Barkley PMHNP Ultimate Exam Review 2026 |
High-Yield Practice Questions & Verified
Answers | PMHNP Board Certification Study
Guide PDF
1. A 28-year-old patient is started on sertraline for major depressive disorder.
They return after 4 weeks reporting no improvement in mood but experiencing
significant nausea and sexual dysfunction. What is the most appropriate next
step?
A. Immediately discontinue sertraline and start fluoxetine.
B. Add bupropion to counteract the side effects.
C. Continue sertraline at the current dose and reassess in 2-4 weeks.
D. Increase the sertraline dose to 100mg daily.
Rationale: SSRIs like sertraline typically take 4-8 weeks to achieve their full
therapeutic effect. Since the patient is tolerating the medication (albeit with side
effects) and has not yet reached the full trial duration, the most appropriate
action is to continue the current dose and wait longer before making a change.
Discontinuing or increasing the dose prematurely is not indicated.
2. Which of the following is a hallmark sign of neuroleptic malignant syndrome
(NMS)?
A. Lead-pipe rigidity and hyperthermia
B. Serotonin syndrome
C. Tardive dyskinesia
D. Acute dystonia
Rationale: NMS is a life-threatening neurological emergency associated with
antipsychotic use. Its classic tetrad of symptoms includes hyperthermia, severe
muscle rigidity (often described as "lead-pipe"), autonomic instability, and altered
mental status. Serotonin syndrome presents with clonus and hyperreflexia.
,3. A patient with bipolar I disorder is currently in a manic episode with psychotic
features. Which medication is the most appropriate first-line treatment?
A. Lamotrigine
B. Lithium
C. Sertraline
D. Buspirone
Rationale: Lithium is a classic mood stabilizer and a first-line treatment for
acute mania and maintenance in bipolar I disorder. It is particularly effective for
the manic phase and has anti-suicidal properties. Lamotrigine is better for bipolar
depression, while sertraline (an SSRI) and buspirone could potentially worsen
mania.
4. What is the primary mechanism of action of benzodiazepines?
A. Inhibition of serotonin reuptake
B. Enhancement of GABA-A receptor activity
C. Blockade of dopamine D2 receptors
D. Inhibition of monoamine oxidase
Rationale: Benzodiazepines work by binding to a specific site on the GABA-A
receptor, which is the primary inhibitory neurotransmitter in the central nervous
system. This binding enhances the effect of GABA, leading to increased chloride
channel opening, hyperpolarization of the neuron, and a resultant anxiolytic,
sedative, and muscle relaxant effect.
5. A 65-year-old patient presents with a 6-month history of progressive memory
loss, apathy, and difficulty finding words. What is the most likely diagnosis?
A. Delirium
B. Major depressive disorder
C. Alzheimer's disease
D. Schizophrenia
Rationale: The insidious onset of progressive memory loss and cognitive
decline in an older adult is characteristic of a major neurocognitive disorder, with
Alzheimer's disease being the most common cause. Delirium has an acute onset
,and fluctuating course, while depression can cause pseudodementia but typically
has a more abrupt onset related to mood.
6. Which of the following is a common side effect of typical (first-generation)
antipsychotics like haloperidol?
A. Weight gain
B. Extrapyramidal symptoms (EPS)
C. Hyperglycemia
D. Hyperprolactinemia (less common than with atypicals)
Rationale: First-generation antipsychotics (FGAs) are potent dopamine D2
receptor antagonists. This action in the nigrostriatal pathway is responsible for a
high rate of extrapyramidal symptoms, including dystonia, parkinsonism, akathisia,
and tardive dyskinesia. While hyperprolactinemia can occur, EPS is the hallmark
side effect. Metabolic side effects are more common with second-generation
antipsychotics.
7. A patient on clozapine reports a fever and sore throat. What is the most
critical immediate lab test to order?
A. Liver function tests
B. Absolute neutrophil count (ANC)
C. Serum glucose
D. Lipid panel
Rationale: Clozapine carries a significant risk of severe neutropenia and
agranulocytosis. Patients must be monitored with regular ANC counts. A fever and
sore throat are classic signs of infection, which can be life-threatening in a patient
with clozapine-induced neutropenia. This requires immediate assessment.
8. Which antidepressant class has the highest risk of hypertensive crisis when
combined with tyramine-rich foods?
A. SSRIs
B. SNRIs
C. MAOIs
D. TCAs
, Rationale: Monoamine oxidase inhibitors (MAOIs) prevent the breakdown of
tyramine, a compound found in aged cheeses, cured meats, and other foods. The
accumulation of tyramine can lead to a massive release of norepinephrine,
causing a hypertensive crisis. This is a classic "cheese reaction."
9. A child is diagnosed with ADHD. Which of the following is a non-stimulant
medication approved for its treatment?
A. Methylphenidate
B. Amphetamine
C. Atomoxetine
D. Clonidine
Rationale: Atomoxetine is a selective norepinephrine reuptake inhibitor (SNRI)
that is FDA-approved for the treatment of ADHD. While clonidine and guanfacine
(alpha-2 agonists) are also non-stimulants used for ADHD, atomoxetine is a
primary example. Methylphenidate and amphetamines are central nervous
system stimulants.
10. The term "therapeutic alliance" refers to:
A. The legal agreement between a therapist and patient.
B. The collaborative relationship between the clinician and the patient.
C. The patient's ability to pay for services.
D. The clinician's theoretical orientation.
Rationale: The therapeutic alliance (or working alliance) is a key concept in
psychotherapy, referring to the collaborative and trusting relationship between
the therapist and the patient. It comprises agreement on goals, agreement on
tasks, and an emotional bond.
11. Which medication is considered a first-line treatment for obsessive-
compulsive disorder (OCD)?
A. Alprazolam
B. Fluoxetine
C. Lithium
D. Haloperidol
High-Yield Practice Questions & Verified
Answers | PMHNP Board Certification Study
Guide PDF
1. A 28-year-old patient is started on sertraline for major depressive disorder.
They return after 4 weeks reporting no improvement in mood but experiencing
significant nausea and sexual dysfunction. What is the most appropriate next
step?
A. Immediately discontinue sertraline and start fluoxetine.
B. Add bupropion to counteract the side effects.
C. Continue sertraline at the current dose and reassess in 2-4 weeks.
D. Increase the sertraline dose to 100mg daily.
Rationale: SSRIs like sertraline typically take 4-8 weeks to achieve their full
therapeutic effect. Since the patient is tolerating the medication (albeit with side
effects) and has not yet reached the full trial duration, the most appropriate
action is to continue the current dose and wait longer before making a change.
Discontinuing or increasing the dose prematurely is not indicated.
2. Which of the following is a hallmark sign of neuroleptic malignant syndrome
(NMS)?
A. Lead-pipe rigidity and hyperthermia
B. Serotonin syndrome
C. Tardive dyskinesia
D. Acute dystonia
Rationale: NMS is a life-threatening neurological emergency associated with
antipsychotic use. Its classic tetrad of symptoms includes hyperthermia, severe
muscle rigidity (often described as "lead-pipe"), autonomic instability, and altered
mental status. Serotonin syndrome presents with clonus and hyperreflexia.
,3. A patient with bipolar I disorder is currently in a manic episode with psychotic
features. Which medication is the most appropriate first-line treatment?
A. Lamotrigine
B. Lithium
C. Sertraline
D. Buspirone
Rationale: Lithium is a classic mood stabilizer and a first-line treatment for
acute mania and maintenance in bipolar I disorder. It is particularly effective for
the manic phase and has anti-suicidal properties. Lamotrigine is better for bipolar
depression, while sertraline (an SSRI) and buspirone could potentially worsen
mania.
4. What is the primary mechanism of action of benzodiazepines?
A. Inhibition of serotonin reuptake
B. Enhancement of GABA-A receptor activity
C. Blockade of dopamine D2 receptors
D. Inhibition of monoamine oxidase
Rationale: Benzodiazepines work by binding to a specific site on the GABA-A
receptor, which is the primary inhibitory neurotransmitter in the central nervous
system. This binding enhances the effect of GABA, leading to increased chloride
channel opening, hyperpolarization of the neuron, and a resultant anxiolytic,
sedative, and muscle relaxant effect.
5. A 65-year-old patient presents with a 6-month history of progressive memory
loss, apathy, and difficulty finding words. What is the most likely diagnosis?
A. Delirium
B. Major depressive disorder
C. Alzheimer's disease
D. Schizophrenia
Rationale: The insidious onset of progressive memory loss and cognitive
decline in an older adult is characteristic of a major neurocognitive disorder, with
Alzheimer's disease being the most common cause. Delirium has an acute onset
,and fluctuating course, while depression can cause pseudodementia but typically
has a more abrupt onset related to mood.
6. Which of the following is a common side effect of typical (first-generation)
antipsychotics like haloperidol?
A. Weight gain
B. Extrapyramidal symptoms (EPS)
C. Hyperglycemia
D. Hyperprolactinemia (less common than with atypicals)
Rationale: First-generation antipsychotics (FGAs) are potent dopamine D2
receptor antagonists. This action in the nigrostriatal pathway is responsible for a
high rate of extrapyramidal symptoms, including dystonia, parkinsonism, akathisia,
and tardive dyskinesia. While hyperprolactinemia can occur, EPS is the hallmark
side effect. Metabolic side effects are more common with second-generation
antipsychotics.
7. A patient on clozapine reports a fever and sore throat. What is the most
critical immediate lab test to order?
A. Liver function tests
B. Absolute neutrophil count (ANC)
C. Serum glucose
D. Lipid panel
Rationale: Clozapine carries a significant risk of severe neutropenia and
agranulocytosis. Patients must be monitored with regular ANC counts. A fever and
sore throat are classic signs of infection, which can be life-threatening in a patient
with clozapine-induced neutropenia. This requires immediate assessment.
8. Which antidepressant class has the highest risk of hypertensive crisis when
combined with tyramine-rich foods?
A. SSRIs
B. SNRIs
C. MAOIs
D. TCAs
, Rationale: Monoamine oxidase inhibitors (MAOIs) prevent the breakdown of
tyramine, a compound found in aged cheeses, cured meats, and other foods. The
accumulation of tyramine can lead to a massive release of norepinephrine,
causing a hypertensive crisis. This is a classic "cheese reaction."
9. A child is diagnosed with ADHD. Which of the following is a non-stimulant
medication approved for its treatment?
A. Methylphenidate
B. Amphetamine
C. Atomoxetine
D. Clonidine
Rationale: Atomoxetine is a selective norepinephrine reuptake inhibitor (SNRI)
that is FDA-approved for the treatment of ADHD. While clonidine and guanfacine
(alpha-2 agonists) are also non-stimulants used for ADHD, atomoxetine is a
primary example. Methylphenidate and amphetamines are central nervous
system stimulants.
10. The term "therapeutic alliance" refers to:
A. The legal agreement between a therapist and patient.
B. The collaborative relationship between the clinician and the patient.
C. The patient's ability to pay for services.
D. The clinician's theoretical orientation.
Rationale: The therapeutic alliance (or working alliance) is a key concept in
psychotherapy, referring to the collaborative and trusting relationship between
the therapist and the patient. It comprises agreement on goals, agreement on
tasks, and an emotional bond.
11. Which medication is considered a first-line treatment for obsessive-
compulsive disorder (OCD)?
A. Alprazolam
B. Fluoxetine
C. Lithium
D. Haloperidol
