NR 606 — DIAGNOSIS & MANAGEMENT IN PSYCHIATRIC EXAM QUESTIONS AND ANSWERS
|FALL 2026/2027 UPDATE | 100% CORRECT LATEST
Question 1
A 28-year-old woman presents with a 3-month history of low mood, anergy, hypersomnia,
increased appetite with 10-lb weight gain, feelings of worthlessness, and difficulty
concentrating. Symptoms are worse in the winter and remit somewhat in spring. She reports
significant functional impairment at work. Which diagnosis best fits and what first-line
management would you recommend?
Answer: Major depressive disorder (seasonal pattern); initiate an SSRI (e.g., sertraline) plus
bright light therapy and psychotherapy (CBT).
Rationale:
This patient meets DSM-5 criteria for Major Depressive Disorder (MDD): ≥2 weeks of depressed
mood, anhedonia (implied by anergy), cognitive impairment, sleep and appetite disturbance,
and functional impairment. The seasonal pattern suggests the specifier “with seasonal pattern”
(previously seasonal affective disorder). First-line evidence-based treatment for moderate-to-
severe MDD includes an SSRI (sertraline is commonly used), and psychotherapy—particularly
cognitive behavioral therapy (CBT). For seasonal pattern, bright light therapy has strong
evidence and can be used alone or as an adjunct. Assess suicidality and start safety planning.
Discuss treatment risks/benefits and expect 4–6 weeks for full antidepressant response;
monitor closely in early weeks.
Question 2
A 22-year-old college student reports 6 months of excessive worry about exams, finances, and
relationships, muscle tension, restlessness, fatigue, and difficulty sleeping. Worries are difficult
to control and interfere with academics. What is the most likely diagnosis and recommended
first-line treatments?
Answer: Generalized Anxiety Disorder (GAD); recommend SSRIs or SNRIs (e.g., escitalopram,
venlafaxine) combined with cognitive behavioral therapy; consider short-term benzodiazepine
only for acute severe episodes.
Rationale:
GAD is characterized by excessive anxiety and worry occurring more days than not for ≥6
months, difficulty controlling worry, and associated symptoms (sleep disturbance, muscle
,tension, fatigue). First-line treatments per guidelines include SSRIs or SNRIs and cognitive
behavioral therapy (CBT). Benzodiazepines can be effective for short-term relief but are not
recommended long-term given risks of dependence and cognitive effects—reserve for severe
acute distress and discuss safety. Also screen for substance use and medical causes
(hyperthyroidism, stimulants).
Question 3
A 45-year-old man presents to the emergency department with sudden onset visual and tactile
hallucinations, agitation, and diaphoresis 8 hours after his last heavy alcohol use. He has a
history of prior similar episodes. Vital signs: T 38.4°C, HR 120, BP 160/100. What is the most
appropriate immediate management?
Answer: Treat for alcohol withdrawal with IV benzodiazepines (e.g., diazepam or lorazepam)
using symptom-triggered dosing (CIWA-Ar), monitor vitals, and admit for medical
management.
Rationale:
This presentation is consistent with alcohol withdrawal with autonomic instability and
hallucinations; given vital sign abnormalities and prior episodes (risk for progression),
immediate benzodiazepine therapy is indicated to prevent progression to delirium tremens and
seizures. Use a symptom-triggered protocol (CIWA-Ar) when possible. Provide thiamine and
correct electrolytes (magnesium, potassium), monitor for aspiration risk, and consider ICU level
care if unstable. Avoid antipsychotics alone for withdrawal because they may lower seizure
threshold—antipsychotics can be used adjunctively for severe agitation after benzodiazepines
have been given.
Question 4
A 30-year-old woman is brought in by family for a 2-week period of markedly elevated mood,
decreased sleep (2–3 hrs/night), pressured speech, flight of ideas, increased goal-directed
activity, and risky spending. She has had similar but longer episodes requiring hospitalization in
the past year. What is the most likely diagnosis and acute management?
Answer: Bipolar I disorder, current manic episode; initiate a mood stabilizer (e.g., lithium or
valproate) plus an antipsychotic (e.g., risperidone) if severe or psychotic features, ensure
safety and consider hospitalization.
,Rationale:
Symptoms meet criteria for a manic episode (≥1 week of elevated/irritable mood with marked
impairment). Bipolar I is diagnosed with a history of mania. Acute management depends on
severity—hospitalization for safety risk, impaired judgment, or psychosis. Lithium and valproate
are first-line mood stabilizers for mania; atypical antipsychotics are also effective and often used
for rapid control of agitation/psychosis. Check baseline labs (CBC, LFTs, renal, pregnancy test),
ECG when indicated, and initiate monitoring (lithium levels, liver function for valproate). Provide
psychoeducation and involve family in safety planning.
Question 5
A 68-year-old man with chronic schizophrenia on fluphenazine (a first-generation antipsychotic)
presents with acute rigidity, fever 39.0°C, autonomic instability, and elevated creatine kinase.
What is the diagnosis and immediate treatment?
Answer: Neuroleptic malignant syndrome (NMS); immediately discontinue all antipsychotics,
provide supportive care (cooling, hydration), and consider dantrolene and/or bromocriptine.
Admit to ICU.
Rationale:
NMS is a life-threatening idiosyncratic reaction to dopamine antagonists characterized by severe
muscle rigidity (“lead-pipe”), hyperthermia, autonomic instability, and elevated CK due to
rhabdomyolysis. Management requires immediate cessation of offending agent(s), aggressive
supportive care (temperature control, IV fluids), and pharmacologic therapy with dantrolene
(muscle relaxant) and/or bromocriptine (dopamine agonist). Monitor for complications (renal
failure, DIC). Differentiate from serotonin syndrome (which has hyperreflexia and clonus). Avoid
restarting antipsychotics until full recovery; if needed, use low-dose atypical antipsychotics
cautiously.
Question 6
A 26-year-old male reports hearing voices commenting on his behavior for the past 3 months,
disorganized speech, flattened affect, and social withdrawal. He denies mood symptoms. What
diagnosis is most likely and what is the first-line outpatient pharmacologic treatment?
Answer: Schizophrenia; begin an atypical antipsychotic (e.g., risperidone, olanzapine, or
aripiprazole) with psychosocial interventions.
, Rationale:
Duration of psychotic symptoms ≥6 months is required for a formal DSM-5 diagnosis of
schizophrenia; however, at 3 months, this meets criteria for schizophreniform disorder (1–6
months). Given the severity of symptoms, antipsychotic treatment is indicated. Atypical
antipsychotics are often first-line due to lower extrapyramidal side effects compared with first-
generation agents. Start at therapeutic doses, counsel regarding metabolic side effects (weight
gain, dyslipidemia, diabetes risk) and EPS, and obtain baseline labs (glucose, lipids, weight, ECG
if indicated). Provide psychoeducation and coordinate care for adherence and safety.
Question 7
A 19-year-old college student presents with recurrent intrusive images of sexual assault after a
campus attack 2 months ago, nightmares, hypervigilance, avoidance of reminders, and marked
functional impairment. What is the diagnosis and evidence-based treatment?
Answer: Posttraumatic stress disorder (PTSD); trauma-focused psychotherapy (prolonged
exposure or cognitive processing therapy) is first-line; SSRIs (sertraline, paroxetine) can be
added if needed.
Rationale:
PTSD requires symptoms >1 month after a traumatic event, including intrusive recollections,
avoidance, negative alterations in cognition/mood, and hyperarousal. Trauma-focused
psychotherapies (prolonged exposure, cognitive processing therapy) have the best evidence for
sustained improvement. SSRIs (sertraline and paroxetine are FDA-approved) can be helpful for
comorbid depression/anxiety or when psychotherapy is unavailable. Evaluate for safety (self-
harm) and substance use. Consider adjunctive therapies (prazosin for nightmares) as clinically
indicated.
Question 8
A 34-year-old woman with major depressive disorder has been on sertraline 100 mg daily for 8
weeks with partial improvement but residual anhedonia and insomnia. She is not suicidal. What
is an evidence-based next step?
Answer: Optimize antidepressant therapy: consider dose increase if tolerated, augmentation
with bupropion for residual anergia/anhedonia, or add psychotherapy (CBT); assess
adherence and comorbidities.
|FALL 2026/2027 UPDATE | 100% CORRECT LATEST
Question 1
A 28-year-old woman presents with a 3-month history of low mood, anergy, hypersomnia,
increased appetite with 10-lb weight gain, feelings of worthlessness, and difficulty
concentrating. Symptoms are worse in the winter and remit somewhat in spring. She reports
significant functional impairment at work. Which diagnosis best fits and what first-line
management would you recommend?
Answer: Major depressive disorder (seasonal pattern); initiate an SSRI (e.g., sertraline) plus
bright light therapy and psychotherapy (CBT).
Rationale:
This patient meets DSM-5 criteria for Major Depressive Disorder (MDD): ≥2 weeks of depressed
mood, anhedonia (implied by anergy), cognitive impairment, sleep and appetite disturbance,
and functional impairment. The seasonal pattern suggests the specifier “with seasonal pattern”
(previously seasonal affective disorder). First-line evidence-based treatment for moderate-to-
severe MDD includes an SSRI (sertraline is commonly used), and psychotherapy—particularly
cognitive behavioral therapy (CBT). For seasonal pattern, bright light therapy has strong
evidence and can be used alone or as an adjunct. Assess suicidality and start safety planning.
Discuss treatment risks/benefits and expect 4–6 weeks for full antidepressant response;
monitor closely in early weeks.
Question 2
A 22-year-old college student reports 6 months of excessive worry about exams, finances, and
relationships, muscle tension, restlessness, fatigue, and difficulty sleeping. Worries are difficult
to control and interfere with academics. What is the most likely diagnosis and recommended
first-line treatments?
Answer: Generalized Anxiety Disorder (GAD); recommend SSRIs or SNRIs (e.g., escitalopram,
venlafaxine) combined with cognitive behavioral therapy; consider short-term benzodiazepine
only for acute severe episodes.
Rationale:
GAD is characterized by excessive anxiety and worry occurring more days than not for ≥6
months, difficulty controlling worry, and associated symptoms (sleep disturbance, muscle
,tension, fatigue). First-line treatments per guidelines include SSRIs or SNRIs and cognitive
behavioral therapy (CBT). Benzodiazepines can be effective for short-term relief but are not
recommended long-term given risks of dependence and cognitive effects—reserve for severe
acute distress and discuss safety. Also screen for substance use and medical causes
(hyperthyroidism, stimulants).
Question 3
A 45-year-old man presents to the emergency department with sudden onset visual and tactile
hallucinations, agitation, and diaphoresis 8 hours after his last heavy alcohol use. He has a
history of prior similar episodes. Vital signs: T 38.4°C, HR 120, BP 160/100. What is the most
appropriate immediate management?
Answer: Treat for alcohol withdrawal with IV benzodiazepines (e.g., diazepam or lorazepam)
using symptom-triggered dosing (CIWA-Ar), monitor vitals, and admit for medical
management.
Rationale:
This presentation is consistent with alcohol withdrawal with autonomic instability and
hallucinations; given vital sign abnormalities and prior episodes (risk for progression),
immediate benzodiazepine therapy is indicated to prevent progression to delirium tremens and
seizures. Use a symptom-triggered protocol (CIWA-Ar) when possible. Provide thiamine and
correct electrolytes (magnesium, potassium), monitor for aspiration risk, and consider ICU level
care if unstable. Avoid antipsychotics alone for withdrawal because they may lower seizure
threshold—antipsychotics can be used adjunctively for severe agitation after benzodiazepines
have been given.
Question 4
A 30-year-old woman is brought in by family for a 2-week period of markedly elevated mood,
decreased sleep (2–3 hrs/night), pressured speech, flight of ideas, increased goal-directed
activity, and risky spending. She has had similar but longer episodes requiring hospitalization in
the past year. What is the most likely diagnosis and acute management?
Answer: Bipolar I disorder, current manic episode; initiate a mood stabilizer (e.g., lithium or
valproate) plus an antipsychotic (e.g., risperidone) if severe or psychotic features, ensure
safety and consider hospitalization.
,Rationale:
Symptoms meet criteria for a manic episode (≥1 week of elevated/irritable mood with marked
impairment). Bipolar I is diagnosed with a history of mania. Acute management depends on
severity—hospitalization for safety risk, impaired judgment, or psychosis. Lithium and valproate
are first-line mood stabilizers for mania; atypical antipsychotics are also effective and often used
for rapid control of agitation/psychosis. Check baseline labs (CBC, LFTs, renal, pregnancy test),
ECG when indicated, and initiate monitoring (lithium levels, liver function for valproate). Provide
psychoeducation and involve family in safety planning.
Question 5
A 68-year-old man with chronic schizophrenia on fluphenazine (a first-generation antipsychotic)
presents with acute rigidity, fever 39.0°C, autonomic instability, and elevated creatine kinase.
What is the diagnosis and immediate treatment?
Answer: Neuroleptic malignant syndrome (NMS); immediately discontinue all antipsychotics,
provide supportive care (cooling, hydration), and consider dantrolene and/or bromocriptine.
Admit to ICU.
Rationale:
NMS is a life-threatening idiosyncratic reaction to dopamine antagonists characterized by severe
muscle rigidity (“lead-pipe”), hyperthermia, autonomic instability, and elevated CK due to
rhabdomyolysis. Management requires immediate cessation of offending agent(s), aggressive
supportive care (temperature control, IV fluids), and pharmacologic therapy with dantrolene
(muscle relaxant) and/or bromocriptine (dopamine agonist). Monitor for complications (renal
failure, DIC). Differentiate from serotonin syndrome (which has hyperreflexia and clonus). Avoid
restarting antipsychotics until full recovery; if needed, use low-dose atypical antipsychotics
cautiously.
Question 6
A 26-year-old male reports hearing voices commenting on his behavior for the past 3 months,
disorganized speech, flattened affect, and social withdrawal. He denies mood symptoms. What
diagnosis is most likely and what is the first-line outpatient pharmacologic treatment?
Answer: Schizophrenia; begin an atypical antipsychotic (e.g., risperidone, olanzapine, or
aripiprazole) with psychosocial interventions.
, Rationale:
Duration of psychotic symptoms ≥6 months is required for a formal DSM-5 diagnosis of
schizophrenia; however, at 3 months, this meets criteria for schizophreniform disorder (1–6
months). Given the severity of symptoms, antipsychotic treatment is indicated. Atypical
antipsychotics are often first-line due to lower extrapyramidal side effects compared with first-
generation agents. Start at therapeutic doses, counsel regarding metabolic side effects (weight
gain, dyslipidemia, diabetes risk) and EPS, and obtain baseline labs (glucose, lipids, weight, ECG
if indicated). Provide psychoeducation and coordinate care for adherence and safety.
Question 7
A 19-year-old college student presents with recurrent intrusive images of sexual assault after a
campus attack 2 months ago, nightmares, hypervigilance, avoidance of reminders, and marked
functional impairment. What is the diagnosis and evidence-based treatment?
Answer: Posttraumatic stress disorder (PTSD); trauma-focused psychotherapy (prolonged
exposure or cognitive processing therapy) is first-line; SSRIs (sertraline, paroxetine) can be
added if needed.
Rationale:
PTSD requires symptoms >1 month after a traumatic event, including intrusive recollections,
avoidance, negative alterations in cognition/mood, and hyperarousal. Trauma-focused
psychotherapies (prolonged exposure, cognitive processing therapy) have the best evidence for
sustained improvement. SSRIs (sertraline and paroxetine are FDA-approved) can be helpful for
comorbid depression/anxiety or when psychotherapy is unavailable. Evaluate for safety (self-
harm) and substance use. Consider adjunctive therapies (prazosin for nightmares) as clinically
indicated.
Question 8
A 34-year-old woman with major depressive disorder has been on sertraline 100 mg daily for 8
weeks with partial improvement but residual anhedonia and insomnia. She is not suicidal. What
is an evidence-based next step?
Answer: Optimize antidepressant therapy: consider dose increase if tolerated, augmentation
with bupropion for residual anergia/anhedonia, or add psychotherapy (CBT); assess
adherence and comorbidities.
