NRNP6675 PMHNP Midterm Exam Quiz
Bank - 2026/2027 | Complete Guide |
Psychiatric Assessment & Clinical
Reasoning
I. Advanced Psychopharmacology (21 questions)
Q1
A 34-year-old woman with TRD has failed sertraline 200 mg × 12 wks and
desvenlafaxine 200 mg × 10 wks. Genotype shows CYP2D6 poor-metabolizer. She now
reports hypersomnia & psychomotor slowing. Which augmentation strategy is MOST
evidence-based as next step?
A. Switch to phenelzine 45 mg daily
B. Augment with aripiprazole 2 mg daily
C. Add lithium 300 mg BID
D. Switch to duloxetine 120 mg daily
Verified Answer: B
Rationale: APA TRD Guidelines 2025 list atypical-antipsychotic augmentation
(aripiprazole, quetiapine, brexpiprazole) as Level-1 evidence after two adequate AD
trials. Aripiprazole also targets fatigue & retardation via D2 partial agonism. MAOI (A) is
4th-line; lithium (C) lacks strong data after only two failures; duloxetine (D) is same
class as desvenlafaxine (SNRI) and offers no new mechanism.
,Q2 (SATA)
Before starting clozapine for TRS, which baseline labs are REQUIRED? (Select ALL)
A. CBC with ANC
B. Fasting glucose & lipids
C. ECG
D. Liver enzymes
E. CYP2D6 genotype
Verified Answers: A, B, D
Rationale: Clozapine REMS 2025 mandates CBC/ANC, metabolic panel (glucose, lipids,
LFTs). ECG (C) is advised only if cardiac risk. Genotype (E) is optional—dosing is
adjusted clinically.
Q3
A patient on lithium 900 mg hs (level 0.8 mmol/L) develops new hand tremor, polyuria,
nausea. Na 130 mEq/L, Li level 1.3 mmol/L. Which interaction is MOST likely?
A. Started ibuprofen 600 mg BID 5 days ago
B. Started sertraline 100 mg
C. Increased salt intake
D. Started aripiprazole 10 mg
Verified Answer: A
,Rationale: NSAIDs reduce renal prostaglandin-mediated Na loss → body retains Na →
kidney reabsorbs Li → level rise. SSRIs (B) and aripiprazole (D) do not significantly alter
lithium clearance. Increased salt (C) would lower Li level.
Q4
Which antipsychotic requires NO dose adjustment in Child-Pugh B hepatic impairment?
A. Risperidone
B. Olanzapine
C. Quetiapine
D. Lurasidone
Verified Answer: B
Rationale: Olanzapine undergoes direct glucuronidation; mild-moderate hepatic
impairment does not significantly alter kinetics. Others (A, C, D) are metabolized via
CYP pathways and need dose reduction.
Q5
Patient on quetiapine XR 400 mg develops fasting glucose 140 mg/dL and weight +6 kg
in 3 months. A1c 6.7 %. BEST switch?
A. Olanzapine 15 mg
B. Lurasidone 40 mg daily with food
C. Ziprasidone 80 mg BID
, D. Asenapine 10 mg SL
Verified Answer: B
Rationale: Lurasidone is weight-neutral & improves lipids; FDA-approved for bipolar
depression. Ziprasidone (C) also low metabolic risk but requires BID dosing and 500
kcal meal. Olanzapine (A) worst metabolic profile.
Q6
Clozapine 300 mg → ANC 1.9 k/µL (baseline 4.2). ANC next day 1.7 k/µL. Classification
& action?
A. Benign ethnic neutropenia—continue
B. Mild neutropenia—continue & monitor twice weekly
C. Moderate neutropenia—stop clozapine
D. Severe neutropenia—start filgrastim
Verified Answer: B
Rationale: ANC 1.0–1.5 k = mild (REMS); can continue with twice-weekly ANC; <1.0 k
requires immediate discontinuation. Filgrastim (D) used only if confirmed severe and
clinician wants to rechallenge.
Q7
Patient on valproate 1500 mg → level 120 µg/mL (target 50–100), platelet 90 k/µL.
Action?
A. Continue—level therapeutic
Bank - 2026/2027 | Complete Guide |
Psychiatric Assessment & Clinical
Reasoning
I. Advanced Psychopharmacology (21 questions)
Q1
A 34-year-old woman with TRD has failed sertraline 200 mg × 12 wks and
desvenlafaxine 200 mg × 10 wks. Genotype shows CYP2D6 poor-metabolizer. She now
reports hypersomnia & psychomotor slowing. Which augmentation strategy is MOST
evidence-based as next step?
A. Switch to phenelzine 45 mg daily
B. Augment with aripiprazole 2 mg daily
C. Add lithium 300 mg BID
D. Switch to duloxetine 120 mg daily
Verified Answer: B
Rationale: APA TRD Guidelines 2025 list atypical-antipsychotic augmentation
(aripiprazole, quetiapine, brexpiprazole) as Level-1 evidence after two adequate AD
trials. Aripiprazole also targets fatigue & retardation via D2 partial agonism. MAOI (A) is
4th-line; lithium (C) lacks strong data after only two failures; duloxetine (D) is same
class as desvenlafaxine (SNRI) and offers no new mechanism.
,Q2 (SATA)
Before starting clozapine for TRS, which baseline labs are REQUIRED? (Select ALL)
A. CBC with ANC
B. Fasting glucose & lipids
C. ECG
D. Liver enzymes
E. CYP2D6 genotype
Verified Answers: A, B, D
Rationale: Clozapine REMS 2025 mandates CBC/ANC, metabolic panel (glucose, lipids,
LFTs). ECG (C) is advised only if cardiac risk. Genotype (E) is optional—dosing is
adjusted clinically.
Q3
A patient on lithium 900 mg hs (level 0.8 mmol/L) develops new hand tremor, polyuria,
nausea. Na 130 mEq/L, Li level 1.3 mmol/L. Which interaction is MOST likely?
A. Started ibuprofen 600 mg BID 5 days ago
B. Started sertraline 100 mg
C. Increased salt intake
D. Started aripiprazole 10 mg
Verified Answer: A
,Rationale: NSAIDs reduce renal prostaglandin-mediated Na loss → body retains Na →
kidney reabsorbs Li → level rise. SSRIs (B) and aripiprazole (D) do not significantly alter
lithium clearance. Increased salt (C) would lower Li level.
Q4
Which antipsychotic requires NO dose adjustment in Child-Pugh B hepatic impairment?
A. Risperidone
B. Olanzapine
C. Quetiapine
D. Lurasidone
Verified Answer: B
Rationale: Olanzapine undergoes direct glucuronidation; mild-moderate hepatic
impairment does not significantly alter kinetics. Others (A, C, D) are metabolized via
CYP pathways and need dose reduction.
Q5
Patient on quetiapine XR 400 mg develops fasting glucose 140 mg/dL and weight +6 kg
in 3 months. A1c 6.7 %. BEST switch?
A. Olanzapine 15 mg
B. Lurasidone 40 mg daily with food
C. Ziprasidone 80 mg BID
, D. Asenapine 10 mg SL
Verified Answer: B
Rationale: Lurasidone is weight-neutral & improves lipids; FDA-approved for bipolar
depression. Ziprasidone (C) also low metabolic risk but requires BID dosing and 500
kcal meal. Olanzapine (A) worst metabolic profile.
Q6
Clozapine 300 mg → ANC 1.9 k/µL (baseline 4.2). ANC next day 1.7 k/µL. Classification
& action?
A. Benign ethnic neutropenia—continue
B. Mild neutropenia—continue & monitor twice weekly
C. Moderate neutropenia—stop clozapine
D. Severe neutropenia—start filgrastim
Verified Answer: B
Rationale: ANC 1.0–1.5 k = mild (REMS); can continue with twice-weekly ANC; <1.0 k
requires immediate discontinuation. Filgrastim (D) used only if confirmed severe and
clinician wants to rechallenge.
Q7
Patient on valproate 1500 mg → level 120 µg/mL (target 50–100), platelet 90 k/µL.
Action?
A. Continue—level therapeutic
