NRNP6665 Week 11 Final Exam - 2026/2027 |
Questions & 100% Correct Verified Answers |
PMHNP Capstone Assessment
DOMAIN 1 – Complex Psychopharmacology & Treatment Resistance (26 Q)
Q1. Ms. K, 45, TRD: failed escitalopram 20 mg ×12 wks, venlafaxine 300 mg ×10 wks,
bupropion 450 mg ×8 wks (all plasma levels therapeutic). Aripiprazole 5 mg
augmentation → intolerable akathia. Pharmacogenomics: CYP2D6 poor metabolizer.
MADRS 38; prominent anhedonia, fatigue. Medical: HTN, CKD stage 2.
Next evidence-based step:
A. Nortriptyline 50 mg hs (titrated to level 80 µg/L)
B. Refer for left-side 10 Hz rTMS 5 days/wk ×4 wks
C. Lithium 300 mg bid (target 0.8 mmol/L)
D. Desvenlafaxine 100 mg daily
Correct Answer: B
Rationale: Multiple oral AD failures + akathisia intolerance; CYP2D6 PM makes TCA
levels unpredictable. rTMS Level I evidence for TRD, no pharmacokinetic issues, safe in
CKD. Lithium (C) valid but higher side-effect burden; desvenlafaxine (D) is another SNRI
with limited incremental benefit.
,Q2. After 20 rTMS sessions Ms. K’s MADRS 18 (50 % ↓). She develops severe sinus
bradycardia 38 bpm asymptomatic.
Best action:
A. Discontinue rTMS immediately
B. Reduce rTMS intensity by 20 %
C. Continue rTMS; bradycardia unrelated
D. Cardiology consult & 48 h Holter before next session
Correct Answer: D
Rationale: rTMS rarely affects cardiac conduction; however new brady arrhythmia
warrants cardiology clearance to rule sick-sinus syndrome before continuing
high-intensity stimulation.
Q3. Mr. J, 38, schizoaffective d/o, maintained on clozapine 450 mg (level 0.7). WBC 2.8
k/µL (ANC 1.4), down from 4.5 k 3 wks ago, afebrile.
REMS classification & action:
A. Yellow – enhance monitoring twice weekly, continue clozapine
B. Red – stop clozapine immediately, start aripiprazole
C. Green – routine weekly CBC
D. Orange – hospitalize for neutropenia work-up
Correct Answer: A
,Rationale: ANC 1.0–1.5 = REMS “yellow”; continue with twice-weekly CBC; no infection
yet. Immediate discontinuation (B) risks rebound psychosis; hospitalization (D)
unnecessary if afebrile.
Q4. Mr. J’s ANC falls to 0.8 k/µL next check.
Next step:
A. Continue clozapine with G-CSF
B. Stop clozapine, start G-CSF, switch to LAI aripiprazole bridge
C. Reduce clozapine to 200 mg
D. Rechallenge after 1 week off
Correct Answer: B
Rationale: ANC <1 k mandates “red” stop; G-CSF accelerates recovery; LAI antipsychotic
bridge avoids oral adherence issues during transition.
Q5. Ms. L, 29, BP-I, first manic episode psychotic features, failed lithium 1.0 mmol/L
(level 0.9) + haloperidol 5 mg ×4 wks (YMRS 32).
Evidence-based next:
A. Increase lithium to 1.2 mmol/L
B. Add valproate 20 mg/kg (target 100 µg/mL)
C. Start ECT track
D. Add risperidone 2 mg
Correct Answer: B
, Rationale: Lithium + valproate combination Level I for manic symptoms >4 wks
inadequate response. ECT (C) reserved for life-threatening or refractory; risperidone (D)
overlaps with haloperidol (both FGAs/SGAs).
Q6. On lithium + valproate Ms. L develops platelets 85 k/µL (baseline 220).
Most appropriate:
A. Stop valproate, continue lithium, start quetiapine 600 mg
B. Stop lithium, continue valproate
C. Reduce valproate to 80 µg/mL and monitor weekly
D. Add eltrombopag
Correct Answer: A
Rationale: Valproate-induced thrombocytopenia; lithium lacks hematologic toxicity.
Quetiapine monotherapy effective antimanic alternative.
Q7. Mr. D, 55, TRD, on duloxetine 90 mg, bupropion 300 mg, lithium 600 mg (level 0.6),
MADRS 30. New-onset tremor, coarse, bilateral, no rigidity.
Likely cause:
A. Duloxetine-induced EPS
B. Early Parkinson’s
C. Lithium toxicity
D. Bupropion tremor
Correct Answer: C
Questions & 100% Correct Verified Answers |
PMHNP Capstone Assessment
DOMAIN 1 – Complex Psychopharmacology & Treatment Resistance (26 Q)
Q1. Ms. K, 45, TRD: failed escitalopram 20 mg ×12 wks, venlafaxine 300 mg ×10 wks,
bupropion 450 mg ×8 wks (all plasma levels therapeutic). Aripiprazole 5 mg
augmentation → intolerable akathia. Pharmacogenomics: CYP2D6 poor metabolizer.
MADRS 38; prominent anhedonia, fatigue. Medical: HTN, CKD stage 2.
Next evidence-based step:
A. Nortriptyline 50 mg hs (titrated to level 80 µg/L)
B. Refer for left-side 10 Hz rTMS 5 days/wk ×4 wks
C. Lithium 300 mg bid (target 0.8 mmol/L)
D. Desvenlafaxine 100 mg daily
Correct Answer: B
Rationale: Multiple oral AD failures + akathisia intolerance; CYP2D6 PM makes TCA
levels unpredictable. rTMS Level I evidence for TRD, no pharmacokinetic issues, safe in
CKD. Lithium (C) valid but higher side-effect burden; desvenlafaxine (D) is another SNRI
with limited incremental benefit.
,Q2. After 20 rTMS sessions Ms. K’s MADRS 18 (50 % ↓). She develops severe sinus
bradycardia 38 bpm asymptomatic.
Best action:
A. Discontinue rTMS immediately
B. Reduce rTMS intensity by 20 %
C. Continue rTMS; bradycardia unrelated
D. Cardiology consult & 48 h Holter before next session
Correct Answer: D
Rationale: rTMS rarely affects cardiac conduction; however new brady arrhythmia
warrants cardiology clearance to rule sick-sinus syndrome before continuing
high-intensity stimulation.
Q3. Mr. J, 38, schizoaffective d/o, maintained on clozapine 450 mg (level 0.7). WBC 2.8
k/µL (ANC 1.4), down from 4.5 k 3 wks ago, afebrile.
REMS classification & action:
A. Yellow – enhance monitoring twice weekly, continue clozapine
B. Red – stop clozapine immediately, start aripiprazole
C. Green – routine weekly CBC
D. Orange – hospitalize for neutropenia work-up
Correct Answer: A
,Rationale: ANC 1.0–1.5 = REMS “yellow”; continue with twice-weekly CBC; no infection
yet. Immediate discontinuation (B) risks rebound psychosis; hospitalization (D)
unnecessary if afebrile.
Q4. Mr. J’s ANC falls to 0.8 k/µL next check.
Next step:
A. Continue clozapine with G-CSF
B. Stop clozapine, start G-CSF, switch to LAI aripiprazole bridge
C. Reduce clozapine to 200 mg
D. Rechallenge after 1 week off
Correct Answer: B
Rationale: ANC <1 k mandates “red” stop; G-CSF accelerates recovery; LAI antipsychotic
bridge avoids oral adherence issues during transition.
Q5. Ms. L, 29, BP-I, first manic episode psychotic features, failed lithium 1.0 mmol/L
(level 0.9) + haloperidol 5 mg ×4 wks (YMRS 32).
Evidence-based next:
A. Increase lithium to 1.2 mmol/L
B. Add valproate 20 mg/kg (target 100 µg/mL)
C. Start ECT track
D. Add risperidone 2 mg
Correct Answer: B
, Rationale: Lithium + valproate combination Level I for manic symptoms >4 wks
inadequate response. ECT (C) reserved for life-threatening or refractory; risperidone (D)
overlaps with haloperidol (both FGAs/SGAs).
Q6. On lithium + valproate Ms. L develops platelets 85 k/µL (baseline 220).
Most appropriate:
A. Stop valproate, continue lithium, start quetiapine 600 mg
B. Stop lithium, continue valproate
C. Reduce valproate to 80 µg/mL and monitor weekly
D. Add eltrombopag
Correct Answer: A
Rationale: Valproate-induced thrombocytopenia; lithium lacks hematologic toxicity.
Quetiapine monotherapy effective antimanic alternative.
Q7. Mr. D, 55, TRD, on duloxetine 90 mg, bupropion 300 mg, lithium 600 mg (level 0.6),
MADRS 30. New-onset tremor, coarse, bilateral, no rigidity.
Likely cause:
A. Duloxetine-induced EPS
B. Early Parkinson’s
C. Lithium toxicity
D. Bupropion tremor
Correct Answer: C
