BARKLEY PMHNP PRACTICE EXAM
1. A patient with acute mania is started on lithium. Which serum lithium range is
generally targeted for acute manic episodes?
A. 0.2-0.4 mEq/L
B. 0.8-1.2 mEq/L
C. 0.4-0.6 mEq/L
D. 1.5-2.0 mEq/L
Correct Answer: B. 0.8-1.2 mEq/L
Rationale: Acute mania is usually treated at 0.8-1.2 mEq/L, while maintenance is
typically 0.6-1.0 mEq/L. Levels above 1.5 mEq/L raise the risk of toxicity.
2. Which finding suggests lithium toxicity rather than a therapeutic side effect?
A. Coarse tremor with vomiting, diarrhea, and ataxia
B. Fine tremor and mild thirst
C. Mild polyuria
D. Transient nausea after the first dose
Correct Answer: A. Coarse tremor with vomiting, diarrhea, and ataxia
Rationale: A fine tremor is a common therapeutic effect. Coarse tremor with GI and
neurologic signs (ataxia, confusion) signals toxicity, which can progress to seizures
and coma and may require hemodialysis.
3. Which medication is most likely to INCREASE serum lithium levels?
A. Caffeine
B. Theophylline
C. Acetazolamide
D. Hydrochlorothiazide
Correct Answer: D. Hydrochlorothiazide
Rationale: Thiazide diuretics (as well as NSAIDs and ACE inhibitors) reduce renal
lithium clearance. Caffeine, theophylline, and acetazolamide increase lithium
excretion.
Page 1
,4. Which monitoring parameter is essential for a patient taking clozapine?
A. Serum lithium level
B. Thyroid antibodies
C. Absolute neutrophil count (ANC)
D. Serum amylase
Correct Answer: C. Absolute neutrophil count (ANC)
Rationale: Clozapine can cause severe neutropenia and agranulocytosis, so ANC
monitoring is required per labeling, with the frequency determined by the baseline and
ongoing ANC.
5. In week 3 of clozapine therapy, a patient develops fever, chest pain,
tachycardia, and flu-like symptoms. What is the most likely cause?
A. Agranulocytosis
B. Clozapine-induced myocarditis
C. Tardive dyskinesia
D. Serotonin syndrome
Correct Answer: B. Clozapine-induced myocarditis
Rationale: Myocarditis typically occurs in the first 4-8 weeks of clozapine. Obtain
troponin, CRP, and ECG and stop the drug if confirmed.
6. A woman of childbearing age is prescribed valproate. Which fetal risk is most
characteristic?
A. Neural tube defects
B. Ebstein anomaly
C. Neonatal hearing loss
D. Limb reduction defects only
Correct Answer: A. Neural tube defects
Rationale: Valproate carries a boxed warning for neural tube defects, lower IQ, and
other major malformations. Ebstein anomaly is associated with lithium.
Page 2
,7. Before starting carbamazepine in a patient of Asian ancestry, which
screening is recommended?
A. CYP2D6 genotyping
B. Factor V Leiden
C. APOE e4 testing
D. HLA-B*1502 testing
Correct Answer: D. HLA-B*1502 testing
Rationale: HLA-B*1502 is associated with Stevens-Johnson syndrome and toxic
epidermal necrolysis with carbamazepine.
8. A patient taking valproate is to be started on lamotrigine. What is the
appropriate adjustment?
A. Use the usual starting dose
B. Double the starting dose
C. Use about half the usual starting dose and titrate slowly
D. The combination is absolutely contraindicated
Correct Answer: C. Use about half the usual starting dose and titrate slowly
Rationale: Valproate inhibits lamotrigine metabolism, roughly doubling its levels and
increasing the risk of serious rash (SJS). Slow titration with a reduced dose is
required.
9. Which finding best distinguishes serotonin syndrome from neuroleptic
malignant syndrome?
A. Lead-pipe rigidity with bradyreflexia
B. Clonus and hyperreflexia with rapid onset
C. Onset over several days
D. Elevated creatine kinase
Correct Answer: B. Clonus and hyperreflexia with rapid onset
Rationale: Serotonin syndrome develops within hours and shows neuromuscular
hyperactivity (clonus, hyperreflexia, diarrhea). NMS evolves over days with lead-pipe
rigidity and hyporeflexia.
Page 3
, 10. What is the initial management of neuroleptic malignant syndrome?
A. Stop the antipsychotic and give supportive care; consider dantrolene or
bromocriptine
B. Increase the antipsychotic dose
C. Add an SSRI
D. Administer flumazenil
Correct Answer: A. Stop the antipsychotic and give supportive care; consider
dantrolene or bromocriptine
Rationale: NMS is an emergency. Discontinue the offending agent, cool the patient,
hydrate, monitor CK and renal function, and consider dantrolene or bromocriptine for
severe cases.
11. A patient on phenelzine should avoid which food?
A. Fresh fruit
B. Plain rice
C. Steamed vegetables
D. Aged cheese and cured meats
Correct Answer: D. Aged cheese and cured meats
Rationale: Tyramine-rich foods can trigger a hypertensive crisis in patients taking
MAOIs.
12. A patient is switching from fluoxetine to phenelzine. What is the minimum
washout period after stopping fluoxetine?
A. 3 days
B. 1 week
C. 5 weeks
D. 2 weeks
Correct Answer: C. 5 weeks
Rationale: Fluoxetine and its metabolite norfluoxetine have long half-lives, so 5
weeks is needed. Most other SSRIs require 2 weeks.
Page 4
1. A patient with acute mania is started on lithium. Which serum lithium range is
generally targeted for acute manic episodes?
A. 0.2-0.4 mEq/L
B. 0.8-1.2 mEq/L
C. 0.4-0.6 mEq/L
D. 1.5-2.0 mEq/L
Correct Answer: B. 0.8-1.2 mEq/L
Rationale: Acute mania is usually treated at 0.8-1.2 mEq/L, while maintenance is
typically 0.6-1.0 mEq/L. Levels above 1.5 mEq/L raise the risk of toxicity.
2. Which finding suggests lithium toxicity rather than a therapeutic side effect?
A. Coarse tremor with vomiting, diarrhea, and ataxia
B. Fine tremor and mild thirst
C. Mild polyuria
D. Transient nausea after the first dose
Correct Answer: A. Coarse tremor with vomiting, diarrhea, and ataxia
Rationale: A fine tremor is a common therapeutic effect. Coarse tremor with GI and
neurologic signs (ataxia, confusion) signals toxicity, which can progress to seizures
and coma and may require hemodialysis.
3. Which medication is most likely to INCREASE serum lithium levels?
A. Caffeine
B. Theophylline
C. Acetazolamide
D. Hydrochlorothiazide
Correct Answer: D. Hydrochlorothiazide
Rationale: Thiazide diuretics (as well as NSAIDs and ACE inhibitors) reduce renal
lithium clearance. Caffeine, theophylline, and acetazolamide increase lithium
excretion.
Page 1
,4. Which monitoring parameter is essential for a patient taking clozapine?
A. Serum lithium level
B. Thyroid antibodies
C. Absolute neutrophil count (ANC)
D. Serum amylase
Correct Answer: C. Absolute neutrophil count (ANC)
Rationale: Clozapine can cause severe neutropenia and agranulocytosis, so ANC
monitoring is required per labeling, with the frequency determined by the baseline and
ongoing ANC.
5. In week 3 of clozapine therapy, a patient develops fever, chest pain,
tachycardia, and flu-like symptoms. What is the most likely cause?
A. Agranulocytosis
B. Clozapine-induced myocarditis
C. Tardive dyskinesia
D. Serotonin syndrome
Correct Answer: B. Clozapine-induced myocarditis
Rationale: Myocarditis typically occurs in the first 4-8 weeks of clozapine. Obtain
troponin, CRP, and ECG and stop the drug if confirmed.
6. A woman of childbearing age is prescribed valproate. Which fetal risk is most
characteristic?
A. Neural tube defects
B. Ebstein anomaly
C. Neonatal hearing loss
D. Limb reduction defects only
Correct Answer: A. Neural tube defects
Rationale: Valproate carries a boxed warning for neural tube defects, lower IQ, and
other major malformations. Ebstein anomaly is associated with lithium.
Page 2
,7. Before starting carbamazepine in a patient of Asian ancestry, which
screening is recommended?
A. CYP2D6 genotyping
B. Factor V Leiden
C. APOE e4 testing
D. HLA-B*1502 testing
Correct Answer: D. HLA-B*1502 testing
Rationale: HLA-B*1502 is associated with Stevens-Johnson syndrome and toxic
epidermal necrolysis with carbamazepine.
8. A patient taking valproate is to be started on lamotrigine. What is the
appropriate adjustment?
A. Use the usual starting dose
B. Double the starting dose
C. Use about half the usual starting dose and titrate slowly
D. The combination is absolutely contraindicated
Correct Answer: C. Use about half the usual starting dose and titrate slowly
Rationale: Valproate inhibits lamotrigine metabolism, roughly doubling its levels and
increasing the risk of serious rash (SJS). Slow titration with a reduced dose is
required.
9. Which finding best distinguishes serotonin syndrome from neuroleptic
malignant syndrome?
A. Lead-pipe rigidity with bradyreflexia
B. Clonus and hyperreflexia with rapid onset
C. Onset over several days
D. Elevated creatine kinase
Correct Answer: B. Clonus and hyperreflexia with rapid onset
Rationale: Serotonin syndrome develops within hours and shows neuromuscular
hyperactivity (clonus, hyperreflexia, diarrhea). NMS evolves over days with lead-pipe
rigidity and hyporeflexia.
Page 3
, 10. What is the initial management of neuroleptic malignant syndrome?
A. Stop the antipsychotic and give supportive care; consider dantrolene or
bromocriptine
B. Increase the antipsychotic dose
C. Add an SSRI
D. Administer flumazenil
Correct Answer: A. Stop the antipsychotic and give supportive care; consider
dantrolene or bromocriptine
Rationale: NMS is an emergency. Discontinue the offending agent, cool the patient,
hydrate, monitor CK and renal function, and consider dantrolene or bromocriptine for
severe cases.
11. A patient on phenelzine should avoid which food?
A. Fresh fruit
B. Plain rice
C. Steamed vegetables
D. Aged cheese and cured meats
Correct Answer: D. Aged cheese and cured meats
Rationale: Tyramine-rich foods can trigger a hypertensive crisis in patients taking
MAOIs.
12. A patient is switching from fluoxetine to phenelzine. What is the minimum
washout period after stopping fluoxetine?
A. 3 days
B. 1 week
C. 5 weeks
D. 2 weeks
Correct Answer: C. 5 weeks
Rationale: Fluoxetine and its metabolite norfluoxetine have long half-lives, so 5
weeks is needed. Most other SSRIs require 2 weeks.
Page 4
