Final Exam: NR 547/ NR547 (New 2025/ 2026 Update)
Differential Diagnosis in Psychiatric-Mental Health
Review| Questions and Answers| (Solutions)-
Chamberlain
Section I: Diagnostic Foundations & Clinical Reasoning
1. A PMHNP is evaluating a 34-year-old patient with new-onset depressive symptoms.
According to the DSM-5-TR differential diagnosis hierarchy, which step should be completed
FIRST?
A. Rule out medical conditions that may explain symptoms
B. Rule out malingering and factitious disorder
C. Determine the specific primary mental disorder
D. Rule out substance/medication-induced conditions
Correct Answer: B
Rationale: The DSM-5-TR differential diagnosis hierarchy prioritizes ruling out malingering
and factitious disorder first, as these involve intentional deception that must be distinguished
from genuine psychopathology. Step 2 rules out substance/medication-induced conditions, Step
3 rules out medical conditions, and Step 4 determines the specific primary mental disorder .
2. Which of the following represents the correct sequential order of the DSM-5-TR differential
diagnosis hierarchy?
A. Medical conditions → Substance-induced → Malingering → Primary disorder
B. Malingering/Factitious → Substance/medication-induced → Medical conditions → Primary
disorder
C. Substance-induced conditions → Medical conditions → Malingering → Primary disorder
D. Primary disorder → Malingering → Substance-induced → Medical conditions
Correct Answer: B
Rationale: The correct hierarchy is: Step 1 — Rule out malingering and factitious disorder;
Step 2 — Rule out substance/medication-induced conditions; Step 3 — Rule out medical
conditions; Step 4 — Determine the primary psychiatric disorder .
,3. A PMHNP student is conducting a diagnostic interview. The patient describes feeling
"down" for the past month. Which interviewing technique is most appropriate to clarify the
diagnostic picture?
A. Immediately diagnosing major depressive disorder based on the statement
B. Using open-ended questions followed by clarifying and summarizing to gather specific
symptoms and duration
C. Asking only yes/no questions to speed up the interview
D. Focusing exclusively on family history without exploring current symptoms
Correct Answer: B
Rationale: Effective diagnostic interviewing uses open-ended questions to elicit narrative,
followed by clarifying questions to establish specific symptoms, duration, and functional
impairment. Summarizing ensures accuracy. This approach prevents premature diagnosis and
ensures DSM-5-TR criteria are thoroughly evaluated .
4. What is a differential diagnosis?
A. The final diagnosis after all testing is complete
B. The provider's initial hypothesis — a working list of potential problems associated with the
chief complaint
C. A treatment plan based on presenting symptoms
D. A medication prescription guideline for psychiatric disorders
Correct Answer: B
Rationale: A differential diagnosis is the provider's initial hypothesis and a working list of
potential problems that can be associated with the initial or chief complaint. The DSM-5-TR
provides guidance for identifying psychiatric diagnoses. The differential is refined as more
information becomes available .
5. Which of the following best describes the process of diagnostic reasoning?
A. The process of prescribing medications based on symptom checklists
B. A rigid, step-by-step algorithm that always leads to a single correct diagnosis
C. The process of questioning one's thinking to determine if all possible avenues have been
explored and if conclusions are based on evidence
D. The process of confirming a diagnosis by treating the presumed condition
,Correct Answer: C
Rationale: Diagnostic reasoning involves critical thinking and self-reflection to ensure all
possible avenues have been explored and conclusions are based on evidence rather than
assumptions. It is not rigid or algorithmic, and treatment response is not a valid diagnostic
confirmation method .
6. The PMHNP is evaluating a patient with hallucinations, delusions, and disorganized speech.
According to the hierarchical approach, the PMHNP should FIRST:
A. Diagnose schizophrenia based on symptom presentation
B. Order a comprehensive metabolic panel and toxicology screen
C. Assess for malingering and factitious disorder
D. Begin antipsychotic medication immediately
Correct Answer: C
Rationale: According to the DSM-5-TR hierarchy, ruling out malingering and factitious
disorder is the first step before considering other etiologies. Diagnosing schizophrenia is
premature without ruling out other causes. Laboratory testing is appropriate as Step 2 after
ruling out intentional deception .
7. What is the primary purpose of the differential diagnosis process in psychiatric-mental
health practice?
A. To confirm the patient's self-reported diagnosis
B. To develop a working list of potential disorders that could explain the patient's symptoms
C. To rule out all medical causes before considering any mental health diagnosis
D. To assign a single diagnosis that will guide all future treatment decisions
Correct Answer: B
Rationale: The differential diagnosis process involves developing a working hypothesis or
list of potential disorders that could account for the presenting symptoms. This list is prioritized,
and each potential diagnosis is systematically ruled in or out based on diagnostic criteria,
history, and assessment findings .
, 8. Which of the following best describes the "treat or refer" decision point in clinical practice
for a PMHNP?
A. To discharge patients who are uncooperative with treatment
B. To determine if a patient's condition is within the NP's scope of practice or requires a higher
level of care
C. To decide between pharmacological and non-pharmacological treatment
D. To evaluate if the patient can afford prescribed medications
Correct Answer: B
Rationale: The "treat or refer" decision point is a critical clinical judgment step where the
PMHNP must determine whether a patient's presentation can be safely managed in the current
outpatient setting or if it necessitates referral to a higher level of care (e.g., inpatient psychiatric
hospitalization, emergency department) due to acuity or complexity .
9. A PMHNP is building a differential diagnosis for a patient with anxiety. What is the second
step in the differential diagnosis process, immediately following the initial rule-out of
factitious presentations?
A. Ruling out medical etiology
B. Ruling out substance or medication-induced etiology
C. Determining the specific primary disorder
D. Establishing the boundary with no mental disorder
Correct Answer: B
Rationale: The second step is to rule out substance or medication-induced etiology, as many
psychiatric symptoms can be directly caused by intoxication, withdrawal, or adverse effects of
prescribed medications, supplements, or illicit drugs .
10. The DIGFAST mnemonic is used to assess for symptoms of:
A. Major depressive disorder
B. Manic or hypomanic episodes
C. Generalized anxiety disorder
D. Post-traumatic stress disorder
Correct Answer: B
Differential Diagnosis in Psychiatric-Mental Health
Review| Questions and Answers| (Solutions)-
Chamberlain
Section I: Diagnostic Foundations & Clinical Reasoning
1. A PMHNP is evaluating a 34-year-old patient with new-onset depressive symptoms.
According to the DSM-5-TR differential diagnosis hierarchy, which step should be completed
FIRST?
A. Rule out medical conditions that may explain symptoms
B. Rule out malingering and factitious disorder
C. Determine the specific primary mental disorder
D. Rule out substance/medication-induced conditions
Correct Answer: B
Rationale: The DSM-5-TR differential diagnosis hierarchy prioritizes ruling out malingering
and factitious disorder first, as these involve intentional deception that must be distinguished
from genuine psychopathology. Step 2 rules out substance/medication-induced conditions, Step
3 rules out medical conditions, and Step 4 determines the specific primary mental disorder .
2. Which of the following represents the correct sequential order of the DSM-5-TR differential
diagnosis hierarchy?
A. Medical conditions → Substance-induced → Malingering → Primary disorder
B. Malingering/Factitious → Substance/medication-induced → Medical conditions → Primary
disorder
C. Substance-induced conditions → Medical conditions → Malingering → Primary disorder
D. Primary disorder → Malingering → Substance-induced → Medical conditions
Correct Answer: B
Rationale: The correct hierarchy is: Step 1 — Rule out malingering and factitious disorder;
Step 2 — Rule out substance/medication-induced conditions; Step 3 — Rule out medical
conditions; Step 4 — Determine the primary psychiatric disorder .
,3. A PMHNP student is conducting a diagnostic interview. The patient describes feeling
"down" for the past month. Which interviewing technique is most appropriate to clarify the
diagnostic picture?
A. Immediately diagnosing major depressive disorder based on the statement
B. Using open-ended questions followed by clarifying and summarizing to gather specific
symptoms and duration
C. Asking only yes/no questions to speed up the interview
D. Focusing exclusively on family history without exploring current symptoms
Correct Answer: B
Rationale: Effective diagnostic interviewing uses open-ended questions to elicit narrative,
followed by clarifying questions to establish specific symptoms, duration, and functional
impairment. Summarizing ensures accuracy. This approach prevents premature diagnosis and
ensures DSM-5-TR criteria are thoroughly evaluated .
4. What is a differential diagnosis?
A. The final diagnosis after all testing is complete
B. The provider's initial hypothesis — a working list of potential problems associated with the
chief complaint
C. A treatment plan based on presenting symptoms
D. A medication prescription guideline for psychiatric disorders
Correct Answer: B
Rationale: A differential diagnosis is the provider's initial hypothesis and a working list of
potential problems that can be associated with the initial or chief complaint. The DSM-5-TR
provides guidance for identifying psychiatric diagnoses. The differential is refined as more
information becomes available .
5. Which of the following best describes the process of diagnostic reasoning?
A. The process of prescribing medications based on symptom checklists
B. A rigid, step-by-step algorithm that always leads to a single correct diagnosis
C. The process of questioning one's thinking to determine if all possible avenues have been
explored and if conclusions are based on evidence
D. The process of confirming a diagnosis by treating the presumed condition
,Correct Answer: C
Rationale: Diagnostic reasoning involves critical thinking and self-reflection to ensure all
possible avenues have been explored and conclusions are based on evidence rather than
assumptions. It is not rigid or algorithmic, and treatment response is not a valid diagnostic
confirmation method .
6. The PMHNP is evaluating a patient with hallucinations, delusions, and disorganized speech.
According to the hierarchical approach, the PMHNP should FIRST:
A. Diagnose schizophrenia based on symptom presentation
B. Order a comprehensive metabolic panel and toxicology screen
C. Assess for malingering and factitious disorder
D. Begin antipsychotic medication immediately
Correct Answer: C
Rationale: According to the DSM-5-TR hierarchy, ruling out malingering and factitious
disorder is the first step before considering other etiologies. Diagnosing schizophrenia is
premature without ruling out other causes. Laboratory testing is appropriate as Step 2 after
ruling out intentional deception .
7. What is the primary purpose of the differential diagnosis process in psychiatric-mental
health practice?
A. To confirm the patient's self-reported diagnosis
B. To develop a working list of potential disorders that could explain the patient's symptoms
C. To rule out all medical causes before considering any mental health diagnosis
D. To assign a single diagnosis that will guide all future treatment decisions
Correct Answer: B
Rationale: The differential diagnosis process involves developing a working hypothesis or
list of potential disorders that could account for the presenting symptoms. This list is prioritized,
and each potential diagnosis is systematically ruled in or out based on diagnostic criteria,
history, and assessment findings .
, 8. Which of the following best describes the "treat or refer" decision point in clinical practice
for a PMHNP?
A. To discharge patients who are uncooperative with treatment
B. To determine if a patient's condition is within the NP's scope of practice or requires a higher
level of care
C. To decide between pharmacological and non-pharmacological treatment
D. To evaluate if the patient can afford prescribed medications
Correct Answer: B
Rationale: The "treat or refer" decision point is a critical clinical judgment step where the
PMHNP must determine whether a patient's presentation can be safely managed in the current
outpatient setting or if it necessitates referral to a higher level of care (e.g., inpatient psychiatric
hospitalization, emergency department) due to acuity or complexity .
9. A PMHNP is building a differential diagnosis for a patient with anxiety. What is the second
step in the differential diagnosis process, immediately following the initial rule-out of
factitious presentations?
A. Ruling out medical etiology
B. Ruling out substance or medication-induced etiology
C. Determining the specific primary disorder
D. Establishing the boundary with no mental disorder
Correct Answer: B
Rationale: The second step is to rule out substance or medication-induced etiology, as many
psychiatric symptoms can be directly caused by intoxication, withdrawal, or adverse effects of
prescribed medications, supplements, or illicit drugs .
10. The DIGFAST mnemonic is used to assess for symptoms of:
A. Major depressive disorder
B. Manic or hypomanic episodes
C. Generalized anxiety disorder
D. Post-traumatic stress disorder
Correct Answer: B
