PMHNP-BCPractice set · PMHNP-BC outline of Apr 28, 2023
ANCC PMHNP practice questions, all five domains
Facts read from nursingworld.org and 1 more · last checked Nov 7, 2026
60 questions, drawn from every domain of the current outline and none repeated from the domain pages of this guide. Each has four options, and each option gets its own explanation once you answer. Stems range from a teenager’s intake to an older adult’s dose change, as ANCC’s do.
Figure 1.Test content outline: 150 scored questions, one mark each
Advanced practice skills and diagnosis and treatment: about a quarter of the set each. On the outline they carry 27% and 22%.
Scientific foundation: a little over a fifth, in line with its 22%.
Ethics, legal and cultural care: a little over a fifth, above its 17%.
Psychotherapy and related theories: a handful of items, below its 11%. Its own page carries a separate set to make up the difference.
To redo one area alone after a first pass, pick its chip above the quiz.
60 mixed questions with explanations
0 / 60 answered60 questions
Tap an option: why each one is right or wrong appears under it.
Advanced Practice Skills · 27%
Asked why he came in, a 23-year-old man says, "I took the bus, buses are red, red is anger, my brother is angry, the government watches." How should the PMHNP document his thought process?
Circumstantial speech piles on detail but eventually reaches the point; his never does.
In tangential speech each idea follows from the one before while drifting away from the question; here the links themselves are missing.
Thought blocking is a sudden stop mid-sentence with loss of the thread, not a stream of unconnected ideas.
Ideas that jump with no logical link between them (bus, red, anger, brother, government) are loose associations, a disorganized thought process.
A 16-year-old boy completes the CRAFFT during an intake for anxiety at an outpatient psychiatric clinic. He reports riding with a friend who had been drinking and using cannabis "to relax," and answers no to the other 4 items. What is the most appropriate next step?
The CRAFFT cutoff is 2 or more; using a higher threshold misses a positive screen and a safety risk.
A positive screen calls for brief intervention and further assessment, not the most intensive level of care.
With no imminent danger, disclosing to parents before talking with him breaks adolescent confidentiality and costs his trust.
Two 'yes' answers make the CRAFFT positive, which calls for a brief intervention, and a yes on the car item needs safety counseling right away.
A 58-year-old man 3 days after emergency surgery is confused, sees insects on the walls, and pulls at his IV line. His temperature is 38.6°C (101.5°F), pulse 132, and blood pressure 178/104. His wife says he drinks heavily every day. What is the priority action?
Haloperidol does not treat withdrawal and lowers the seizure threshold, and restraints increase injury and hyperthermia risk.
The history is already enough to act; a detailed interview delays life-saving treatment.
Hallucinations, confusion, fever, tachycardia, and hypertension 2 to 4 days after heavy drinking stopped are delirium tremens, a medical emergency treated with benzodiazepines and close monitoring.
A cognitive screen during delirium measures nothing useful and postpones treatment.
On MoCA testing, a 74-year-old man draws a clock with the numbers crowded on one side and the hands wrong, and he fails the trail-making task. He recalls 4 of 5 words after a delay and is fully oriented. Which cognitive domain is most impaired?
Naming, repetition, and fluency test language; nothing here suggests a language deficit.
He is fully oriented, and these tasks do not test orientation.
He recalled 4 of 5 words, so memory is the domain least affected.
Clock drawing and trail-making test planning, sequencing, and spatial layout, so failing both with intact recall and orientation points to executive and visuospatial deficits.
A 28-year-old man facing a court date reports hearing voices that tell him to steal. He describes the voices in textbook terms, says they are constant, has no negative symptoms, and his symptoms increase when he is watched. What is the most appropriate next step?
Labeling malingering on suspicion alone can miss real illness, and discharge abandons a patient whose status is unclear.
A legal stake and atypical features raise suspicion of malingering, which is supported or refuted by comparing records, collateral, and observation with his report.
Prescribing before the inconsistencies are resolved exposes him to side effects for symptoms that may not be real.
Accusation without evidence damages the alliance and gives no new information.
A 19-year-old woman has superficial cuts on her forearms. She says she cuts "to feel something" when she is numb, but that last night she swallowed 20 acetaminophen tablets "to not wake up." What is the priority action?
Looking well hours after an acetaminophen overdose does not mean she is stable; liver injury peaks days later.
Stated intent to die separates the overdose from her cutting; calling both nonsuicidal misses a suicide attempt.
Taking 20 tablets 'to not wake up' is a suicide attempt, and acetaminophen can cause delayed liver failure even when the patient looks well, so urgent medical care comes first.
Wound care and support address the cutting but ignore the overdose and the stated intent to die.
A patient scores 18 on the PHQ-9 but shows a bright, reactive affect and denies feeling depressed during the interview. What is the PMHNP's best next step?
Bright affect in a short interview does not prove exaggeration; many depressed patients present well socially.
A mismatch is a reason to ask more, not to throw away the patient's own report.
A PHQ-9 is a screen; diagnosis and treatment need a clinical interview.
A screen and the observed presentation are reconciled through further interview, item by item, before either is discounted.
An 81-year-old woman admitted with a urinary tract infection can repeat only 3 digits forward, loses track during questions, and recalls 0 of 3 words after 5 minutes. How should the PMHNP interpret the memory result?
Attention is clearly impaired here, so the test cannot isolate a memory disorder.
A major neurocognitive disorder cannot be diagnosed while delirium is present.
A digit span of 3 and 0 of 3 recall are abnormal at any age; normal attention is about 5 or more digits forward.
A digit span of 3 shows poor attention, and recall cannot be judged when attention fails; this picture suggests delirium, so memory is retested after it clears.
A patient believes his neighbors have installed cameras to monitor him, despite clear evidence otherwise. Which MSE component does this finding reflect?
Insight is awareness of being ill; it is a separate MSE item from the belief itself.
A fixed false belief held against clear evidence is a delusion, which is recorded under thought content.
Thought process describes how ideas are organized and linked, not what the patient believes.
Perception covers hallucinations and illusions, sensory experiences without an external stimulus.
A 20-year-old college student with ADHD has taken extended-release methylphenidate 36 mg each morning for 8 months with good symptom control. He has lost 3 kg because he skips breakfast and lunch. His blood pressure and heart rate are normal. Which is the MOST appropriate next step?
Adding an antidepressant to counter a side effect is premature before simple timing and meal changes.
Replacing an effective stimulant with a less effective non-stimulant is not the first step for manageable appetite loss.
Stimulant appetite loss is first managed by giving the dose after a substantial breakfast and adding calorie-dense food in the evening as the effect wears off, keeping good ADHD control.
Amphetamines suppress appetite at least as much as methylphenidate.
A 45-year-old man with treatment-resistant depression started aripiprazole 5 mg daily as augmentation to venlafaxine 2 weeks ago. He now reports an inner urge to move, cannot sit through meals, and paces in the office while rocking from foot to foot. Which adverse effect is MOST likely?
Tardive dyskinesia appears after months of exposure as involuntary orofacial or choreiform movements, not an urge to move.
Calling akathisia anxiety leads to dose increases that make it worse; the timing after aripiprazole and the motor restlessness point to the drug.
Serotonin syndrome brings autonomic instability, hyperreflexia, and clonus, none of which he has.
Inner restlessness with pacing and rocking from foot to foot soon after starting aripiprazole is akathisia, its most common movement side effect.
A PMHNP is evaluating four patients for PTSD. According to DSM-5-TR, which exposure meets Criterion A for a traumatic event?
Criterion A includes repeated or extreme exposure to aversive details of traumatic events in the course of work, as with police officers reviewing abuse evidence.
Learning of a death qualifies only for a close family member or friend, and only if it was violent or accidental.
Exposure through television or other media counts only when it is part of a person's work.
Job loss and humiliation are stressors but do not involve actual or threatened death, serious injury, or sexual violence.
A 28-year-old man with ADHD has an active stimulant use disorder involving cocaine and has sold his prescription medications in the past. His symptoms impair his work. Which medication is the MOST appropriate choice?
Immediate-release stimulants carry the highest misuse and diversion risk.
Extended-release amphetamine remains a Schedule II stimulant with clear diversion risk in this patient.
Its prodrug design lowers misuse potential, but it is still a Schedule II amphetamine that can be sold.
With active stimulant misuse and past diversion, a non-controlled option such as atomoxetine, a norepinephrine reuptake inhibitor without abuse potential, is preferred.
Before starting an antidepressant in a 24-year-old with a depressive episode, the PMHNP screens for any history of mania or hypomania. What is the primary reason for this screening?
A manic history changes the strategy toward a mood stabilizer, but it does not slow SSRI onset.
An antidepressant without a mood stabilizer can precipitate mania or hypomania in bipolar disorder, so a history of either changes the treatment plan.
Discontinuation symptoms depend on half-life and abrupt stopping, not on bipolar history.
Serotonin syndrome follows serotonergic drug combinations or overdose, not a history of mania.
A 34-year-old man has no physical symptoms but has been convinced for a year that he is developing ALS. He checks his muscles for twitching daily and has seen three neurologists, all with normal exams. He accepts that he could be wrong but cannot stop worrying. Which diagnosis is MOST likely?
Preoccupation with having a serious illness with no or minimal somatic symptoms, plus repeated checking and doctor visits, defines illness anxiety disorder.
This diagnosis requires actual motor or sensory symptoms inconsistent with neurological disease.
Somatic symptom disorder needs distressing physical symptoms, which he does not have.
He accepts he could be wrong, so the belief is not held with delusional conviction.
A 30-year-old woman is 5 weeks postpartum with severe depression but no psychosis or suicidal plan. She is not breastfeeding and asks for a rapid-acting oral medication approved specifically for postpartum depression. Which medication fits her request?
Brexanolone is approved for postpartum depression but is a 60-hour continuous IV infusion, not an oral drug.
Esketamine is a nasal spray for treatment-resistant depression or acute suicidality, given under supervision in a certified setting, not an oral postpartum treatment.
Sertraline is a first-line option but takes weeks to work and is not specifically approved for postpartum depression.
Zuranolone, an oral GABA-A positive modulator, is FDA-approved for postpartum depression as a 14-day course with effects within days.
A 39-year-old woman with major depressive disorder with psychotic features is scheduled for ECT after failing combined sertraline and olanzapine. She also takes clonazepam 1 mg twice daily and levothyroxine. Which medication is MOST important to taper before ECT?
Benzodiazepines raise the seizure threshold and shorten ECT seizures, reducing efficacy, so clonazepam is tapered or minimized before treatment.
Antipsychotics are usually continued during ECT and may add benefit in psychotic depression.
Thyroid replacement does not interfere with ECT and should continue.
SSRIs are commonly continued during ECT and may enhance response.
A patient with remitted depression takes modafinil 200 mg at noon as an off-label adjunct for residual fatigue. Energy has improved, but the patient now has trouble falling asleep. The PMHNP recommends:
Armodafinil is the longer-acting enantiomer, so the same timing would keep or worsen the insomnia.
The fatigue has responded, so the drug is working; the problem is timing.
Modafinil's half-life is about 15 hours, so a noon dose is still active at bedtime; moving it to early morning usually fixes the insomnia and keeps the benefit.
Adding a hypnotic treats one drug's side effect with another drug.
A 50-year-old man with major depressive disorder has failed four adequate antidepressant trials, and the PMHNP is considering esketamine nasal spray. Which finding in his history is a contraindication to esketamine?
Esketamine raises blood pressure after each dose (peak about 40 minutes, lasting about 4 hours), so aneurysmal vascular disease, an arteriovenous malformation, or past intracerebral hemorrhage contraindicates it.
Esketamine is labeled for treatment-resistant depression alone or together with an oral antidepressant, so current sertraline is not a contraindication.
ECT nonresponse makes the depression more treatment-resistant but does not bar esketamine.
Controlled hypertension calls for blood pressure checks before and after dosing, not avoidance; the label contraindication is aneurysmal or AVM disease.
A 42-year-old hears the comforting voice of a deceased grandmother a few times a month. They have no other psychotic symptoms, work full time, and are not distressed. Which plan is MOST appropriate?
Hearing a deceased relative's voice is common after bereavement, and isolated, non-distressing experiences without impairment meet no psychotic disorder criteria; education and monitoring are enough.
Brief psychotic disorder needs psychotic symptoms lasting at least a day with disturbance; occasional comforting voices are not that.
Antipsychotics are not given prophylactically for one benign perceptual experience.
Schizophrenia spectrum diagnoses require clinically significant distress or impairment, which are absent.
A PMHNP in a small rural town, where she is the only mental health clinician, learns that a new patient with panic disorder is her son's elementary school teacher. What is the most appropriate action?
Leaving an unavoidable overlap unspoken invites role confusion and confidentiality slips.
In rural practice overlapping relationships are often unavoidable; discussing the overlap, agreeing how to handle outside contact, protecting confidentiality, and documenting the plan is the ethical path.
Sending him an hour away imposes a real access barrier when the overlap can be managed, and an overlap is not by itself a violation.
Withdrawing from her own child's school life is neither required nor sustainable; boundaries are managed, not avoided.
A 25-year-old woman with anorexia nervosa has a BMI of 13.5 and a heart rate of 38. She refuses medical admission. She accurately recites the risks of starvation and bradycardia but insists they do not apply to her because she is "not that thin." Which conclusion about her capacity to refuse admission is most accurate?
Reciting risks shows understanding only; capacity also needs appreciation and reasoning.
A diagnosis never removes capacity by itself; capacity is judged decision by decision.
Her refusal grows out of the illness's distortion rather than stable values she has held over time.
She understands the facts but cannot accept that they apply to her because of distorted body image, so the appreciation ability, and with it capacity for this decision, is impaired.
A PMHNP is principal investigator on a trial of a new therapy for PTSD and wants to recruit participants from among her own outpatients. Which step best protects them from undue influence?
Research participation always changes care in some way, and the claim feeds the therapeutic misconception.
When the treating clinician is also the investigator, patients may feel obliged to agree, so consent is obtained by someone outside the treatment relationship.
Her rapport is the very source of pressure that a neutral consenter removes.
Linking care benefits to enrollment is coercive inducement.
A 38-year-old man with alcohol use disorder in early remission for six months is applying for a job that requires a background check. He asks the PMHNP to remove the diagnosis from his medical record. What is the most appropriate response?
Substituting a diagnosis is fraudulent documentation.
Waiting a year does not make deletion acceptable; remission is documented, not erased.
Records must stay accurate, but a background check does not reach medical records without his authorization, and the diagnosis can be updated to 'in remission'; explaining this answers his real concern.
Deleting an accurate diagnosis falsifies the record and can compromise his future care.
A 32-year-old asylum seeker who fled political violence is seen for insomnia, nightmares, and hypervigilance. At the first visit, she is guarded and asks who will see her records. What is the most appropriate focus of this visit?
Exposure therapy needs assessment, an alliance, and stabilization first.
Trauma-informed care puts safety, transparency, and her control over what she shares first, including who sees her records, before a detailed trauma narrative.
Pressing for the full narrative at a first, guarded visit can retraumatize her and end engagement.
Immigration status does not guide PTSD treatment, and asking raises her fear about who sees her information.
A patient with borderline personality disorder alternately idealizes and devalues the PMHNP between visits. Which approach best manages this splitting?
Harsh confrontation is felt as rejection and usually inflames the devaluation.
Consistent limits plus validation of the ambivalence behind idealization and devaluation reduce splitting and model a stable relationship.
Going along with each extreme reinforces splitting and erodes the frame.
Ignoring the pattern leaves it unaddressed and lets it drive the treatment.
At a civil commitment hearing for a 40-year-old man with schizophrenia, his attorney argues that the state has not met its burden of proof. Under Addington v. Texas, what standard must the state meet for involuntary commitment?
Preponderance is the ordinary civil standard and is too low for a deprivation of liberty this serious.
Addington v. Texas (1979) held that due process requires at least clear and convincing evidence for civil commitment, an intermediate standard.
Probable cause supports a short emergency hold, not a commitment order after a hearing.
The Court declined to require the criminal standard for a civil proceeding.
During a quality review, a PMHNP finds that she ordered intramuscular antipsychotics for agitation more often for Black patients than for White patients with the same agitation scale scores. She holds no conscious prejudice and is surprised by the data. Which concept best explains this pattern?
Confirmation bias is seeking evidence for an existing hypothesis about one case, not a group-level pattern by race.
Implicit bias is an unconscious association that shapes decisions despite consciously egalitarian values, as in more coercive treatment of Black patients with the same scores.
The availability heuristic judges likelihood by how easily examples come to mind.
Anchoring is fixing on the first piece of information in a case.
During a confidential session, a 16-year-old says he will bring his father's gun to school tomorrow to shoot a classmate who has been bullying him. He knows where the key to the gun safe is kept and asks the PMHNP not to tell anyone. What is the most appropriate immediate action?
A serious threat against an identifiable person with access to a gun triggers the duty to protect; the clinician tells him, acts today (emergency evaluation, securing the weapon, warning as state law directs), and documents.
Exploring feelings first delays protective action that the threat requires now.
The threat is for tomorrow at school; a meeting then is too late.
Confidentiality yields to a serious threat of violence; weekly skills work leaves the classmate in danger.
A 57-year-old woman developed depression after her husband died eight months ago. She avoids talking about him, has withdrawn from friends, and cannot enter his study. Her PMHNP uses interpersonal psychotherapy. Which strategy is most consistent with IPT for this problem area?
In the IPT grief problem area the therapist helps the patient mourn by reviewing the relationship and feelings, then helps her re-establish interests and relationships.
Distress-tolerance skills come from DBT, not IPT.
Interpreting unconscious ambivalence is a psychodynamic technique.
Disputing thoughts is CBT; IPT works on the interpersonal loss itself.
On the C-SSRS screener, a 19-year-old college student reports thoughts of killing herself with some intent to act, but no worked-out plan. She has no suicidal behavior in her lifetime. How should the PMHNP interpret this result?
The C-SSRS is a screening tool meant for use before any attempt.
Waiting weeks leaves active intent unaddressed.
On the C-SSRS screener, ideation with some intent to act, with or without a plan, is high risk and calls for same-day evaluation and safety measures.
Intent alone places her in the high-risk band; the absence of a plan does not lower it.
A 36-year-old with persistent depressive disorder has had partial response to two adequate SSRI trials and has never received psychotherapy. They ask whether therapy would add anything. Which response by the PMHNP is most accurate?
In chronic depression, medication plus psychotherapy outperforms either alone, and CBASP was built for persistent depressive disorder.
The belief that chronic depression does not respond to therapy is a common misconception.
Stopping effective medication once therapy helps raises relapse risk.
There is no reason to hold psychotherapy until more medication trials fail.
A 34-year-old with moderate binge-eating disorder and no cardiac or substance use history has improved only partly with CBT and asks about medication. The PMHNP prescribes the FDA-approved agent for this disorder:
Topiramate has off-label evidence in binge eating but no FDA approval for it.
Naltrexone-bupropion is approved for chronic weight management, not for binge-eating disorder.
Lisdexamfetamine is the only FDA-approved drug for moderate to severe binge-eating disorder in adults, prescribed after screening cardiac history and misuse risk.
Fluoxetine is FDA-approved for bulimia nervosa, not binge-eating disorder; the two are often swapped.
A hospital administrator asks a PMHNP to provide eye movement desensitization and reprocessing (EMDR) for trauma, stating that it is within the psychiatric-mental health role. The PMHNP has observed EMDR but never been formally trained. What primarily determines whether the PMHNP may lawfully provide EMDR?
Certification attests to population-focused knowledge but does not grant legal authority to practice.
Professional association statements guide practice but have no legal force.
Legal scope of practice is set by state statute and board of nursing rules; within it, the clinician still needs formal training to provide EMDR competently.
An employer can narrow what the law allows but cannot expand it.
A 38-year-old with generalized anxiety disorder describes constant vigilance for danger and startles easily; symptoms lessen after 8 weeks of escitalopram. Which neurocircuit alteration best explains these symptoms and the treatment response?
The amygdala drives threat appraisal, and its overactivity produces hypervigilance and exaggerated startle; SSRIs dampen this limbic response over weeks.
Ventral striatum underactivity is linked to anhedonia and low motivation.
Hippocampal volume loss relates to chronic stress and memory, not moment-to-moment fear.
Nigrostriatal dopamine loss produces parkinsonian motor signs, not vigilance for danger.
A 21-year-old with first-episode schizophrenia has auditory hallucinations that resolve after 3 weeks of haloperidol, but he develops a resting tremor and cogwheel rigidity. Which mechanism accounts for the resolution of his hallucinations?
Hallucinations reflect mesolimbic dopamine overactivity, and D2 blockade in that pathway relieves positive symptoms.
Haloperidol has little 5-HT2A activity, which is more relevant to second-generation agents.
Nigrostriatal blockade explains his tremor and rigidity, not the antipsychotic effect.
Mesocortical dopamine is already low in schizophrenia, and blocking it can worsen negative and cognitive symptoms.
A 25-year-old with schizophrenia started olanzapine 10 mg nightly 3 weeks ago. His hallucinations have improved, but he now sleeps 12 hours a night and feels groggy every morning. Blockade of which receptor best explains this new complaint?
Potent H1 antagonism by olanzapine causes heavy sedation and morning grogginess.
Muscarinic blockade causes dry mouth, constipation, and blurred vision.
D2 blockade explains the antipsychotic response and any EPS or prolactin rise, not oversleeping.
Alpha-1 blockade causes orthostatic dizziness rather than long sleep.
A 24-year-old with cocaine use disorder, abstinent for 3 weeks, reports intense cravings whenever he drives past the bar where he used to buy cocaine. Which mechanism best explains this cue-induced craving?
Through repeated pairing, drug cues come to trigger dopamine release in the nucleus accumbens, producing the anticipatory 'wanting' that drives relapse.
GABA-A changes explain tolerance and withdrawal with alcohol or benzodiazepines.
Serotonin depletion is not the mechanism of cue-induced craving.
Locus coeruleus hyperactivity explains the noradrenergic signs of opioid withdrawal, not cue reactivity to cocaine.
A man with schizophrenia, stable on clozapine 300 mg daily for 3 years, is started on fluvoxamine 100 mg daily for obsessive-compulsive disorder. Two weeks later he has sedation, myoclonus, and tachycardia, and his clozapine level is 1100 ng/mL. Which mechanism and next step are most likely?
Induction, as with smoking, lowers clozapine levels, the opposite of this picture.
Fluvoxamine strongly inhibits CYP1A2, the main route of clozapine clearance, so levels climb into the toxic range; the clozapine dose is reduced and the combination reconsidered.
Neutropenia shows on the ANC and presents with infection, not with sedation, myoclonus, and a toxic level.
CYP3A4 plays a minor role in clozapine clearance, and switching away from clozapine in treatment-resistant illness is unnecessary.
A 66-year-old with schizophrenia and chronic kidney disease (creatinine clearance 40 mL/min) is switching from risperidone to paliperidone extended-release because of drug interactions. Which prescribing approach is most appropriate?
Paliperidone is not recommended only in severe impairment (below 10 mL/min); at 40 mL/min it is dose-reduced.
Paliperidone is excreted largely unchanged by the kidneys, so moderate renal impairment calls for a lower starting dose and a lower ceiling.
Minimal hepatic metabolism is exactly why kidney function governs its dosing.
Every-other-day dosing of an extended-release tablet produces unstable levels.
A 28-year-old man began clozapine 3 weeks ago. He now has chest pain, dyspnea, tachycardia, and a temperature of 38.3 °C. Which adverse effect is most likely?
NMS causes rigidity and altered consciousness rather than chest pain.
Severe neutropenia presents with infection and a low neutrophil count, not chest pain and dyspnea.
Serotonin syndrome needs a serotonergic drug and causes clonus and hyperreflexia; clozapine alone does not cause it.
Clozapine myocarditis usually appears in the first 8 weeks, often around week 3, with chest pain, dyspnea, tachycardia, and fever; clozapine is stopped and troponin and CRP are checked urgently.
A patient stabilized on haloperidol is prescribed ziprasidone for breakthrough symptoms. Both agents prolong the QT interval. Which action is most appropriate?
A lower dose still adds QT effect, and a month without an ECG leaves the risk unmeasured.
The lack of a CYP interaction is the trap; the danger is additive QT prolongation.
Both drugs prolong the QT interval, and their additive pharmacodynamic effect raises torsades risk even without a CYP interaction, so an ECG and a single optimized agent are indicated.
Correcting potassium and magnesium helps but does not remove the additive QT risk.
A 39-year-old woman with major depressive disorder has not responded to phenelzine and will be switched to fluoxetine. Her last phenelzine dose is today. What is the most appropriate plan?
Phenelzine inhibits MAO irreversibly, so activity returns only as new enzyme is made over about two weeks; overlapping it with an SSRI risks serotonin syndrome.
Plasma half-life is irrelevant with an irreversible enzyme inhibitor; the enzyme, not the drug, sets the washout.
Tyramine restriction prevents hypertensive crisis from food, not serotonin syndrome from the drug combination.
Any overlap of an MAOI and an SSRI risks serotonin syndrome, so cross-tapering is never used for this switch.
A 45-year-old man with major depressive disorder and no prior antidepressant trials is to start nortriptyline for depression with neuropathic pain. Pharmacogenomic testing reports CYP2D6 poor metabolizer. Which action is most appropriate?
Poor metabolizer status calls for dose reduction and monitoring or an alternative, not an absolute ban.
Usual dosing predicts supratherapeutic levels with anticholinergic and cardiac conduction toxicity.
Fluoxetine strongly inhibits CYP2D6 and would raise nortriptyline levels even further.
A poor metabolizer clears nortriptyline slowly and tricyclics have a narrow therapeutic index, so CPIC guidance is a reduced starting dose with plasma levels to titrate, or a different drug.
A pharmacogenomic report for a patient starting an antidepressant lists a CYP2D6 activity score of 1.0. How should this result guide prescribing?
A score of 1.0 was read as normal before the 2020 update; the normal range now starts at 1.25.
Absent activity is an activity score of 0 (poor metabolizer).
Under the 2020 CPIC–DPWG consensus a score of 1.0 is an intermediate metabolizer; whether the dose changes depends on the drug (CPIC suggests a lower start for tricyclics but standard starts for several SSRIs), so the drug-specific guideline decides.
Increased activity (ultrarapid metabolizer) corresponds to scores above 2.25.
A 44-year-old with alcohol use disorder in sustained remission has chronic sleep-onset insomnia that improved only partly with a full course of CBT-I. They ask for a medication for ongoing use. Which option is most appropriate?
A benzodiazepine hypnotic carries misuse and relapse risk in someone with an alcohol use disorder.
Ramelteon, a melatonin receptor agonist for sleep-onset insomnia, is not a controlled substance and has no abuse potential, which suits a patient in remission from alcohol use disorder after CBT-I.
Zolpidem is a Schedule IV sedative-hypnotic with misuse and dependence risk.
Low-dose quetiapine is not recommended for insomnia; evidence is poor and it adds metabolic and anticholinergic harm.
A 27-year-old woman with bipolar I disorder talks rapidly and cannot be interrupted, jumping from her trip to Paris, to French art, to painting her kitchen, to the price of paint. Each topic is loosely linked to the one before. Which term best describes her thought process?
Circumstantiality is slow and over-detailed but reaches the goal; her speech is rapid and never returns.
Rapid movement between topics that still have a traceable link, with pressured speech, is flight of ideas, typical of mania.
Clang associations link words by sound or rhyme, not by meaning.
Perseveration is returning to the same idea or word, the opposite of her constant shifting.
A 45-year-old man with treatment-resistant depression and a past stroke is scheduled for ECT. He is a lawyer and is very concerned about memory loss. Which ECT technique would BEST minimize cognitive side effects?
Bitemporal placement works faster but causes more memory impairment, the outcome he most fears.
Right unilateral placement with an ultrabrief pulse width causes the fewest cognitive side effects while keeping efficacy when dosed adequately above seizure threshold.
Sine-wave stimulation is outdated and causes the most cognitive impairment.
More frequent treatments add cognitive side effects; two to three sessions a week is standard.
A PMHNP's sister, who has a fear of flying, asks the PMHNP to prescribe alprazolam for an upcoming flight. The sister has no history of substance misuse and is not the PMHNP's patient. What is the most appropriate response?
A small quantity does not remove the conflict of interest or the lack of a proper clinical relationship.
A clean history does not make a benzodiazepine for a relative appropriate.
Prescribing for a family member, especially a controlled substance, compromises objectivity and is prohibited or strongly discouraged by boards of nursing.
A chart note does not turn a sister into an arm's-length patient; the personal relationship still clouds judgment.
A 68-year-old woman has taken citalopram 40 mg daily for major depressive disorder for three years with good response. The PMHNP reviews the FDA safety communication on dose-dependent QT prolongation with citalopram. What is the most appropriate action?
Abrupt discontinuation risks withdrawal symptoms and relapse when a dose reduction solves the problem.
Waiting for symptoms ignores a dose limit that applies regardless of symptoms.
QT prolongation is usually silent until an arrhythmia occurs, so good tolerance does not show safety.
The FDA caps citalopram at 20 mg a day after age 60 because QT prolongation is dose-dependent, so she is told and the dose is tapered to the maximum.
A patient with panic disorder has taken alprazolam for 2 years and requests an early refill, saying the medication was lost. The state prescription drug monitoring program shows that the patient filled a different benzodiazepine prescription from an emergency department last week. The PMHNP's next step is to:
Refilling early ignores an undisclosed second benzodiazepine prescription.
Discharge on one finding abandons a patient who may need treatment for a use disorder.
A PDMP red flag calls for a direct, nonjudgmental conversation and reassessment for misuse, a use disorder, or diversion before any prescribing decision.
Stopping alprazolam abruptly after 2 years risks withdrawal seizures.
A patient's decision-making capacity fluctuates with their level of intoxication during a visit. How should the PMHNP proceed with a non-urgent consent decision?
Intoxication impairs capacity only temporarily, and a surrogate is not used when the patient will soon be able to decide.
Non-urgency is the reason to wait for consent, not to skip it.
Because the decision is not urgent, waiting until capacity returns gives valid consent.
Cooperation is not capacity; consent given while intoxicated and impaired is not valid.
A 48-year-old man with schizophrenia treated with olanzapine by a PMHNP has an HbA1c of 9.4% and asks her to take over management of his type 2 diabetes because he dislikes his primary care office. What is the most appropriate response?
Metabolic monitoring of antipsychotic effects is part of PMHNP care, but full diabetes management belongs to primary care, so she coordinates with his PCP and explores why he avoids that office.
Antipsychotic-related hyperglycemia is squarely the prescriber's concern and may call for a lower-risk agent.
Prescriptive authority does not extend practice beyond the certified population focus.
Stopping an effective antipsychotic abruptly risks relapse; a planned switch, if needed, is the route.
A PMHNP in a rural clinic is asked to take over care of a 10-year-old with bipolar I disorder who has been stable on lithium with therapeutic levels. The child's psychiatrist has retired. The PMHNP has limited pediatric psychopharmacology experience. The most appropriate action is to:
Sending the family off alone risks a gap in care for a child on lithium.
Lithium is FDA-approved for bipolar I disorder from age 7, and a taper risks relapse.
Continuing a regimen that works while getting expert consultation keeps the child stable and addresses the clinician's limited pediatric experience.
Valproate also needs levels and blood tests and carries hepatotoxicity and pancreatitis risks; switching a stable child adds risk.
At the start of a video visit, a 29-year-old woman being treated for depression whispers that her husband is in the next room, that he checks her phone, and that she cannot speak freely. What is the most appropriate response?
Her explicit statement that she cannot speak freely overrides the location she chose.
Privacy is a precondition for a telehealth session, and her remarks suggest coercive control, so a private time or place, possibly with a safety signal, comes before sensitive discussion.
Ending telehealth altogether may cut off care she can safely access; privacy can be arranged within it.
Bringing in a possibly controlling partner could put her in danger.
A patient with a first episode of major depressive disorder has taken fluoxetine 20 mg daily for 12 weeks. The PHQ-9 score has fallen from 17 to 4, and the patient has returned to work. The PMHNP recommends:
Lowering the dose during continuation raises relapse risk; the dose that achieved remission is kept.
Indefinite maintenance is reserved for recurrent, severe, or chronic depression, not a first episode.
After remission of a first episode, the full effective dose continues through a continuation phase, commonly 6 to 9 months, to prevent relapse.
Stopping after a few weeks of remission is the classic error behind early relapse.
A 30-year-old inpatient with acute mania has received lithium 900 mg daily, given by nursing staff, for 7 days. A 12-hour trough lithium level is 0.4 mEq/L, and manic symptoms persist. The PMHNP's next step is to:
Switching abandons lithium before it has reached a therapeutic level.
Waiting at a subtherapeutic level prolongs the mania.
Repeating the level helps when adherence or timing is in doubt, but both are confirmed here.
Acute mania needs a level of about 0.8 to 1.2 mEq/L; with supervised dosing and a correctly timed trough at steady state, 0.4 mEq/L means the dose is too low.
A 28-year-old woman has panic disorder with four unexpected attacks in the past month and new avoidance of places where attacks occurred. She agrees to start sertraline and says she is very sensitive to medication side effects. Which dosing plan is MOST appropriate?
A high starting dose worsens early activation and anxiety and often ends the trial before benefit.
SSRIs work only with daily dosing over weeks; as-needed use treats them like a benzodiazepine.
SSRIs do not act faster at higher doses; this front-loads side effects in a medication-sensitive patient.
Patients with panic disorder are prone to early jitteriness on SSRIs, so starting at half the usual dose and titrating after about a week improves tolerance and adherence.
A running total sits here; it fills in after your last pick.
Reading the age in a stem
ANCC’s outline lists eight age groups, from infant to frail elderly, for items to take into account where they apply (outline, p. 2). When a stem states an age, read it as part of the question:
Older adults: smaller starting doses, kidney function before renally cleared drugs, and fall and anticholinergic risk. The 2023 AGS Beers Criteria advise avoiding benzodiazepines and the “Z-drug” hypnotics in most older adults.
Dementia: antipsychotics carry an FDA boxed warning for higher mortality in older adults with dementia-related psychosis, so nondrug measures come first and any drug trial is time-limited, with a planned taper attempt (APA practice guideline, 2016).
Children and adolescents: FDA approvals start at set ages; risperidone is labeled for irritability with autism from age 5 and aripiprazole from age 6. Rating scales from home and school replace self-report in younger children.
Young adults: antidepressants carry the suicidality boxed warning through age 24, which shapes what you tell the patient and how soon you see them again.
What a percentage here can tell you
ANCC reports a scaled score, and only on a failing attempt, so no percentage on a practice set converts to a pass. Use the misses by domain instead: two or three wrong in one domain point to where to read next. Test day gives 3.5 hours to answer 175 items, roughly 1.2 minutes per item. Take this set once untimed, then again at that pace.
Written for this guide
Every item was written for this guide and checked against current guidelines and drug labels. None is an ANCC item. ANCC posts its own sample questions for this exam.
AOCNP practice testFour-option oncology NP questions across the outline, each option explained
About these questions
Are these real ANCC PMHNP questions?
No. Live ANCC items are never published. Ours were drafted for this guide and sorted by the outline’s five domains.
How many should I get right before booking?
ANCC publishes no raw-score target, so no number here maps to 350. A steadier sign is getting most items right in every domain, not an average propped up by one strong area.
Do the explanations cover the wrong options too?
Yes. Every wrong option carries a short reason next to the reason for the key, so you see why a tempting choice fails.