2026 NR 546 / NR546 Midterm Exam (Latest
2026) Tested Questions with Revised Answers,
(A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 28-year-old woman with MDD, PHQ-9 18, no prior meds. CYP2D6 genotype
*1/*4 (intermediate). PMH: migraine with aura. BP 118/76, HR 82. Asks for med least
likely to trigger headache or weight gain.
Question: Which initial antidepressant is best supported?
Options:
A. Paroxetine 20 mg
B. Amitriptyline 50 mg
C. Duloxetine 30 mg
D. Venlafaxine XR 37.5 mg
(Correct: C)
Rationale:
● Answer: C
, ● Why (2026 Standard): SNRI duloxetine (CYP2D6 minor substrate) avoids
serotonergic triptan interaction, weight-neutral vs TCA/paroxetine, and migraine
benefit via descending pain inhibition.
● Errors: A strong CYP2D6 inhibitor, anticholinergic, weight gain; B high headache
risk, weight gain; D discontinuation syndrome, dose-dependent HTN.
Q002:
Type: Expert MCQ
Scenario: 45-year-old man with bipolar I, lithium 900 mg hs, level 0.9 mmol/L. Reports
new tremor, 3 kg weight gain, TSH 4.8 mIU/L (nl 0.4–4.2). Creatinine stable at 1.1.
Question: Best next action?
Options:
A. Reduce lithium to 600 mg
B. Add propranolol 20 mg bid
C. Switch to valproate
D. Start levothyroxine 25 µg
(Correct: B)
Rationale:
● Answer: B
● Why (2026 Standard): Benign essential tremor from lithium; non-selective
β-blocker preferred, no need to lower therapeutic level.
● Errors: A risks subtherapeutic/manic relapse; C unnecessary; D subclinical
hypothyroidism, repeat first.
Q003:
,Type: NGN - Psychopharm
Scenario: 19-year-old college male with ADHD, failing 2 stimulant trials
(methylphenidate 36 mg → irritability; lisdexamfetamine 50 mg → palpitations). HR 96,
BP 124/78. GC-MS CYP2D6 ultrarapid (*1xN/*2).
Question: Best non-stimulant option?
Options:
A. Atomoxetine 40 mg
B. Guanfacine ER 1 mg
C. Bupropion XL 150 mg
D. Clonidine 0.1 mg patch
(Correct: B)
Rationale:
● Answer: B
● Why (2026 Standard): α2A-agonist guanfacine bypasses catecholaminergic surge,
no CYP2D6 involvement, cardiovascular-safe.
● Errors: A CYP2D6 substrate → ultrarapid metabolizers have lower levels yet GI
side effects; C seizure risk college alcohol use; D sedation limits academics.
Q004:
Type: Expert MCQ
Scenario: 66-year-old woman with MDD, HTN, CKD G4 (eGFR 25). On sertraline 100
mg, remains PHQ-9 16. Nephrology cautious about nephrotoxic polypharmacy.
, Question: Evidence-based augmentation?
Options:
A. Bupropion 150 mg
B. Aripiprazole 2 mg
C. Lithium 300 mg
D. Duloxetine 60 mg
(Correct: B)
Rationale:
● Answer: B
● Why (2026 Standard): Aripiprazole renal-neutral, FDA-adjunct MDD, minimal
anticholinergic in elderly.
● Errors: A seizure/stroke elderly; C contraindicated G4; D 50% renally cleared →
toxicity.
Q005:
Type: NGN - Psychopharm
Scenario: 32-year-old woman 24 wks pregnant, stable on quetiapine 200 mg for bipolar
depression. OB consult requests med switch due to newborn EPS meta-analysis. Patient
refuses ECT.
Question: Best alternative?
Options:
A. Olanzapine 5 mg
2026) Tested Questions with Revised Answers,
(A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 28-year-old woman with MDD, PHQ-9 18, no prior meds. CYP2D6 genotype
*1/*4 (intermediate). PMH: migraine with aura. BP 118/76, HR 82. Asks for med least
likely to trigger headache or weight gain.
Question: Which initial antidepressant is best supported?
Options:
A. Paroxetine 20 mg
B. Amitriptyline 50 mg
C. Duloxetine 30 mg
D. Venlafaxine XR 37.5 mg
(Correct: C)
Rationale:
● Answer: C
, ● Why (2026 Standard): SNRI duloxetine (CYP2D6 minor substrate) avoids
serotonergic triptan interaction, weight-neutral vs TCA/paroxetine, and migraine
benefit via descending pain inhibition.
● Errors: A strong CYP2D6 inhibitor, anticholinergic, weight gain; B high headache
risk, weight gain; D discontinuation syndrome, dose-dependent HTN.
Q002:
Type: Expert MCQ
Scenario: 45-year-old man with bipolar I, lithium 900 mg hs, level 0.9 mmol/L. Reports
new tremor, 3 kg weight gain, TSH 4.8 mIU/L (nl 0.4–4.2). Creatinine stable at 1.1.
Question: Best next action?
Options:
A. Reduce lithium to 600 mg
B. Add propranolol 20 mg bid
C. Switch to valproate
D. Start levothyroxine 25 µg
(Correct: B)
Rationale:
● Answer: B
● Why (2026 Standard): Benign essential tremor from lithium; non-selective
β-blocker preferred, no need to lower therapeutic level.
● Errors: A risks subtherapeutic/manic relapse; C unnecessary; D subclinical
hypothyroidism, repeat first.
Q003:
,Type: NGN - Psychopharm
Scenario: 19-year-old college male with ADHD, failing 2 stimulant trials
(methylphenidate 36 mg → irritability; lisdexamfetamine 50 mg → palpitations). HR 96,
BP 124/78. GC-MS CYP2D6 ultrarapid (*1xN/*2).
Question: Best non-stimulant option?
Options:
A. Atomoxetine 40 mg
B. Guanfacine ER 1 mg
C. Bupropion XL 150 mg
D. Clonidine 0.1 mg patch
(Correct: B)
Rationale:
● Answer: B
● Why (2026 Standard): α2A-agonist guanfacine bypasses catecholaminergic surge,
no CYP2D6 involvement, cardiovascular-safe.
● Errors: A CYP2D6 substrate → ultrarapid metabolizers have lower levels yet GI
side effects; C seizure risk college alcohol use; D sedation limits academics.
Q004:
Type: Expert MCQ
Scenario: 66-year-old woman with MDD, HTN, CKD G4 (eGFR 25). On sertraline 100
mg, remains PHQ-9 16. Nephrology cautious about nephrotoxic polypharmacy.
, Question: Evidence-based augmentation?
Options:
A. Bupropion 150 mg
B. Aripiprazole 2 mg
C. Lithium 300 mg
D. Duloxetine 60 mg
(Correct: B)
Rationale:
● Answer: B
● Why (2026 Standard): Aripiprazole renal-neutral, FDA-adjunct MDD, minimal
anticholinergic in elderly.
● Errors: A seizure/stroke elderly; C contraindicated G4; D 50% renally cleared →
toxicity.
Q005:
Type: NGN - Psychopharm
Scenario: 32-year-old woman 24 wks pregnant, stable on quetiapine 200 mg for bipolar
depression. OB consult requests med switch due to newborn EPS meta-analysis. Patient
refuses ECT.
Question: Best alternative?
Options:
A. Olanzapine 5 mg
