NR 546 Psychopharmacology for the Psychiatric-
Mental Health Nurse Practitioner – Chamberlain
College of Nursing – Midterm Exam3 2026/2027
Question 1: A patient with a known genetic variation resulting in a "poor
metabolizer" phenotype for CYP2D6 is prescribed risperidone. What is the
most significant clinical implication of this genetic status?
A. The medication will be eliminated from the body more rapidly, requiring higher
doses.
B. The patient will have a higher risk of experiencing extrapyramidal symptoms and
hyperprolactinemia.
C. The medication will be completely inactive and provide no therapeutic benefit.
D. The patient will have an increased risk of agranulocytosis and requires CBC
monitoring.
CORRECT ANSWER: B. The patient will have a higher risk of experiencing
extrapyramidal symptoms and hyperprolactinemia.
Rationale: CYP2D6 is a key enzyme in the metabolism of many antipsychotics,
including risperidone. A poor metabolizer phenotype results in reduced enzyme activity,
leading to higher-than-expected serum concentrations of the drug at standard doses.
This elevated level increases the risk of dose-dependent adverse effects. For
risperidone, this includes a higher risk of extrapyramidal symptoms (EPS) due to potent
D2 antagonism in the nigrostriatal pathway and hyperprolactinemia due to D2
antagonism in the tuberoinfundibular pathway .
Question 2: Which neurotransmitter system is primarily synthesized in the
basal nucleus of Meynert and is crucial for learning, short-term memory, and
arousal?
A. Dopamine
B. Serotonin
C. Acetylcholine
D. Norepinephrine
CORRECT ANSWER: C. Acetylcholine
Rationale: The basal nucleus of Meynert is a major source of cholinergic projections to
the cerebral cortex and hippocampus. Acetylcholine plays a critical role in cognitive
functions such as learning, short-term memory, and arousal. Degeneration of these
cholinergic neurons is a hallmark of Alzheimer's disease, which is why cholinesterase
inhibitors like donepezil are used to increase acetylcholine levels .
Question 3: A patient on lithium carbonate presents with a coarse tremor,
ataxia, confusion, and persistent vomiting. Serum lithium level is 2.0 mEq/L.
What is the most appropriate initial intervention?
A. Continue lithium at a reduced dose and add a tremor-suppressing medication.
B. Hold the lithium and provide supportive care with IV hydration.
,C. Immediately administer a dose of haloperidol to control agitation.
D. Switch the patient from lithium to valproic acid.
CORRECT ANSWER: B. Hold the lithium and provide supportive care with IV
hydration.
Rationale: A serum lithium level of 2.0 mEq/L is indicative of lithium toxicity, as the
therapeutic range is typically 0.6-1.2 mEq/L. Symptoms of toxicity include coarse
tremor, ataxia, confusion, and gastrointestinal distress. The initial management involves
discontinuing the lithium and providing supportive care, including IV hydration to
enhance renal clearance. Severe cases may require hemodialysis .
Question 4: The PMHNP is prescribing a medication for a patient with
treatment-resistant depression. Which medication, administered intranasally
in a certified healthcare setting, works via NMDA receptor antagonism?
A. Bupropion
B. Mirtazapine
C. Esketamine
D. Trazodone
CORRECT ANSWER: C. Esketamine
Rationale: Esketamine (Spravato) is an NMDA receptor antagonist that is FDA-
approved for treatment-resistant depression. Its mechanism involves blocking the
NMDA receptor, leading to a cascade of events that promote synaptogenesis and
neuroplasticity, producing a rapid antidepressant effect. Due to the risk of significant
sedation and dissociation, it must be administered in a certified healthcare setting where
the patient can be monitored for at least two hours following administration .
Question 5: A patient on risperidone develops gynecomastia and galactorrhea.
This adverse effect is attributed to antagonism of dopamine D2 receptors in
which specific pathway?
A. Mesolimbic pathway
B. Mesocortical pathway
C. Nigrostriatal pathway
D. Tuberoinfundibular pathway
CORRECT ANSWER: D. Tuberoinfundibular pathway
Rationale: The tuberoinfundibular pathway, which connects the hypothalamus to the
pituitary gland, regulates prolactin release. Dopamine D2 receptors in this pathway
normally inhibit prolactin secretion. When a medication like risperidone with high D2
affinity antagonizes these receptors, it disinhibits prolactin release, leading to
hyperprolactinemia. This can manifest as gynecomastia (breast enlargement in males),
galactorrhea (lactation), and sexual dysfunction .
Question 6: Which of the following antipsychotics requires enrollment in a
REMS (Risk Evaluation and Mitigation Strategy) program with mandatory
,baseline and ongoing Complete Blood Count (CBC) monitoring due to the risk
of agranulocytosis?
A. Haloperidol
B. Olanzapine
C. Clozapine
D. Aripiprazole
CORRECT ANSWER: C. Clozapine
Rationale: Clozapine is a unique atypical antipsychotic effective in treatment-resistant
schizophrenia but carries a 1-2% risk of agranulocytosis, a potentially fatal condition.
The Clozapine REMS Program mandates strict monitoring of absolute neutrophil counts
(ANC) to mitigate this risk. Baseline CBC is required, and ongoing monitoring is
necessary; dispensing is linked to lab results .
Question 7: A patient is initiating an SSRI for depression. The PMHNP
counsels the patient that initial side effects like GI upset will often subside, but
which side effect is a common reason for long-term non-adherence?
A. Weight loss
B. Sexual dysfunction
C. Sedation
D. Diarrhea
CORRECT ANSWER: B. Sexual dysfunction
Rationale: Sexual dysfunction—including decreased libido, anorgasmia, and erectile
dysfunction—is a common and persistent side effect of SSRIs. While other initial side
effects like nausea and gastrointestinal upset often improve after the first few weeks,
sexual dysfunction frequently persists and is a primary reason patients discontinue their
antidepressant medication .
Question 8: A patient on a monoamine oxidase inhibitor (MAOI) presents with
a sudden, severe headache, palpitations, and hypertension. Which dietary
intake is the most likely cause of this hypertensive crisis?
A. Chocolate
B. Leafy green vegetables
C. Aged cheese and cured meats
D. Caffeine
CORRECT ANSWER: C. Aged cheese and cured meats
Rationale: MAOIs (monoamine oxidase inhibitors) block the enzyme that breaks down
tyramine, a compound found in high concentrations in aged, fermented, or cured foods
(e.g., aged cheeses, cured meats, fermented soy products). When a patient on an MAOI
consumes these tyramine-rich foods, a rapid and dangerous increase in blood pressure
(hypertensive crisis) can occur. Patients must be counseled on this dietary restriction .
, Question 9: The PMHNP is managing a patient on valproic acid for bipolar
disorder. In addition to monitoring serum drug levels, which labs are essential
for monitoring due to the risk of serious adverse effects?
A. Serum creatinine and BUN
B. Hepatic function panels and serum amylase/lipase
C. Fasting blood glucose and lipid panel
D. Serum calcium and magnesium
CORRECT ANSWER: B. Hepatic function panels and serum amylase/lipase
Rationale: Valproic acid (valproate) requires careful monitoring due to risks of
hepatotoxicity and pancreatitis. Hepatic function panels (AST, ALT, bilirubin) should be
monitored regularly. Additionally, serum amylase and lipase should be checked to
monitor for pancreatitis, another potentially serious adverse effect associated with
valproic acid use .
Question 10: A patient with major depressive disorder and comorbid nicotine
dependence is seeking an antidepressant. Which medication is most
appropriate, as it is weight-neutral, does not cause sexual side effects, and can
also aid in smoking cessation?
A. Mirtazapine
B. Bupropion
C. Paroxetine
D. Escitalopram
CORRECT ANSWER: B. Bupropion
Rationale: Bupropion (Wellbutrin) is a norepinephrine-dopamine reuptake inhibitor
(NDRI). It is an excellent choice for this patient due to its favorable side effect profile: it
is weight-neutral, does not cause the sexual dysfunction commonly associated with
SSRIs/SNRIs, and is FDA-approved for smoking cessation (Zyban) .
Question 11: Which of the following best describes the primary function of a
second messenger system in a neuron?
A. Directly opening an ion channel to allow neurotransmitter influx.
B. Transporting neurotransmitters back into the presynaptic terminal.
C. Amplifying the intracellular signal initiated by a neurotransmitter binding to its
receptor.
D. Degrading monoamine neurotransmitters in the synaptic cleft.
CORRECT ANSWER: C. Amplifying the intracellular signal initiated by a
neurotransmitter binding to its receptor.
Rationale: When a neurotransmitter (first messenger) binds to a G-protein coupled
receptor, it can activate a signaling cascade inside the cell. Second messengers (e.g.,
cyclic AMP, inositol triphosphate) are molecules that amplify this signal, leading to a
Mental Health Nurse Practitioner – Chamberlain
College of Nursing – Midterm Exam3 2026/2027
Question 1: A patient with a known genetic variation resulting in a "poor
metabolizer" phenotype for CYP2D6 is prescribed risperidone. What is the
most significant clinical implication of this genetic status?
A. The medication will be eliminated from the body more rapidly, requiring higher
doses.
B. The patient will have a higher risk of experiencing extrapyramidal symptoms and
hyperprolactinemia.
C. The medication will be completely inactive and provide no therapeutic benefit.
D. The patient will have an increased risk of agranulocytosis and requires CBC
monitoring.
CORRECT ANSWER: B. The patient will have a higher risk of experiencing
extrapyramidal symptoms and hyperprolactinemia.
Rationale: CYP2D6 is a key enzyme in the metabolism of many antipsychotics,
including risperidone. A poor metabolizer phenotype results in reduced enzyme activity,
leading to higher-than-expected serum concentrations of the drug at standard doses.
This elevated level increases the risk of dose-dependent adverse effects. For
risperidone, this includes a higher risk of extrapyramidal symptoms (EPS) due to potent
D2 antagonism in the nigrostriatal pathway and hyperprolactinemia due to D2
antagonism in the tuberoinfundibular pathway .
Question 2: Which neurotransmitter system is primarily synthesized in the
basal nucleus of Meynert and is crucial for learning, short-term memory, and
arousal?
A. Dopamine
B. Serotonin
C. Acetylcholine
D. Norepinephrine
CORRECT ANSWER: C. Acetylcholine
Rationale: The basal nucleus of Meynert is a major source of cholinergic projections to
the cerebral cortex and hippocampus. Acetylcholine plays a critical role in cognitive
functions such as learning, short-term memory, and arousal. Degeneration of these
cholinergic neurons is a hallmark of Alzheimer's disease, which is why cholinesterase
inhibitors like donepezil are used to increase acetylcholine levels .
Question 3: A patient on lithium carbonate presents with a coarse tremor,
ataxia, confusion, and persistent vomiting. Serum lithium level is 2.0 mEq/L.
What is the most appropriate initial intervention?
A. Continue lithium at a reduced dose and add a tremor-suppressing medication.
B. Hold the lithium and provide supportive care with IV hydration.
,C. Immediately administer a dose of haloperidol to control agitation.
D. Switch the patient from lithium to valproic acid.
CORRECT ANSWER: B. Hold the lithium and provide supportive care with IV
hydration.
Rationale: A serum lithium level of 2.0 mEq/L is indicative of lithium toxicity, as the
therapeutic range is typically 0.6-1.2 mEq/L. Symptoms of toxicity include coarse
tremor, ataxia, confusion, and gastrointestinal distress. The initial management involves
discontinuing the lithium and providing supportive care, including IV hydration to
enhance renal clearance. Severe cases may require hemodialysis .
Question 4: The PMHNP is prescribing a medication for a patient with
treatment-resistant depression. Which medication, administered intranasally
in a certified healthcare setting, works via NMDA receptor antagonism?
A. Bupropion
B. Mirtazapine
C. Esketamine
D. Trazodone
CORRECT ANSWER: C. Esketamine
Rationale: Esketamine (Spravato) is an NMDA receptor antagonist that is FDA-
approved for treatment-resistant depression. Its mechanism involves blocking the
NMDA receptor, leading to a cascade of events that promote synaptogenesis and
neuroplasticity, producing a rapid antidepressant effect. Due to the risk of significant
sedation and dissociation, it must be administered in a certified healthcare setting where
the patient can be monitored for at least two hours following administration .
Question 5: A patient on risperidone develops gynecomastia and galactorrhea.
This adverse effect is attributed to antagonism of dopamine D2 receptors in
which specific pathway?
A. Mesolimbic pathway
B. Mesocortical pathway
C. Nigrostriatal pathway
D. Tuberoinfundibular pathway
CORRECT ANSWER: D. Tuberoinfundibular pathway
Rationale: The tuberoinfundibular pathway, which connects the hypothalamus to the
pituitary gland, regulates prolactin release. Dopamine D2 receptors in this pathway
normally inhibit prolactin secretion. When a medication like risperidone with high D2
affinity antagonizes these receptors, it disinhibits prolactin release, leading to
hyperprolactinemia. This can manifest as gynecomastia (breast enlargement in males),
galactorrhea (lactation), and sexual dysfunction .
Question 6: Which of the following antipsychotics requires enrollment in a
REMS (Risk Evaluation and Mitigation Strategy) program with mandatory
,baseline and ongoing Complete Blood Count (CBC) monitoring due to the risk
of agranulocytosis?
A. Haloperidol
B. Olanzapine
C. Clozapine
D. Aripiprazole
CORRECT ANSWER: C. Clozapine
Rationale: Clozapine is a unique atypical antipsychotic effective in treatment-resistant
schizophrenia but carries a 1-2% risk of agranulocytosis, a potentially fatal condition.
The Clozapine REMS Program mandates strict monitoring of absolute neutrophil counts
(ANC) to mitigate this risk. Baseline CBC is required, and ongoing monitoring is
necessary; dispensing is linked to lab results .
Question 7: A patient is initiating an SSRI for depression. The PMHNP
counsels the patient that initial side effects like GI upset will often subside, but
which side effect is a common reason for long-term non-adherence?
A. Weight loss
B. Sexual dysfunction
C. Sedation
D. Diarrhea
CORRECT ANSWER: B. Sexual dysfunction
Rationale: Sexual dysfunction—including decreased libido, anorgasmia, and erectile
dysfunction—is a common and persistent side effect of SSRIs. While other initial side
effects like nausea and gastrointestinal upset often improve after the first few weeks,
sexual dysfunction frequently persists and is a primary reason patients discontinue their
antidepressant medication .
Question 8: A patient on a monoamine oxidase inhibitor (MAOI) presents with
a sudden, severe headache, palpitations, and hypertension. Which dietary
intake is the most likely cause of this hypertensive crisis?
A. Chocolate
B. Leafy green vegetables
C. Aged cheese and cured meats
D. Caffeine
CORRECT ANSWER: C. Aged cheese and cured meats
Rationale: MAOIs (monoamine oxidase inhibitors) block the enzyme that breaks down
tyramine, a compound found in high concentrations in aged, fermented, or cured foods
(e.g., aged cheeses, cured meats, fermented soy products). When a patient on an MAOI
consumes these tyramine-rich foods, a rapid and dangerous increase in blood pressure
(hypertensive crisis) can occur. Patients must be counseled on this dietary restriction .
, Question 9: The PMHNP is managing a patient on valproic acid for bipolar
disorder. In addition to monitoring serum drug levels, which labs are essential
for monitoring due to the risk of serious adverse effects?
A. Serum creatinine and BUN
B. Hepatic function panels and serum amylase/lipase
C. Fasting blood glucose and lipid panel
D. Serum calcium and magnesium
CORRECT ANSWER: B. Hepatic function panels and serum amylase/lipase
Rationale: Valproic acid (valproate) requires careful monitoring due to risks of
hepatotoxicity and pancreatitis. Hepatic function panels (AST, ALT, bilirubin) should be
monitored regularly. Additionally, serum amylase and lipase should be checked to
monitor for pancreatitis, another potentially serious adverse effect associated with
valproic acid use .
Question 10: A patient with major depressive disorder and comorbid nicotine
dependence is seeking an antidepressant. Which medication is most
appropriate, as it is weight-neutral, does not cause sexual side effects, and can
also aid in smoking cessation?
A. Mirtazapine
B. Bupropion
C. Paroxetine
D. Escitalopram
CORRECT ANSWER: B. Bupropion
Rationale: Bupropion (Wellbutrin) is a norepinephrine-dopamine reuptake inhibitor
(NDRI). It is an excellent choice for this patient due to its favorable side effect profile: it
is weight-neutral, does not cause the sexual dysfunction commonly associated with
SSRIs/SNRIs, and is FDA-approved for smoking cessation (Zyban) .
Question 11: Which of the following best describes the primary function of a
second messenger system in a neuron?
A. Directly opening an ion channel to allow neurotransmitter influx.
B. Transporting neurotransmitters back into the presynaptic terminal.
C. Amplifying the intracellular signal initiated by a neurotransmitter binding to its
receptor.
D. Degrading monoamine neurotransmitters in the synaptic cleft.
CORRECT ANSWER: C. Amplifying the intracellular signal initiated by a
neurotransmitter binding to its receptor.
Rationale: When a neurotransmitter (first messenger) binds to a G-protein coupled
receptor, it can activate a signaling cascade inside the cell. Second messengers (e.g.,
cyclic AMP, inositol triphosphate) are molecules that amplify this signal, leading to a
