CHAMBERLAIN UNIVERSITY
A+ VERIFIED
WEEK 4 MIDTERM EXAM
NR546 Week 4 Midterm
Advanced Pharmacology — Psychopharmacology for the PMHNP
ACADEMIC YEAR
75 150 4
MULTIPLE-CHOICE ITEMS MINUTES OPTIONS PER ITEM
WHAT THIS COVERS
ANTIDEPRESSANTS & MOOD ANTIPSYCHOTICS
SSRIs, SNRIs, TCAs, MAOIs, atypicals; onset, side effects, dietary Typical vs. atypical agents, metabolic monitoring, EPS, NMS, tardive
restrictions. dyskinesia.
ANXIOLYTICS & SEDATIVES SPECIAL POPULATIONS
Benzodiazepines, buspirone, non-benzodiazepine hypnotics; tapering Pregnancy/lactation, pediatrics, older adults, hepatic and renal dose
and dependence. adjustments.
ABOUT THIS ASSESSMENT
This original study assessment was newly written for the review cycle. It evaluates advanced psychopharmacology
knowledge expected of the PMHNP candidate, including mechanism, indications, monitoring, interactions, and patient education for the
major psychotropic drug classes. Each item includes four single-best-answer options and a rationale that explains the correct choice and
why the distractors are incorrect. Use it as a self-evaluation tool.
FORM: A | VERSION: V1 | ITEMS: 75 | TIME: 150 MIN | LEVEL: GRADUATE / PMHNP
STUVIA ACTUAL EXAM
,NR546 WEEK 4 MIDTERM | ADVANCED PHARMACOLOGY — PSYCHOPHARMACOLOGY FOR THE PMHNP
ACADEMIC YEAR
EXAM QUESTIONS — MULTIPLE CHOICE
1. Maria is a 34-year-old woman who has taken fluoxetine 20 mg daily for six months for major depressive disorder.
Her symptoms have remitted, and she now wants to switch to phenelzine for residual atypical features. What is the
minimum washout period before phenelzine may be started?
A. 10 days
B. 2 weeks
C. 1 week
D. At least 5 weeks
Correct Answer: D
Rationale: Fluoxetine has an active metabolite, norfluoxetine, with a long half-life of 1 to 4 days. A minimum 5-week washout is required before
initiating an MAOI to prevent serotonin syndrome. Shorter intervals are unsafe and not supported by labeling.
2. Robert is 41 years old and has taken paroxetine 30 mg daily for one year. He stops abruptly due to cost, and three
days later reports dizziness, nausea, electric shock sensations in the head, and vivid dreams. Which pharmacologic
property of paroxetine best explains these symptoms?
A. Muscarinic receptor antagonism
B. Strong dopamine D2 affinity
C. Long half-life with active metabolite
D. Short half-life with no active metabolite
Correct Answer: D
Rationale: Paroxetine has a short elimination half-life and no active metabolite, so abrupt discontinuation produces a classic antidepressant
discontinuation syndrome. Electric shock sensations, dizziness, nausea, and vivid dreams are characteristic. Agents with longer half-lives such as
fluoxetine are much less prone to this syndrome.
3. David is 58 years old with coronary artery disease and a recent myocardial infarction, now presenting with major
depressive disorder. The team prefers an SSRI with the strongest cardiovascular safety data in this population. Which
SSRI is most appropriate to initiate?
A. Fluoxetine
B. Paroxetine
C. Citalopram
D. Sertraline
Correct Answer: D
Rationale: Sertraline has the strongest evidence base for safe use in patients with recent MI or established coronary disease, with minimal QTc
effect at therapeutic doses. Citalopram carries a QTc warning, paroxetine is less studied here, and fluoxetine has more CYP interactions.
Sertraline is the most data-supported SSRI in this scenario.
STUVIA ACTUAL EXAM Page 2
, NR546 WEEK 4 MIDTERM | ADVANCED PHARMACOLOGY — PSYCHOPHARMACOLOGY FOR THE PMHNP
ACADEMIC YEAR
4. Eleanor is 79 years old and is started on citalopram 40 mg daily for depression. She also takes amiodarone 200 mg
daily for atrial fibrillation, and her baseline QTc is 470 ms. What adjustment is most appropriate?
A. Increase to 60 mg daily for full response
B. Reduce citalopram to a maximum of 20 mg daily with ECG monitoring
C. Continue 40 mg daily as prescribed
D. Switch to escitalopram 30 mg daily
Correct Answer: B
Rationale: Citalopram prolongs the QTc interval in a dose-dependent manner, and FDA labeling limits the dose to 20 mg daily in patients older
than 60, with hepatic impairment, or who take other QT-prolonging drugs. Amiodarone adds additional QTc risk, so dose reduction with ECG
monitoring is appropriate. Escitalopram at 30 mg daily exceeds its 20 mg geriatric ceiling and does not eliminate the risk.
5. James is 45 years old and takes clozapine 300 mg daily for treatment-resistant schizophrenia. He develops intrusive
obsessive thoughts, and the team considers adding fluvoxamine. What is the most important pharmacokinetic concern
with this combination?
A. The combination independently lowers the seizure threshold through a non-kinetic mechanism
B. Fluvoxamine lowers clozapine levels via CYP induction
C. Fluvoxamine antagonizes clozapine at D2 receptors
D. Fluvoxamine markedly raises clozapine plasma levels via CYP1A2 inhibition
Correct Answer: D
Rationale: Fluvoxamine is a potent inhibitor of CYP1A2, the main enzyme metabolizing clozapine. Combining them can cause dangerous
clozapine accumulation and toxicity, often requiring a clozapine dose reduction of about one-third. This is a kinetic interaction rather than a direct
receptor or seizure-threshold mechanism.
6. Helen is 72 years old and began sertraline 6 weeks ago for depression. Today her daughter reports new confusion,
headache, and a near-fall; her serum sodium is 124 mEq/L. Which SSRI-associated adverse effect is most likely?
A. Hepatic enzyme induction
B. Syndrome of inappropriate antidiuretic hormone causing hyponatremia
C. Serotonin syndrome
D. Discontinuation syndrome
Correct Answer: B
Rationale: SSRIs can precipitate SIADH and hyponatremia, especially in older women within the first month of therapy. Confusion, headache,
and falls are typical presenting features once sodium falls below 125 mEq/L. Serotonin syndrome would include hyperthermia, clonus, and
autonomic instability rather than isolated hyponatremia.
7. Daniel is 47 years old with generalized anxiety disorder and is titrated to venlafaxine XR 225 mg daily. His baseline
blood pressure was 122/76 mmHg; today it is 144/92 mmHg. What is the most appropriate next step?
A. Add a beta-blocker and continue the same dose
B. Reduce the venlafaxine dose and monitor blood pressure, with consideration of an alternative agent if hypertension persists
C. Discontinue immediately and start fluoxetine
D. Increase to 300 mg daily and recheck in 2 weeks
Correct Answer: B
Rationale: Venlafaxine produces a dose-dependent rise in blood pressure through norepinephrine reuptake inhibition, particularly at higher doses.
The appropriate response is dose reduction or switching agents rather than masking the side effect with antihypertensives. Abrupt discontinuation
can precipitate withdrawal symptoms.
STUVIA ACTUAL EXAM Page 3
A+ VERIFIED
WEEK 4 MIDTERM EXAM
NR546 Week 4 Midterm
Advanced Pharmacology — Psychopharmacology for the PMHNP
ACADEMIC YEAR
75 150 4
MULTIPLE-CHOICE ITEMS MINUTES OPTIONS PER ITEM
WHAT THIS COVERS
ANTIDEPRESSANTS & MOOD ANTIPSYCHOTICS
SSRIs, SNRIs, TCAs, MAOIs, atypicals; onset, side effects, dietary Typical vs. atypical agents, metabolic monitoring, EPS, NMS, tardive
restrictions. dyskinesia.
ANXIOLYTICS & SEDATIVES SPECIAL POPULATIONS
Benzodiazepines, buspirone, non-benzodiazepine hypnotics; tapering Pregnancy/lactation, pediatrics, older adults, hepatic and renal dose
and dependence. adjustments.
ABOUT THIS ASSESSMENT
This original study assessment was newly written for the review cycle. It evaluates advanced psychopharmacology
knowledge expected of the PMHNP candidate, including mechanism, indications, monitoring, interactions, and patient education for the
major psychotropic drug classes. Each item includes four single-best-answer options and a rationale that explains the correct choice and
why the distractors are incorrect. Use it as a self-evaluation tool.
FORM: A | VERSION: V1 | ITEMS: 75 | TIME: 150 MIN | LEVEL: GRADUATE / PMHNP
STUVIA ACTUAL EXAM
,NR546 WEEK 4 MIDTERM | ADVANCED PHARMACOLOGY — PSYCHOPHARMACOLOGY FOR THE PMHNP
ACADEMIC YEAR
EXAM QUESTIONS — MULTIPLE CHOICE
1. Maria is a 34-year-old woman who has taken fluoxetine 20 mg daily for six months for major depressive disorder.
Her symptoms have remitted, and she now wants to switch to phenelzine for residual atypical features. What is the
minimum washout period before phenelzine may be started?
A. 10 days
B. 2 weeks
C. 1 week
D. At least 5 weeks
Correct Answer: D
Rationale: Fluoxetine has an active metabolite, norfluoxetine, with a long half-life of 1 to 4 days. A minimum 5-week washout is required before
initiating an MAOI to prevent serotonin syndrome. Shorter intervals are unsafe and not supported by labeling.
2. Robert is 41 years old and has taken paroxetine 30 mg daily for one year. He stops abruptly due to cost, and three
days later reports dizziness, nausea, electric shock sensations in the head, and vivid dreams. Which pharmacologic
property of paroxetine best explains these symptoms?
A. Muscarinic receptor antagonism
B. Strong dopamine D2 affinity
C. Long half-life with active metabolite
D. Short half-life with no active metabolite
Correct Answer: D
Rationale: Paroxetine has a short elimination half-life and no active metabolite, so abrupt discontinuation produces a classic antidepressant
discontinuation syndrome. Electric shock sensations, dizziness, nausea, and vivid dreams are characteristic. Agents with longer half-lives such as
fluoxetine are much less prone to this syndrome.
3. David is 58 years old with coronary artery disease and a recent myocardial infarction, now presenting with major
depressive disorder. The team prefers an SSRI with the strongest cardiovascular safety data in this population. Which
SSRI is most appropriate to initiate?
A. Fluoxetine
B. Paroxetine
C. Citalopram
D. Sertraline
Correct Answer: D
Rationale: Sertraline has the strongest evidence base for safe use in patients with recent MI or established coronary disease, with minimal QTc
effect at therapeutic doses. Citalopram carries a QTc warning, paroxetine is less studied here, and fluoxetine has more CYP interactions.
Sertraline is the most data-supported SSRI in this scenario.
STUVIA ACTUAL EXAM Page 2
, NR546 WEEK 4 MIDTERM | ADVANCED PHARMACOLOGY — PSYCHOPHARMACOLOGY FOR THE PMHNP
ACADEMIC YEAR
4. Eleanor is 79 years old and is started on citalopram 40 mg daily for depression. She also takes amiodarone 200 mg
daily for atrial fibrillation, and her baseline QTc is 470 ms. What adjustment is most appropriate?
A. Increase to 60 mg daily for full response
B. Reduce citalopram to a maximum of 20 mg daily with ECG monitoring
C. Continue 40 mg daily as prescribed
D. Switch to escitalopram 30 mg daily
Correct Answer: B
Rationale: Citalopram prolongs the QTc interval in a dose-dependent manner, and FDA labeling limits the dose to 20 mg daily in patients older
than 60, with hepatic impairment, or who take other QT-prolonging drugs. Amiodarone adds additional QTc risk, so dose reduction with ECG
monitoring is appropriate. Escitalopram at 30 mg daily exceeds its 20 mg geriatric ceiling and does not eliminate the risk.
5. James is 45 years old and takes clozapine 300 mg daily for treatment-resistant schizophrenia. He develops intrusive
obsessive thoughts, and the team considers adding fluvoxamine. What is the most important pharmacokinetic concern
with this combination?
A. The combination independently lowers the seizure threshold through a non-kinetic mechanism
B. Fluvoxamine lowers clozapine levels via CYP induction
C. Fluvoxamine antagonizes clozapine at D2 receptors
D. Fluvoxamine markedly raises clozapine plasma levels via CYP1A2 inhibition
Correct Answer: D
Rationale: Fluvoxamine is a potent inhibitor of CYP1A2, the main enzyme metabolizing clozapine. Combining them can cause dangerous
clozapine accumulation and toxicity, often requiring a clozapine dose reduction of about one-third. This is a kinetic interaction rather than a direct
receptor or seizure-threshold mechanism.
6. Helen is 72 years old and began sertraline 6 weeks ago for depression. Today her daughter reports new confusion,
headache, and a near-fall; her serum sodium is 124 mEq/L. Which SSRI-associated adverse effect is most likely?
A. Hepatic enzyme induction
B. Syndrome of inappropriate antidiuretic hormone causing hyponatremia
C. Serotonin syndrome
D. Discontinuation syndrome
Correct Answer: B
Rationale: SSRIs can precipitate SIADH and hyponatremia, especially in older women within the first month of therapy. Confusion, headache,
and falls are typical presenting features once sodium falls below 125 mEq/L. Serotonin syndrome would include hyperthermia, clonus, and
autonomic instability rather than isolated hyponatremia.
7. Daniel is 47 years old with generalized anxiety disorder and is titrated to venlafaxine XR 225 mg daily. His baseline
blood pressure was 122/76 mmHg; today it is 144/92 mmHg. What is the most appropriate next step?
A. Add a beta-blocker and continue the same dose
B. Reduce the venlafaxine dose and monitor blood pressure, with consideration of an alternative agent if hypertension persists
C. Discontinue immediately and start fluoxetine
D. Increase to 300 mg daily and recheck in 2 weeks
Correct Answer: B
Rationale: Venlafaxine produces a dose-dependent rise in blood pressure through norepinephrine reuptake inhibition, particularly at higher doses.
The appropriate response is dose reduction or switching agents rather than masking the side effect with antihypertensives. Abrupt discontinuation
can precipitate withdrawal symptoms.
STUVIA ACTUAL EXAM Page 3
