Facts read from nursingworld.org and 1 more · last checked Nov 7, 2026
33 scored items, 22%. The domain joins the two halves of a psychiatric visit: naming the disorder by DSM-5-TR, then choosing, dosing and monitoring treatment for this patient’s age, body and other medicines. On this site it is the home of psychiatric prescribing; the other exams’ pages link here for it.
Practice questions
60 questions written to the PMHNP-BC outline; each choice is explained once you pick.
DSM-5-TR diagnostic criteria, including the differential
Diagnostic and laboratory tests: which to order and how to read them
Evidence-based treatment: dosing, off-label use and psychotherapy selection
Psychopharmacologic management: selection and monitoring
Management of other drugs: selection and monitoring of non-psychiatric medicines
Complementary and alternative treatments
2
DSM-5-TR time thresholds
Duration is the most common reason a near-miss option is wrong. From DSM-5-TR:
Major depressive episode: 2 weeks. Persistent depressive disorder: two years for adults, one for youth.
Manic episode: 1 week, or any length if hospitalization is needed. Hypomanic episode: 4 consecutive days.
Generalized anxiety disorder: 6 months.
Brief psychotic disorder: at least 1 day and less than 1 month. Schizophreniform: 1 to 6 months. Schizophrenia: 6 months, including 1 month of active-phase symptoms.
Acute stress disorder: from day 3 through the first month after the event. PTSD: longer than a month.
Prolonged grief disorder: a year or more since the loss in adults; half that in children and teens.
3
Prescribing errors the stems are built around
Antidepressant before a bipolar screen. Ask about past mania or hypomania and family history first; CANMAT/ISBD (2018) advises against antidepressant monotherapy in bipolar I.
Citalopram has a ceiling. FDA limits it to 40 mg a day for QT prolongation, and 20 mg a day over age 60 or with CYP2C19 poor metabolism or hepatic impairment.
Valproate and pregnancy potential. Its boxed warning covers neural tube defects and lower IQ after fetal exposure; in patients who could become pregnant it is a last resort, with contraception counseling.
Lithium levels are troughs: draw them roughly 12 hours post-dose, and recheck after a dose change once steady state is reached, about five days.
Bupropion and seizures. Its labeling lists a seizure disorder and abrupt alcohol or sedative withdrawal among its contraindications.
Dementia and antipsychotics. The FDA boxed warning for higher mortality applies to every antipsychotic in older adults with dementia-related psychosis.
4
Pregnancy, childhood and late life
Perinatal: psychiatric medication choice in pregnancy and after birth is tested here. Perinatal mood disorders also appear on the WHNP outline, alongside postpartum care: WHNP complications and postpartum.
Children: FDA approvals start at set ages, and many pediatric uses are off-label, which the outline names under evidence-based practice.
Older adults: AGS Beers Criteria (2023 update) advise avoiding benzodiazepines and Z-drug hypnotics in most older adults; start lower and titrate more slowly with renally cleared drugs.
5
16 questions on diagnosis and prescribing
0 / 16 answered16 questions
Tap an option: why each one is right or wrong appears under it.
Diagnosis and Treatment · 22%
A 19-year-old college student has recurrent episodes of binge eating followed by self-induced vomiting to prevent weight gain. She has an intense fear of gaining weight and judges herself largely by her shape. Which feature BEST distinguishes bulimia nervosa from anorexia nervosa, binge-eating/purging type?
Shape-driven self-evaluation and fear of weight gain occur in both disorders, so they cannot separate them.
Both disorders can involve vomiting, laxatives, or diuretics; the purging method does not decide the diagnosis.
Frequency sets bulimia severity, but a low-weight patient who binges and purges weekly still has anorexia, binge-eating/purging type.
Anorexia nervosa requires significantly low body weight, so binge-purge behavior at a weight that is not significantly low points to bulimia nervosa.
A 58-year-old woman on long-term lithium develops vomiting, coarse tremor, confusion, and then a generalized seizure. Her serum lithium level is 4.2 mEq/L and her eGFR is 25 mL/min/1.73 m². Lithium has been stopped. Which intervention is MOST appropriate?
Saline supports renal excretion, but with an eGFR of 25 and neurotoxicity the kidneys cannot clear the drug fast enough on their own.
A level above 4.0 mEq/L with impaired kidney function and a seizure meets EXTRIP criteria for extracorporeal removal, and hemodialysis clears lithium fastest.
Whole bowel irrigation is for a recent large ingestion of sustained-release tablets; this is chronic toxicity already in the tissues.
Charcoal does not bind lithium or other small ions, so it removes none of the drug.
A 24-year-old man has first-episode schizophrenia with auditory hallucinations and persecutory delusions. His BMI is 31, his hemoglobin A1c is 6.1%, and his father has type 2 diabetes. Which antipsychotic is the MOST appropriate initial choice?
Clozapine is reserved for schizophrenia that has failed two adequate antipsychotic trials, and it has one of the highest metabolic burdens.
Samidorphan blunts olanzapine's weight gain, but the glucose and lipid effects remain, a poor match for prediabetes.
Aripiprazole treats first-episode psychosis with a low risk of weight gain and glucose dysregulation, which matters with obesity, an A1c of 6.1%, and a family history of diabetes.
Quetiapine causes substantial weight gain and dyslipidemia, so it adds the risk this patient most needs to avoid.
A 38-year-old man with schizophrenia has been stable on clozapine 400 mg daily. He stopped smoking 1 pack a day when admitted for knee surgery and is using a nicotine patch. A week later he is very sedated, drooling, and has new myoclonic jerks. Which explanation is MOST likely?
Clozapine is cleared by the liver, so a brief postoperative change in kidney function would not raise its level this way.
Nicotine withdrawal causes irritability, restlessness, and craving, not heavy sedation, sialorrhea, and myoclonus.
Hydrocarbons in tobacco smoke induce CYP1A2, the main route of clozapine clearance; after quitting, levels can rise sharply within days and cause sedation, drooling, and myoclonus.
Nicotine itself neither induces CYP1A2 nor inhibits CYP2D6; the patch does not explain the rise in clozapine levels.
An 80-year-old man with major depressive disorder has benign prostatic hyperplasia, chronic constipation, and mild cognitive impairment. Which SSRI is the MOST important to avoid in this patient?
Twenty milligrams is the maximum citalopram dose after age 60 because of QT prolongation; at that dose it is a reasonable late-life SSRI.
Paroxetine is the most anticholinergic SSRI, which can worsen urinary retention with prostatic hyperplasia, constipation, and cognition in an 80-year-old.
Escitalopram has minimal anticholinergic activity and is a common first choice in older adults.
Sertraline has little anticholinergic effect and few interactions, which is why it is widely used in late-life depression.
A 43-year-old teacher with major depressive disorder has failed two adequate antidepressant trials. She has no psychotic features or suicidal ideation, wants to keep working, and wishes to avoid anesthesia and memory side effects. Which treatment is MOST appropriate?
ECT is the most effective option but needs anesthesia and can cause transient memory loss, which she wants to avoid; it is favored for psychotic, catatonic, or urgent cases.
Deep brain stimulation is an investigational neurosurgical option for depression, far beyond two failed trials.
rTMS is FDA-cleared for depression after failed antidepressant trials, needs no anesthesia, and does not impair memory, so she can keep teaching during the course.
VNS is a surgically implanted adjunct for chronic depression after four or more failed treatments, and its benefit builds over months.
A 76-year-old woman is diagnosed with mild major neurocognitive disorder due to Alzheimer disease (MoCA 21). Her heart rate is 74/min, and she has no history of syncope or peptic ulcer. The family asks about a symptomatic medication for cognition. Which medication is MOST appropriate to start?
Controlled trials have shown no cognitive benefit from ginkgo, and it raises bleeding risk with anticoagulants.
Memantine's benefit is shown in moderate to severe Alzheimer disease; at a mild stage it is not the first agent.
Antipsychotics do not improve cognition, and in dementia they carry a boxed warning for increased mortality.
A cholinesterase inhibitor is first-line symptomatic therapy for mild to moderate Alzheimer disease; her normal heart rate and lack of syncope or ulcer history remove the main cautions.
A 78-year-old man with major depressive disorder has marked insomnia, poor appetite, and a 5-kg weight loss. He has benign prostatic hyperplasia and is worried about sexual side effects. Which antidepressant is the MOST appropriate choice?
Tertiary-amine tricyclics are strongly anticholinergic, cause orthostasis, and are dangerous in overdose in older adults.
Duloxetine's noradrenergic action can cause urinary hesitancy with an enlarged prostate, and it often lowers appetite and causes sexual side effects.
Bupropion is sexually neutral, but it is activating and suppresses appetite, which would worsen his insomnia and weight loss.
Mirtazapine improves sleep and appetite, tends to restore weight, and rarely causes sexual dysfunction, which fits his insomnia, weight loss, and concerns.
A 29-year-old woman with recurrent major depressive disorder had an inadequate response to two SSRIs. Her BMI is 31 and she is worried about weight gain. She had bulimia nervosa as a teenager and has been in remission for 5 years. Which antidepressant is the MOST appropriate next choice?
The olanzapine-fluoxetine combination is approved for treatment-resistant depression but brings marked weight gain and metabolic harm, the opposite of her goal.
An SNRI offers a different mechanism after two SSRI failures and is relatively weight-neutral, which suits her concern.
Bupropion looks attractive for weight, but its label contraindicates it with any current or past bulimia or anorexia because of seizure risk.
Tricyclics such as amitriptyline cause marked weight gain and are dangerous in overdose, a poor next step for her.
A 4-year-old girl was adopted 1 year ago from an institution where she had many changing caregivers. She readily approaches and hugs unfamiliar adults, wanders off with strangers without checking back with her parents, and seeks comfort normally from them when hurt. Which diagnosis is MOST likely?
Overly familiar approach to strangers and wandering off without checking back, after a history of changing caregivers, define disinhibited social engagement disorder.
Reactive attachment disorder shares the neglect history but presents with inhibited, withdrawn behavior and little comfort seeking, the opposite of her picture.
ADHD impulsivity shows across settings and is not specifically indiscriminate approach to unfamiliar adults after neglect.
Autism involves deficits in social reciprocity and restricted interests; she seeks and accepts comfort from her parents normally.
A 71-year-old patient on risperidone for 6 months develops lip smacking and tongue protrusion; the AIMS confirms moderate tardive dyskinesia. Psychosis is stable. The PMHNP adds:
VMAT2 inhibitors (valbenazine, deutetrabenazine) are the FDA-approved treatments for tardive dyskinesia and let the stable antipsychotic continue.
Anticholinergics help acute dystonia and parkinsonism but can worsen tardive dyskinesia, and they add confusion and retention risk at 71.
Propranolol treats antipsychotic-induced akathisia, not choreiform tardive movements.
Amantadine treats drug-induced parkinsonism; its evidence in tardive dyskinesia is weak and short-term.
A 22-year-old is starting sertraline for major depressive disorder. Which statement by the psychiatric-mental health nurse practitioner best conveys the boxed warning?
The antidepressant boxed warning covers increased suicidal thinking and behavior in patients under 25, most often early in treatment and after dose changes, so a 22-year-old needs direct instruction to report it.
The warning extends through age 24; ending it at 18 is the common age-threshold error.
Discontinuation symptoms belong in counseling, yet they are not the subject of the boxed warning.
Early GI upset and fatigue are useful teaching points, but they are routine adverse effects, not the boxed warning.
A 75-year-old with recurrent major depression, type 2 diabetes, and chronic low back pain takes sertraline 100 mg daily, metformin, lisinopril, and gabapentin 600 mg three times daily. Two weeks after her primary care provider adds tramadol 50 mg three times daily, she becomes confused with worsening suicidal ideation and auditory hallucinations. BP is 160/90 mm Hg, HR 115/min, and T 38.1°C; clonus and hyperreflexia are present. Which is the most likely cause of the acute change?
Infection-related delirium is common at 75, but it does not produce clonus and hyperreflexia.
Gabapentin toxicity brings sedation, ataxia, and dizziness, not fever, hypertension, and inducible clonus.
A primary mood relapse does not explain fever, tachycardia, and neuromuscular hyperactivity starting right after a new serotonergic drug.
Tramadol adds serotonin reuptake inhibition to sertraline, and the result is altered mentation, autonomic instability, fever, and inducible clonus with hyperreflexia.
A 50-year-old man with major depressive disorder has a partial response to sertraline 200 mg daily, and lithium augmentation is being considered. Which finding in his work-up MOST warrants choosing a different augmentation strategy?
A normal TSH is the baseline value to record before lithium, not a reason to avoid it.
Lithium can add some weight, but obesity weighs more heavily against antipsychotic augmentation than against lithium.
Lithium is cleared by the kidneys and can damage them, so severe chronic kidney disease makes lithium augmentation unsafe and favors another strategy.
Family history of depression does not bear on lithium safety.
A 48-year-old man who drinks heavily every day presents 24 hours after his last drink with tremor, diaphoresis, anxiety, and a heart rate of 118/min. Which management is most appropriate?
A beta-blocker masks tachycardia and tremor while withdrawal progresses toward seizures; it is never used alone.
Tremor, sweating, anxiety, and tachycardia 24 hours after heavy drinking are alcohol withdrawal; a benzodiazepine taper, fixed or symptom-triggered, prevents seizures and delirium tremens.
An SSRI treats a mood or anxiety disorder over weeks; it has no role in acute withdrawal.
Buspirone does not act on GABA-A and does nothing to prevent withdrawal seizures.
A 30-year-old woman with bipolar I disorder has had five mood episodes in the past year, including mixed features. She takes lithium 900 mg daily (level 0.8 mEq/L) and sertraline 100 mg daily, added during her last depression. Her TSH is normal. Which change is MOST appropriate?
Bupropion is still an antidepressant; adding it raises the antidepressant exposure that is feeding the cycling.
Antidepressant monotherapy in bipolar I disorder is the arrangement most likely to worsen cycling and trigger mania.
A higher dose deepens the problem: more antidepressant exposure in a patient with mixed features and frequent episodes.
Antidepressants can drive rapid cycling and mixed states in bipolar disorder, so the antidepressant is tapered off while mood stabilization is optimized.