1
NR607 MIDTERM EXAM ACTUAL 2026/2027 | Diagnosis &
Management in PMHNP III | Weeks 1-4 Complete Review |
Verified Answers 100% Correct | Grade A | Chamberlain |
Pass Guaranteed - A+ Graded
Section 1: Advanced Psychopharmacology - Pharmacokinetics &
Pharmacodynamics (Week 1) (Q1-14)
Q1. A 42-year-old patient with major depressive disorder is prescribed fluoxetine 20
mg daily. She also takes metoprolol 50 mg twice daily for hypertension. After 2
weeks, she reports dizziness, bradycardia, and fatigue. Which cytochrome P450
enzyme is primarily responsible for this drug-drug interaction?
A. CYP1A2
B. CYP2C19
C. CYP2D6
D. CYP3A4
C. CYP2D6 [CORRECT]
Rationale: Fluoxetine is a potent CYP2D6 inhibitor that significantly reduces
metoprolol metabolism, leading to increased beta-blocker levels and exaggerated
bradycardia and hypotension. Metoprolol is a CYP2D6 substrate, and co-
administration with strong 2D6 inhibitors requires dose reduction or alternative
agents. CYP1A2 primarily metabolizes olanzapine and clozapine, CYP2C19 activates
clopidogrel, and CYP3A4 metabolizes quetiapine and midazolam.
"Correct Answer: C"
Q2. A 58-year-old male is started on buspirone 15 mg daily for generalized anxiety
disorder. He enjoys grapefruit juice with breakfast each morning. Within 3 days, he
presents with severe dizziness, nausea, and somnolence. Which CYP450 enzyme
interaction explains this clinical presentation?
,2
A. CYP1A2 inhibition by grapefruit juice
B. CYP2D6 inhibition by buspirone
C. CYP3A4 inhibition by grapefruit juice
D. CYP2C19 inhibition by buspirone
C. CYP3A4 inhibition by grapefruit juice [CORRECT]
Rationale: Grapefruit juice contains furanocoumarins that irreversibly inhibit intestinal
CYP3A4, increasing bioavailability of CYP3A4 substrates like buspirone by up to 10-
fold and causing toxicity. Buspirone is not significantly metabolized by CYP2D6 or
CYP2C19, and CYP1A2 is induced by smoking, not inhibited by grapefruit.
"Correct Answer: C"
Q3. A 67-year-old patient post-MI is prescribed clopidogrel 75 mg daily. The PMHNP
notes she also takes omeprazole 20 mg daily for GERD. Which pharmacogenomic
and metabolic principle requires immediate intervention to prevent cardiovascular
events?
A. Omeprazole inhibits CYP3A4, reducing clopidogrel activation
B. The patient may be a CYP2C19 poor metabolizer, and omeprazole further inhibits
clopidogrel activation
C. Omeprazole induces CYP1A2, increasing clopidogrel clearance
D. Clopidogrel inhibits CYP2D6, reducing omeprazole metabolism
B. The patient may be a CYP2C19 poor metabolizer, and omeprazole further inhibits
clopidogrel activation [CORRECT]
Rationale: Clopidogrel requires CYP2C19-mediated bioactivation to its active
metabolite; omeprazole competes for CYP2C19, and poor metabolizers have
significantly reduced antiplatelet effect, increasing stent thrombosis and MI risk. The
FDA warns against omeprazole/esomeprazole with clopidogrel. CYP3A4 and CYP1A2
are not primarily involved in clopidogrel activation.
"Correct Answer: B"
,3
Q4. A 29-year-old male with schizophrenia stabilized on olanzapine 20 mg daily
decides to quit smoking. Two weeks later, he develops sedation, weight gain, and
orthostatic hypotension. Which metabolic change explains this clinical deterioration?
A. CYP2D6 inhibition from nicotine cessation
B. CYP1A2 induction from tobacco smoke is lost, increasing olanzapine levels
C. CYP3A4 inhibition from carbon monoxide clearance
D. CYP2C19 autoinduction from olanzapine metabolism
B. CYP1A2 induction from tobacco smoke is lost, increasing olanzapine levels
[CORRECT]
Rationale: Polycyclic aromatic hydrocarbons in tobacco smoke induce CYP1A2, which
metabolizes olanzapine and clozapine; smoking cessation reduces CYP1A2 activity by
30-40%, effectively increasing antipsychotic levels and adverse effects. Dose
reduction of 30-50% is often required when patients quit smoking. CYP2D6 and
CYP3A4 are not significantly affected by tobacco in this manner.
"Correct Answer: B"
Q5. A 35-year-old female on paroxetine 40 mg daily for panic disorder requires
tramadol for postoperative pain. The surgical team notes inadequate analgesia
despite escalating tramadol doses. Which CYP450 polymorphism or interaction best
explains this therapeutic failure?
A. CYP3A4 induction reducing tramadol levels
B. CYP2D6 inhibition by paroxetine preventing tramadol O-demethylation to active
M1 metabolite
C. CYP1A2 poor metabolizer status reducing tramadol clearance
D. CYP2C19 ultrarapid metabolism increasing tramadol excretion
B. CYP2D6 inhibition by paroxetine preventing tramadol O-demethylation to active
M1 metabolite [CORRECT]
Rationale: Tramadol requires CYP2D6-mediated O-demethylation to produce the
active M1 mu-opioid agonist metabolite; paroxetine is a potent CYP2D6 inhibitor
that blocks this conversion, resulting in prodrug failure and inadequate analgesia.
, 4
Codeine and tramadol efficacy is entirely dependent on CYP2D6 activity, not CYP3A4,
CYP1A2, or CYP2C19.
"Correct Answer: B"
Q6. A 24-year-old female with bipolar disorder on quetiapine 400 mg daily is started
on carbamazepine 400 mg daily for mood stabilization. Within 2 weeks, her psychotic
symptoms worsen. Which metabolic mechanism is responsible?
A. Carbamazepine inhibits CYP2D6, reducing quetiapine metabolism
B. Carbamazepine induces CYP3A4, increasing quetiapine clearance
C. Carbamazepine inhibits CYP1A2, reducing quetiapine absorption
D. Carbamazepine induces CYP2C19, increasing quetiapine protein binding
B. Carbamazepine induces CYP3A4, increasing quetiapine clearance [CORRECT]
Rationale: Carbamazepine is a potent CYP3A4 inducer that increases metabolism of
CYP3A4 substrates including quetiapine, midazolam, and oral contraceptives, often
requiring 2-3 fold dose increases to maintain therapeutic levels. Carbamazepine does
not significantly inhibit CYP2D6 or CYP1A2, and CYP2C19 induction is not relevant to
quetiapine pharmacokinetics.
"Correct Answer: B"
Q7. A 7-year-old child post-tonsillectomy is prescribed codeine 15 mg every 6 hours
for pain. The mother reports excessive somnolence and respiratory depression within
4 hours of the first dose. Pharmacogenomic testing reveals CYP2D6 ultrarapid
metabolizer status. Which metabolic conversion explains this life-threatening
reaction?
A. Rapid CYP3A4 conversion of codeine to norcodeine
B. Excessive CYP2D6 conversion of codeine to morphine
C. CYP1A2 induction converting codeine to toxic metabolites
D. CYP2C19 poor metabolism accumulating codeine prodrug
NR607 MIDTERM EXAM ACTUAL 2026/2027 | Diagnosis &
Management in PMHNP III | Weeks 1-4 Complete Review |
Verified Answers 100% Correct | Grade A | Chamberlain |
Pass Guaranteed - A+ Graded
Section 1: Advanced Psychopharmacology - Pharmacokinetics &
Pharmacodynamics (Week 1) (Q1-14)
Q1. A 42-year-old patient with major depressive disorder is prescribed fluoxetine 20
mg daily. She also takes metoprolol 50 mg twice daily for hypertension. After 2
weeks, she reports dizziness, bradycardia, and fatigue. Which cytochrome P450
enzyme is primarily responsible for this drug-drug interaction?
A. CYP1A2
B. CYP2C19
C. CYP2D6
D. CYP3A4
C. CYP2D6 [CORRECT]
Rationale: Fluoxetine is a potent CYP2D6 inhibitor that significantly reduces
metoprolol metabolism, leading to increased beta-blocker levels and exaggerated
bradycardia and hypotension. Metoprolol is a CYP2D6 substrate, and co-
administration with strong 2D6 inhibitors requires dose reduction or alternative
agents. CYP1A2 primarily metabolizes olanzapine and clozapine, CYP2C19 activates
clopidogrel, and CYP3A4 metabolizes quetiapine and midazolam.
"Correct Answer: C"
Q2. A 58-year-old male is started on buspirone 15 mg daily for generalized anxiety
disorder. He enjoys grapefruit juice with breakfast each morning. Within 3 days, he
presents with severe dizziness, nausea, and somnolence. Which CYP450 enzyme
interaction explains this clinical presentation?
,2
A. CYP1A2 inhibition by grapefruit juice
B. CYP2D6 inhibition by buspirone
C. CYP3A4 inhibition by grapefruit juice
D. CYP2C19 inhibition by buspirone
C. CYP3A4 inhibition by grapefruit juice [CORRECT]
Rationale: Grapefruit juice contains furanocoumarins that irreversibly inhibit intestinal
CYP3A4, increasing bioavailability of CYP3A4 substrates like buspirone by up to 10-
fold and causing toxicity. Buspirone is not significantly metabolized by CYP2D6 or
CYP2C19, and CYP1A2 is induced by smoking, not inhibited by grapefruit.
"Correct Answer: C"
Q3. A 67-year-old patient post-MI is prescribed clopidogrel 75 mg daily. The PMHNP
notes she also takes omeprazole 20 mg daily for GERD. Which pharmacogenomic
and metabolic principle requires immediate intervention to prevent cardiovascular
events?
A. Omeprazole inhibits CYP3A4, reducing clopidogrel activation
B. The patient may be a CYP2C19 poor metabolizer, and omeprazole further inhibits
clopidogrel activation
C. Omeprazole induces CYP1A2, increasing clopidogrel clearance
D. Clopidogrel inhibits CYP2D6, reducing omeprazole metabolism
B. The patient may be a CYP2C19 poor metabolizer, and omeprazole further inhibits
clopidogrel activation [CORRECT]
Rationale: Clopidogrel requires CYP2C19-mediated bioactivation to its active
metabolite; omeprazole competes for CYP2C19, and poor metabolizers have
significantly reduced antiplatelet effect, increasing stent thrombosis and MI risk. The
FDA warns against omeprazole/esomeprazole with clopidogrel. CYP3A4 and CYP1A2
are not primarily involved in clopidogrel activation.
"Correct Answer: B"
,3
Q4. A 29-year-old male with schizophrenia stabilized on olanzapine 20 mg daily
decides to quit smoking. Two weeks later, he develops sedation, weight gain, and
orthostatic hypotension. Which metabolic change explains this clinical deterioration?
A. CYP2D6 inhibition from nicotine cessation
B. CYP1A2 induction from tobacco smoke is lost, increasing olanzapine levels
C. CYP3A4 inhibition from carbon monoxide clearance
D. CYP2C19 autoinduction from olanzapine metabolism
B. CYP1A2 induction from tobacco smoke is lost, increasing olanzapine levels
[CORRECT]
Rationale: Polycyclic aromatic hydrocarbons in tobacco smoke induce CYP1A2, which
metabolizes olanzapine and clozapine; smoking cessation reduces CYP1A2 activity by
30-40%, effectively increasing antipsychotic levels and adverse effects. Dose
reduction of 30-50% is often required when patients quit smoking. CYP2D6 and
CYP3A4 are not significantly affected by tobacco in this manner.
"Correct Answer: B"
Q5. A 35-year-old female on paroxetine 40 mg daily for panic disorder requires
tramadol for postoperative pain. The surgical team notes inadequate analgesia
despite escalating tramadol doses. Which CYP450 polymorphism or interaction best
explains this therapeutic failure?
A. CYP3A4 induction reducing tramadol levels
B. CYP2D6 inhibition by paroxetine preventing tramadol O-demethylation to active
M1 metabolite
C. CYP1A2 poor metabolizer status reducing tramadol clearance
D. CYP2C19 ultrarapid metabolism increasing tramadol excretion
B. CYP2D6 inhibition by paroxetine preventing tramadol O-demethylation to active
M1 metabolite [CORRECT]
Rationale: Tramadol requires CYP2D6-mediated O-demethylation to produce the
active M1 mu-opioid agonist metabolite; paroxetine is a potent CYP2D6 inhibitor
that blocks this conversion, resulting in prodrug failure and inadequate analgesia.
, 4
Codeine and tramadol efficacy is entirely dependent on CYP2D6 activity, not CYP3A4,
CYP1A2, or CYP2C19.
"Correct Answer: B"
Q6. A 24-year-old female with bipolar disorder on quetiapine 400 mg daily is started
on carbamazepine 400 mg daily for mood stabilization. Within 2 weeks, her psychotic
symptoms worsen. Which metabolic mechanism is responsible?
A. Carbamazepine inhibits CYP2D6, reducing quetiapine metabolism
B. Carbamazepine induces CYP3A4, increasing quetiapine clearance
C. Carbamazepine inhibits CYP1A2, reducing quetiapine absorption
D. Carbamazepine induces CYP2C19, increasing quetiapine protein binding
B. Carbamazepine induces CYP3A4, increasing quetiapine clearance [CORRECT]
Rationale: Carbamazepine is a potent CYP3A4 inducer that increases metabolism of
CYP3A4 substrates including quetiapine, midazolam, and oral contraceptives, often
requiring 2-3 fold dose increases to maintain therapeutic levels. Carbamazepine does
not significantly inhibit CYP2D6 or CYP1A2, and CYP2C19 induction is not relevant to
quetiapine pharmacokinetics.
"Correct Answer: B"
Q7. A 7-year-old child post-tonsillectomy is prescribed codeine 15 mg every 6 hours
for pain. The mother reports excessive somnolence and respiratory depression within
4 hours of the first dose. Pharmacogenomic testing reveals CYP2D6 ultrarapid
metabolizer status. Which metabolic conversion explains this life-threatening
reaction?
A. Rapid CYP3A4 conversion of codeine to norcodeine
B. Excessive CYP2D6 conversion of codeine to morphine
C. CYP1A2 induction converting codeine to toxic metabolites
D. CYP2C19 poor metabolism accumulating codeine prodrug
