NRNP6665 FINAL EXAM - 2026/2027 | PMHNP
Capstone Competency & Clinical Synthesis
Assessment
Chamberlain College | PMHNP Certification-Ready | 80 Questions & 100 % Verified
Answers
DOMAIN 1 – ADVANCED PSYCHOPHARMACOLOGY & NEUROMODULATION
(30 % | 24 Q)
Q1
A 38-year-old man with schizoaffective disorder, bipolar type, on lithium 900 mg (level
0.8 mEq/L) and paliperidone palmitate 156 mg monthly, is admitted for manic relapse
with psychosis. Olanzapine 15 mg is added; within 72 h he develops rigidity, fever 39.1
°C, confusion, CK 12 000 U/L. The MOST critical immediate action is:
A. Administer IV dantrolene.
B. Discontinue olanzapine and lithium, initiate aggressive supportive care (IVF, cooling),
and monitor in ICU.
C. Stat head CT to rule out intracranial catastrophe.
D. Load IV lorazepam 8 mg and consult neurosurgery.
Correct: B
,Rationale: Classic neuroleptic malignant syndrome (NMS). Guideline first step is stop all
dopaminergic blockers & contributory agents (lithium can potentiate), followed by
supportive care. Dantrolene reserved for refractory hyperthermia or severe rigidity;
imaging delays care.
Q2
A 29-year-old woman with treatment-resistant major depression (failed 2 SSRIs, SNRI,
augmentation with aripiprazole) is started on oral ketamine 0.5 mg/kg twice weekly.
After 4 doses she reports palpitations, BP 158/96, HR 118, and mild chest discomfort
30 min post-dose. ECG shows sinus tachycardia, QTc 465 ms. Next BEST action:
A. Discontinue ketamine permanently; switch to ECT.
B. Reduce dose to 0.2 mg/kg and monitor vitals every 15 min; obtain cardiology consult.
C. Add IV esmolol during infusion sessions.
D. Switch to intranasal esketamine 56 mg with same monitoring.
Correct: B
Rationale: Ketamine can cause transient sympathetic surge; dose reduction + tight
monitoring is first-line. Esketamine (D) carries same risk; esmolol (C) not
evidence-based first step. ECT (A) premature before dose/schedule optimization.
Q3
A 45-year-old veteran with PTSD and chronic pain is on sertraline 150 mg, prazosin 6 mg
qhs, and gabapentin 1800 mg BID. Genotype report shows CYP2D6 *1/*4 (intermediate)
,and CYP2C19 *2/*2 (poor). He remains symptomatic. Which medication change is
MOST evidence-based?
A. Increase sertraline (CYP2C19 substrate) to 200 mg.
B. Switch sertraline to desvenlafaxine (minimal CYP2C19).
C. Add risperidone augmentation for PTSD.
D. Taper gabapentin and start duloxetine.
Correct: B
Rationale: Poor CYP2C19 metabolizer → ↓ clearance of sertraline → increased
side-effects without added benefit. Desvenlafaxine primarily conjugated—preferred in
poor metabolizers. Risperidone (C) not first-line for PTSD; duloxetine (D) does not
address genotype.
Q4
A 33-year-old woman with bipolar-I on lithium 1200 mg (level 1.0 mEq/L) and quetiapine
400 mg becomes pregnant at 6 weeks’ gestation. She had 2 prior manic episodes with
hospitalization. Which plan BEST balances maternal & fetal risk?
A. Discontinue lithium immediately; continue quetiapine monotherapy.
B. Taper lithium to 300 mg and add lamotrigine.
C. Continue lithium at lowest effective level (0.6–0.8 mEq/L) with 4-week fetal
echocardiography; add folate 4 mg.
D. Switch to valproate because lower teratogenicity.
, Correct: C
Rationale: 2023 NICE & APA guidelines: lithium cardiac teratogenicity dose-dependent;
continuing with level trim <0.8 + imaging superior to relapse risk. Valproate (D) has
higher neural-tube & neurodevelopmental risk.
Q5
A 52-year-old man with schizophrenia on clozapine 450 mg daily (level 600 ng/mL)
develops WBC 2.8 (granulocytes 1200) on week 16. Repeat next day: WBC 2.2,
granulocytes 900. He is afebrile. According to clozapine REMS, the MOST appropriate
action is:
A. Continue clozapine and add filgrastim.
B. Interrupt clozapine immediately, monitor CBC 3× weekly; resume only if WBC ≥3.0 &
ANC ≥1.5.
C. Reduce dose to 300 mg and recheck in 1 week.
D. Switch to olanzapine 20 mg and discharge.
Correct: B
Rationale: REMS mandates discontinuation for WBC <3.0 or ANC <1.5 with 2-samples
rule; re-challenge only after counts normalize and benefits outweigh risks.
Q6
A 27-year-old graduate student with ADHD on methylphenidate IR 20 mg BID develops
tachycardia (HR 110), BP 138/88, and anxiety. ECG shows sinus tachycardia, QTc 420
ms. Which adjustment BEST mitigates cardiovascular risk while preserving efficacy?
Capstone Competency & Clinical Synthesis
Assessment
Chamberlain College | PMHNP Certification-Ready | 80 Questions & 100 % Verified
Answers
DOMAIN 1 – ADVANCED PSYCHOPHARMACOLOGY & NEUROMODULATION
(30 % | 24 Q)
Q1
A 38-year-old man with schizoaffective disorder, bipolar type, on lithium 900 mg (level
0.8 mEq/L) and paliperidone palmitate 156 mg monthly, is admitted for manic relapse
with psychosis. Olanzapine 15 mg is added; within 72 h he develops rigidity, fever 39.1
°C, confusion, CK 12 000 U/L. The MOST critical immediate action is:
A. Administer IV dantrolene.
B. Discontinue olanzapine and lithium, initiate aggressive supportive care (IVF, cooling),
and monitor in ICU.
C. Stat head CT to rule out intracranial catastrophe.
D. Load IV lorazepam 8 mg and consult neurosurgery.
Correct: B
,Rationale: Classic neuroleptic malignant syndrome (NMS). Guideline first step is stop all
dopaminergic blockers & contributory agents (lithium can potentiate), followed by
supportive care. Dantrolene reserved for refractory hyperthermia or severe rigidity;
imaging delays care.
Q2
A 29-year-old woman with treatment-resistant major depression (failed 2 SSRIs, SNRI,
augmentation with aripiprazole) is started on oral ketamine 0.5 mg/kg twice weekly.
After 4 doses she reports palpitations, BP 158/96, HR 118, and mild chest discomfort
30 min post-dose. ECG shows sinus tachycardia, QTc 465 ms. Next BEST action:
A. Discontinue ketamine permanently; switch to ECT.
B. Reduce dose to 0.2 mg/kg and monitor vitals every 15 min; obtain cardiology consult.
C. Add IV esmolol during infusion sessions.
D. Switch to intranasal esketamine 56 mg with same monitoring.
Correct: B
Rationale: Ketamine can cause transient sympathetic surge; dose reduction + tight
monitoring is first-line. Esketamine (D) carries same risk; esmolol (C) not
evidence-based first step. ECT (A) premature before dose/schedule optimization.
Q3
A 45-year-old veteran with PTSD and chronic pain is on sertraline 150 mg, prazosin 6 mg
qhs, and gabapentin 1800 mg BID. Genotype report shows CYP2D6 *1/*4 (intermediate)
,and CYP2C19 *2/*2 (poor). He remains symptomatic. Which medication change is
MOST evidence-based?
A. Increase sertraline (CYP2C19 substrate) to 200 mg.
B. Switch sertraline to desvenlafaxine (minimal CYP2C19).
C. Add risperidone augmentation for PTSD.
D. Taper gabapentin and start duloxetine.
Correct: B
Rationale: Poor CYP2C19 metabolizer → ↓ clearance of sertraline → increased
side-effects without added benefit. Desvenlafaxine primarily conjugated—preferred in
poor metabolizers. Risperidone (C) not first-line for PTSD; duloxetine (D) does not
address genotype.
Q4
A 33-year-old woman with bipolar-I on lithium 1200 mg (level 1.0 mEq/L) and quetiapine
400 mg becomes pregnant at 6 weeks’ gestation. She had 2 prior manic episodes with
hospitalization. Which plan BEST balances maternal & fetal risk?
A. Discontinue lithium immediately; continue quetiapine monotherapy.
B. Taper lithium to 300 mg and add lamotrigine.
C. Continue lithium at lowest effective level (0.6–0.8 mEq/L) with 4-week fetal
echocardiography; add folate 4 mg.
D. Switch to valproate because lower teratogenicity.
, Correct: C
Rationale: 2023 NICE & APA guidelines: lithium cardiac teratogenicity dose-dependent;
continuing with level trim <0.8 + imaging superior to relapse risk. Valproate (D) has
higher neural-tube & neurodevelopmental risk.
Q5
A 52-year-old man with schizophrenia on clozapine 450 mg daily (level 600 ng/mL)
develops WBC 2.8 (granulocytes 1200) on week 16. Repeat next day: WBC 2.2,
granulocytes 900. He is afebrile. According to clozapine REMS, the MOST appropriate
action is:
A. Continue clozapine and add filgrastim.
B. Interrupt clozapine immediately, monitor CBC 3× weekly; resume only if WBC ≥3.0 &
ANC ≥1.5.
C. Reduce dose to 300 mg and recheck in 1 week.
D. Switch to olanzapine 20 mg and discharge.
Correct: B
Rationale: REMS mandates discontinuation for WBC <3.0 or ANC <1.5 with 2-samples
rule; re-challenge only after counts normalize and benefits outweigh risks.
Q6
A 27-year-old graduate student with ADHD on methylphenidate IR 20 mg BID develops
tachycardia (HR 110), BP 138/88, and anxiety. ECG shows sinus tachycardia, QTc 420
ms. Which adjustment BEST mitigates cardiovascular risk while preserving efficacy?
