NRNP 6675 MIDTERM EXAM 2026/2027 | Questions &
Answers w/ Explanations | 100% Verified | Most
Comprehensive Version | Pass Guaranteed - A+ Graded
Q1: A 34-year-old female presents with symptoms of major depressive disorder (MDD).
She has a history of inadequate response to sertraline 200mg and fluoxetine 40mg,
each trialed for 8 weeks. According to the STAR*D trial and current APA guidelines, what
is the most appropriate next step?
A. Increase fluoxetine to 60mg for another 4 weeks
B. Switch to venlafaxine XR 150mg daily [CORRECT]
C. Add aripiprazole 2mg to current fluoxetine dose
D. Discontinue antidepressants and initiate cognitive behavioral therapy only
Correct Answer: B
Rationale: The STARD trial demonstrated that after two failed SSRI trials, switching to an
agent with a different mechanism (such as an SNRI like venlafaxine) is more effective than
continuing within the same class. This represents Level 2 of the STARD algorithm. Option
A is incorrect because dose escalation beyond 8 weeks at therapeutic doses is unlikely
to yield remission in treatment-resistant depression. Option C (augmentation) is
typically considered after three failed monotherapy trials or in Level 3-4 of STAR*D.
Option D is inappropriate because evidence supports combined pharmacotherapy and
psychotherapy rather than discontinuing medication entirely in treatment-resistant
cases.
Q2: A PMHNP is prescribing fluoxetine for a 29-year-old patient with MDD. Which
statement regarding CYP450 enzyme interactions is correct?
,A. Fluoxetine is a potent inhibitor of CYP2D6 and requires dose reduction of concurrent
tramadol
B. Fluoxetine induces CYP3A4, reducing effectiveness of oral contraceptives
C. Fluoxetine has minimal CYP450 interactions and is safe with most medications
D. Fluoxetine inhibits CYP1A2, increasing theophylline toxicity risk [CORRECT]
Correct Answer: D
Rationale: Fluoxetine is a potent inhibitor of CYP2D6 and a moderate inhibitor of
CYP2C19 and CYP3A4, but it also inhibits CYP1A2. This inhibition can increase levels of
CYP1A2 substrates like theophylline and clozapine. Option A is partially correct
regarding CYP2D6 inhibition, but tramadol requires CYP2D6 for conversion to its active
metabolite (M1), so fluoxetine would reduce tramadol's analgesic effect rather than
require dose reduction of tramadol. Option B is incorrect because fluoxetine inhibits
rather than induces enzymes. Option C is dangerously incorrect given fluoxetine's
significant interaction profile.
Q3: A 45-year-old male with bipolar I disorder is currently manic and requires
pharmacological intervention. He has a history of non-adherence to lithium. Which
medication combination is most appropriate for acute mania?
A. Lithium carbonate 900mg daily plus lorazepam 2mg PRN
B. Valproic acid 750mg daily plus quetiapine 200mg BID [CORRECT]
C. Lamotrigine 25mg daily titrated slowly
D. Carbamazepine monotherapy 400mg BID
Correct Answer: B
Rationale: For acute mania with history of lithium non-adherence, guidelines
recommend initiating either valproic acid or an atypical antipsychotic as first-line. The
combination of valproic acid and quetiapine addresses both GABA-ergic modulation
and dopamine/serotonin antagonism, providing rapid mood stabilization and antimanic
,effects. Option A relies on lithium which the patient has not adhered to previously.
Option C (lamotrigine) is inappropriate for acute mania as it is primarily effective for
bipolar depression maintenance and requires slow titration due to risk of
Stevens-Johnson syndrome. Option D (carbamazepine) is a second-line option with
significant drug interactions and requires monitoring.
Q4: Select all that apply regarding black box warnings for antidepressants in children
and adolescents:
A. Increased risk of suicidal thinking and behavior [CORRECT]
B. Contraindicated in patients under 18 years of age
C. Requires weekly monitoring for first 4 weeks of treatment [CORRECT]
D. Applies to all antidepressant classes including TCAs and MAOIs [CORRECT]
E. Only applies to SSRIs and SNRIs
Correct Answer: A, C, D
Rationale: The FDA black box warning applies to all antidepressant classes (SSRIs,
SNRIs, TCAs, MAOIs) prescribed to patients under 24 years of age, warning of increased
risk of suicidal thinking and behavior. Close monitoring is required weekly for the first 4
weeks, then biweekly for weeks 5-12, then at week 12. Option B is incorrect because
antidepressants are not contraindicated in youth—they are widely used with appropriate
monitoring. Option E is incorrect because the warning encompasses all antidepressant
classes, not just SSRIs/SNRIs.
Q5: A patient on clozapine 400mg daily presents with fever, sore throat, and malaise.
Lab results reveal WBC 2,800/μL with absolute neutrophil count (ANC) 1,200/μL. What
is the appropriate management?
A. Continue clozapine and recheck labs in one week
B. Hold clozapine immediately and obtain CBC with differential daily [CORRECT]
, C. Reduce clozapine dose by 50% and monitor symptoms
D. Initiate granulocyte colony-stimulating factor (G-CSF) and continue clozapine
Correct Answer: B
Rationale: ANC 1,000-1,499/μL with symptoms constitutes moderate neutropenia (ANC
500-999/μL without symptoms also moderate). Clozapine must be held immediately,
and daily CBC monitoring is required until ANC >1,500/μL. If ANC drops to 500-999/μL,
clozapine is contraindicated until ANC normalizes with hematology consultation. Option
A is dangerous and could lead to agranulocytosis. Option C is inappropriate because
dose reduction does not prevent progression of neutropenia. Option D is premature;
G-CSF is reserved for severe neutropenia or treatment of agranulocytosis, not moderate
cases.
Q6: Which laboratory monitoring is required for a patient starting lithium carbonate for
bipolar disorder? (Select all that apply)
A. Thyroid function tests (TSH) [CORRECT]
B. Complete metabolic panel including creatinine and electrolytes [CORRECT]
C. Pregnancy test for females of childbearing potential [CORRECT]
D. Liver function tests every 3 months
E. ECG for patients over 40 or with cardiac risk factors [CORRECT]
Correct Answer: A, B, C, E
Rationale: Baseline and ongoing monitoring for lithium includes: renal function
(creatinine, BUN, electrolytes—lithium is renally cleared and can cause nephrogenic
diabetes insipidus), thyroid function (lithium inhibits thyroid hormone release and can
cause hypothyroidism and goiter), pregnancy testing (Category D with Ebstein's
anomaly risk), and ECG for older adults or those with cardiac risk factors (lithium can
Answers w/ Explanations | 100% Verified | Most
Comprehensive Version | Pass Guaranteed - A+ Graded
Q1: A 34-year-old female presents with symptoms of major depressive disorder (MDD).
She has a history of inadequate response to sertraline 200mg and fluoxetine 40mg,
each trialed for 8 weeks. According to the STAR*D trial and current APA guidelines, what
is the most appropriate next step?
A. Increase fluoxetine to 60mg for another 4 weeks
B. Switch to venlafaxine XR 150mg daily [CORRECT]
C. Add aripiprazole 2mg to current fluoxetine dose
D. Discontinue antidepressants and initiate cognitive behavioral therapy only
Correct Answer: B
Rationale: The STARD trial demonstrated that after two failed SSRI trials, switching to an
agent with a different mechanism (such as an SNRI like venlafaxine) is more effective than
continuing within the same class. This represents Level 2 of the STARD algorithm. Option
A is incorrect because dose escalation beyond 8 weeks at therapeutic doses is unlikely
to yield remission in treatment-resistant depression. Option C (augmentation) is
typically considered after three failed monotherapy trials or in Level 3-4 of STAR*D.
Option D is inappropriate because evidence supports combined pharmacotherapy and
psychotherapy rather than discontinuing medication entirely in treatment-resistant
cases.
Q2: A PMHNP is prescribing fluoxetine for a 29-year-old patient with MDD. Which
statement regarding CYP450 enzyme interactions is correct?
,A. Fluoxetine is a potent inhibitor of CYP2D6 and requires dose reduction of concurrent
tramadol
B. Fluoxetine induces CYP3A4, reducing effectiveness of oral contraceptives
C. Fluoxetine has minimal CYP450 interactions and is safe with most medications
D. Fluoxetine inhibits CYP1A2, increasing theophylline toxicity risk [CORRECT]
Correct Answer: D
Rationale: Fluoxetine is a potent inhibitor of CYP2D6 and a moderate inhibitor of
CYP2C19 and CYP3A4, but it also inhibits CYP1A2. This inhibition can increase levels of
CYP1A2 substrates like theophylline and clozapine. Option A is partially correct
regarding CYP2D6 inhibition, but tramadol requires CYP2D6 for conversion to its active
metabolite (M1), so fluoxetine would reduce tramadol's analgesic effect rather than
require dose reduction of tramadol. Option B is incorrect because fluoxetine inhibits
rather than induces enzymes. Option C is dangerously incorrect given fluoxetine's
significant interaction profile.
Q3: A 45-year-old male with bipolar I disorder is currently manic and requires
pharmacological intervention. He has a history of non-adherence to lithium. Which
medication combination is most appropriate for acute mania?
A. Lithium carbonate 900mg daily plus lorazepam 2mg PRN
B. Valproic acid 750mg daily plus quetiapine 200mg BID [CORRECT]
C. Lamotrigine 25mg daily titrated slowly
D. Carbamazepine monotherapy 400mg BID
Correct Answer: B
Rationale: For acute mania with history of lithium non-adherence, guidelines
recommend initiating either valproic acid or an atypical antipsychotic as first-line. The
combination of valproic acid and quetiapine addresses both GABA-ergic modulation
and dopamine/serotonin antagonism, providing rapid mood stabilization and antimanic
,effects. Option A relies on lithium which the patient has not adhered to previously.
Option C (lamotrigine) is inappropriate for acute mania as it is primarily effective for
bipolar depression maintenance and requires slow titration due to risk of
Stevens-Johnson syndrome. Option D (carbamazepine) is a second-line option with
significant drug interactions and requires monitoring.
Q4: Select all that apply regarding black box warnings for antidepressants in children
and adolescents:
A. Increased risk of suicidal thinking and behavior [CORRECT]
B. Contraindicated in patients under 18 years of age
C. Requires weekly monitoring for first 4 weeks of treatment [CORRECT]
D. Applies to all antidepressant classes including TCAs and MAOIs [CORRECT]
E. Only applies to SSRIs and SNRIs
Correct Answer: A, C, D
Rationale: The FDA black box warning applies to all antidepressant classes (SSRIs,
SNRIs, TCAs, MAOIs) prescribed to patients under 24 years of age, warning of increased
risk of suicidal thinking and behavior. Close monitoring is required weekly for the first 4
weeks, then biweekly for weeks 5-12, then at week 12. Option B is incorrect because
antidepressants are not contraindicated in youth—they are widely used with appropriate
monitoring. Option E is incorrect because the warning encompasses all antidepressant
classes, not just SSRIs/SNRIs.
Q5: A patient on clozapine 400mg daily presents with fever, sore throat, and malaise.
Lab results reveal WBC 2,800/μL with absolute neutrophil count (ANC) 1,200/μL. What
is the appropriate management?
A. Continue clozapine and recheck labs in one week
B. Hold clozapine immediately and obtain CBC with differential daily [CORRECT]
, C. Reduce clozapine dose by 50% and monitor symptoms
D. Initiate granulocyte colony-stimulating factor (G-CSF) and continue clozapine
Correct Answer: B
Rationale: ANC 1,000-1,499/μL with symptoms constitutes moderate neutropenia (ANC
500-999/μL without symptoms also moderate). Clozapine must be held immediately,
and daily CBC monitoring is required until ANC >1,500/μL. If ANC drops to 500-999/μL,
clozapine is contraindicated until ANC normalizes with hematology consultation. Option
A is dangerous and could lead to agranulocytosis. Option C is inappropriate because
dose reduction does not prevent progression of neutropenia. Option D is premature;
G-CSF is reserved for severe neutropenia or treatment of agranulocytosis, not moderate
cases.
Q6: Which laboratory monitoring is required for a patient starting lithium carbonate for
bipolar disorder? (Select all that apply)
A. Thyroid function tests (TSH) [CORRECT]
B. Complete metabolic panel including creatinine and electrolytes [CORRECT]
C. Pregnancy test for females of childbearing potential [CORRECT]
D. Liver function tests every 3 months
E. ECG for patients over 40 or with cardiac risk factors [CORRECT]
Correct Answer: A, B, C, E
Rationale: Baseline and ongoing monitoring for lithium includes: renal function
(creatinine, BUN, electrolytes—lithium is renally cleared and can cause nephrogenic
diabetes insipidus), thyroid function (lithium inhibits thyroid hormone release and can
cause hypothyroidism and goiter), pregnancy testing (Category D with Ebstein's
anomaly risk), and ECG for older adults or those with cardiac risk factors (lithium can
