NR 605 Final Exam (New 2025/2026 Update) —
Diagnosis & Management in Psychiatric Mental
Health Across the Lifespan I | 100% Correct Practice
Questions & Verified Answers – Chamberlain
1
A 27-year-old woman presents to the outpatient clinic with 6 weeks of “racing thoughts,”
decreased need for sleep (3–4 h nightly), and shopping sprees totaling $8,000 on credit
cards. She has pressured speech, claims to be “the next tech unicorn,” and is
argumentative when challenged. Her roommate notes these behaviors are new and began
after she started prednisone 40 mg daily for lupus cerebritis 8 weeks ago. Urine
toxicology is negative. Which diagnosis is MOST accurate?
A. Bipolar I disorder, manic episode
B. Substance/medication-induced bipolar and related disorder
C. Steroid-exacerbated borderline personality disorder
D. Brief psychotic disorder
Correct Answer: B
Rationale: DSM-5-TR requires evidence that the substance (prednisone) is capable of
producing the mood syndrome, that symptoms developed during exposure, and that they
are not better explained by a primary bipolar disorder. High-dose corticosteroids are
well-documented to induce manic states that remit once the dose is tapered. Because the
episode started AFTER steroid initiation, a primary bipolar diagnosis (A) cannot be made
until 1 month of abstinence from the offending agent. Borderline personality (C) does not
explain the classic manic triad of decreased sleep, pressured speech, and excessive
goal-directed activity. Brief psychotic disorder (D) requires hallucinations or delusions
lasting <1 month without prominent mood symptoms.
2
A 72-year-old retired engineer is brought by his daughter after 18 months of progressive
apathy, loss of interest in woodworking, and 25-lb weight loss. He scores 20/30 on the
MoCA, losing points on delayed recall and executive tasks. MRI shows bilateral frontal
and anterior temporal lobe atrophy disproportionate to global volume loss. Which
additional finding best supports behavioral-variant frontotemporal neurocognitive
disorder over major NCD due to Alzheimer’s disease?
A. Presence of hippocampal sparing on volumetric MRI
B. Cerebellar tonsillar herniation
C. Multiple lacunar infarcts on FLAIR
,D. Insidious onset before age 65 years
Correct Answer: A
Rationale: Behavioral-variant FTD is characterized by frontal and/or temporal atrophy
with relative hippocampal sparing, explaining preserved cued recall early in the course.
While early onset (D) is common, it is not pathognomonic. Lacunar infarcts (C) suggest
vascular etiology, and cerebellar herniation (B) is unrelated.
3
A 35-year-old woman with bipolar I disorder, maintained on lithium 1,200 mg daily
(level 0.9 mEq/L), is now 8 weeks pregnant. She had a prior life-threatening manic
episode postpartum. Renal function and thyroid are normal. Which shared
decision-making statement is MOST evidence-based?
A. Lithium is absolutely contraindicated in the first trimester and must be stopped
immediately
B. Risk of Ebstein anomaly is approximately 0.6 %, lower than previously thought, and
may be acceptable given high maternal relapse risk
C. Switching to valproate now will eliminate teratogenic risk
D. Lithium levels should be checked monthly because GFR falls in pregnancy
Correct Answer: B
Rationale: Contemporary registry data show Ebstein anomaly risk with first-trimester
lithium is 0.6 % (vs 0.1 % baseline) and that absolute risk remains low. Discontinuation
carries a 50 % relapse rate, especially postpartum. Valproate (C) has 6–9 %
neural-tube-defect risk and is pregnancy category X. GFR increases 30–50 % in
pregnancy, so lithium levels should be checked weekly initially, not monthly (D false).
4
A 19-year-old college sophomore reports sudden 10-minute episodes of palpitations,
chest pain, and fear of dying while studying. She avoids the library, fearing another
episode. She has no medical problems and normal ECG. Which neurotransmitter system
is PRIMARILY implicated in panic-pathophysiology?
A. GABAergic inhibition of the locus coeruleus
B. Excess dopamine in the mesolimbic tract
C. Acetylcholine excess at the neuromuscular junction
D. Histamine blockade at H1 receptors
Correct Answer: A
Rationale: Functional imaging shows heightened locus coeruleus noradrenergic firing
during panic; deficient GABAergic inhibition permits surges of norepinephrine,
producing autonomic symptoms. Dopamine (B) is central to psychosis, not panic.
Acetylcholine (C) relates to delirium, and histamine (D) to sedation or weight gain.
, 5
A 45-year-old man with schizophrenia on haloperidol decanoate 150 mg q4 weeks
develops fever (39 °C), rigidity, and confusion. CK is 12,000 IU/L. After IV fluids and
dantrolene, which medication adjustment is MOST appropriate?
A. Switch to clozapine immediately
B. Discontinue haloperidol and switch to quetiapine
C. Add benztropine 4 mg daily
D. Resume haloperidol at 50 % dose after 48 h
Correct Answer: B
Rationale: Neuroleptic malignant syndrome mandates stopping the offending agent;
quetiapine has lower D2 affinity and less NMS risk. Clozapine (A) is effective but carries
its own NMS risk and requires prolonged washout. Benztropine (C) treats extrapyramidal
symptoms, not NMS. Re-challenge (D) should wait ≥2 weeks with different agent.
6
A 52-year-old woman with treatment-resistant depression is scheduled for her first ECT.
She takes metoprolol for hypertension. Which modification reduces cardiovascular risk
during the seizure?
A. Hold metoprolol day of treatment to allow tachycardic response
B. Use etomidate rather than propofol for anesthesia
C. Administer glycopyrrolate pre-treatment to blunt vagal response
D. Increase succinylcholine dose to 2 mg/kg
Correct Answer: C
Rationale: Glycopyrrolate reduces bradycardia and oral secretions without crossing the
blood–brain barrier, maintaining cerebral seizure duration. Beta-blockade should be
continued (A false) to prevent hypertensive surge. Etomidate (B) lengthens seizure but
does not reduce arrhythmia risk.
7
A 28-year-old veteran reports nightly combat nightmares, hypervigilance, and avoiding
fireworks. He has failed prazosin 15 mg because of orthostatic syncope. Which
medication is MOST supported by randomized trials for PTSD nightmares?
A. Topiramate 200 mg nightly
B. Clonazepam 1 mg nightly
C. Trazodone 150 mg nightly
D. Risperidone 2 mg nightly
Correct Answer: A
Rationale: Topiramate reduced nightmare frequency and re-experiencing in double-blind
VA trials. Clonazepam (B) worsens avoidance and addiction risk. Trazodone (C) aids
Diagnosis & Management in Psychiatric Mental
Health Across the Lifespan I | 100% Correct Practice
Questions & Verified Answers – Chamberlain
1
A 27-year-old woman presents to the outpatient clinic with 6 weeks of “racing thoughts,”
decreased need for sleep (3–4 h nightly), and shopping sprees totaling $8,000 on credit
cards. She has pressured speech, claims to be “the next tech unicorn,” and is
argumentative when challenged. Her roommate notes these behaviors are new and began
after she started prednisone 40 mg daily for lupus cerebritis 8 weeks ago. Urine
toxicology is negative. Which diagnosis is MOST accurate?
A. Bipolar I disorder, manic episode
B. Substance/medication-induced bipolar and related disorder
C. Steroid-exacerbated borderline personality disorder
D. Brief psychotic disorder
Correct Answer: B
Rationale: DSM-5-TR requires evidence that the substance (prednisone) is capable of
producing the mood syndrome, that symptoms developed during exposure, and that they
are not better explained by a primary bipolar disorder. High-dose corticosteroids are
well-documented to induce manic states that remit once the dose is tapered. Because the
episode started AFTER steroid initiation, a primary bipolar diagnosis (A) cannot be made
until 1 month of abstinence from the offending agent. Borderline personality (C) does not
explain the classic manic triad of decreased sleep, pressured speech, and excessive
goal-directed activity. Brief psychotic disorder (D) requires hallucinations or delusions
lasting <1 month without prominent mood symptoms.
2
A 72-year-old retired engineer is brought by his daughter after 18 months of progressive
apathy, loss of interest in woodworking, and 25-lb weight loss. He scores 20/30 on the
MoCA, losing points on delayed recall and executive tasks. MRI shows bilateral frontal
and anterior temporal lobe atrophy disproportionate to global volume loss. Which
additional finding best supports behavioral-variant frontotemporal neurocognitive
disorder over major NCD due to Alzheimer’s disease?
A. Presence of hippocampal sparing on volumetric MRI
B. Cerebellar tonsillar herniation
C. Multiple lacunar infarcts on FLAIR
,D. Insidious onset before age 65 years
Correct Answer: A
Rationale: Behavioral-variant FTD is characterized by frontal and/or temporal atrophy
with relative hippocampal sparing, explaining preserved cued recall early in the course.
While early onset (D) is common, it is not pathognomonic. Lacunar infarcts (C) suggest
vascular etiology, and cerebellar herniation (B) is unrelated.
3
A 35-year-old woman with bipolar I disorder, maintained on lithium 1,200 mg daily
(level 0.9 mEq/L), is now 8 weeks pregnant. She had a prior life-threatening manic
episode postpartum. Renal function and thyroid are normal. Which shared
decision-making statement is MOST evidence-based?
A. Lithium is absolutely contraindicated in the first trimester and must be stopped
immediately
B. Risk of Ebstein anomaly is approximately 0.6 %, lower than previously thought, and
may be acceptable given high maternal relapse risk
C. Switching to valproate now will eliminate teratogenic risk
D. Lithium levels should be checked monthly because GFR falls in pregnancy
Correct Answer: B
Rationale: Contemporary registry data show Ebstein anomaly risk with first-trimester
lithium is 0.6 % (vs 0.1 % baseline) and that absolute risk remains low. Discontinuation
carries a 50 % relapse rate, especially postpartum. Valproate (C) has 6–9 %
neural-tube-defect risk and is pregnancy category X. GFR increases 30–50 % in
pregnancy, so lithium levels should be checked weekly initially, not monthly (D false).
4
A 19-year-old college sophomore reports sudden 10-minute episodes of palpitations,
chest pain, and fear of dying while studying. She avoids the library, fearing another
episode. She has no medical problems and normal ECG. Which neurotransmitter system
is PRIMARILY implicated in panic-pathophysiology?
A. GABAergic inhibition of the locus coeruleus
B. Excess dopamine in the mesolimbic tract
C. Acetylcholine excess at the neuromuscular junction
D. Histamine blockade at H1 receptors
Correct Answer: A
Rationale: Functional imaging shows heightened locus coeruleus noradrenergic firing
during panic; deficient GABAergic inhibition permits surges of norepinephrine,
producing autonomic symptoms. Dopamine (B) is central to psychosis, not panic.
Acetylcholine (C) relates to delirium, and histamine (D) to sedation or weight gain.
, 5
A 45-year-old man with schizophrenia on haloperidol decanoate 150 mg q4 weeks
develops fever (39 °C), rigidity, and confusion. CK is 12,000 IU/L. After IV fluids and
dantrolene, which medication adjustment is MOST appropriate?
A. Switch to clozapine immediately
B. Discontinue haloperidol and switch to quetiapine
C. Add benztropine 4 mg daily
D. Resume haloperidol at 50 % dose after 48 h
Correct Answer: B
Rationale: Neuroleptic malignant syndrome mandates stopping the offending agent;
quetiapine has lower D2 affinity and less NMS risk. Clozapine (A) is effective but carries
its own NMS risk and requires prolonged washout. Benztropine (C) treats extrapyramidal
symptoms, not NMS. Re-challenge (D) should wait ≥2 weeks with different agent.
6
A 52-year-old woman with treatment-resistant depression is scheduled for her first ECT.
She takes metoprolol for hypertension. Which modification reduces cardiovascular risk
during the seizure?
A. Hold metoprolol day of treatment to allow tachycardic response
B. Use etomidate rather than propofol for anesthesia
C. Administer glycopyrrolate pre-treatment to blunt vagal response
D. Increase succinylcholine dose to 2 mg/kg
Correct Answer: C
Rationale: Glycopyrrolate reduces bradycardia and oral secretions without crossing the
blood–brain barrier, maintaining cerebral seizure duration. Beta-blockade should be
continued (A false) to prevent hypertensive surge. Etomidate (B) lengthens seizure but
does not reduce arrhythmia risk.
7
A 28-year-old veteran reports nightly combat nightmares, hypervigilance, and avoiding
fireworks. He has failed prazosin 15 mg because of orthostatic syncope. Which
medication is MOST supported by randomized trials for PTSD nightmares?
A. Topiramate 200 mg nightly
B. Clonazepam 1 mg nightly
C. Trazodone 150 mg nightly
D. Risperidone 2 mg nightly
Correct Answer: A
Rationale: Topiramate reduced nightmare frequency and re-experiencing in double-blind
VA trials. Clonazepam (B) worsens avoidance and addiction risk. Trazodone (C) aids
