20 free PMHNP-BC practice questions

Correct answer: C · Stop haloperidol right now and arrange emergency treatment and monitoring

The haloperidol labeling lists hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability, such as an irregular pulse or blood pressure and sweating, as the clinical features of neuroleptic malignant syndrome (NMS), and it adds that an elevated creatine phosphokinase can be another sign. Its management is immediate discontinuation of the antipsychotic and other nonessential drugs, intensive symptomatic treatment with medical monitoring, and treatment of related medical problems, so he needs emergency care now. An anticholinergic drug does not treat NMS, and keeping haloperidol continues the exposure. Lowering the dose and waiting a week delays care for a potentially fatal reaction. Switching tonight to another antipsychotic still exposes him to the drug class linked to NMS.

Look for this next time: Fever, rigidity, confusion, and autonomic instability on an antipsychotic suggest NMS: stop the drug and arrange emergency medical care.

Correct answer: A · Test for HLA-B*1502, because it is linked to SJS and TEN risk

Carbamazepine's boxed warning describes serious and sometimes fatal skin reactions, including toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), and a strong association between that risk and the HLA-B*1502 allele in patients of Chinese ancestry. The labeling says the allele is found almost exclusively in people with ancestry across broad areas of Asia and that patients with ancestry in genetically at-risk populations should be screened before treatment starts. A patient who tests positive should not be treated with carbamazepine unless the benefit clearly outweighs the risk. Waiting for a rash defeats the purpose of screening. The labeling ties screening to ancestry, not to a relative's history of rashes, and CYP2D6 genotyping is not the test the boxed warning names.

Look for this next time: Before carbamazepine, screen patients with ancestry in at-risk Asian populations for HLA-B*1502 (FDA boxed warning).

Correct answer: D · Lithium toxicity from reduced renal lithium clearance

Lithium labeling lists NSAIDs, diuretics, and renin-angiotensin system antagonists as drugs that can raise serum lithium concentrations. For NSAIDs it explains that they decrease renal blood flow, which lowers renal lithium clearance, and it advises checking serum lithium after any change in concurrent medication. Gastrointestinal symptoms, tremor, and ataxia after two weeks of daily naproxen fit the toxicity the labeling describes, and its boxed warning notes that toxicity can occur at doses close to therapeutic concentrations, so a serum lithium level is needed promptly. A new movement disorder would not explain the gastrointestinal symptoms or the timing. Vomiting and diarrhea cause fluid loss, which the labeling links to a higher risk of toxicity, not a lower level. Thyroid disease does not account for a rapid change that followed the daily NSAID.

Look for this next time: NSAIDs, including over-the-counter ones, thiazides, and ACE inhibitors or ARBs can raise lithium levels; check a serum level after any such change.

Correct answer: B · Fasting glucose and fasting lipids, with regular weight checks

The olanzapine labeling warns that atypical antipsychotics are associated with metabolic changes, including hyperglycemia, dyslipidemia, and weight gain. It calls for fasting blood glucose testing and fasting lipid testing at the beginning of treatment and periodically during it, along with regular monitoring of weight. Baseline values matter because later changes are judged against them, so waiting for weight gain before testing skips that baseline. An ECG alone does not address the metabolic risks the labeling highlights, and the labeling's monitoring advice does not call for routine serum olanzapine levels.

Look for this next time: Before and during olanzapine treatment, check fasting glucose and lipids and track weight (FDA labeling).

Correct answer: B · Complete a brief suicide safety assessment to see if a full evaluation is needed

On the NIMH ASQ screening tool (version dated 9/29/25), a yes to any of the first four questions is a positive screen, and a fifth question asks about thoughts of suicide right now. A yes to question 5 is an acute positive screen that needs a STAT safety and full mental health evaluation before the patient may leave. A no to question 5, as here, is a non-acute positive screen: the patient needs a brief suicide safety assessment to determine whether a full mental health evaluation is needed, and when. The pathway does not require one-to-one observation while he waits unless there are other safety concerns. Denying current thoughts does not make the screen negative, and the ASQ does not direct admission for every positive answer. Crisis resources such as 988 go to every patient.

Look for this next time: On the ASQ, a yes to questions 1–4 with a no to question 5 is a non-acute positive screen that calls for a brief suicide safety assessment.

Correct answer: D · COWS, the 11-item Clinical Opiate Withdrawal Scale

NIDA describes the Clinical Opiate Withdrawal Scale (COWS) as an 11-item scale administered by a clinician to rate common signs and symptoms of opiate withdrawal and monitor them over time. Its items include resting pulse, sweating, restlessness, pupil size, yawning, runny nose or tearing, and gooseflesh, and the summed score reads as mild (5–12), moderate (13–24), moderately severe (25–36), or severe (above 36) withdrawal. The CIWA, which ANCC's outline names as an alcohol withdrawal scale, does not rate opioid withdrawal. The AUDIT identifies problem alcohol use, and the DAST-10 screens for problems related to drug use; neither scores withdrawal severity as it changes over hours.

Look for this next time: Use the clinician-rated COWS to score and track opioid withdrawal; the CIWA is for alcohol withdrawal.

Correct answer: A · “Fitting in with your crew matters, and so does being at your son’s games.”

TIP 35 (updated 2019) lists the core MI skills as OARS: open questions, affirmations, reflective listening, and summaries, and it calls reflective listening fundamental and essential for expressing empathy. A reflection that captures both sides of his ambivalence, belonging with his crew and missing his son’s games, invites him to keep talking and to voice his own reasons for change. TIP 35 warns against the righting reflex, the impulse to direct a client toward a specific change, because a directive style tends to produce sustain talk and discord; telling him to stop now does exactly that. Launching into health risks he has not asked about is the expert stance TIP 35 cautions against. A question about why he has not changed sounds like blame and is likely to make him defend his drinking.

Look for this next time: In motivational interviewing, reflect both sides of the client’s ambivalence instead of arguing for change (SAMHSA TIP 35).

Correct answer: C · Severe-range anxiety symptoms and mild-range depressive symptoms

The PHQ and GAD-7 Instruction Manual sets GAD-7 cutpoints of 5, 10, and 15 for mild, moderate, and severe anxiety, and PHQ-9 cutpoints of 5, 10, 15, and 20 for mild, moderate, moderately severe, and severe depression. A GAD-7 of 16 is in the severe range, and a PHQ-9 of 7 is in the mild range of 5 to 9. Moderate anxiety would be 10 to 14 on the GAD-7, and moderately severe depression would be 15 to 19 on the PHQ-9. Scores in these ranges call for clinical follow-up, and because the totals rate symptom severity rather than establish a diagnosis, the PMHNP confirms the picture in the clinical interview.

Look for this next time: GAD-7 cutpoints 5, 10, and 15 mark mild, moderate, and severe; PHQ-9 cutpoints 5, 10, 15, and 20 mark mild through severe.

Correct answer: D · Offer varenicline with counseling, and watch for changes in mood or behavior

In December 2016, FDA removed the boxed warning about serious mental health side effects from varenicline's labeling after reviewing a large required trial. The current labeling describes that randomized trial, which enrolled about 4,000 patients with a psychiatric history and about 3,900 without; every treatment group in the psychiatric cohort, placebo included, reported more neuropsychiatric events than its counterpart in the non-psychiatric cohort. The labeling tells clinicians to provide educational materials and counseling to support the quit attempt and to observe patients for neuropsychiatric adverse events, and it notes that quitting, with or without treatment, is linked to nicotine withdrawal symptoms and to worsening of underlying psychiatric illness. A stable patient with schizophrenia is therefore a candidate, with monitoring. No boxed warning bars its use, and the labeling sets no symptom-free period before a quit attempt.

Look for this next time: Varenicline has carried no boxed psychiatric warning since 2016; offer it with counseling and monitor mood and behavior.

Correct answer: A · Ask them to say in their own words what to watch for and what to do

AHRQ's Tool 5, Use the Teach-Back Method, describes teach-back as asking patients to state in their own words what they need to know or do about their health. The toolkit says that “Do you understand?” is not a teach-back question, because patients tend to answer yes whether or not they understand. Patients may look at a handout during teach-back, but they should explain in their own words rather than read it back verbatim, since parroting the material does not show understanding. Teach-back is not a memory test, so reciting every side effect is not the goal. If teach-back reveals a gap, the clinician explains it a different way and checks again.

Look for this next time: Confirm understanding with teach-back: ask the patient to explain in their own words, then reteach any gap.

Correct answer: B · Bipolar II disorder

AAFP's 2021 review of bipolar disorders summarizes the DSM-5 criteria: a hypomanic episode is a distinct period of elevated, expansive, or irritable mood and increased activity or energy lasting at least four consecutive days, with three or more associated symptoms (four if the mood is only irritable), without marked impairment, hospitalization, or psychotic features. His 6-day episode had three such symptoms, a decreased need for sleep, rapid speech, and increased goal-directed activity, and others noticed it. Bipolar II disorder is a hypomanic episode with major depression and no history of mania, which matches his history. Bipolar I disorder requires a manic episode, lasting at least one week or any duration if hospitalization is needed, with marked impairment or psychotic features. Cyclothymia involves hypomanic and depressive symptoms over two years with no major depressive episode, and he has one now. A past hypomanic episode rules out major depressive disorder, which is why depressed patients should be asked about past highs.

Look for this next time: Hypomania lasts at least 4 days, with at least 3 symptoms and no marked impairment; hypomania plus major depression, with no mania, is bipolar II disorder.

Correct answer: C · Reserve it for when other drugs fail, and require effective contraception

Valproate's boxed warning describes fetal risk, including major congenital malformations, particularly neural tube defects, and decreased IQ after exposure in pregnancy. It says valproate should not be given to a woman of childbearing potential unless other medications have failed to control symptoms or are otherwise unacceptable, and that effective contraception should be used in that situation. She has not tried any alternative, so valproate is not the place to start. The labeling notes that folic acid lowers neural tube defect risk in the general population, but that does not make valproate safe or replace contraception. The boxed warning also covers hepatotoxicity and calls for liver testing before therapy and at frequent intervals, so baseline tests are needed.

Look for this next time: Valproate's boxed warning: avoid it in women of childbearing potential unless alternatives fail or are unacceptable, and use effective contraception if it is used.

Correct answer: A · Offer trauma-focused CPT, PE, or EMDR, and avoid a benzodiazepine

The VA/DoD 2023 PTSD guideline recommends individual, manualized trauma-focused psychotherapies (Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing, or Prolonged Exposure) and recommends individual psychotherapy over pharmacologic treatment. It recommends against benzodiazepines for PTSD, a strong recommendation. When medication is used, it recommends paroxetine, sertraline, or venlafaxine. Prescribing alprazolam, whether alone while he waits or alongside sertraline, goes against that recommendation. Offering only supportive check-ins withholds the treatments the guideline rates most strongly.

Look for this next time: For PTSD, offer trauma-focused psychotherapy (CPT, PE, or EMDR) first, and avoid benzodiazepines (VA/DoD 2023).

Correct answer: D · SSRI-associated hyponatremia, often from SIADH

The citalopram labeling warns that SSRIs can cause hyponatremia, in many cases from the syndrome of inappropriate antidiuretic hormone secretion (SIADH). It names older adults, people taking diuretics, and those who are volume depleted as being at greater risk, and it lists headache, difficulty concentrating, memory problems, confusion, weakness, and unsteadiness that can lead to falls. Her sodium fell from 138 to 124 mEq/L after the drug was started. The labeling advises stopping citalopram in symptomatic hyponatremia and starting appropriate medical care. Serotonin syndrome brings features such as agitation, autonomic instability, tremor, myoclonus, or hyperreflexia, and it would not explain the drop in sodium. Neither worsening depression nor Alzheimer disease explains a sodium drop, and Alzheimer disease develops gradually.

Look for this next time: New confusion or a near fall in an older adult on an SSRI and a diuretic calls for a sodium check for SSRI-related hyponatremia.

Correct answer: C · Preparation

TIP 35 describes Precontemplation as not considering change and Contemplation as ambivalence, with reasons both to change and not to change. In Preparation, the decisional balance has tipped toward change: people plan more specifically, are still using but intend to stop very soon, may already be making small changes such as cutting down, set goals, and tell close associates about their plans. That describes him. Action begins when a person chooses a strategy and actively changes the behavior, and he is still using every day. Naming the stage matters because it points to the next step, here helping him build a concrete change plan.

Look for this next time: Decided, planning, cutting down, and telling others while still using: that is the Preparation stage of change.

Correct answer: B · Decline kindly, restate the boundary, and explore it in session

NCSBN's guide to professional boundaries places every nurse-patient relationship on a continuum from under-involvement to over-involvement and states that the nurse, not the patient, is responsible for delineating and maintaining boundaries. Declining the texting and the lunch, kindly, while restating how the patient can reach the clinic and exploring what the request means to him, keeps the relationship therapeutic and protects the alliance. Sharing a personal number for friendly texting moves toward over-involvement. Changing the subject leaves the boundary unstated and the patient guessing. Ending treatment abruptly is out of proportion to a request the clinician can address within the therapy.

Look for this next time: The clinician is responsible for boundaries: decline personal contact kindly and explore the request in therapy.

Correct answer: D · He shows all four abilities of capacity for this particular decision

AAFP's 2018 review lists four elements of medical decision-making capacity: understanding the benefits, risks, and alternatives, including no treatment; appreciating how they apply to oneself; reasoning; and communicating a choice. He shows all four. Capacity is specific to the decision, and a chronic psychiatric condition is a risk factor that prompts a closer look, not proof of incapacity. Patients do not have to make the choice the clinician prefers; they need to reason through the relevant information. Competence is a legal determination made by courts, whereas capacity is a clinical judgment by the treating clinician, so no ruling is needed here.

Look for this next time: Capacity is decision-specific: understanding, appreciation, reasoning, and a clear choice. A psychiatric diagnosis alone does not remove it.

Correct answer: A · The notes need the patient's own authorization, and payment cannot depend on it

Under 45 CFR 164.508(a)(2), a covered entity must obtain an authorization for any use or disclosure of psychotherapy notes, with narrow exceptions such as the originating clinician's own treatment use. Payment is not one of those exceptions, so the general permission to disclose for payment does not reach these notes. Section 164.508(b)(4) bars covered entities, health plans included, from conditioning payment on the patient signing an authorization. The HIPAA definition in 45 CFR 164.501 excludes medication monitoring, test results, and summaries of the diagnosis, treatment plan, symptoms, prognosis, and progress from psychotherapy notes, so those items belong to the medical record and follow the ordinary rules. Billing a claim does not turn separately kept notes into part of the claim.

Look for this next time: Psychotherapy notes kept apart from the record need the patient's authorization, even for payment (45 CFR 164.508).

Correct answer: B · She may qualify for up to 12 workweeks of unpaid, job-protected leave in 12 months

DOL Fact Sheet #28 (revised March 2025) says eligible employees of covered employers can take up to 12 workweeks of job-protected, unpaid leave in a 12-month period, intermittently when medically necessary. She appears eligible: covered private employers have at least 50 employees, and an eligible employee has worked for the employer for at least 12 months, with at least 1,250 hours in the 12 months before leave, at a site with at least 50 employees within 75 miles. DOL Fact Sheet #28O states that mental health conditions are serious health conditions when they require inpatient care or continuing treatment by a health care provider. The leave is unpaid, although employer paid leave may run alongside it, and the employer may require certification from a health care provider. Nothing in the FMLA requires her to resign.

Look for this next time: The FMLA gives eligible employees up to 12 workweeks of unpaid, job-protected leave in 12 months, including for serious mental health conditions.

Correct answer: C · Use the qualified video interpreter, not her 14-year-old grandson

The National CLAS Standards ask organizations to offer language assistance at no cost to people with limited English proficiency, to tell them it is available, and to ensure the competence of those providing it, recognizing that untrained individuals and minors should be avoided and discouraged as interpreters (Standards 5, 6, and 7). A psychiatric evaluation depends on accurate, private communication about symptoms, risk, and history, which a child relative cannot be expected to provide. Speaking slowly in English does not give her language access. Rescheduling delays care when a qualified interpreter is already available, and an untrained bilingual staff member raises the same competence concern.

Look for this next time: Use a qualified interpreter for patients with limited English proficiency, and avoid untrained individuals and minors (CLAS Standard 7).