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PMHNP-BC CERTIFICATION REVIEW |
PSYCHIATRIC-MENTAL HEALTH NURSE
PRACTITIONER BOARD CERTIFIED STUDY
GUIDE | LATEST UPDATE 2026/2027 | PRACTICE
QUESTIONS AND ANSWERS | EXAM REVIEW
Table of Contents
1. Scientific Foundation: Neurobiology and Psychopharmacology
2. Advanced Practice Skills: Assessment, Interviewing, and Screening Tools
3. Diagnosis and Treatment: Mood Disorders
4. Diagnosis and Treatment: Anxiety, OCD, and Trauma-Related Disorders
5. Diagnosis and Treatment: Psychotic Disorders and Antipsychotics
6. Diagnosis and Treatment: Child and Adolescent Psychiatry
7. Diagnosis and Treatment: Geriatric Psychiatry
8. Psychotherapy and Related Theories
9. Ethics, Legal Principles, and Cultural Care
10. Professional Role, Scope of Practice, and Practice Management
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Question 1: A 34-year-old patient with schizophrenia has been stable on risperidone for 2 years.
He presents with involuntary tongue movements, lip smacking, and facial grimacing. Which
condition is most likely?
A) Acute dystonia
B) Akathisia
C) Tardive dyskinesia
D) Parkinsonism
Correct Answer: C) Tardive dyskinesia
Tardive dyskinesia (TD) is a delayed-onset movement disorder characterized by involuntary,
repetitive movements of the tongue, lips, face, and sometimes extremities. It typically develops
after months to years of antipsychotic treatment, particularly with first-generation agents but
also with second-generation antipsychotics. The Abnormal Involuntary Movement Scale (AIMS)
is used for monitoring. FDA-approved treatments for TD include valbenazine and
deutetrabenazine.
Question 2: Which cytochrome P450 enzyme is primarily responsible for the metabolism of most
atypical antipsychotics, making it a common source of drug interactions?
A) CYP2D6
B) CYP1A2
C) CYP3A4
D) CYP2C19
Correct Answer: C) CYP3A4
CYP3A4 is the most abundant CYP enzyme in the liver and is responsible for metabolizing many
atypical antipsychotics, including quetiapine, ziprasidone, and aripiprazole, as well as numerous
other medications. Strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) can
significantly increase antipsychotic levels, while inducers (e.g., carbamazepine, rifampin) can
reduce efficacy. CYP2D6 is also important for risperidone and aripiprazole metabolism but is
not the primary pathway for most atypicals.
Question 3: A patient on clozapine presents with fever, tachycardia, muscle rigidity, altered
mental status, and a creatine kinase level of 2,500 U/L. What is the most likely diagnosis?
A) Neuroleptic malignant syndrome
B) Serotonin syndrome
C) Acute dystonic reaction
D) Malignant hyperthermia
Correct Answer: A) Neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is a life-threatening emergency characterized by the
tetrad of fever, muscle rigidity (lead-pipe), autonomic instability (tachycardia, labile blood
, Page |3
pressure, diaphoresis), and altered mental status. Elevated creatine kinase (often >1,000 U/L)
reflects rhabdomyolysis. Clozapine and other antipsychotics can cause NMS. Treatment includes
immediate discontinuation of the antipsychotic, supportive care, and dantrolene or
bromocriptine. Serotonin syndrome presents with clonus and hyperreflexia rather than lead-pipe
rigidity.
Question 4: Which of the following best describes the mechanism of action of selective serotonin
reuptake inhibitors (SSRIs)?
A) Blockade of serotonin receptors
B) Inhibition of serotonin reuptake at the presynaptic terminal
C) Stimulation of serotonin release
D) Inhibition of monoamine oxidase
Correct Answer: B) Inhibition of serotonin reuptake at the presynaptic terminal
SSRIs work by blocking the serotonin transporter (SERT) at the presynaptic terminal, preventing
the reuptake of serotonin into the presynaptic neuron and increasing its availability in the
synaptic cleft. This mechanism differs from receptor blockade (atypical antipsychotics), serotonin
release (stimulants), and MAO inhibition (MAOIs). SSRIs are first-line for depression, anxiety
disorders, OCD, and PTSD.
Question 5: A patient is prescribed lithium. Which laboratory monitoring parameter is most
critical to assess on a regular basis?
A) Serum sodium
B) Lithium level
C) Liver function tests
D) Complete blood count
Correct Answer: B) Lithium level
Lithium has a narrow therapeutic index, with therapeutic serum levels typically ranging from 0.6
to 1.2 mEq/L for acute treatment and 0.6–0.8 mEq/L for maintenance. Levels must be monitored
regularly, especially after dose changes, addition of interacting medications (NSAIDs, ACE
inhibitors, thiazide diuretics), or changes in hydration status. Lithium toxicity can occur at levels
above 1.5 mEq/L and presents with tremor, ataxia, confusion, and seizures.
Question 6: A patient on fluoxetine is prescribed tramadol for pain. The PMHNP should be most
concerned about which potential interaction?
A) Hypertensive crisis
B) Serotonin syndrome
C) QT prolongation
D) Neuroleptic malignant syndrome
, Page |4
Correct Answer: B) Serotonin syndrome
Tramadol has serotonergic properties in addition to its opioid effects. Combining it with an SSRI
like fluoxetine increases the risk of serotonin syndrome, which presents with altered mental
status, autonomic instability, and neuromuscular abnormalities (clonus, hyperreflexia, tremor).
Other serotonergic combinations to avoid include SSRIs with MAOIs, triptans, and St. John's
wort.
Question 7: Which of the following medications requires routine monitoring of absolute
neutrophil count (ANC) due to the risk of agranulocytosis?
A) Olanzapine
B) Clozapine
C) Quetiapine
D) Risperidone
Correct Answer: B) Clozapine
Clozapine is associated with a significant risk of agranulocytosis, occurring in approximately 1–
2% of patients. The FDA requires weekly ANC monitoring for the first 6 months, then every 2
weeks for 6 months, and monthly thereafter. If ANC falls below 1,500/µL, clozapine should be
held. Clozapine also requires monitoring for myocarditis and seizures.
Question 8: A 45-year-old woman with major depressive disorder is started on sertraline. She
returns after 4 weeks with minimal improvement. What is the most appropriate next step?
A) Immediately switch to a different antidepressant
B) Increase the dose to the maximum tolerated level
C) Add an atypical antipsychotic for augmentation
D) Discontinue the medication and start psychotherapy alone
Correct Answer: B) Increase the dose to the maximum tolerated level
After 4 weeks of treatment with an SSRI, partial response is common. The next step is to optimize
the dose by titrating to the maximum tolerated level before considering a switch or
augmentation. Guidelines generally recommend allowing 6–8 weeks at an adequate dose before
declaring treatment failure. Sertraline has a dose range of 50–200 mg/day.
Question 9: Which mood stabilizer is associated with the highest risk of teratogenicity,
specifically neural tube defects like spina bifida?
A) Lithium
B) Lamotrigine
C) Valproic acid
D) Carbamazepine
Correct Answer: C) Valproic acid
Valproic acid carries the highest teratogenic risk among mood stabilizers, with a 1–2% risk of
PMHNP-BC CERTIFICATION REVIEW |
PSYCHIATRIC-MENTAL HEALTH NURSE
PRACTITIONER BOARD CERTIFIED STUDY
GUIDE | LATEST UPDATE 2026/2027 | PRACTICE
QUESTIONS AND ANSWERS | EXAM REVIEW
Table of Contents
1. Scientific Foundation: Neurobiology and Psychopharmacology
2. Advanced Practice Skills: Assessment, Interviewing, and Screening Tools
3. Diagnosis and Treatment: Mood Disorders
4. Diagnosis and Treatment: Anxiety, OCD, and Trauma-Related Disorders
5. Diagnosis and Treatment: Psychotic Disorders and Antipsychotics
6. Diagnosis and Treatment: Child and Adolescent Psychiatry
7. Diagnosis and Treatment: Geriatric Psychiatry
8. Psychotherapy and Related Theories
9. Ethics, Legal Principles, and Cultural Care
10. Professional Role, Scope of Practice, and Practice Management
, Page |2
Question 1: A 34-year-old patient with schizophrenia has been stable on risperidone for 2 years.
He presents with involuntary tongue movements, lip smacking, and facial grimacing. Which
condition is most likely?
A) Acute dystonia
B) Akathisia
C) Tardive dyskinesia
D) Parkinsonism
Correct Answer: C) Tardive dyskinesia
Tardive dyskinesia (TD) is a delayed-onset movement disorder characterized by involuntary,
repetitive movements of the tongue, lips, face, and sometimes extremities. It typically develops
after months to years of antipsychotic treatment, particularly with first-generation agents but
also with second-generation antipsychotics. The Abnormal Involuntary Movement Scale (AIMS)
is used for monitoring. FDA-approved treatments for TD include valbenazine and
deutetrabenazine.
Question 2: Which cytochrome P450 enzyme is primarily responsible for the metabolism of most
atypical antipsychotics, making it a common source of drug interactions?
A) CYP2D6
B) CYP1A2
C) CYP3A4
D) CYP2C19
Correct Answer: C) CYP3A4
CYP3A4 is the most abundant CYP enzyme in the liver and is responsible for metabolizing many
atypical antipsychotics, including quetiapine, ziprasidone, and aripiprazole, as well as numerous
other medications. Strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) can
significantly increase antipsychotic levels, while inducers (e.g., carbamazepine, rifampin) can
reduce efficacy. CYP2D6 is also important for risperidone and aripiprazole metabolism but is
not the primary pathway for most atypicals.
Question 3: A patient on clozapine presents with fever, tachycardia, muscle rigidity, altered
mental status, and a creatine kinase level of 2,500 U/L. What is the most likely diagnosis?
A) Neuroleptic malignant syndrome
B) Serotonin syndrome
C) Acute dystonic reaction
D) Malignant hyperthermia
Correct Answer: A) Neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is a life-threatening emergency characterized by the
tetrad of fever, muscle rigidity (lead-pipe), autonomic instability (tachycardia, labile blood
, Page |3
pressure, diaphoresis), and altered mental status. Elevated creatine kinase (often >1,000 U/L)
reflects rhabdomyolysis. Clozapine and other antipsychotics can cause NMS. Treatment includes
immediate discontinuation of the antipsychotic, supportive care, and dantrolene or
bromocriptine. Serotonin syndrome presents with clonus and hyperreflexia rather than lead-pipe
rigidity.
Question 4: Which of the following best describes the mechanism of action of selective serotonin
reuptake inhibitors (SSRIs)?
A) Blockade of serotonin receptors
B) Inhibition of serotonin reuptake at the presynaptic terminal
C) Stimulation of serotonin release
D) Inhibition of monoamine oxidase
Correct Answer: B) Inhibition of serotonin reuptake at the presynaptic terminal
SSRIs work by blocking the serotonin transporter (SERT) at the presynaptic terminal, preventing
the reuptake of serotonin into the presynaptic neuron and increasing its availability in the
synaptic cleft. This mechanism differs from receptor blockade (atypical antipsychotics), serotonin
release (stimulants), and MAO inhibition (MAOIs). SSRIs are first-line for depression, anxiety
disorders, OCD, and PTSD.
Question 5: A patient is prescribed lithium. Which laboratory monitoring parameter is most
critical to assess on a regular basis?
A) Serum sodium
B) Lithium level
C) Liver function tests
D) Complete blood count
Correct Answer: B) Lithium level
Lithium has a narrow therapeutic index, with therapeutic serum levels typically ranging from 0.6
to 1.2 mEq/L for acute treatment and 0.6–0.8 mEq/L for maintenance. Levels must be monitored
regularly, especially after dose changes, addition of interacting medications (NSAIDs, ACE
inhibitors, thiazide diuretics), or changes in hydration status. Lithium toxicity can occur at levels
above 1.5 mEq/L and presents with tremor, ataxia, confusion, and seizures.
Question 6: A patient on fluoxetine is prescribed tramadol for pain. The PMHNP should be most
concerned about which potential interaction?
A) Hypertensive crisis
B) Serotonin syndrome
C) QT prolongation
D) Neuroleptic malignant syndrome
, Page |4
Correct Answer: B) Serotonin syndrome
Tramadol has serotonergic properties in addition to its opioid effects. Combining it with an SSRI
like fluoxetine increases the risk of serotonin syndrome, which presents with altered mental
status, autonomic instability, and neuromuscular abnormalities (clonus, hyperreflexia, tremor).
Other serotonergic combinations to avoid include SSRIs with MAOIs, triptans, and St. John's
wort.
Question 7: Which of the following medications requires routine monitoring of absolute
neutrophil count (ANC) due to the risk of agranulocytosis?
A) Olanzapine
B) Clozapine
C) Quetiapine
D) Risperidone
Correct Answer: B) Clozapine
Clozapine is associated with a significant risk of agranulocytosis, occurring in approximately 1–
2% of patients. The FDA requires weekly ANC monitoring for the first 6 months, then every 2
weeks for 6 months, and monthly thereafter. If ANC falls below 1,500/µL, clozapine should be
held. Clozapine also requires monitoring for myocarditis and seizures.
Question 8: A 45-year-old woman with major depressive disorder is started on sertraline. She
returns after 4 weeks with minimal improvement. What is the most appropriate next step?
A) Immediately switch to a different antidepressant
B) Increase the dose to the maximum tolerated level
C) Add an atypical antipsychotic for augmentation
D) Discontinue the medication and start psychotherapy alone
Correct Answer: B) Increase the dose to the maximum tolerated level
After 4 weeks of treatment with an SSRI, partial response is common. The next step is to optimize
the dose by titrating to the maximum tolerated level before considering a switch or
augmentation. Guidelines generally recommend allowing 6–8 weeks at an adequate dose before
declaring treatment failure. Sertraline has a dose range of 50–200 mg/day.
Question 9: Which mood stabilizer is associated with the highest risk of teratogenicity,
specifically neural tube defects like spina bifida?
A) Lithium
B) Lamotrigine
C) Valproic acid
D) Carbamazepine
Correct Answer: C) Valproic acid
Valproic acid carries the highest teratogenic risk among mood stabilizers, with a 1–2% risk of
