NRNP 6675 FINAL EXAM 2026/2027 | Questions & Answers w/
Explanations | 100% Verified | Most Comprehensive Version |
PMHNP Prep | Pass Guaranteed - A+ Graded
EXAMINATION INSTRUCTIONS: This 100-question comprehensive final exam review
covers all domains of advanced psychiatric mental health nursing practice. Questions
progress from foundational knowledge to complex clinical integration. Allow
approximately 120 minutes for completion.
DOMAIN 1: COMPLEX PSYCHOPHARMACOLOGY & TREATMENT-RESISTANT
DISORDERS
Q1: A 34-year-old patient with treatment-resistant major depressive disorder (TRD) has
failed trials of sertraline 200mg, venlafaxine XR 225mg, and augmentation with
aripiprazole. The patient experiences significant cognitive slowing and psychomotor
retardation. Which next-step intervention is most appropriate?
A. Add lithium carbonate 300mg TID
B. Initiate intranasal esketamine 56mg twice weekly for 4 weeks [CORRECT]
C. Switch to phenelzine 15mg TID
D. Add lamotrigine 25mg daily
Correct Answer: B
Rationale: This patient meets criteria for treatment-resistant depression (failure of 2+
antidepressant trials at adequate doses/duration). Intranasal esketamine is
,FDA-approved for TRD with acute suicidal ideation or behavior, showing rapid
antidepressant effects (within 24 hours). The cognitive/psychomotor symptoms
suggest potential bipolar depression features, but the primary issue is TRD.
Why other options are incorrect:
● A: Lithium augmentation has evidence in TRD but slower onset; less optimal for
acute symptoms
● C: MAOIs require dietary restrictions, have significant drug interactions, and
slower titration; not first-line for TRD after esketamine availability
● D: Lamotrigine is primarily for bipolar maintenance, not acute TRD; titration too
slow for acute needs
Q2: A 28-year-old patient with bipolar I disorder is started on lithium carbonate 300mg
TID. After 5 days, the patient presents with nausea, coarse hand tremor, ataxia, and
confusion. Lithium level is 2.8 mEq/L (therapeutic 0.6-1.2). Which intervention is
priority?
A. Discontinue lithium immediately and initiate IV normal saline hydration [CORRECT]
B. Reduce lithium to 300mg daily and recheck level in 1 week
C. Add valproic acid 500mg BID for mood stabilization
D. Administer hemodialysis emergently regardless of clinical status
Correct Answer: A
Rationale: This patient has lithium toxicity (level >2.0 mEq/L with neurotoxicity
symptoms). Immediate discontinuation and hydration are first-line. Lithium is renally
eliminated; hydration enhances excretion. Hemodialysis is reserved for levels >4.0
mEq/L or severe toxicity with renal failure.
,Clinical pearl: Risk factors for toxicity include dehydration, NSAID use, ACE inhibitors,
and renal impairment. Always check creatinine and electrolytes before starting lithium.
Q3: A 45-year-old patient with schizophrenia has been stable on clozapine 400mg daily
for 18 months. Recent labs show: WBC 3.2 × 10³/μL, ANC 1.8 × 10³/μL (baseline WBC
6.5, ANC 4.2). The patient reports mild fatigue but no fever or infection symptoms. What
is the appropriate management?
A. Continue clozapine, repeat CBC in 1 week, monitor for infection symptoms
[CORRECT]
B. Discontinue clozapine immediately and do not rechallenge
C. Initiate granulocyte colony-stimulating factor (G-CSF) prophylaxis
D. Reduce clozapine to 200mg daily and add olanzapine
Correct Answer: A
Rationale: Per FDA REMS guidelines, benign ethnic neutropenia (BEN) or mild
leukopenia (WBC 3.0-3.5, ANC 1.5-2.0) requires monitoring, not discontinuation. ANC
>1.5 × 10³/μL allows continuation with increased monitoring. Discontinuation is
required only for ANC <1.0 (moderate neutropenia) or <0.5 (severe).
Why other options are incorrect:
● B: Unnecessary for mild leukopenia; premature discontinuation risks psychotic
relapse
● C: G-CSF reserved for treatment of neutropenia, not prophylaxis
● D: Dose reduction not indicated; adding another antipsychotic doesn't address
monitoring needs
, Q4: [SELECT ALL THAT APPLY] A 52-year-old patient with treatment-resistant
schizophrenia on clozapine requires monitoring for which potential adverse effects?
A. Agranulocytosis requiring weekly then biweekly CBC monitoring [CORRECT]
B. Myocarditis presenting with chest pain, fever, and eosinophilia [CORRECT]
C. Seizures, particularly at doses >600mg daily [CORRECT]
D. Severe constipation leading to ileus [CORRECT]
E. Diabetes insipidus with hypernatremia [Incorrect]
Correct Answer: A, B, C, D
Rationale: Clozapine carries multiple black box warnings requiring vigilant monitoring:
● Agranulocytosis: Weekly CBC × 6 months, then biweekly × 6 months, then
monthly if stable
● Myocarditis: Highest risk first 2 months; monitor for chest pain, dyspnea, fever,
elevated troponin/CRP
● Seizures: Dose-dependent; risk 1% at <300mg, 2.7% at 300-600mg, 4.4% at
>600mg
● Constipation: Can progress to paralytic ileus, bowel obstruction, and death;
prophylactic bowel regimen essential
Why E is incorrect: Clozapine causes anticholinergic effects and potentially SIADH
(hyponatremia), not diabetes insipidus. Lithium causes diabetes insipidus.
Q5: A 38-year-old patient with bipolar II disorder presents with breakthrough depressive
episodes despite lamotrigine 200mg daily. The patient has rapid cycling (4 episodes in
12 months). Which augmentation strategy has the strongest evidence?
A. Add fluoxetine 20mg daily
Explanations | 100% Verified | Most Comprehensive Version |
PMHNP Prep | Pass Guaranteed - A+ Graded
EXAMINATION INSTRUCTIONS: This 100-question comprehensive final exam review
covers all domains of advanced psychiatric mental health nursing practice. Questions
progress from foundational knowledge to complex clinical integration. Allow
approximately 120 minutes for completion.
DOMAIN 1: COMPLEX PSYCHOPHARMACOLOGY & TREATMENT-RESISTANT
DISORDERS
Q1: A 34-year-old patient with treatment-resistant major depressive disorder (TRD) has
failed trials of sertraline 200mg, venlafaxine XR 225mg, and augmentation with
aripiprazole. The patient experiences significant cognitive slowing and psychomotor
retardation. Which next-step intervention is most appropriate?
A. Add lithium carbonate 300mg TID
B. Initiate intranasal esketamine 56mg twice weekly for 4 weeks [CORRECT]
C. Switch to phenelzine 15mg TID
D. Add lamotrigine 25mg daily
Correct Answer: B
Rationale: This patient meets criteria for treatment-resistant depression (failure of 2+
antidepressant trials at adequate doses/duration). Intranasal esketamine is
,FDA-approved for TRD with acute suicidal ideation or behavior, showing rapid
antidepressant effects (within 24 hours). The cognitive/psychomotor symptoms
suggest potential bipolar depression features, but the primary issue is TRD.
Why other options are incorrect:
● A: Lithium augmentation has evidence in TRD but slower onset; less optimal for
acute symptoms
● C: MAOIs require dietary restrictions, have significant drug interactions, and
slower titration; not first-line for TRD after esketamine availability
● D: Lamotrigine is primarily for bipolar maintenance, not acute TRD; titration too
slow for acute needs
Q2: A 28-year-old patient with bipolar I disorder is started on lithium carbonate 300mg
TID. After 5 days, the patient presents with nausea, coarse hand tremor, ataxia, and
confusion. Lithium level is 2.8 mEq/L (therapeutic 0.6-1.2). Which intervention is
priority?
A. Discontinue lithium immediately and initiate IV normal saline hydration [CORRECT]
B. Reduce lithium to 300mg daily and recheck level in 1 week
C. Add valproic acid 500mg BID for mood stabilization
D. Administer hemodialysis emergently regardless of clinical status
Correct Answer: A
Rationale: This patient has lithium toxicity (level >2.0 mEq/L with neurotoxicity
symptoms). Immediate discontinuation and hydration are first-line. Lithium is renally
eliminated; hydration enhances excretion. Hemodialysis is reserved for levels >4.0
mEq/L or severe toxicity with renal failure.
,Clinical pearl: Risk factors for toxicity include dehydration, NSAID use, ACE inhibitors,
and renal impairment. Always check creatinine and electrolytes before starting lithium.
Q3: A 45-year-old patient with schizophrenia has been stable on clozapine 400mg daily
for 18 months. Recent labs show: WBC 3.2 × 10³/μL, ANC 1.8 × 10³/μL (baseline WBC
6.5, ANC 4.2). The patient reports mild fatigue but no fever or infection symptoms. What
is the appropriate management?
A. Continue clozapine, repeat CBC in 1 week, monitor for infection symptoms
[CORRECT]
B. Discontinue clozapine immediately and do not rechallenge
C. Initiate granulocyte colony-stimulating factor (G-CSF) prophylaxis
D. Reduce clozapine to 200mg daily and add olanzapine
Correct Answer: A
Rationale: Per FDA REMS guidelines, benign ethnic neutropenia (BEN) or mild
leukopenia (WBC 3.0-3.5, ANC 1.5-2.0) requires monitoring, not discontinuation. ANC
>1.5 × 10³/μL allows continuation with increased monitoring. Discontinuation is
required only for ANC <1.0 (moderate neutropenia) or <0.5 (severe).
Why other options are incorrect:
● B: Unnecessary for mild leukopenia; premature discontinuation risks psychotic
relapse
● C: G-CSF reserved for treatment of neutropenia, not prophylaxis
● D: Dose reduction not indicated; adding another antipsychotic doesn't address
monitoring needs
, Q4: [SELECT ALL THAT APPLY] A 52-year-old patient with treatment-resistant
schizophrenia on clozapine requires monitoring for which potential adverse effects?
A. Agranulocytosis requiring weekly then biweekly CBC monitoring [CORRECT]
B. Myocarditis presenting with chest pain, fever, and eosinophilia [CORRECT]
C. Seizures, particularly at doses >600mg daily [CORRECT]
D. Severe constipation leading to ileus [CORRECT]
E. Diabetes insipidus with hypernatremia [Incorrect]
Correct Answer: A, B, C, D
Rationale: Clozapine carries multiple black box warnings requiring vigilant monitoring:
● Agranulocytosis: Weekly CBC × 6 months, then biweekly × 6 months, then
monthly if stable
● Myocarditis: Highest risk first 2 months; monitor for chest pain, dyspnea, fever,
elevated troponin/CRP
● Seizures: Dose-dependent; risk 1% at <300mg, 2.7% at 300-600mg, 4.4% at
>600mg
● Constipation: Can progress to paralytic ileus, bowel obstruction, and death;
prophylactic bowel regimen essential
Why E is incorrect: Clozapine causes anticholinergic effects and potentially SIADH
(hyponatremia), not diabetes insipidus. Lithium causes diabetes insipidus.
Q5: A 38-year-old patient with bipolar II disorder presents with breakthrough depressive
episodes despite lamotrigine 200mg daily. The patient has rapid cycling (4 episodes in
12 months). Which augmentation strategy has the strongest evidence?
A. Add fluoxetine 20mg daily
