NSG 527 Midterm Exam (Latest ) – 150+ Questions
& Verified Answers with Rationales | 100% Pass Guarantee –
Wilkes University PMHNP
1. A 34-year-old woman with major depressive disorder has been on sertraline 200 mg daily for
8 weeks with only a partial response. She reports a history of poor adherence due to forgetting
doses. Which strategy is most appropriate given her history?
A. Switch to fluoxetine 20 mg daily immediately, given its long half-life and similar side effect profile.
B. Augment with bupropion SR 150 mg twice daily to address residual symptoms and improve adherence.
C. Cross-taper sertraline to venlafaxine XR over 4 weeks, starting venlafaxine at 37.5 mg.
D. Increase sertraline to 300 mg daily, the maximum FDA-approved dose, before considering a switch.
Answer: B. Augment with bupropion SR 150 mg twice daily to address residual symptoms and
improve adherence.
2. In a patient with chronic schizophrenia who has persistent negative symptoms despite
adequate clozapine trial, which evidence-based intervention is most likely to improve functional
outcomes?
A. Increase clozapine to the maximum tolerated dose to further reduce D2 receptor occupancy.
B. Add a second antipsychotic, such as risperidone, to target negative symptoms specifically.
C. Refer for cognitive behavioral therapy for psychosis and social skills training.
D. Switch to a long-acting injectable antipsychotic to ensure adherence and reduce relapse.
Answer: C. Refer for cognitive behavioral therapy for psychosis and social skills training.
3. A 28-year-old man with generalized anxiety disorder has been treated with venlafaxine XR
225 mg daily for 12 weeks. He reports significant reduction in worry but still experiences
occasional panic attacks. He is unwilling to add a benzodiazepine. What is the best next
evidence-based step?
A. Increase venlafaxine to 300 mg daily, the maximum FDA-approved dose for GAD.
B. Add pregabalin 150 mg daily, an evidence-based augmentation for residual anxiety symptoms.
C. Refer for cognitive behavioral therapy specifically targeting panic symptoms.
D. Switch to an SSRI such as sertraline, as SSRIs are more effective for panic disorder.
Answer: C. Refer for cognitive behavioral therapy specifically targeting panic symptoms.
4. A 45-year-old man with bipolar I disorder, currently euthymic on lithium 900 mg daily (serum
level 0.8 mEq/L), reports new-onset tremor and polyuria. His renal function is normal. What is
the most appropriate next step in medication management?
A. Discontinue lithium and start valproic acid 1000 mg daily to avoid nephrotoxicity.
B. Reduce lithium dose to 600 mg daily and check a serum level in 1 week to keep within therapeutic range.
C. Switch to lamotrigine 200 mg daily as maintenance monotherapy, given its favorable side effect profile.
D. Continue lithium at the same dose and add a beta-blocker, such as propranolol 20 mg twice daily, for
tremor.
Answer: B. Reduce lithium dose to 600 mg daily and check a serum level in 1 week to keep
within therapeutic range.
5. A 67-year-old woman with major depressive disorder and mild cognitive impairment (MCI) is
started on paroxetine 20 mg daily. Which factor is most important to consider when monitoring
,this patient?
A. Paroxetine has strong anticholinergic effects that may worsen cognitive impairment, so consider alternative
SSRIs if symptoms worsen.
B. Paroxetine is safe in MCI, but the dose should be increased to 40 mg after 4 weeks to ensure efficacy.
C. The patient's age requires a slower titration of paroxetine, but it is the SSRI of choice in the elderly.
D. Paroxetine has no significant drug-drug interactions, so monitoring is only needed for hyponatremia.
Answer: A. Paroxetine has strong anticholinergic effects that may worsen cognitive
impairment, so consider alternative SSRIs if symptoms worsen.
6. A 52-year-old woman with treatment-resistant depression is started on phenelzine 45 mg/day.
She presents to the emergency department with a severe headache, palpitations, and elevated
blood pressure (180/110 mmHg) after eating aged cheese. What is the priority intervention?
A. Administer chlorpromazine 25 mg IM to induce alpha-blockade and control blood pressure.
B. Discontinue phenelzine immediately and start an alternative antidepressant after a 2-week washout.
C. Administer phentolamine 5 mg IV and support blood pressure; hold phenelzine and educate on dietary
restrictions.
D. Give propranolol 10 mg IV to block beta-receptors and reduce heart rate, as hypertension is secondary to
tachycardia.
Answer: C. Administer phentolamine 5 mg IV and support blood pressure; hold phenelzine and
educate on dietary restrictions.
7. During a therapy session, a patient with borderline personality disorder tells you that she is
planning to leave therapy because she feels you are 'completely useless and don't care.' She
has made similar statements in past sessions. Which therapeutic approach is most consistent
with evidence-based practice?
A. Validate her feeling that therapy is not helping and agree to refer her to another therapist, emphasizing a
collaborative approach.
B. Gently confront her use of splitting and explore what she fears about continuing therapy.
C. Outline the limits of your role and remind her of the therapy contract, focusing on the consequences of
premature termination.
D. Explore the pattern of devaluation and use the therapeutic relationship to address her fear of abandonment,
while setting boundaries and validating the underlying emotion.
Answer: D. Explore the pattern of devaluation and use the therapeutic relationship to address
her fear of abandonment, while setting boundaries and validating the underlying emotion.
8. A 40-year-old man with obsessive-compulsive disorder has had 15 sessions of exposure and
response prevention (ERP) with modest improvement. He asks about adding cognitive therapy
to better address his 'unbearable anxiety.' What is the most evidence-based response?
A. Cognitive therapy has proven additive value in OCD; we should incorporate cognitive restructuring to target
his maladaptive beliefs.
B. ERP is the psychological treatment of choice; adding cognitive therapy is unlikely to significantly enhance
outcomes, and we should continue ERP.
C. Switching to cognitive therapy alone is indicated because ERP has plateaued, and cognitive approaches
target the root cause.
D. Adding mindfulness-based therapy would be more beneficial, as it has superior efficacy compared with
ERP in treatment-resistant OCD.
Answer: B. ERP is the psychological treatment of choice; adding cognitive therapy is unlikely
to significantly enhance outcomes, and we should continue ERP.
, 9. A 29-year-old woman with posttraumatic stress disorder (PTSD) after a sexual assault is
considering treatment. She has a history of medication nonadherence and is interested in a
non-pharmacological approach. Which psychotherapy has the strongest evidence base for
trauma-focused treatment?
A. Cognitive processing therapy (CPT) is the only psychotherapy with Level A evidence for PTSD.
B. Prolonged exposure (PE) has the most robust evidence base, but trauma-focused cognitive behavioral
therapy (TF-CBT) is also effective.
C. Eye movement desensitization and reprocessing (EMDR) is contraindicated in trauma survivors because of
potential retraumatization.
D. Present-centered therapy is as effective as trauma-focused therapies and is preferred for patients with
adherence issues.
Answer: B. Prolonged exposure (PE) has the most robust evidence base, but trauma-focused
cognitive behavioral therapy (TF-CBT) is also effective.
10. A 38-year-old woman with bipolar II disorder is currently on lamotrigine 200 mg/day and
reports a depressive episode. Her last hypomanic episode was 6 months ago. Which treatment
strategy is most evidence-based for acute bipolar depression?
A. Increase lamotrigine to 400 mg/day, the maximum dose for bipolar depression, and wait 4 more weeks.
B. Add an antidepressant such as sertraline 100 mg daily, as SSRIs are first-line for bipolar depression.
C. Add lurasidone 20 mg/day or quetiapine 300 mg/day as adjunctive therapy to lamotrigine.
D. Switch to lithium monotherapy and discontinue lamotrigine, as lithium is the gold standard for bipolar
depression.
Answer: C. Add lurasidone 20 mg/day or quetiapine 300 mg/day as adjunctive therapy to
lamotrigine.
11. A 55-year-old man with schizophrenia is stable on risperidone long-acting injectable 50 mg
every 2 weeks. He develops new-onset parkinsonism and hyperprolactinemia. Which strategy is
most appropriate according to evidence-based guidelines?
A. Continue risperidone and prescribe benztropine 1 mg twice daily to manage EPS and lower prolactin with a
dopamine agonist.
B. Switch to paliperidone palmitate, as it has similar efficacy but fewer EPS and prolactin elevations.
C. Reduce risperidone dose to 25 mg every 2 weeks and assess symptoms, as EPS and prolactin are
dose-dependent.
D. Add aripiprazole 10 mg daily to counteract EPS and reduce prolactin via partial agonism.
Answer: C. Reduce risperidone dose to 25 mg every 2 weeks and assess symptoms, as EPS
and prolactin are dose-dependent.
12. A 30-year-old woman with panic disorder has been on sertraline 100 mg daily for 6 months
and has complete remission. She asks about discontinuing the medication. What is the most
evidence-based recommendation regarding duration of continuation treatment?
A. Continue medication for at least 12 months after remission, then consider gradual taper over 6-12 weeks.
B. Discontinue now, as 6 months without panic attacks indicates that the underlying disorder has resolved.
C. Taper over 2 weeks to avoid prolonged medication exposure, as long-term use may lead to tolerance.
D. Continue medication indefinitely, as relapse is inevitable upon discontinuation and no evidence supports
timed discontinuation.
Answer: A. Continue medication for at least 12 months after remission, then consider gradual
taper over 6-12 weeks.
& Verified Answers with Rationales | 100% Pass Guarantee –
Wilkes University PMHNP
1. A 34-year-old woman with major depressive disorder has been on sertraline 200 mg daily for
8 weeks with only a partial response. She reports a history of poor adherence due to forgetting
doses. Which strategy is most appropriate given her history?
A. Switch to fluoxetine 20 mg daily immediately, given its long half-life and similar side effect profile.
B. Augment with bupropion SR 150 mg twice daily to address residual symptoms and improve adherence.
C. Cross-taper sertraline to venlafaxine XR over 4 weeks, starting venlafaxine at 37.5 mg.
D. Increase sertraline to 300 mg daily, the maximum FDA-approved dose, before considering a switch.
Answer: B. Augment with bupropion SR 150 mg twice daily to address residual symptoms and
improve adherence.
2. In a patient with chronic schizophrenia who has persistent negative symptoms despite
adequate clozapine trial, which evidence-based intervention is most likely to improve functional
outcomes?
A. Increase clozapine to the maximum tolerated dose to further reduce D2 receptor occupancy.
B. Add a second antipsychotic, such as risperidone, to target negative symptoms specifically.
C. Refer for cognitive behavioral therapy for psychosis and social skills training.
D. Switch to a long-acting injectable antipsychotic to ensure adherence and reduce relapse.
Answer: C. Refer for cognitive behavioral therapy for psychosis and social skills training.
3. A 28-year-old man with generalized anxiety disorder has been treated with venlafaxine XR
225 mg daily for 12 weeks. He reports significant reduction in worry but still experiences
occasional panic attacks. He is unwilling to add a benzodiazepine. What is the best next
evidence-based step?
A. Increase venlafaxine to 300 mg daily, the maximum FDA-approved dose for GAD.
B. Add pregabalin 150 mg daily, an evidence-based augmentation for residual anxiety symptoms.
C. Refer for cognitive behavioral therapy specifically targeting panic symptoms.
D. Switch to an SSRI such as sertraline, as SSRIs are more effective for panic disorder.
Answer: C. Refer for cognitive behavioral therapy specifically targeting panic symptoms.
4. A 45-year-old man with bipolar I disorder, currently euthymic on lithium 900 mg daily (serum
level 0.8 mEq/L), reports new-onset tremor and polyuria. His renal function is normal. What is
the most appropriate next step in medication management?
A. Discontinue lithium and start valproic acid 1000 mg daily to avoid nephrotoxicity.
B. Reduce lithium dose to 600 mg daily and check a serum level in 1 week to keep within therapeutic range.
C. Switch to lamotrigine 200 mg daily as maintenance monotherapy, given its favorable side effect profile.
D. Continue lithium at the same dose and add a beta-blocker, such as propranolol 20 mg twice daily, for
tremor.
Answer: B. Reduce lithium dose to 600 mg daily and check a serum level in 1 week to keep
within therapeutic range.
5. A 67-year-old woman with major depressive disorder and mild cognitive impairment (MCI) is
started on paroxetine 20 mg daily. Which factor is most important to consider when monitoring
,this patient?
A. Paroxetine has strong anticholinergic effects that may worsen cognitive impairment, so consider alternative
SSRIs if symptoms worsen.
B. Paroxetine is safe in MCI, but the dose should be increased to 40 mg after 4 weeks to ensure efficacy.
C. The patient's age requires a slower titration of paroxetine, but it is the SSRI of choice in the elderly.
D. Paroxetine has no significant drug-drug interactions, so monitoring is only needed for hyponatremia.
Answer: A. Paroxetine has strong anticholinergic effects that may worsen cognitive
impairment, so consider alternative SSRIs if symptoms worsen.
6. A 52-year-old woman with treatment-resistant depression is started on phenelzine 45 mg/day.
She presents to the emergency department with a severe headache, palpitations, and elevated
blood pressure (180/110 mmHg) after eating aged cheese. What is the priority intervention?
A. Administer chlorpromazine 25 mg IM to induce alpha-blockade and control blood pressure.
B. Discontinue phenelzine immediately and start an alternative antidepressant after a 2-week washout.
C. Administer phentolamine 5 mg IV and support blood pressure; hold phenelzine and educate on dietary
restrictions.
D. Give propranolol 10 mg IV to block beta-receptors and reduce heart rate, as hypertension is secondary to
tachycardia.
Answer: C. Administer phentolamine 5 mg IV and support blood pressure; hold phenelzine and
educate on dietary restrictions.
7. During a therapy session, a patient with borderline personality disorder tells you that she is
planning to leave therapy because she feels you are 'completely useless and don't care.' She
has made similar statements in past sessions. Which therapeutic approach is most consistent
with evidence-based practice?
A. Validate her feeling that therapy is not helping and agree to refer her to another therapist, emphasizing a
collaborative approach.
B. Gently confront her use of splitting and explore what she fears about continuing therapy.
C. Outline the limits of your role and remind her of the therapy contract, focusing on the consequences of
premature termination.
D. Explore the pattern of devaluation and use the therapeutic relationship to address her fear of abandonment,
while setting boundaries and validating the underlying emotion.
Answer: D. Explore the pattern of devaluation and use the therapeutic relationship to address
her fear of abandonment, while setting boundaries and validating the underlying emotion.
8. A 40-year-old man with obsessive-compulsive disorder has had 15 sessions of exposure and
response prevention (ERP) with modest improvement. He asks about adding cognitive therapy
to better address his 'unbearable anxiety.' What is the most evidence-based response?
A. Cognitive therapy has proven additive value in OCD; we should incorporate cognitive restructuring to target
his maladaptive beliefs.
B. ERP is the psychological treatment of choice; adding cognitive therapy is unlikely to significantly enhance
outcomes, and we should continue ERP.
C. Switching to cognitive therapy alone is indicated because ERP has plateaued, and cognitive approaches
target the root cause.
D. Adding mindfulness-based therapy would be more beneficial, as it has superior efficacy compared with
ERP in treatment-resistant OCD.
Answer: B. ERP is the psychological treatment of choice; adding cognitive therapy is unlikely
to significantly enhance outcomes, and we should continue ERP.
, 9. A 29-year-old woman with posttraumatic stress disorder (PTSD) after a sexual assault is
considering treatment. She has a history of medication nonadherence and is interested in a
non-pharmacological approach. Which psychotherapy has the strongest evidence base for
trauma-focused treatment?
A. Cognitive processing therapy (CPT) is the only psychotherapy with Level A evidence for PTSD.
B. Prolonged exposure (PE) has the most robust evidence base, but trauma-focused cognitive behavioral
therapy (TF-CBT) is also effective.
C. Eye movement desensitization and reprocessing (EMDR) is contraindicated in trauma survivors because of
potential retraumatization.
D. Present-centered therapy is as effective as trauma-focused therapies and is preferred for patients with
adherence issues.
Answer: B. Prolonged exposure (PE) has the most robust evidence base, but trauma-focused
cognitive behavioral therapy (TF-CBT) is also effective.
10. A 38-year-old woman with bipolar II disorder is currently on lamotrigine 200 mg/day and
reports a depressive episode. Her last hypomanic episode was 6 months ago. Which treatment
strategy is most evidence-based for acute bipolar depression?
A. Increase lamotrigine to 400 mg/day, the maximum dose for bipolar depression, and wait 4 more weeks.
B. Add an antidepressant such as sertraline 100 mg daily, as SSRIs are first-line for bipolar depression.
C. Add lurasidone 20 mg/day or quetiapine 300 mg/day as adjunctive therapy to lamotrigine.
D. Switch to lithium monotherapy and discontinue lamotrigine, as lithium is the gold standard for bipolar
depression.
Answer: C. Add lurasidone 20 mg/day or quetiapine 300 mg/day as adjunctive therapy to
lamotrigine.
11. A 55-year-old man with schizophrenia is stable on risperidone long-acting injectable 50 mg
every 2 weeks. He develops new-onset parkinsonism and hyperprolactinemia. Which strategy is
most appropriate according to evidence-based guidelines?
A. Continue risperidone and prescribe benztropine 1 mg twice daily to manage EPS and lower prolactin with a
dopamine agonist.
B. Switch to paliperidone palmitate, as it has similar efficacy but fewer EPS and prolactin elevations.
C. Reduce risperidone dose to 25 mg every 2 weeks and assess symptoms, as EPS and prolactin are
dose-dependent.
D. Add aripiprazole 10 mg daily to counteract EPS and reduce prolactin via partial agonism.
Answer: C. Reduce risperidone dose to 25 mg every 2 weeks and assess symptoms, as EPS
and prolactin are dose-dependent.
12. A 30-year-old woman with panic disorder has been on sertraline 100 mg daily for 6 months
and has complete remission. She asks about discontinuing the medication. What is the most
evidence-based recommendation regarding duration of continuation treatment?
A. Continue medication for at least 12 months after remission, then consider gradual taper over 6-12 weeks.
B. Discontinue now, as 6 months without panic attacks indicates that the underlying disorder has resolved.
C. Taper over 2 weeks to avoid prolonged medication exposure, as long-term use may lead to tolerance.
D. Continue medication indefinitely, as relapse is inevitable upon discontinuation and no evidence supports
timed discontinuation.
Answer: A. Continue medication for at least 12 months after remission, then consider gradual
taper over 6-12 weeks.
