NRNP 6675 — ORIGINAL PRACTICE
QUESTION BANK
Questions 1–100 with Complete Solutions
QUESTION 1
A 29-year-old patient with bipolar I disorder presents with decreased need for sleep,
pressured speech, grandiosity, and impulsive spending for 10 days. The patient has no
psychotic symptoms but is unable to maintain employment because of the behavior.
Which diagnosis best fits the presentation?
A) Bipolar II disorder
B) Cyclothymic disorder
C) Bipolar I disorder, current manic episode
D) Major depressive disorder with mixed features
Answer: C) Bipolar I disorder, current manic episode
Rationale: Bipolar I disorder is defined by the occurrence of at least one manic
episode. The episode described is sufficiently severe to cause marked functional
impairment and has lasted more than one week. Bipolar II requires hypomania and
major depression without a history of mania. Cyclothymic disorder involves chronic
subthreshold mood symptoms that do not meet full episode criteria. Major depressive
disorder does not account for a sustained manic episode.
QUESTION 2
A patient taking lithium for bipolar disorder develops coarse tremor, vomiting,
diarrhea, confusion, and ataxia. The lithium level is 2.1 mEq/L. What is the priority
intervention?
A) Increase the lithium dose because the patient is likely experiencing relapse
B) Hold lithium and arrange urgent medical evaluation
C) Administer an additional dose with food
D) Add an SSRI to treat the neurologic symptoms
Answer: B) Hold lithium and arrange urgent medical evaluation
Rationale: The symptoms are consistent with significant lithium toxicity, particularly
at a level of 2.1 mEq/L. Lithium should be held and the patient urgently evaluated for
hydration, renal function, electrolytes, and possible dialysis depending on severity.
Increasing lithium would worsen toxicity. Food does not treat toxicity, and an SSRI
has no role in reversing lithium poisoning.
1
,QUESTION 3
A patient taking lithium develops polyuria and polydipsia. Serum sodium is mildly
elevated, and urine remains dilute despite dehydration. Which adverse effect should
the clinician suspect?
A) Nephrogenic diabetes insipidus
B) SIADH
C) Acute glomerulonephritis
D) Psychogenic polydipsia
Answer: A) Nephrogenic diabetes insipidus
Rationale: Lithium can impair renal responsiveness to antidiuretic hormone and
cause nephrogenic diabetes insipidus, producing polyuria, polydipsia, and dilute
urine. SIADH generally produces concentrated urine and hyponatremia. Acute
glomerulonephritis does not explain this characteristic pattern. Psychogenic
polydipsia can cause excessive water intake but typically does not produce persistent
inability to concentrate urine in this context.
QUESTION 4
A patient with major depressive disorder reports depressed mood, anhedonia,
insomnia, low energy, and recurrent thoughts that life is not worth living. There is no
plan or intent for suicide. What is the most appropriate immediate clinical action?
A) Document the symptoms and schedule routine follow-up in six months
B) Complete a structured suicide-risk assessment and establish a safety plan
C) Start a stimulant without further assessment
D) Tell the patient that suicidal thoughts are expected during depression
Answer: B) Complete a structured suicide-risk assessment and establish a safety
plan
Rationale: Passive suicidal thoughts require direct assessment of intent, plan, means,
prior attempts, protective factors, and other risk factors. A safety plan and
appropriate follow-up should be established. Routine follow-up without risk
assessment is inadequate. Stimulants are not first-line treatment for major depression,
and normalizing suicidal thinking without assessment is unsafe.
QUESTION 5
2
,A patient taking sertraline develops agitation, diaphoresis, diarrhea, hyperreflexia,
inducible clonus, and fever after another serotonergic medication is added. Which
diagnosis is most likely?
A) Neuroleptic malignant syndrome
B) Serotonin syndrome
C) Anticholinergic toxicity
D) Lithium-induced nephrotoxicity
Answer: B) Serotonin syndrome
Rationale: Serotonin syndrome is characterized by serotonergic exposure combined
with autonomic instability, gastrointestinal symptoms, agitation, hyperreflexia, and
clonus. Neuroleptic malignant syndrome more typically causes severe rigidity,
hyperthermia, altered consciousness, and elevated creatine kinase after dopamine
blockade. Anticholinergic toxicity causes dry skin, urinary retention, mydriasis, and
decreased bowel sounds. Lithium nephrotoxicity does not produce this neuromuscular
syndrome.
QUESTION 6
A patient develops severe rigidity, hyperthermia, altered mental status, diaphoresis,
and elevated creatine kinase after the dose of an antipsychotic is rapidly increased.
Which diagnosis is most likely?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Panic disorder
D) Acute dystonia
Answer: B) Neuroleptic malignant syndrome
Rationale: Neuroleptic malignant syndrome is a potentially life-threatening reaction
associated with dopamine antagonism. Classic findings include severe muscle rigidity,
hyperthermia, autonomic instability, altered mental status, and elevated creatine
kinase. Serotonin syndrome generally produces hyperreflexia and clonus rather than
the prominent lead-pipe rigidity characteristic of NMS. Acute dystonia is usually
localized and does not cause hyperthermia or major systemic instability.
QUESTION 7
A patient develops painful neck spasms and involuntary upward deviation of the eyes
two days after starting a high-potency antipsychotic. What is the best acute treatment?
A) Benztropine
B) Fluoxetine
3
, C) Propranolol
D) Lithium
Answer: A) Benztropine
Rationale: The presentation is acute dystonia, an extrapyramidal adverse effect that
commonly occurs shortly after initiation of dopamine-blocking antipsychotics.
Anticholinergic agents such as benztropine are effective acute treatments. Fluoxetine
and lithium do not treat dystonia. Propranolol is more commonly used for akathisia.
QUESTION 8
A patient taking an antipsychotic reports an intense internal sense of restlessness and
an inability to sit still. There are no involuntary muscle contractions. Which treatment
is most appropriate?
A) Propranolol
B) Benztropine as first-line therapy
C) Levodopa
D) Fluoxetine
Answer: A) Propranolol
Rationale: The description is characteristic of akathisia. Propranolol is commonly
used as a first-line pharmacologic treatment. Benztropine is more useful for acute
dystonia and parkinsonism. Levodopa is not routinely used to treat antipsychotic-
induced akathisia and can worsen psychosis. Fluoxetine is not an acute treatment for
this adverse effect.
QUESTION 9
A patient receiving long-term antipsychotic therapy develops repetitive lip smacking,
tongue movements, and chewing motions. Which adverse effect is most likely?
A) Acute dystonia
B) Tardive dyskinesia
C) Akathisia
D) Neuroleptic malignant syndrome
Answer: B) Tardive dyskinesia
Rationale: Tardive dyskinesia is characterized by involuntary choreoathetoid
movements, often involving the mouth and tongue, after prolonged exposure to
dopamine receptor-blocking agents. Acute dystonia usually occurs early and involves
sustained muscle contractions. Akathisia causes subjective restlessness. NMS presents
with systemic toxicity, rigidity, and hyperthermia.
4
QUESTION BANK
Questions 1–100 with Complete Solutions
QUESTION 1
A 29-year-old patient with bipolar I disorder presents with decreased need for sleep,
pressured speech, grandiosity, and impulsive spending for 10 days. The patient has no
psychotic symptoms but is unable to maintain employment because of the behavior.
Which diagnosis best fits the presentation?
A) Bipolar II disorder
B) Cyclothymic disorder
C) Bipolar I disorder, current manic episode
D) Major depressive disorder with mixed features
Answer: C) Bipolar I disorder, current manic episode
Rationale: Bipolar I disorder is defined by the occurrence of at least one manic
episode. The episode described is sufficiently severe to cause marked functional
impairment and has lasted more than one week. Bipolar II requires hypomania and
major depression without a history of mania. Cyclothymic disorder involves chronic
subthreshold mood symptoms that do not meet full episode criteria. Major depressive
disorder does not account for a sustained manic episode.
QUESTION 2
A patient taking lithium for bipolar disorder develops coarse tremor, vomiting,
diarrhea, confusion, and ataxia. The lithium level is 2.1 mEq/L. What is the priority
intervention?
A) Increase the lithium dose because the patient is likely experiencing relapse
B) Hold lithium and arrange urgent medical evaluation
C) Administer an additional dose with food
D) Add an SSRI to treat the neurologic symptoms
Answer: B) Hold lithium and arrange urgent medical evaluation
Rationale: The symptoms are consistent with significant lithium toxicity, particularly
at a level of 2.1 mEq/L. Lithium should be held and the patient urgently evaluated for
hydration, renal function, electrolytes, and possible dialysis depending on severity.
Increasing lithium would worsen toxicity. Food does not treat toxicity, and an SSRI
has no role in reversing lithium poisoning.
1
,QUESTION 3
A patient taking lithium develops polyuria and polydipsia. Serum sodium is mildly
elevated, and urine remains dilute despite dehydration. Which adverse effect should
the clinician suspect?
A) Nephrogenic diabetes insipidus
B) SIADH
C) Acute glomerulonephritis
D) Psychogenic polydipsia
Answer: A) Nephrogenic diabetes insipidus
Rationale: Lithium can impair renal responsiveness to antidiuretic hormone and
cause nephrogenic diabetes insipidus, producing polyuria, polydipsia, and dilute
urine. SIADH generally produces concentrated urine and hyponatremia. Acute
glomerulonephritis does not explain this characteristic pattern. Psychogenic
polydipsia can cause excessive water intake but typically does not produce persistent
inability to concentrate urine in this context.
QUESTION 4
A patient with major depressive disorder reports depressed mood, anhedonia,
insomnia, low energy, and recurrent thoughts that life is not worth living. There is no
plan or intent for suicide. What is the most appropriate immediate clinical action?
A) Document the symptoms and schedule routine follow-up in six months
B) Complete a structured suicide-risk assessment and establish a safety plan
C) Start a stimulant without further assessment
D) Tell the patient that suicidal thoughts are expected during depression
Answer: B) Complete a structured suicide-risk assessment and establish a safety
plan
Rationale: Passive suicidal thoughts require direct assessment of intent, plan, means,
prior attempts, protective factors, and other risk factors. A safety plan and
appropriate follow-up should be established. Routine follow-up without risk
assessment is inadequate. Stimulants are not first-line treatment for major depression,
and normalizing suicidal thinking without assessment is unsafe.
QUESTION 5
2
,A patient taking sertraline develops agitation, diaphoresis, diarrhea, hyperreflexia,
inducible clonus, and fever after another serotonergic medication is added. Which
diagnosis is most likely?
A) Neuroleptic malignant syndrome
B) Serotonin syndrome
C) Anticholinergic toxicity
D) Lithium-induced nephrotoxicity
Answer: B) Serotonin syndrome
Rationale: Serotonin syndrome is characterized by serotonergic exposure combined
with autonomic instability, gastrointestinal symptoms, agitation, hyperreflexia, and
clonus. Neuroleptic malignant syndrome more typically causes severe rigidity,
hyperthermia, altered consciousness, and elevated creatine kinase after dopamine
blockade. Anticholinergic toxicity causes dry skin, urinary retention, mydriasis, and
decreased bowel sounds. Lithium nephrotoxicity does not produce this neuromuscular
syndrome.
QUESTION 6
A patient develops severe rigidity, hyperthermia, altered mental status, diaphoresis,
and elevated creatine kinase after the dose of an antipsychotic is rapidly increased.
Which diagnosis is most likely?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Panic disorder
D) Acute dystonia
Answer: B) Neuroleptic malignant syndrome
Rationale: Neuroleptic malignant syndrome is a potentially life-threatening reaction
associated with dopamine antagonism. Classic findings include severe muscle rigidity,
hyperthermia, autonomic instability, altered mental status, and elevated creatine
kinase. Serotonin syndrome generally produces hyperreflexia and clonus rather than
the prominent lead-pipe rigidity characteristic of NMS. Acute dystonia is usually
localized and does not cause hyperthermia or major systemic instability.
QUESTION 7
A patient develops painful neck spasms and involuntary upward deviation of the eyes
two days after starting a high-potency antipsychotic. What is the best acute treatment?
A) Benztropine
B) Fluoxetine
3
, C) Propranolol
D) Lithium
Answer: A) Benztropine
Rationale: The presentation is acute dystonia, an extrapyramidal adverse effect that
commonly occurs shortly after initiation of dopamine-blocking antipsychotics.
Anticholinergic agents such as benztropine are effective acute treatments. Fluoxetine
and lithium do not treat dystonia. Propranolol is more commonly used for akathisia.
QUESTION 8
A patient taking an antipsychotic reports an intense internal sense of restlessness and
an inability to sit still. There are no involuntary muscle contractions. Which treatment
is most appropriate?
A) Propranolol
B) Benztropine as first-line therapy
C) Levodopa
D) Fluoxetine
Answer: A) Propranolol
Rationale: The description is characteristic of akathisia. Propranolol is commonly
used as a first-line pharmacologic treatment. Benztropine is more useful for acute
dystonia and parkinsonism. Levodopa is not routinely used to treat antipsychotic-
induced akathisia and can worsen psychosis. Fluoxetine is not an acute treatment for
this adverse effect.
QUESTION 9
A patient receiving long-term antipsychotic therapy develops repetitive lip smacking,
tongue movements, and chewing motions. Which adverse effect is most likely?
A) Acute dystonia
B) Tardive dyskinesia
C) Akathisia
D) Neuroleptic malignant syndrome
Answer: B) Tardive dyskinesia
Rationale: Tardive dyskinesia is characterized by involuntary choreoathetoid
movements, often involving the mouth and tongue, after prolonged exposure to
dopamine receptor-blocking agents. Acute dystonia usually occurs early and involves
sustained muscle contractions. Akathisia causes subjective restlessness. NMS presents
with systemic toxicity, rigidity, and hyperthermia.
4
