
2. Which brain structure's dysregulation is most consistently implicated in the impaired
hypothalamic-pituitary-adrenal (HPA) axis feedback seen in major depression?
A) Cerebellum
B) Hippocampus
C) Occipital lobe
D) Basal ganglia only
Correct Answer: Hippocampus
Rationale: Chronic hypercortisolism in depression is linked to reduced hippocampal glucocorticoid receptor
sensitivity, impairing negative feedback on the HPA axis. This contributes to sustained cortisol elevation
and is associated with the reduced hippocampal volume seen in some depressed patients.
3. A patient with bipolar I disorder describes past episodes of decreased need for sleep,
grandiosity, and rapid speech lasting most of the day for over a week, with significant
occupational impairment. What best characterizes this presentation?
A) Hypomanic episode
B) Mixed anxiety-depression
C) Manic episode
D) Cyclothymic pattern
Correct Answer: Manic episode
Rationale: A manic episode requires abnormally elevated, expansive, or irritable mood and increased
energy for at least one week (or any duration if hospitalization is required), with associated symptoms
causing marked functional impairment — distinguishing it from hypomania, which by definition does not
,cause marked impairment.
4. Which of the following most strongly increases suspicion of bipolar disorder in a patient
initially diagnosed with unipolar depression?
A) Onset of depression at age 45
B) Depression that improved with cognitive behavioral therapy
C) A family history of bipolar disorder and early-onset, recurrent depressive episodes
D) Depression accompanied by generalized anxiety
Correct Answer: A family history of bipolar disorder and early-onset, recurrent depressive
episodes
Rationale: Family history of bipolar disorder, early age of onset, high recurrence, atypical features, and
psychotic features in depression are all recognized red flags that raise suspicion for an underlying bipolar
diathesis, prompting caution with antidepressant monotherapy.
5. What is the primary neurobiological rationale for augmenting an antidepressant with an
atypical antipsychotic in treatment-resistant depression?
A) Atypical antipsychotics have no receptor activity relevant to mood
B) Partial dopamine and serotonin receptor modulation may enhance monoaminergic
antidepressant effects
C) They eliminate the need for psychotherapy
D) They work exclusively through anticholinergic blockade
Correct Answer: Partial dopamine and serotonin receptor modulation may enhance
monoaminergic antidepressant effects
Rationale: Several atypical antipsychotics (e.g., aripiprazole, quetiapine) have FDA-approved
augmentation indications in treatment-resistant depression. Their serotonin-dopamine receptor activity is
thought to complement monoaminergic antidepressant mechanisms, improving response in patients with
inadequate benefit from an antidepressant alone.
6. A patient describes recurrent depressive episodes only during fall and winter months, with
full remission in spring and summer. Which specifier applies?
A) Melancholic features
B) Atypical features
C) Seasonal pattern
D) Peripartum onset
Correct Answer: Seasonal pattern
Rationale: The seasonal pattern specifier applies when there is a regular temporal relationship between
the onset of major depressive episodes and a particular time of year, most classically fall/winter onset with
remission in spring, and is thought to relate to circadian and light-related mechanisms.
7. Which finding is most characteristic of melancholic features in major depressive disorder?
A) Mood reactivity to positive events
B) Increased appetite and weight gain
C) Anhedonia with lack of mood reactivity and worse mood in the morning
D) Leaden paralysis of the limbs
Correct Answer: Anhedonia with lack of mood reactivity and worse mood in the morning
, Rationale: Melancholic features include profound anhedonia, mood that does not brighten even
temporarily in response to positive events, distinct quality of depressed mood, worse mood in the morning,
early morning awakening, and psychomotor changes — contrasting with atypical features (mood reactivity,
hyperphagia, hypersomnia, leaden paralysis).
8. A postpartum patient develops depressive symptoms with onset during pregnancy through
four weeks postpartum, per DSM-5 criteria. What specifier is used?
A) Postpartum psychosis
B) Peripartum onset
C) Baby blues
D) Seasonal pattern
Correct Answer: Peripartum onset
Rationale: DSM-5 uses the peripartum onset specifier for a major depressive episode with onset during
pregnancy or within four weeks after delivery, distinguishing it clinically from the much more common and
self-limited 'baby blues,' which resolves within two weeks without treatment.
9. Which of the following is the best description of the monoamine hypothesis of depression's
major limitation?
A) It has never been supported by any clinical evidence
B) It cannot explain the delayed onset of antidepressant therapeutic effect despite immediate
neurotransmitter changes
C) It only applies to bipolar disorder
D) It excludes serotonin from any role in mood
Correct Answer: It cannot explain the delayed onset of antidepressant therapeutic effect
despite immediate neurotransmitter changes
Rationale: A key criticism of the monoamine hypothesis is the mismatch between the rapid pharmacologic
increase in synaptic monoamines after starting an antidepressant and the typical two-to-four-week delay
before clinical improvement, suggesting downstream neuroplastic and receptor-adaptation changes are
more central to therapeutic effect.
10. A patient with a two-year history of hypomanic and mild depressive symptoms that never
meet full episode criteria, without symptom-free periods longer than two months, most likely
has which condition?
A) Bipolar II disorder
B) Cyclothymic disorder
C) Bipolar I disorder
D) Persistent depressive disorder
Correct Answer: Cyclothymic disorder
Rationale: Cyclothymic disorder involves numerous periods of hypomanic and depressive symptoms that
do not meet full criteria for hypomanic or major depressive episodes, present for at least two years in
adults, with no symptom-free interval exceeding two months.
Section 2: Antidepressants and Mood Stabilizers
11. A patient taking an SSRI develops agitation, diaphoresis, hyperreflexia, and tremor shortly
after a tramadol prescription is added. What is the most likely explanation?
