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NR547 DIFFERENTIAL DIAGNOSIS IN PSYCHIATRIC-MENTAL
HEALTH ACROSS THE LIFESPAN PRACTICUM | 2026/2027 FINAL
EXAM TEST BANK (100 Q&A) | PMHNP CHAMBERLAIN – UPDATED &
FULLY RATIONALIZED
Question 1
A 68-year-old woman presents with a 3-month history of progressive memory loss,
frequent disorientation to time, and a recent change in personality (irritability,
apathy). Family reports fluctuating attention and visual hallucinations over the past
2 weeks. Which diagnosis is most likely?
A. Alzheimer disease
B. Vascular dementia
C. Lewy body dementia
D. Major depressive disorder with pseudodementia
Correct answer: C. Lewy body dementia
Rationale:
Lewy body dementia classically presents with fluctuating cognition/attention,
visual hallucinations, parkinsonian features may be present, and relatively early
visuospatial and executive dysfunction. Alzheimer disease is progressive memory-
predominant with less prominent hallucinations/attention fluctuation early on.
Vascular dementia often shows stepwise decline and focal neurologic signs or
stroke history. Major depressive disorder with pseudodementia can mimic
cognitive decline but commonly has prominent depressed mood, pessimism, and
variable effort on testing rather than true visual hallucinations and fluctuating
attention. Clinical considerations: assess for parkinsonism, orthostatic risk with
antipsychotics (very sensitive—antipsychotics can precipitate severe worsening),
consider cognitive testing and neuroimaging.
Question 2
A 9-year-old boy demonstrates attention problems, inability to sustain tasks at
school, frequent interrupting classmates, but symptoms are present only during
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school hours and not at home. What is the most likely explanation?
A. ADHD, combined presentation
B. ADHD, predominantly inattentive presentation
C. Situational inattention related to classroom environment or learning disorder
D. Oppositional defiant disorder
Correct answer: C. Situational inattention related to classroom environment
or learning disorder
Rationale:
ADHD requires pervasive symptoms across ≥2 settings (home, school) and
evidence since before age 12. Symptoms limited to school suggest situational
factors (e.g., classroom structure, teacher practices), sensory issues, or an
underlying learning disorder (e.g., dyslexia) causing apparent inattention.
Combined ADHD would show hyperactivity/impulsivity across contexts;
predominantly inattentive would still be present at home. ODD primarily involves
hostile/defiant behavior toward authority, not isolated attentional deficits. Clinical
action: screen for learning disorders, classroom observation, obtain teacher reports,
consider environmental interventions before diagnosing ADHD.
Question 3
A 32-year-old man presents with 2 months of low mood, hypersomnia, increased
appetite with weight gain, psychomotor slowing, and profound feelings of
worthlessness. He reports waking early but then sleeping more than usual. Which
specifier or diagnosis best fits?
A. Major depressive disorder with melancholic features
B. Major depressive disorder with atypical features
C. Persistent depressive disorder (dysthymia)
D. Bipolar II disorder, depressed phase
Correct answer: B. Major depressive disorder with atypical features
Rationale:
Atypical features include mood reactivity, hypersomnia, increased appetite/weight
gain, leaden paralysis, and interpersonal rejection sensitivity. Melancholic features
show early-morning awakening (terminal insomnia), significant anorexia/weight
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loss, excessive guilt, and psychomotor agitation/retardation—opposite vegetative
pattern. Persistent depressive disorder has chronic (≥2 years) lower-level
depression, not acute 2-month severe episode. Bipolar II depressed phase would
require history of hypomania; absence of hypomanic symptoms makes unipolar
MDD more likely. Clinical considerations: consider SSRI/SNRI and
psychotherapy; consider screening for bipolar history before starting
antidepressants.
Question 4
A 45-year-old woman with chest pain is referred for anxiety evaluation. She
reports episodic palpitations, sweating, shortness of breath, and a sense of
impending doom lasting 20–30 minutes, occurring unpredictably. She also avoids
driving for fear of having another episode. Most likely diagnosis?
A. Panic disorder with agoraphobia
B. Generalized anxiety disorder
C. Specific phobia, situational
D. Social anxiety disorder
Correct answer: A. Panic disorder with agoraphobia
Rationale:
Panic disorder involves recurrent unexpected panic attacks with concern about
future attacks and behavioral changes to avoid them. Avoidance of situations
(driving) because of fear of panic indicates agoraphobia often comorbid with
panic disorder. GAD is pervasive excessive worry, not discrete panic attacks.
Specific phobia and social anxiety are situation-specific and usually tied to a
particular object or performance/social situations. Clinical actions: assess for
cardiac/medical causes first (rule out MI, arrhythmia, hyperthyroidism, POTS),
then CBT and SSRIs; consider safety planning.
Question 5
A 24-year-old pregnant woman (22 weeks) presents with severe vomiting, 12%
weight loss, ketonuria, dehydration, and inability to maintain oral intake. Which is
the most appropriate initial diagnosis and management priority?
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A. Gastroenteritis — start antibiotics
B. Hyperemesis gravidarum — hospitalize for IV fluids, electrolytes, and
antiemetics safe in pregnancy
C. Anorexia nervosa — begin CBT for eating disorder
D. Acute pancreatitis — NPO and pain control
Correct answer: B. Hyperemesis gravidarum — hospitalize for IV fluids,
electrolytes, and antiemetics safe in pregnancy
Rationale:
Severe persistent vomiting in pregnancy with significant weight loss, ketones, and
dehydration indicates hyperemesis gravidarum. Immediate priority is
stabilization: IV fluids, repletion of electrolytes, antiemetics safe in pregnancy
(e.g., doxylamine + pyridoxine, ondansetron if needed), and nutritional support.
Gastroenteritis is less likely given pregnancy timing and ketonuria; empiric
antibiotics are not indicated. Anorexia nervosa features body image distortion and
intentional restriction; pregnant weight loss from vomiting is different. Acute
pancreatitis presents with severe epigastric pain and elevated pancreatic enzymes.
Clinical: monitor maternal/fetal status and consider hospitalization.
Question 6
An 80-year-old man is noted to have new-onset visual hallucinations and rapid
decline in executive functioning over 6 weeks after a large right-sided ischemic
stroke. He is alert but has significant inattention and visual misperceptions. Which
is the best working diagnosis?
A. Major neurocognitive disorder due to Alzheimer disease
B. Vascular neurocognitive disorder (post-stroke) with delirium features
C. Lewy body dementia
D. Brief psychotic disorder
Correct answer: B. Vascular neurocognitive disorder (post-stroke) with
delirium features
Rationale:
Acute/subacute cognitive decline temporally related to a stroke suggests vascular
neurocognitive disorder. Post-stroke patients can have fluctuating attention and
NR547 DIFFERENTIAL DIAGNOSIS IN PSYCHIATRIC-MENTAL
HEALTH ACROSS THE LIFESPAN PRACTICUM | 2026/2027 FINAL
EXAM TEST BANK (100 Q&A) | PMHNP CHAMBERLAIN – UPDATED &
FULLY RATIONALIZED
Question 1
A 68-year-old woman presents with a 3-month history of progressive memory loss,
frequent disorientation to time, and a recent change in personality (irritability,
apathy). Family reports fluctuating attention and visual hallucinations over the past
2 weeks. Which diagnosis is most likely?
A. Alzheimer disease
B. Vascular dementia
C. Lewy body dementia
D. Major depressive disorder with pseudodementia
Correct answer: C. Lewy body dementia
Rationale:
Lewy body dementia classically presents with fluctuating cognition/attention,
visual hallucinations, parkinsonian features may be present, and relatively early
visuospatial and executive dysfunction. Alzheimer disease is progressive memory-
predominant with less prominent hallucinations/attention fluctuation early on.
Vascular dementia often shows stepwise decline and focal neurologic signs or
stroke history. Major depressive disorder with pseudodementia can mimic
cognitive decline but commonly has prominent depressed mood, pessimism, and
variable effort on testing rather than true visual hallucinations and fluctuating
attention. Clinical considerations: assess for parkinsonism, orthostatic risk with
antipsychotics (very sensitive—antipsychotics can precipitate severe worsening),
consider cognitive testing and neuroimaging.
Question 2
A 9-year-old boy demonstrates attention problems, inability to sustain tasks at
school, frequent interrupting classmates, but symptoms are present only during
,2 | Page
school hours and not at home. What is the most likely explanation?
A. ADHD, combined presentation
B. ADHD, predominantly inattentive presentation
C. Situational inattention related to classroom environment or learning disorder
D. Oppositional defiant disorder
Correct answer: C. Situational inattention related to classroom environment
or learning disorder
Rationale:
ADHD requires pervasive symptoms across ≥2 settings (home, school) and
evidence since before age 12. Symptoms limited to school suggest situational
factors (e.g., classroom structure, teacher practices), sensory issues, or an
underlying learning disorder (e.g., dyslexia) causing apparent inattention.
Combined ADHD would show hyperactivity/impulsivity across contexts;
predominantly inattentive would still be present at home. ODD primarily involves
hostile/defiant behavior toward authority, not isolated attentional deficits. Clinical
action: screen for learning disorders, classroom observation, obtain teacher reports,
consider environmental interventions before diagnosing ADHD.
Question 3
A 32-year-old man presents with 2 months of low mood, hypersomnia, increased
appetite with weight gain, psychomotor slowing, and profound feelings of
worthlessness. He reports waking early but then sleeping more than usual. Which
specifier or diagnosis best fits?
A. Major depressive disorder with melancholic features
B. Major depressive disorder with atypical features
C. Persistent depressive disorder (dysthymia)
D. Bipolar II disorder, depressed phase
Correct answer: B. Major depressive disorder with atypical features
Rationale:
Atypical features include mood reactivity, hypersomnia, increased appetite/weight
gain, leaden paralysis, and interpersonal rejection sensitivity. Melancholic features
show early-morning awakening (terminal insomnia), significant anorexia/weight
,3 | Page
loss, excessive guilt, and psychomotor agitation/retardation—opposite vegetative
pattern. Persistent depressive disorder has chronic (≥2 years) lower-level
depression, not acute 2-month severe episode. Bipolar II depressed phase would
require history of hypomania; absence of hypomanic symptoms makes unipolar
MDD more likely. Clinical considerations: consider SSRI/SNRI and
psychotherapy; consider screening for bipolar history before starting
antidepressants.
Question 4
A 45-year-old woman with chest pain is referred for anxiety evaluation. She
reports episodic palpitations, sweating, shortness of breath, and a sense of
impending doom lasting 20–30 minutes, occurring unpredictably. She also avoids
driving for fear of having another episode. Most likely diagnosis?
A. Panic disorder with agoraphobia
B. Generalized anxiety disorder
C. Specific phobia, situational
D. Social anxiety disorder
Correct answer: A. Panic disorder with agoraphobia
Rationale:
Panic disorder involves recurrent unexpected panic attacks with concern about
future attacks and behavioral changes to avoid them. Avoidance of situations
(driving) because of fear of panic indicates agoraphobia often comorbid with
panic disorder. GAD is pervasive excessive worry, not discrete panic attacks.
Specific phobia and social anxiety are situation-specific and usually tied to a
particular object or performance/social situations. Clinical actions: assess for
cardiac/medical causes first (rule out MI, arrhythmia, hyperthyroidism, POTS),
then CBT and SSRIs; consider safety planning.
Question 5
A 24-year-old pregnant woman (22 weeks) presents with severe vomiting, 12%
weight loss, ketonuria, dehydration, and inability to maintain oral intake. Which is
the most appropriate initial diagnosis and management priority?
, 4 | Page
A. Gastroenteritis — start antibiotics
B. Hyperemesis gravidarum — hospitalize for IV fluids, electrolytes, and
antiemetics safe in pregnancy
C. Anorexia nervosa — begin CBT for eating disorder
D. Acute pancreatitis — NPO and pain control
Correct answer: B. Hyperemesis gravidarum — hospitalize for IV fluids,
electrolytes, and antiemetics safe in pregnancy
Rationale:
Severe persistent vomiting in pregnancy with significant weight loss, ketones, and
dehydration indicates hyperemesis gravidarum. Immediate priority is
stabilization: IV fluids, repletion of electrolytes, antiemetics safe in pregnancy
(e.g., doxylamine + pyridoxine, ondansetron if needed), and nutritional support.
Gastroenteritis is less likely given pregnancy timing and ketonuria; empiric
antibiotics are not indicated. Anorexia nervosa features body image distortion and
intentional restriction; pregnant weight loss from vomiting is different. Acute
pancreatitis presents with severe epigastric pain and elevated pancreatic enzymes.
Clinical: monitor maternal/fetal status and consider hospitalization.
Question 6
An 80-year-old man is noted to have new-onset visual hallucinations and rapid
decline in executive functioning over 6 weeks after a large right-sided ischemic
stroke. He is alert but has significant inattention and visual misperceptions. Which
is the best working diagnosis?
A. Major neurocognitive disorder due to Alzheimer disease
B. Vascular neurocognitive disorder (post-stroke) with delirium features
C. Lewy body dementia
D. Brief psychotic disorder
Correct answer: B. Vascular neurocognitive disorder (post-stroke) with
delirium features
Rationale:
Acute/subacute cognitive decline temporally related to a stroke suggests vascular
neurocognitive disorder. Post-stroke patients can have fluctuating attention and
