PMHNP certification, one exam across the lifespan

A 40-year-old man with schizophrenia on an inpatient unit is pacing and shouting but has not hit anyone. Verbal de-escalation in a quiet area has helped only partly. He says, "I just want this feeling to stop." What is the most appropriate next step?

1. Give an intramuscular antipsychotic now
   An injection before he has refused oral medication skips a step; intramuscular dosing is for refusal or escalation toward imminent danger.
2. Place him in seclusion until he stops shouting
   Seclusion is also an emergency measure for imminent harm, and shouting alone does not meet that bar; it skips the medication offer he is asking for.
3. Apply 4-point restraints to prevent violence
   Restraint is reserved for imminent danger after less restrictive measures fail; using it to prevent violence in a man who has hit no one breaks the least-restrictive rule.
4. Offer an oral antipsychotic or benzodiazepine
   Project BETA places voluntary oral medication right after verbal de-escalation; it treats the distress he describes while leaving the choice with him.

Item 559728 · Flag an error

A PMHNP is screening four patients with treatment-resistant depression for repetitive transcranial magnetic stimulation (rTMS). Which patient characteristic is a contraindication to rTMS?

1. A cochlear implant
   A cochlear implant sits in the skull beside the coil, and the pulsed magnetic field can heat, move, or damage it, so it rules out rTMS.
2. A prior failed course of ECT
   ECT nonresponse predicts a lower rTMS response rate but is not a contraindication.
3. Metal dental fillings
   Dental fillings and braces are not the implants of concern; the exclusion covers conductive or magnet-sensitive devices in or near the head.
4. Age over 70 years
   Older age does not exclude rTMS; it is used in late-life depression and needs no anesthesia.

Item 559771 · Flag an error

A 26-year-old with schizophrenia, stable on risperidone 4 mg daily, reports galactorrhea and 4 months of amenorrhea that began 2 months after starting the drug. Her prolactin is 98 ng/mL, a pregnancy test is negative, and she has no headache or visual change. She wants to stay on risperidone because it has worked well. What is the most appropriate next step?

1. Add bromocriptine and continue risperidone
   A full dopamine agonist can worsen psychosis and works against the antipsychotic.
2. Add low-dose aripiprazole to her regimen
   Risperidone blocks D2 in the tuberoinfundibular tract and releases prolactin from dopamine's inhibition; a low dose of aripiprazole, a D2 partial agonist, lowers prolactin while keeping the regimen that works.
3. Order a pituitary MRI before changing the regimen
   Moderate hyperprolactinemia that began on a prolactin-raising drug, with no headache or visual change, does not need imaging before the drug effect is addressed.
4. Switch risperidone to oral paliperidone
   Paliperidone is risperidone's active metabolite and raises prolactin at least as much.

Item 2154345 · Flag an error

A patient with moderate obsessive-compulsive disorder is hesitant to start therapy because they fear the anxiety will be unbearable. Which statement by the psychiatric-mental health nurse practitioner is most accurate?

1. "Thought-stopping will train your mind to block the obsessions."
   Suppressing an obsession tends to make it rebound; ERP has the patient allow the thought without neutralizing it.
2. "In ERP, distress rises and then eases as you hold off on rituals."
   Exposure and response prevention works through this curve: anxiety peaks during an exposure and eases as the ritual is withheld, and repeated practice teaches that the feared outcome does not come.
3. "We'll start with your most feared situation so it works faster."
   ERP climbs a graded hierarchy built with the patient, starting with moderate items; flooding with the worst fear first raises dropout and is not standard.
4. "Relaxation training is first-line, so you won't face your fears."
   Relaxation is the control condition in OCD trials and does not reduce obsessions on its own; promising no exposure misstates first-line therapy.

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While euthymic, a 38-year-old woman with bipolar I disorder writes a psychiatric advance directive stating that if she becomes manic and refuses treatment, she wants to be hospitalized and given lithium despite her objections at that time. What is this provision called?

1. A Ulysses clause
   A Ulysses clause lets a person with capacity consent in advance to treatment over her own objections during a foreseeable episode; enforceability depends on state law.
2. A springing power of attorney
   A springing power of attorney names an agent whose authority starts at incapacity; it appoints a decision-maker rather than pre-consenting to treatment over objection.
3. A substituted judgment clause
   Substituted judgment is the standard a surrogate uses to choose as the patient would have; here the patient binds her own future self.
4. A do-not-resuscitate order
   A DNR order limits resuscitation after cardiac or respiratory arrest; it has nothing to do with treatment during mania.

Item 559927 · Flag an error