PMHNP Board Exam

Postpartum Psychiatric Disorders:

1. The PMHNP sees a 29-year-old patient 2 weeks after she gives birth to twin boys. She has rarely slept and will not let her husband help care for the babies because she fears he will hurt them. She feels tired, excessively worried about the babies' health, and says she feels she is "losing it." She has no psychiatric history, and labs and physical exam are normal. Which is the most likely diagnosis?

• A. Postpartum psychosis
• B. Premenstrual dysphoric disorder
• C. Postpartum depression
• D. Schizoaffective disorder

Answer: C. The patient shows classic postpartum depression: onset within 4 weeks of delivery, severe fatigue, insomnia, intrusive anxious thoughts about the infants' safety, and ego-dystonic distress — without the hallucinations or fixed delusions that would indicate postpartum psychosis.

Pediatric Neurodevelopmental Disorders:

2. The PMHNP assesses a 6-year-old female with hypotonia, reduced eye contact, and disinterest in play. Parents report developmental delays beginning around age 15 months, with decelerated head growth, loss of purposeful hand movement, and language regression. These symptoms are most likely related to:

• A. Autism
• B. Fetal alcohol syndrome
• C. Landau-Kleffner syndrome
• D. Rett syndrome

Answer: D. Rett syndrome (typically an X-linked MECP2 mutation affecting females) presents with normal early development followed by regression at 6–18 months: head growth deceleration, loss of purposeful hand skills replaced by stereotyped hand-wringing, language loss, and social withdrawal.

Psychopharmacology — Boxed Warnings:

3. Which of the following symptoms is included in the boxed warning for lamotrigine (Lamictal)?

• A. Joint pain
• B. Hair loss
• C. Rash
• D. Blurred vision

Answer: C. Lamotrigine carries an FDA Black Box Warning for severe, life-threatening dermatologic reactions, including Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Patients must be told to stop the drug at the first sign of a rash.

Psychopharmacology — Required Monitoring:

4. A patient taking clozapine (Clozaril) has a lab value showing an absolute neutrophil count of less than 1,000/µL. What is the PMHNP's most appropriate action?

• A. Stop the medication
• B. Continue the medication but plan to monitor labs weekly
• C. Order a reduction in the dose of clozapine and continue it
• D. The neutrophil count is not affected by clozapine, so continue and monitor every 6 months

Answer: A. Per FDA Clozapine REMS guidelines, an ANC below 1,000/µL indicates severe neutropenia. Clozapine must be stopped immediately to prevent life-threatening agranulocytosis, with a hematology consult initiated.

Geriatric / Neurocognitive Disorders:

5. An older male patient's daughter describes his fluctuating cognition with variations in attention and arousal, along with detailed recurrent visual hallucinations, plus repeated falls. The PMHNP suspects:

• A. Alzheimer's disease
• B. Dementia with Lewy bodies
• C. Schizophrenia
• D. A cerebrovascular accident

Answer: B. Dementia with Lewy Bodies is defined by the core triad of fluctuating cognition/attention, recurrent well-formed visual hallucinations, and spontaneous parkinsonism/postural instability causing falls.

Psychopharmacology — Therapeutic Monitoring:

6. The PMHNP is starting a new patient on lithium for bipolar disorder. She must check a lithium level how long after starting therapy?

• A. 1 day
• B. 12 hours
• C. 5 days and 12 hours after the last dose
• D. 2 weeks and 8 hours after last dose

Answer: C. Lithium reaches steady-state kinetics in approximately 5 days (5 half-lives). Trough levels must be drawn exactly 12 hours after the preceding evening dose to be interpreted accurately against the therapeutic range (0.6–1.2 mEq/L).

Legal & Ethical Practice:

7. Which of the following would constitute an intentional tort?

• A. The therapist tells the patient that sex with the therapist is therapeutic.
• B. The PMHNP inadvertently prescribes an incorrect dose of a psychoactive medication.
• C. The patient has an exacerbation of heart failure that results in a decline in cognition.
• D. The patient quits taking his medications and subsequently requires an inpatient stay.

Answer: A. An intentional tort involves a deliberate, purposeful act causing injury or a rights violation — such as coercing a patient into sexual activity under false therapeutic pretense. Inadvertent prescribing errors are negligence, not intentional torts.