BARKLEY PMHNP EXAM REVIEW PDF
2026/2027 | VERIFIED QUESTIONS &
RATIONALES | COMPLETE BOARD EXAM
PREP
BARKLEY PMHNP EXAM REVIEW 2026/2027 VERIFIED QUESTIONS & RATIONALES
| COMPLETE BOARD EXAM PREP
───────────────────────────────────────────────────────
────────────────────────
DOCUMENT OVERVIEW
• Comprehensive 200-question practice examination designed to simulate the
actual PMHNP board exam with detailed evidence-based rationales for every
question to reinforce clinical decision-making and pharmacological knowledge.
• Study this material by reviewing questions in topic blocks, focusing on areas of
weakness, and using rationales to understand the "why" behind each correct
answer rather than memorizing options.
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SECTION 1: PSYCHOPHARMACOLOGY & MEDICATION MANAGEMENT (Questions 1-
40)
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1. A 34-year-old woman with major depressive disorder has failed trials of
sertraline and escitalopram. She presents with persistent depressed mood,
anhedonia, and suicidal ideation. Which medication would be most
appropriate as a third-line agent?
A) Fluoxetine 20 mg daily
B) Paroxetine 20 mg daily
C) Bupropion XL 300 mg daily
D) Citalopram 40 mg daily
E) Buspiron 15 mg twice daily
,CORRECT ANSWER: Bupropion XL 300 mg daily is the most appropriate choice.
Rationale: Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) with
a different mechanism from SSRIs. When SSRIs fail, switching to a medication with a
different pharmacological profile increases the likelihood of response. Bupropion is
particularly effective for depression with anhedonia and fatigue, and may enhance
motivation and energy. It also has no sexual side effects and lower risk of weight
gain compared to other antidepressants. Fluoxetine, paroxetine, and citalopram
are all SSRIs and would likely produce similar ineffective responses. Buspiron is an
azapirone anxiolytic and is not a first-line antidepressant.
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2. A 52-year-old man with bipolar I disorder currently on lithium 900 mg daily
presents with polyuria, polydipsia, and a serum lithium level of 0.6 mEq/L.
Which intervention is most appropriate?
A) Increase lithium to 1200 mg daily
B) Add hydrochlorothiazide to decrease polyuria
C) Switch to valproate as the mood stabilizer
D) Continue current dose and monitor renal function quarterly
E) Discontinue lithium and start lamotrigine
CORRECT ANSWER: Continue current dose and monitor renal function
quarterly is the most appropriate intervention.
Rationale: A lithium level of 0.6 mEq/L is within the therapeutic range (0.5–1.2
mEq/L for maintenance). Polyuria and polydipsia are common side effects of
lithium related to nephrogenic diabetes insipidus, occurring in 20–40% of patients
on chronic therapy. These symptoms do not indicate toxicity or need for dose
adjustment. Increasing the dose would increase the risk of toxicity. Adding
hydrochlorothiazide can paradoxically increase lithium levels by reducing renal
clearance and would worsen polyuria. Switching mood stabilizers is not indicated
when the current therapy is working at a therapeutic level. Monitoring renal
,function is important because chronic lithium use can cause renal impairment, and
this patient's polyuria warrants surveillance.
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────────────────────────
3. A 28-year-old woman with panic disorder is started on paroxetine. She
reports significant anxiety and akathisia within three days of starting the
medication. What is the most appropriate clinical response?
A) Discontinue paroxetine immediately and start alprazolam
B) Add propranolol to address akathisia and anxiety
C) Decrease the dose of paroxetine and continue with reassurance
D) Add benztropine to treat akathisia symptoms
E) Switch to a tricyclic antidepressant immediately
CORRECT ANSWER: Decrease the dose of paroxetine and continue with
reassurance is the most appropriate response.
Rationale: Initial activation and increased anxiety within the first few days of SSRI
therapy is common, especially in patients with anxiety disorders, and typically
resolves within 1–2 weeks. Rather than discontinuing the medication, dose
reduction to half the starting dose with gradual titration over 2–4 weeks is
recommended. Reassurance about the transient nature of these symptoms
improves adherence. Benztropine is used for extrapyramidal side effects, not SSRI-
induced akathisia. Propranolol may provide symptom relief but does not address
the underlying cause. Immediate discontinuation and switching agents is
premature when the side effects are expected to be transient.
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────────────────────────
4. A 45-year-old man with schizophrenia on haloperidol 10 mg daily develops a
high fever, muscle rigidity, and elevated creatinine kinase. Which medication
should be administered immediately?
A) Anticholinergic agent (benztropine)
, B) Dantrolene sodium
C) Lorazepam
D) Propranolol
E) Antihistamine (diphenhydramine)
CORRECT ANSWER: Dantrolene sodium is the immediate medication to
administer.
Rationale: This clinical presentation is classic for neuroleptic malignant syndrome
(NMS), a life-threatening complication of antipsychotic use. NMS is characterized by
fever (often >38.5°C), "lead pipe" rigidity, altered mental status, and elevated CK.
Dantrolene sodium is a skeletal muscle relaxant that directly inhibits calcium
release from the sarcoplasmic reticulum and is the definitive pharmacological
treatment for NMS. The typical dose is 1 mg/kg IV, repeated every 5–10 minutes up
to 10 mg/kg or until symptoms resolve. Benztropine is used for acute dystonia, not
NMS. Lorazepam can provide supportive care but is not the primary treatment.
Supportive measures (cooling, IV fluids, monitoring) are also essential.
───────────────────────────────────────────────────────
────────────────────────
5. A 38-year-old woman with generalized anxiety disorder on sertraline 50 mg
daily reports that her anxiety symptoms have worsened over the past two
weeks. She denies new stressors and medication non-compliance. What is the
most likely explanation?
A) Development of SSRI resistance
B) Worsening of the underlying anxiety disorder
C) Normal fluctuation in symptoms unrelated to medication
D) SSRI-induced activation or jitteriness
E) Sertraline is not indicated for generalized anxiety disorder
CORRECT ANSWER: SSRI-induced activation or jitteriness is the most likely
explanation.
2026/2027 | VERIFIED QUESTIONS &
RATIONALES | COMPLETE BOARD EXAM
PREP
BARKLEY PMHNP EXAM REVIEW 2026/2027 VERIFIED QUESTIONS & RATIONALES
| COMPLETE BOARD EXAM PREP
───────────────────────────────────────────────────────
────────────────────────
DOCUMENT OVERVIEW
• Comprehensive 200-question practice examination designed to simulate the
actual PMHNP board exam with detailed evidence-based rationales for every
question to reinforce clinical decision-making and pharmacological knowledge.
• Study this material by reviewing questions in topic blocks, focusing on areas of
weakness, and using rationales to understand the "why" behind each correct
answer rather than memorizing options.
───────────────────────────────────────────────────────
────────────────────────
SECTION 1: PSYCHOPHARMACOLOGY & MEDICATION MANAGEMENT (Questions 1-
40)
───────────────────────────────────────────────────────
────────────────────────
1. A 34-year-old woman with major depressive disorder has failed trials of
sertraline and escitalopram. She presents with persistent depressed mood,
anhedonia, and suicidal ideation. Which medication would be most
appropriate as a third-line agent?
A) Fluoxetine 20 mg daily
B) Paroxetine 20 mg daily
C) Bupropion XL 300 mg daily
D) Citalopram 40 mg daily
E) Buspiron 15 mg twice daily
,CORRECT ANSWER: Bupropion XL 300 mg daily is the most appropriate choice.
Rationale: Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) with
a different mechanism from SSRIs. When SSRIs fail, switching to a medication with a
different pharmacological profile increases the likelihood of response. Bupropion is
particularly effective for depression with anhedonia and fatigue, and may enhance
motivation and energy. It also has no sexual side effects and lower risk of weight
gain compared to other antidepressants. Fluoxetine, paroxetine, and citalopram
are all SSRIs and would likely produce similar ineffective responses. Buspiron is an
azapirone anxiolytic and is not a first-line antidepressant.
───────────────────────────────────────────────────────
────────────────────────
2. A 52-year-old man with bipolar I disorder currently on lithium 900 mg daily
presents with polyuria, polydipsia, and a serum lithium level of 0.6 mEq/L.
Which intervention is most appropriate?
A) Increase lithium to 1200 mg daily
B) Add hydrochlorothiazide to decrease polyuria
C) Switch to valproate as the mood stabilizer
D) Continue current dose and monitor renal function quarterly
E) Discontinue lithium and start lamotrigine
CORRECT ANSWER: Continue current dose and monitor renal function
quarterly is the most appropriate intervention.
Rationale: A lithium level of 0.6 mEq/L is within the therapeutic range (0.5–1.2
mEq/L for maintenance). Polyuria and polydipsia are common side effects of
lithium related to nephrogenic diabetes insipidus, occurring in 20–40% of patients
on chronic therapy. These symptoms do not indicate toxicity or need for dose
adjustment. Increasing the dose would increase the risk of toxicity. Adding
hydrochlorothiazide can paradoxically increase lithium levels by reducing renal
clearance and would worsen polyuria. Switching mood stabilizers is not indicated
when the current therapy is working at a therapeutic level. Monitoring renal
,function is important because chronic lithium use can cause renal impairment, and
this patient's polyuria warrants surveillance.
───────────────────────────────────────────────────────
────────────────────────
3. A 28-year-old woman with panic disorder is started on paroxetine. She
reports significant anxiety and akathisia within three days of starting the
medication. What is the most appropriate clinical response?
A) Discontinue paroxetine immediately and start alprazolam
B) Add propranolol to address akathisia and anxiety
C) Decrease the dose of paroxetine and continue with reassurance
D) Add benztropine to treat akathisia symptoms
E) Switch to a tricyclic antidepressant immediately
CORRECT ANSWER: Decrease the dose of paroxetine and continue with
reassurance is the most appropriate response.
Rationale: Initial activation and increased anxiety within the first few days of SSRI
therapy is common, especially in patients with anxiety disorders, and typically
resolves within 1–2 weeks. Rather than discontinuing the medication, dose
reduction to half the starting dose with gradual titration over 2–4 weeks is
recommended. Reassurance about the transient nature of these symptoms
improves adherence. Benztropine is used for extrapyramidal side effects, not SSRI-
induced akathisia. Propranolol may provide symptom relief but does not address
the underlying cause. Immediate discontinuation and switching agents is
premature when the side effects are expected to be transient.
───────────────────────────────────────────────────────
────────────────────────
4. A 45-year-old man with schizophrenia on haloperidol 10 mg daily develops a
high fever, muscle rigidity, and elevated creatinine kinase. Which medication
should be administered immediately?
A) Anticholinergic agent (benztropine)
, B) Dantrolene sodium
C) Lorazepam
D) Propranolol
E) Antihistamine (diphenhydramine)
CORRECT ANSWER: Dantrolene sodium is the immediate medication to
administer.
Rationale: This clinical presentation is classic for neuroleptic malignant syndrome
(NMS), a life-threatening complication of antipsychotic use. NMS is characterized by
fever (often >38.5°C), "lead pipe" rigidity, altered mental status, and elevated CK.
Dantrolene sodium is a skeletal muscle relaxant that directly inhibits calcium
release from the sarcoplasmic reticulum and is the definitive pharmacological
treatment for NMS. The typical dose is 1 mg/kg IV, repeated every 5–10 minutes up
to 10 mg/kg or until symptoms resolve. Benztropine is used for acute dystonia, not
NMS. Lorazepam can provide supportive care but is not the primary treatment.
Supportive measures (cooling, IV fluids, monitoring) are also essential.
───────────────────────────────────────────────────────
────────────────────────
5. A 38-year-old woman with generalized anxiety disorder on sertraline 50 mg
daily reports that her anxiety symptoms have worsened over the past two
weeks. She denies new stressors and medication non-compliance. What is the
most likely explanation?
A) Development of SSRI resistance
B) Worsening of the underlying anxiety disorder
C) Normal fluctuation in symptoms unrelated to medication
D) SSRI-induced activation or jitteriness
E) Sertraline is not indicated for generalized anxiety disorder
CORRECT ANSWER: SSRI-induced activation or jitteriness is the most likely
explanation.
