NR 547 MIDTERM EXAM ACTUAL EXAM 2026 | AAPC CPB | PRACTICAL APPLICATION
EXAM QUESTIONS AND CORRECT ANSWERS (DETAILED ANSWERS) | UPDATED
VERSION
Question 1
A 58-year-old female presents to the outpatient psychiatric clinic reporting persistent fatigue, low
energy, and sluggishness for the past two months. Her laboratory workup reveals a thyroid-
stimulating hormone (TSH) level of 6.3 mIU/L. What is the most appropriate initial clinical
action by the Psychiatric-Mental Health Nurse Practitioner (PMHNP)?
A) Initiate treatment with an SSRI such as sertraline for major depressive disorder.
B) Refer the client to primary care or endocrinology for management of hypothyroidism.
C) Prescribe low-dose bupropion to target her fatigue and lethargy.
D) Order a brain MRI to rule out pituitary adenoma before taking action.
E) Reassure the client that her TSH level is normal and schedule a follow-up in 6 months.
Correct Answer: B) Refer the client to primary care or endocrinology for management of
hypothyroidism.
Rationale: A normal serum TSH level is between 0.4 and 4.5 mIU/L. A TSH level of 6.3
mIU/L is elevated, which indicates hypothyroidism. Hypothyroidism is a well-established
medical etiology for fatigue, psychomotor slowing, and depressive symptoms. Psychiatric
diagnoses cannot be accurately assigned until underlying general medical etiologies are
addressed. Once thyroid hormone levels are normalized with medical management, the
client can be reevaluated to see if depressive symptoms persist.
Question 2
A 49-year-old male presents with persistent complaints of fatigue, lack of motivation, and
sadness. A complete blood count (CBC) is ordered to evaluate his symptoms. His hemoglobin is
15 g/dL and his hematocrit is 42%. Which of the following is the most appropriate clinical
decision?
A) Refer the client to a hematologist for further evaluation of anemia.
B) Order an iron panel and ferritin level before proceeding.
C) Begin psychiatric treatment based on a comprehensive diagnostic evaluation.
D) Defer psychiatric treatment until repeat laboratory testing is performed in 4 weeks.
E) Prescribe oral iron supplementation and monitor his red blood cell counts.
Correct Answer: C) Begin psychiatric treatment based on a comprehensive diagnostic
evaluation.
Rationale: Normal hemoglobin levels for adult males range between 12 and 18 g/dL, and
hematocrit ranges between 38% and 48%. Because the client's hemoglobin (15 g/dL) and
hematocrit (42%) are completely within normal limits, anemia is ruled out as the primary
etiology of his fatigue. The PMHNP should proceed with psychiatric evaluation and initiate
appropriate treatment for his depressive symptoms.
, 2
Question 3
A 79-year-old female client living in an assisted living facility is brought to the clinic due to
sudden acute confusion, disorientation, and mild agitation that started two days ago. A urinalysis
(UA) reveals positive leukocyte esterase and nitrites. What is the PMHNP's priority management
step?
A) Diagnose the client with major neurocognitive disorder and begin donepezil.
B) Initiate low-dose haloperidol to manage her agitation and behavioral changes.
C) Refer the client to primary care or the emergency setting for treatment of a urinary tract
infection.
D) Order a 24-hour urine collection to evaluate creatinine clearance.
E) Initiate citalopram for underlying anxiety-induced confusion.
Correct Answer: C) Refer the client to primary care or the emergency setting for treatment
of a urinary tract infection.
Rationale: Acute mental status changes and delirium in older adults are frequently
precipitated by systemic infections, most commonly urinary tract infections (UTIs).
Positive leukocyte esterase and nitrites confirm the presence of a UTI. A medical referral
for antibiotic therapy is the absolute priority, as addressing the underlying infection
typically resolves the acute neuropsychiatric symptoms.
Question 4
A 66-year-old client presents with a three-month history of worsening depressed mood, apathy,
and irritability. Routine laboratory testing reveals a 25-hydroxy vitamin D level of 11 ng/mL.
Which of the following best reflects the PMHNP's clinical approach?
A) Immediately start electroconvulsive therapy (ECT) due to metabolic refractory depression.
B) Recognize that a level <12 ng/mL indicates deficiency, and either initiate vitamin D
replacement or refer the client for treatment.
C) Consider this an optimal normal level for adults over age 65 and initiate duloxetine alone.
D) Re-check the 25-hydroxy vitamin D level in 12 months before taking clinical action.
E) Prescribe high-dose methylphenidate to counter apathy caused by vitamin D toxicity.
Correct Answer: B) Recognize that a level <12 ng/mL indicates deficiency, and either
initiate vitamin D replacement or refer the client for treatment.
Rationale: A normal 25-hydroxy vitamin D blood level is 20 to 50 ng/mL; a level below 12
ng/mL indicates a clear deficiency. Vitamin D plays a crucial role in neuroprotection,
neuroimmunomodulation, and neurotransmission. Deficiency is closely associated with
depression and cognitive impairment. The PMHNP may treat the deficiency or refer the
client to primary care depending on provider scope and comfort.
, 3
Question 5
A 24-year-old female presents with severe restlessness, palpitations, tremulousness, heat
intolerance, and free-floating anxiety. Her laboratory work shows a triiodothyronine (T3) level of
260 ng/dL. What is the most appropriate next step?
A) Diagnose generalized anxiety disorder and start buspirone 10 mg BID.
B) Initiate paroxetine 20 mg daily for panic disorder.
C) Refer the client for medical management of hyperthyroidism.
D) Prescribe a PRN benzodiazepine and re-test T3 in 6 months.
E) Recommend cognitive behavioral therapy (CBT) as monotherapy.
Correct Answer: C) Refer the client for medical management of hyperthyroidism.
Rationale: Normal T3 levels range from 100 to 200 ng/dL. A T3 level of 260 ng/dL
represents an elevated level consistent with hyperthyroidism. Hyperthyroidism induces
hypermetabolic adrenergic states that mimic anxiety disorders (tachycardia, tremor,
sweating, anxiety). Medical referral is required. Once euthyroid status is achieved,
persistent anxiety symptoms can be accurately assessed.
Question 6
A 19-year-old male is brought to the clinic exhibiting persecutory delusions, auditory
hallucinations, and social withdrawal. His laboratory workup demonstrates a serum vitamin B12
level of 900 pg/mL. What should the PMHNP conclude?
A) The patient has severe vitamin B12 toxicity causing toxic psychosis.
B) Vitamin B12 deficiency is ruled out as the cause; treatment for a primary psychotic disorder
should begin.
C) Intramuscular cyanocobalamin injections should be initiated immediately.
D) The patient requires repeat B12 testing combined with folic acid levels before diagnosis.
E) The psychotic symptoms will resolve once B12 levels fall below 300 pg/mL.
Correct Answer: B) Vitamin B12 deficiency is ruled out as the cause; treatment for a
primary psychotic disorder should begin.
Rationale: Normal serum vitamin B12 levels range from 190 to 950 pg/mL (with 200–300
pg/mL considered borderline). A level of 900 pg/mL is normal, ruling out B12 deficiency as
a physical etiology for the psychotic symptoms. The provider should proceed with
appropriate psychiatric treatment for the primary psychotic illness.
Question 7
A 64-year-old male with a history of hypertension presents with new-onset confusion, cognitive
lapses, and lethargy. His comprehensive metabolic panel (CMP) reveals a serum creatinine of 7.0
mg/dL and a blood urea nitrogen (BUN) of 32 mg/dL. Which action is indicated?
, 4
A) Prescribe memantine for acute cognitive decline.
B) Refer the client immediately to the emergency department or nephrology for renal
dysfunction.
C) Initiate haloperidol for uremic-induced delirium.
D) Recommend increased fluid intake and recheck labs in 30 days.
E) Begin lithium carbonate therapy while adjusting for renal clearance.
Correct Answer: B) Refer the client immediately to the emergency department or
nephrology for renal dysfunction.
Rationale: Normal serum creatinine is 0.6 to 1.2 mg/dL, and normal BUN is 7 to 18 mg/dL.
A serum creatinine of 7.0 mg/dL accompanied by an elevated BUN indicates severe renal
impairment/failure, which can cause uremic encephalopathy presenting as confusion and
cognitive impairment. Immediate medical referral is required.
Question 8
What is the primary clinical purpose of ordering diagnostic tests and routine laboratory workups
during an initial psychiatric evaluation?
A) To establish definitive biological markers for major depressive and anxiety disorders.
B) To satisfy medical coding guidelines for psychiatric billing complexity.
C) To rule out underlying general medical conditions and evaluate safety/effects of psychotropic
medications.
D) To replace clinical interviews with objective physiological measurements.
E) To identify specific genetic mutations that predict psychotropic drug responses.
Correct Answer: C) To rule out underlying general medical conditions and evaluate
safety/effects of psychotropic medications.
Rationale: In psychiatric practice, diagnostic tests and laboratory screenings are primarily
utilized to exclude general medical conditions (e.g., thyroid dysfunction, metabolic
imbalances, infections, nutritional deficiencies) that present with neuropsychiatric
symptoms, and to establish baseline values to monitor the safety of psychopharmacological
agents.
Question 9
Which of the following ranges represents the normal reference value for platelets on a complete
blood count (CBC)?
A) 50,000–100,000/microliter
B) 150,000–300,000/microliter
C) 500,000–800,000/microliter
D) 10,000–50,000/microliter
EXAM QUESTIONS AND CORRECT ANSWERS (DETAILED ANSWERS) | UPDATED
VERSION
Question 1
A 58-year-old female presents to the outpatient psychiatric clinic reporting persistent fatigue, low
energy, and sluggishness for the past two months. Her laboratory workup reveals a thyroid-
stimulating hormone (TSH) level of 6.3 mIU/L. What is the most appropriate initial clinical
action by the Psychiatric-Mental Health Nurse Practitioner (PMHNP)?
A) Initiate treatment with an SSRI such as sertraline for major depressive disorder.
B) Refer the client to primary care or endocrinology for management of hypothyroidism.
C) Prescribe low-dose bupropion to target her fatigue and lethargy.
D) Order a brain MRI to rule out pituitary adenoma before taking action.
E) Reassure the client that her TSH level is normal and schedule a follow-up in 6 months.
Correct Answer: B) Refer the client to primary care or endocrinology for management of
hypothyroidism.
Rationale: A normal serum TSH level is between 0.4 and 4.5 mIU/L. A TSH level of 6.3
mIU/L is elevated, which indicates hypothyroidism. Hypothyroidism is a well-established
medical etiology for fatigue, psychomotor slowing, and depressive symptoms. Psychiatric
diagnoses cannot be accurately assigned until underlying general medical etiologies are
addressed. Once thyroid hormone levels are normalized with medical management, the
client can be reevaluated to see if depressive symptoms persist.
Question 2
A 49-year-old male presents with persistent complaints of fatigue, lack of motivation, and
sadness. A complete blood count (CBC) is ordered to evaluate his symptoms. His hemoglobin is
15 g/dL and his hematocrit is 42%. Which of the following is the most appropriate clinical
decision?
A) Refer the client to a hematologist for further evaluation of anemia.
B) Order an iron panel and ferritin level before proceeding.
C) Begin psychiatric treatment based on a comprehensive diagnostic evaluation.
D) Defer psychiatric treatment until repeat laboratory testing is performed in 4 weeks.
E) Prescribe oral iron supplementation and monitor his red blood cell counts.
Correct Answer: C) Begin psychiatric treatment based on a comprehensive diagnostic
evaluation.
Rationale: Normal hemoglobin levels for adult males range between 12 and 18 g/dL, and
hematocrit ranges between 38% and 48%. Because the client's hemoglobin (15 g/dL) and
hematocrit (42%) are completely within normal limits, anemia is ruled out as the primary
etiology of his fatigue. The PMHNP should proceed with psychiatric evaluation and initiate
appropriate treatment for his depressive symptoms.
, 2
Question 3
A 79-year-old female client living in an assisted living facility is brought to the clinic due to
sudden acute confusion, disorientation, and mild agitation that started two days ago. A urinalysis
(UA) reveals positive leukocyte esterase and nitrites. What is the PMHNP's priority management
step?
A) Diagnose the client with major neurocognitive disorder and begin donepezil.
B) Initiate low-dose haloperidol to manage her agitation and behavioral changes.
C) Refer the client to primary care or the emergency setting for treatment of a urinary tract
infection.
D) Order a 24-hour urine collection to evaluate creatinine clearance.
E) Initiate citalopram for underlying anxiety-induced confusion.
Correct Answer: C) Refer the client to primary care or the emergency setting for treatment
of a urinary tract infection.
Rationale: Acute mental status changes and delirium in older adults are frequently
precipitated by systemic infections, most commonly urinary tract infections (UTIs).
Positive leukocyte esterase and nitrites confirm the presence of a UTI. A medical referral
for antibiotic therapy is the absolute priority, as addressing the underlying infection
typically resolves the acute neuropsychiatric symptoms.
Question 4
A 66-year-old client presents with a three-month history of worsening depressed mood, apathy,
and irritability. Routine laboratory testing reveals a 25-hydroxy vitamin D level of 11 ng/mL.
Which of the following best reflects the PMHNP's clinical approach?
A) Immediately start electroconvulsive therapy (ECT) due to metabolic refractory depression.
B) Recognize that a level <12 ng/mL indicates deficiency, and either initiate vitamin D
replacement or refer the client for treatment.
C) Consider this an optimal normal level for adults over age 65 and initiate duloxetine alone.
D) Re-check the 25-hydroxy vitamin D level in 12 months before taking clinical action.
E) Prescribe high-dose methylphenidate to counter apathy caused by vitamin D toxicity.
Correct Answer: B) Recognize that a level <12 ng/mL indicates deficiency, and either
initiate vitamin D replacement or refer the client for treatment.
Rationale: A normal 25-hydroxy vitamin D blood level is 20 to 50 ng/mL; a level below 12
ng/mL indicates a clear deficiency. Vitamin D plays a crucial role in neuroprotection,
neuroimmunomodulation, and neurotransmission. Deficiency is closely associated with
depression and cognitive impairment. The PMHNP may treat the deficiency or refer the
client to primary care depending on provider scope and comfort.
, 3
Question 5
A 24-year-old female presents with severe restlessness, palpitations, tremulousness, heat
intolerance, and free-floating anxiety. Her laboratory work shows a triiodothyronine (T3) level of
260 ng/dL. What is the most appropriate next step?
A) Diagnose generalized anxiety disorder and start buspirone 10 mg BID.
B) Initiate paroxetine 20 mg daily for panic disorder.
C) Refer the client for medical management of hyperthyroidism.
D) Prescribe a PRN benzodiazepine and re-test T3 in 6 months.
E) Recommend cognitive behavioral therapy (CBT) as monotherapy.
Correct Answer: C) Refer the client for medical management of hyperthyroidism.
Rationale: Normal T3 levels range from 100 to 200 ng/dL. A T3 level of 260 ng/dL
represents an elevated level consistent with hyperthyroidism. Hyperthyroidism induces
hypermetabolic adrenergic states that mimic anxiety disorders (tachycardia, tremor,
sweating, anxiety). Medical referral is required. Once euthyroid status is achieved,
persistent anxiety symptoms can be accurately assessed.
Question 6
A 19-year-old male is brought to the clinic exhibiting persecutory delusions, auditory
hallucinations, and social withdrawal. His laboratory workup demonstrates a serum vitamin B12
level of 900 pg/mL. What should the PMHNP conclude?
A) The patient has severe vitamin B12 toxicity causing toxic psychosis.
B) Vitamin B12 deficiency is ruled out as the cause; treatment for a primary psychotic disorder
should begin.
C) Intramuscular cyanocobalamin injections should be initiated immediately.
D) The patient requires repeat B12 testing combined with folic acid levels before diagnosis.
E) The psychotic symptoms will resolve once B12 levels fall below 300 pg/mL.
Correct Answer: B) Vitamin B12 deficiency is ruled out as the cause; treatment for a
primary psychotic disorder should begin.
Rationale: Normal serum vitamin B12 levels range from 190 to 950 pg/mL (with 200–300
pg/mL considered borderline). A level of 900 pg/mL is normal, ruling out B12 deficiency as
a physical etiology for the psychotic symptoms. The provider should proceed with
appropriate psychiatric treatment for the primary psychotic illness.
Question 7
A 64-year-old male with a history of hypertension presents with new-onset confusion, cognitive
lapses, and lethargy. His comprehensive metabolic panel (CMP) reveals a serum creatinine of 7.0
mg/dL and a blood urea nitrogen (BUN) of 32 mg/dL. Which action is indicated?
, 4
A) Prescribe memantine for acute cognitive decline.
B) Refer the client immediately to the emergency department or nephrology for renal
dysfunction.
C) Initiate haloperidol for uremic-induced delirium.
D) Recommend increased fluid intake and recheck labs in 30 days.
E) Begin lithium carbonate therapy while adjusting for renal clearance.
Correct Answer: B) Refer the client immediately to the emergency department or
nephrology for renal dysfunction.
Rationale: Normal serum creatinine is 0.6 to 1.2 mg/dL, and normal BUN is 7 to 18 mg/dL.
A serum creatinine of 7.0 mg/dL accompanied by an elevated BUN indicates severe renal
impairment/failure, which can cause uremic encephalopathy presenting as confusion and
cognitive impairment. Immediate medical referral is required.
Question 8
What is the primary clinical purpose of ordering diagnostic tests and routine laboratory workups
during an initial psychiatric evaluation?
A) To establish definitive biological markers for major depressive and anxiety disorders.
B) To satisfy medical coding guidelines for psychiatric billing complexity.
C) To rule out underlying general medical conditions and evaluate safety/effects of psychotropic
medications.
D) To replace clinical interviews with objective physiological measurements.
E) To identify specific genetic mutations that predict psychotropic drug responses.
Correct Answer: C) To rule out underlying general medical conditions and evaluate
safety/effects of psychotropic medications.
Rationale: In psychiatric practice, diagnostic tests and laboratory screenings are primarily
utilized to exclude general medical conditions (e.g., thyroid dysfunction, metabolic
imbalances, infections, nutritional deficiencies) that present with neuropsychiatric
symptoms, and to establish baseline values to monitor the safety of psychopharmacological
agents.
Question 9
Which of the following ranges represents the normal reference value for platelets on a complete
blood count (CBC)?
A) 50,000–100,000/microliter
B) 150,000–300,000/microliter
C) 500,000–800,000/microliter
D) 10,000–50,000/microliter
