NR 546 / NR546 Psychopharmacology
Midterm Exam Questions and Answers
(2026/2027) (Verified Answers)
NR546 Psychopharmacology Midterm Examination
Advanced Pharmacology: Psychopharmacology for the Psychiatric-Mental Health Nurse
Practitioner
Q1. A psychiatric nurse practitioner is reviewing the mechanism of action of selective serotonin
reuptake inhibitors (SSRIs) with a student. Which statement accurately describes the downstream
cellular adaptation responsible for the therapeutic effect of SSRIs?
A. Direct activation of postsynaptic 5-HT2A receptors in the prefrontal cortex
B. Desensitization of presynaptic 5-HT1A autoreceptors, leading to enhanced serotonergic
neurotransmission
C. Irreversible inhibition of monoamine oxidase type A in the presynaptic terminal
D. Blockade of serotonin reuptake at the postsynaptic membrane
Correct Answer: B
Rationale: SSRIs block the serotonin transporter (SERT), increasing synaptic serotonin. However, the
therapeutic effect is delayed because presynaptic 5-HT1A autoreceptors initially limit serotonin
release. With chronic treatment (2-4 weeks), these autoreceptors desensitize, allowing full
enhancement of serotonergic neurotransmission .
Q2. A 34-year-old female with major depressive disorder is started on fluoxetine 20 mg daily. Three
weeks later, she reports new-onset anxiety, diaphoresis, tremor, and confusion after taking over-
the-counter dextromethorphan for a cough. Which adverse event should the PMHNP suspect first?
A. Tyramine-induced hypertensive crisis
B. Neuroleptic malignant syndrome
C. Serotonin syndrome
D. Anticholinergic toxicity
Correct Answer: C
Rationale: Fluoxetine is an SSRI, and dextromethorphan is a serotonergic agent. Combined, they can
precipitate serotonin syndrome, characterized by neuromuscular hyperactivity, autonomic
instability, and altered mental status. NMS requires antipsychotic exposure, anticholinergic toxicity
presents with dry skin and urinary retention, and tyramine crisis is associated with MAOIs .
pg. 1
,Q3. A patient on a monoamine oxidase inhibitor (phenelzine) presents to the clinic with a throbbing
headache, blood pressure 184/112, and diaphoresis 30 minutes after a restaurant meal. Which
dietary substance most likely triggered this event?
A. Aged cheddar cheese and cured meats
B. Whole-grain bread
C. Leafy green vegetables
D. Pasteurized cottage cheese
Correct Answer: A
Rationale: Aged cheeses and cured meats are rich in tyramine, which displaces norepinephrine from
adrenergic nerve terminals when MAO is inhibited, producing a hypertensive crisis. Fresh cheeses
like cottage cheese are generally safe, and bread and vegetables do not contain significant tyramine
.
Q4. A 28-year-old male with schizophrenia has been on haloperidol for 6 months. He presents with
mask-like facies, cogwheel rigidity, and a shuffling gait. Which intervention is most appropriate as a
first-line response?
A. Discontinue haloperidol immediately
B. Increase the haloperidol dose
C. Initiate a beta-blocker
D. Add an anticholinergic such as benztropine
Correct Answer: D
Rationale: The presentation is parkinsonism, an extrapyramidal symptom caused by D2 blockade in
the nigrostriatal pathway. Adding an anticholinergic like benztropine or diphenhydramine is first-
line. Abrupt discontinuation risks relapse, and increasing the dose worsens symptoms .
Q5. A patient with bipolar I disorder on lithium carbonate 900 mg daily is euthymic with a serum
level of 1.1 mEq/L. Which concurrent medication is most likely to precipitate lithium toxicity by
reducing renal clearance?
A. Hydrochlorothiazide
B. Amlodipine
C. Sertraline
D. Propranolol
Correct Answer: A
Rationale: Thiazide diuretics cause sodium depletion and increased proximal tubular lithium
reabsorption, raising serum lithium and risking toxicity. Amlodipine, sertraline, and propranolol do
not significantly alter lithium clearance .
Q6. Which statement best reflects the mechanistic rationale for using aripiprazole as an adjunct in
treatment-resistant major depressive disorder?
pg. 2
, A. It primarily blocks serotonin 5-HT2A receptors with minimal dopaminergic activity
B. It acts as a partial D2 agonist and 5-HT1A agonist, modulating mesolimbic and mesocortical
dopamine
C. It is a potent norepinephrine reuptake inhibitor enhancing prefrontal catecholamines
D. It irreversibly inhibits monoamine oxidase, increasing synaptic monoamines
Correct Answer: B
Rationale: Aripiprazole's partial D2 agonism and 5-HT1A agonism stabilize dopamine transmission
and are thought to contribute to antidepressant augmentation. It is not a potent SNRI or MAOI, and
its 5-HT2A blockade is only one aspect of its mechanism .
Q7. A patient with schizophrenia on clozapine presents with fever, tachycardia, and a clozapine level
of 1200 ng/mL. Which intervention is most appropriate?
A. Continue clozapine and add benztropine for possible dystonia
B. Hold clozapine, obtain CBC and troponin, and provide supportive care
C. Reduce clozapine dose by 50% and start haloperidol
D. Switch to olanzapine immediately without laboratory monitoring
Correct Answer: B
Rationale: Clozapine levels >1000 ng/mL increase risk of toxicity, including myocarditis and
neuroleptic malignant syndrome. Holding the drug and evaluating with CBC, troponin, and
supportive care is indicated. Continuing or rapidly switching without workup is unsafe .
Q8. Which pharmacokinetic property most distinguishes long-acting injectable paliperidone
palmitate from oral paliperidone?
A. It bypasses hepatic first-pass metabolism, increasing bioavailability
B. It has a longer elimination half-life due to slow dissolution from the injection site
C. It is renally excreted unchanged more rapidly than oral paliperidone
D. It is a prodrug requiring hepatic activation
Correct Answer: B
Rationale: Paliperidone palmitate's extended half-life results from slow hydrolysis and absorption
from the intramuscular depot. Oral paliperidone already has minimal first-pass metabolism, and the
injectable is not a prodrug .
Q9. A patient with generalized anxiety disorder and opioid use disorder on buprenorphine/naloxone
requires an anxiolytic. Which agent is most appropriate?
A. Diazepam
B. Alprazolam
C. Buspirone
D. Lorazepam
Correct Answer: C
pg. 3
Midterm Exam Questions and Answers
(2026/2027) (Verified Answers)
NR546 Psychopharmacology Midterm Examination
Advanced Pharmacology: Psychopharmacology for the Psychiatric-Mental Health Nurse
Practitioner
Q1. A psychiatric nurse practitioner is reviewing the mechanism of action of selective serotonin
reuptake inhibitors (SSRIs) with a student. Which statement accurately describes the downstream
cellular adaptation responsible for the therapeutic effect of SSRIs?
A. Direct activation of postsynaptic 5-HT2A receptors in the prefrontal cortex
B. Desensitization of presynaptic 5-HT1A autoreceptors, leading to enhanced serotonergic
neurotransmission
C. Irreversible inhibition of monoamine oxidase type A in the presynaptic terminal
D. Blockade of serotonin reuptake at the postsynaptic membrane
Correct Answer: B
Rationale: SSRIs block the serotonin transporter (SERT), increasing synaptic serotonin. However, the
therapeutic effect is delayed because presynaptic 5-HT1A autoreceptors initially limit serotonin
release. With chronic treatment (2-4 weeks), these autoreceptors desensitize, allowing full
enhancement of serotonergic neurotransmission .
Q2. A 34-year-old female with major depressive disorder is started on fluoxetine 20 mg daily. Three
weeks later, she reports new-onset anxiety, diaphoresis, tremor, and confusion after taking over-
the-counter dextromethorphan for a cough. Which adverse event should the PMHNP suspect first?
A. Tyramine-induced hypertensive crisis
B. Neuroleptic malignant syndrome
C. Serotonin syndrome
D. Anticholinergic toxicity
Correct Answer: C
Rationale: Fluoxetine is an SSRI, and dextromethorphan is a serotonergic agent. Combined, they can
precipitate serotonin syndrome, characterized by neuromuscular hyperactivity, autonomic
instability, and altered mental status. NMS requires antipsychotic exposure, anticholinergic toxicity
presents with dry skin and urinary retention, and tyramine crisis is associated with MAOIs .
pg. 1
,Q3. A patient on a monoamine oxidase inhibitor (phenelzine) presents to the clinic with a throbbing
headache, blood pressure 184/112, and diaphoresis 30 minutes after a restaurant meal. Which
dietary substance most likely triggered this event?
A. Aged cheddar cheese and cured meats
B. Whole-grain bread
C. Leafy green vegetables
D. Pasteurized cottage cheese
Correct Answer: A
Rationale: Aged cheeses and cured meats are rich in tyramine, which displaces norepinephrine from
adrenergic nerve terminals when MAO is inhibited, producing a hypertensive crisis. Fresh cheeses
like cottage cheese are generally safe, and bread and vegetables do not contain significant tyramine
.
Q4. A 28-year-old male with schizophrenia has been on haloperidol for 6 months. He presents with
mask-like facies, cogwheel rigidity, and a shuffling gait. Which intervention is most appropriate as a
first-line response?
A. Discontinue haloperidol immediately
B. Increase the haloperidol dose
C. Initiate a beta-blocker
D. Add an anticholinergic such as benztropine
Correct Answer: D
Rationale: The presentation is parkinsonism, an extrapyramidal symptom caused by D2 blockade in
the nigrostriatal pathway. Adding an anticholinergic like benztropine or diphenhydramine is first-
line. Abrupt discontinuation risks relapse, and increasing the dose worsens symptoms .
Q5. A patient with bipolar I disorder on lithium carbonate 900 mg daily is euthymic with a serum
level of 1.1 mEq/L. Which concurrent medication is most likely to precipitate lithium toxicity by
reducing renal clearance?
A. Hydrochlorothiazide
B. Amlodipine
C. Sertraline
D. Propranolol
Correct Answer: A
Rationale: Thiazide diuretics cause sodium depletion and increased proximal tubular lithium
reabsorption, raising serum lithium and risking toxicity. Amlodipine, sertraline, and propranolol do
not significantly alter lithium clearance .
Q6. Which statement best reflects the mechanistic rationale for using aripiprazole as an adjunct in
treatment-resistant major depressive disorder?
pg. 2
, A. It primarily blocks serotonin 5-HT2A receptors with minimal dopaminergic activity
B. It acts as a partial D2 agonist and 5-HT1A agonist, modulating mesolimbic and mesocortical
dopamine
C. It is a potent norepinephrine reuptake inhibitor enhancing prefrontal catecholamines
D. It irreversibly inhibits monoamine oxidase, increasing synaptic monoamines
Correct Answer: B
Rationale: Aripiprazole's partial D2 agonism and 5-HT1A agonism stabilize dopamine transmission
and are thought to contribute to antidepressant augmentation. It is not a potent SNRI or MAOI, and
its 5-HT2A blockade is only one aspect of its mechanism .
Q7. A patient with schizophrenia on clozapine presents with fever, tachycardia, and a clozapine level
of 1200 ng/mL. Which intervention is most appropriate?
A. Continue clozapine and add benztropine for possible dystonia
B. Hold clozapine, obtain CBC and troponin, and provide supportive care
C. Reduce clozapine dose by 50% and start haloperidol
D. Switch to olanzapine immediately without laboratory monitoring
Correct Answer: B
Rationale: Clozapine levels >1000 ng/mL increase risk of toxicity, including myocarditis and
neuroleptic malignant syndrome. Holding the drug and evaluating with CBC, troponin, and
supportive care is indicated. Continuing or rapidly switching without workup is unsafe .
Q8. Which pharmacokinetic property most distinguishes long-acting injectable paliperidone
palmitate from oral paliperidone?
A. It bypasses hepatic first-pass metabolism, increasing bioavailability
B. It has a longer elimination half-life due to slow dissolution from the injection site
C. It is renally excreted unchanged more rapidly than oral paliperidone
D. It is a prodrug requiring hepatic activation
Correct Answer: B
Rationale: Paliperidone palmitate's extended half-life results from slow hydrolysis and absorption
from the intramuscular depot. Oral paliperidone already has minimal first-pass metabolism, and the
injectable is not a prodrug .
Q9. A patient with generalized anxiety disorder and opioid use disorder on buprenorphine/naloxone
requires an anxiolytic. Which agent is most appropriate?
A. Diazepam
B. Alprazolam
C. Buspirone
D. Lorazepam
Correct Answer: C
pg. 3
