A 70-year-old man started oxcarbazepine 600 mg twice daily 3 weeks ago. He now has nausea, headache and new confusion. He appears euvolemic, serum sodium is 123 mEq/L, serum osmolality is low, urine osmolality is 480 mOsm/kg and urine sodium is elevated. Thyroid and adrenal tests are normal. Which mechanism best explains the hyponatremia?

Drug-induced inappropriate ADH secretion or effect

Renal salt wasting from diuretic exposure

Drug-induced primary adrenal insufficiency

Psychogenic polydipsia with free water excess

A 29-year-old man with opioid use disorder who uses heroin wants to start buprenorphine in clinic today. His last use was 8 hours ago, and his COWS score is 5, with mild yawning and anxiety only. Which of the following is the most appropriate plan?

Wait and repeat the COWS until objective withdrawal reaches about 8 to 12

Give buprenorphine-naloxone 8 mg now to prevent him from leaving the clinic

Start methadone 30 mg in the clinic today and taper it over the next 3 weeks

Give oral naltrexone 50 mg now and start extended-release naltrexone next week

A 30-year-old woman with schizophrenia has persistent command hallucinations and persecutory delusions. She completed risperidone 6 mg daily for 8 weeks and then olanzapine 20 mg daily for 8 weeks, with adherence confirmed by plasma levels, and both were tolerated without benefit. Her ANC is 4,200/µL. Which of the following is the most appropriate next step?

Start clozapine with ANC monitoring per current labeling

Continue olanzapine and add ziprasidone 40 mg twice daily

Switch olanzapine to quetiapine and titrate to 800 mg daily

Switch olanzapine to haloperidol decanoate given monthly

A PMHNP notices that she has begun scheduling a 29-year-old patient with a trauma history at the end of the day so sessions can run over, has shared details of her own divorce, and feels angry at the patient's partner after each visit. The patient has not complained. Which action is most appropriate?

Seek clinical supervision to examine her countertransference

Continue as she is, since the patient is benefiting from the care

Tell the patient that her partner sounds abusive and should leave

Transfer the patient to another clinician without explanation

A 34-year-old woman with treatment-resistant depression who did not respond to three antidepressant trials reports a clear lift in mood and less hopelessness the day after her first esketamine nasal spray session. Which mechanism is most closely linked to this rapid antidepressant effect?

NMDA receptor blockade that triggers a glutamate surge

Inhibition of serotonin reuptake at the synaptic cleft

Partial agonism at postsynaptic serotonin 5-HT1A receptors

Antagonism of presynaptic alpha-2 adrenergic receptors

A 47-year-old man who has taken lithium for 10 years reports drinking water all day and urinating about 5 liters daily, including several times at night. Serum sodium is 146 mEq/L, glucose is normal and urine osmolality is 150 mOsm/kg. After desmopressin, urine osmolality barely changes. Which mechanism best explains his symptoms?

Reduced collecting duct response to ADH

Excess water intake from psychogenic thirst

Osmotic diuresis from glucose in the urine

Deficient ADH release from the pituitary

A 68-year-old woman has taken alprazolam 1 mg three times daily for 12 years for panic disorder. After learning about her fall risk, she asks to stop it. She has no seizure history and does not drink alcohol. Which plan is most appropriate?

Taper gradually over months, adding CBT for panic disorder

Replace alprazolam with nightly zolpidem, then stop both

Stop alprazolam today and use propranolol for any rebound

Cut the dose in half each week to finish within 2 weeks

A 52-year-old woman with chronic low back pain and depressive symptoms tells the PMHNP, "I can't do anything with my life until the pain and these thoughts go away." Years of trying to control the pain have narrowed her life to staying at home. She wants to return to gardening and seeing her grandchildren. Which psychotherapy best fits her presentation?

Acceptance and commitment therapy

Exposure and response prevention

Short-term psychodynamic psychotherapy

Eye movement desensitization and reprocessing

Psychiatric-Mental Health Nurse Practitioner Exam

Free PMHNP Practice Questions

10 sample questions for the Psychiatric-Mental Health Nurse Practitioner Exam, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.

Sections covered on the exam: Neuroanatomy, Neurophysiology and Neurodevelopment, Health Promotion, Psychoeducation, Recovery and Resilience, Neurodevelopmental and Child and Adolescent Disorders, Anxiety, Trauma and Obsessive-Compulsive Disorders, Ethics, Legal Principles and Cultural Care.

Question 1 · Neuroanatomy, Neurophysiology and Neurodevelopment
A 58-year-old man with delusional disorder started haloperidol 10 mg/day 4 weeks ago. He now has masked facies, a shuffling gait, cogwheel rigidity at both wrists and a resting tremor of the right hand. Blockade of D2 receptors in which dopamine pathway best explains these findings?
- A.Tuberoinfundibular pathway
- B.Nigrostriatal pathway
- C.Mesocortical pathway
- D.Mesolimbic pathway
Show answer and explanation
Answer: B. Nigrostriatal pathway
The nigrostriatal pathway runs from the substantia nigra to the striatum and controls motor function, so D2 blockade there produces drug-induced parkinsonism and other extrapyramidal effects. Mesolimbic blockade is the intended antipsychotic action against positive symptoms, and mesocortical hypofunction is linked to negative and cognitive symptoms. Tuberoinfundibular blockade raises prolactin rather than causing rigidity or tremor.
Question 2 · Neuroanatomy, Neurophysiology and Neurodevelopment
A 70-year-old man started oxcarbazepine 600 mg twice daily 3 weeks ago. He now has nausea, headache and new confusion. He appears euvolemic, serum sodium is 123 mEq/L, serum osmolality is low, urine osmolality is 480 mOsm/kg and urine sodium is elevated. Thyroid and adrenal tests are normal. Which mechanism best explains the hyponatremia?
- A.Renal salt wasting from diuretic exposure
- B.Drug-induced primary adrenal insufficiency
- C.Psychogenic polydipsia with free water excess
- D.Drug-induced inappropriate ADH secretion or effect
Show answer and explanation
Answer: D. Drug-induced inappropriate ADH secretion or effect
Oxcarbazepine (more than carbamazepine) commonly causes SIADH-type hyponatremia, especially in older adults, producing euvolemic hypotonic hyponatremia with inappropriately concentrated urine and high urine sodium. Normal adrenal testing excludes adrenal insufficiency. Primary polydipsia produces maximally dilute urine, usually under 100 mOsm/kg, and he has no diuretic exposure.
Question 3 · Health Promotion, Psychoeducation, Recovery and Resilience
A 29-year-old man with opioid use disorder who uses heroin wants to start buprenorphine in clinic today. His last use was 8 hours ago, and his COWS score is 5, with mild yawning and anxiety only. Which of the following is the most appropriate plan?
- A.Wait and repeat the COWS until objective withdrawal reaches about 8 to 12
- B.Give buprenorphine-naloxone 8 mg now to prevent him from leaving the clinic
- C.Start methadone 30 mg in the clinic today and taper it over the next 3 weeks
- D.Give oral naltrexone 50 mg now and start extended-release naltrexone next week
Show answer and explanation
Answer: A. Wait and repeat the COWS until objective withdrawal reaches about 8 to 12
Buprenorphine is a high-affinity partial agonist, so giving it before objective withdrawal, usually a COWS of about 8 to 12 or more, can displace other opioids and precipitate withdrawal. Naltrexone requires 7 to 10 days opioid-free and would precipitate severe withdrawal now. Methadone for opioid use disorder can be dispensed only through an opioid treatment program, and a short taper is not effective treatment.
Question 4 · Neurodevelopmental and Child and Adolescent Disorders
A 30-year-old woman with schizophrenia has persistent command hallucinations and persecutory delusions. She completed risperidone 6 mg daily for 8 weeks and then olanzapine 20 mg daily for 8 weeks, with adherence confirmed by plasma levels, and both were tolerated without benefit. Her ANC is 4,200/µL. Which of the following is the most appropriate next step?
- A.Continue olanzapine and add ziprasidone 40 mg twice daily
- B.Start clozapine with ANC monitoring per current labeling
- C.Switch olanzapine to quetiapine and titrate to 800 mg daily
- D.Switch olanzapine to haloperidol decanoate given monthly
Show answer and explanation
Answer: B. Start clozapine with ANC monitoring per current labeling
Failure of two adequate antipsychotic trials, each at a therapeutic dose for about 6 weeks or more with confirmed adherence, defines treatment-resistant schizophrenia, and clozapine is the only antipsychotic with proven superiority in this group. Trying a third non-clozapine antipsychotic, including a long-acting injectable when adherence is not the problem, yields low response rates. Antipsychotic polypharmacy adds adverse effects without the evidence that clozapine has.
Question 5 · Anxiety, Trauma and Obsessive-Compulsive Disorders
A PMHNP notices that she has begun scheduling a 29-year-old patient with a trauma history at the end of the day so sessions can run over, has shared details of her own divorce, and feels angry at the patient's partner after each visit. The patient has not complained. Which action is most appropriate?
- A.Continue as she is, since the patient is benefiting from the care
- B.Seek clinical supervision to examine her countertransference
- C.Tell the patient that her partner sounds abusive and should leave
- D.Transfer the patient to another clinician without explanation
Show answer and explanation
Answer: B. Seek clinical supervision to examine her countertransference
Extended sessions, self-disclosure that serves the clinician and strong personal feelings toward people in the patient's life are signs of countertransference and boundary crossings that can slide into violations, so the PMHNP should use supervision or consultation to understand her reactions and restore the frame. An abrupt transfer without discussion can feel like abandonment to a patient with a trauma history. Continuing unchanged ignores the risk, and advising the patient about her partner acts on the clinician's feelings rather than the patient's goals.
Question 6 · Neuroanatomy, Neurophysiology and Neurodevelopment
A 34-year-old woman with treatment-resistant depression who did not respond to three antidepressant trials reports a clear lift in mood and less hopelessness the day after her first esketamine nasal spray session. Which mechanism is most closely linked to this rapid antidepressant effect?
- A.Inhibition of serotonin reuptake at the synaptic cleft
- B.Partial agonism at postsynaptic serotonin 5-HT1A receptors
- C.NMDA receptor blockade that triggers a glutamate surge
- D.Antagonism of presynaptic alpha-2 adrenergic receptors
Show answer and explanation
Answer: C. NMDA receptor blockade that triggers a glutamate surge
Esketamine blocks NMDA receptors on GABA interneurons, which disinhibits glutamate release; the resulting AMPA receptor activation increases BDNF signaling and rapid synapse formation in the prefrontal cortex within hours to a day. Serotonin reuptake inhibition describes SSRIs, whose benefit takes weeks. Alpha-2 antagonism is the mechanism of mirtazapine, and 5-HT1A partial agonism describes buspirone and vilazodone, none of which act this quickly.
Question 7 · Neuroanatomy, Neurophysiology and Neurodevelopment
A 47-year-old man who has taken lithium for 10 years reports drinking water all day and urinating about 5 liters daily, including several times at night. Serum sodium is 146 mEq/L, glucose is normal and urine osmolality is 150 mOsm/kg. After desmopressin, urine osmolality barely changes. Which mechanism best explains his symptoms?
- A.Reduced collecting duct response to ADH
- B.Excess water intake from psychogenic thirst
- C.Osmotic diuresis from glucose in the urine
- D.Deficient ADH release from the pituitary
Show answer and explanation
Answer: A. Reduced collecting duct response to ADH
Lithium enters collecting duct cells and reduces aquaporin-2 expression, causing nephrogenic diabetes insipidus: dilute urine that does not concentrate after desmopressin, with high-normal sodium. Central diabetes insipidus would respond to desmopressin. Primary polydipsia tends to lower sodium, and normal glucose excludes osmotic diuresis.
Question 8 · Health Promotion, Psychoeducation, Recovery and Resilience
A 68-year-old woman has taken alprazolam 1 mg three times daily for 12 years for panic disorder. After learning about her fall risk, she asks to stop it. She has no seizure history and does not drink alcohol. Which plan is most appropriate?
- A.Taper gradually over months, adding CBT for panic disorder
- B.Replace alprazolam with nightly zolpidem, then stop both
- C.Stop alprazolam today and use propranolol for any rebound
- D.Cut the dose in half each week to finish within 2 weeks
Show answer and explanation
Answer: A. Taper gradually over months, adding CBT for panic disorder
Long-term benzodiazepine use causes physiologic dependence, so discontinuation requires a slow, individualized taper over months, often starting with reductions of about 5 to 10% every 2 to 4 weeks and sometimes after switching to a longer-acting agent, and CBT for panic disorder improves taper success. Abrupt cessation or a rapid 2-week taper risks severe withdrawal, rebound panic and seizures, and propranolol does not prevent seizures. Zolpidem is a Beers list sedative-hypnotic that adds fall risk and does not treat alprazolam withdrawal.
Question 9 · Neurodevelopmental and Child and Adolescent Disorders
A 45-year-old man with schizophrenia is stable on risperidone 4 mg daily but has gynecomastia, sexual dysfunction and a prolactin of 68 ng/mL. He asks for a medication that does not act directly on dopamine receptors. He has normal liver function, no urinary retention and no narrow-angle glaucoma. Which medication best fits his request?
- A.Xanomeline-trospium
- B.Lurasidone
- C.Brexpiprazole
- D.Olanzapine-samidorphan
Show answer and explanation
Answer: A. Xanomeline-trospium
Xanomeline-trospium acts through central muscarinic M1 and M4 receptor agonism without direct dopamine D2 binding, so it does not raise prolactin; trospium limits peripheral cholinergic effects, and it is avoided in urinary retention and moderate or severe hepatic impairment, which he does not have. Brexpiprazole is a D2 partial agonist, so it still acts directly at dopamine receptors. Lurasidone and olanzapine-samidorphan both block D2 receptors, contrary to his request.
Question 10 · Anxiety, Trauma and Obsessive-Compulsive Disorders
A 52-year-old woman with chronic low back pain and depressive symptoms tells the PMHNP, "I can't do anything with my life until the pain and these thoughts go away." Years of trying to control the pain have narrowed her life to staying at home. She wants to return to gardening and seeing her grandchildren. Which psychotherapy best fits her presentation?
- A.Exposure and response prevention
- B.Acceptance and commitment therapy
- C.Short-term psychodynamic psychotherapy
- D.Eye movement desensitization and reprocessing
Show answer and explanation
Answer: B. Acceptance and commitment therapy
Acceptance and commitment therapy helps patients stop struggling to control pain and painful thoughts (acceptance and cognitive defusion) and commit to actions guided by their values, such as gardening and family time; it has good evidence in chronic pain. Exposure and response prevention is the first-line therapy for obsessive-compulsive disorder, and EMDR is a trauma-focused therapy for PTSD. Psychodynamic therapy explores unconscious conflict and is not the best-supported choice for pain-related avoidance.

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