NU 664: PSYCHOPHARMACOLOGY & ADVANCED PRACTICE PSYCHIATRIC
NURSING – 2025 FINAL EXAM (ALREADY GRADED)
A 32-year-old patient presents with symptoms of major depressive disorder (MDD).
She has a history of hypersomnia and weight gain with previous medication trials.
Which antidepressant would be the MOST appropriate first-line choice considering
her history and side effect profile?
A) Fluoxetine (Prozac)
B) Bupropion (Wellbutrin)
C) Mirtazapine (Remeron)
D) Paroxetine (Paxil)
Answer: B
1. Rationale: Bupropion is a dopamine-norepinephrine reuptake inhibitor (DNRI)
that is weight-neutral or associated with weight loss and does not typically
cause sedation/hypersomnia; in fact, it is often activating. Fluoxetine and
Paroxetine are SSRIs that can cause initial activation but are generally
weight-neutral or associated with weight gain long-term. Mirtazapine is
well-known for causing significant weight gain and sedation due to its
antihistamine effects, which would exacerbate this patient's specific history of
hypersomnia and weight gain.
A PMHNP is initiating treatment for a patient with Bipolar I Disorder, acute manic
episode with mixed features. The patient has a history of renal insufficiency. Which
mood stabilizer is CONTRAINDICATED in this patient?
A) Lithium
B) Valproate (Depakote)
C) Lamotrigine (Lamictal)
D) Carbamazepine (Tegretol)
Answer: A
2. Rationale: Lithium is primarily excreted unchanged by the kidneys. In patients
with renal insufficiency, the risk of lithium toxicity increases significantly
because clearance is reduced. Valproate is metabolized by the liver (though
caution is needed), Lamotrigine is metabolized by the liver (glucuronidation),
and Carbamazepine is hepatically metabolized. Lithium requires strict renal
function monitoring and is contraindicated in severe renal disease.
Which of the following is a BLACK BOX WARNING for Atomoxetine (Strattera) used
in the treatment of ADHD?
A) Sudden death and serious cardiovascular events
B) Severe liver injury
C) Suicidal ideation in children and adolescents
D) Tardive dyskinesia
Answer: C
, 3. Rationale: Atomoxetine carries a Black Box Warning for the increased risk of
suicidal thinking and behavior (suicidality) in children, adolescents, and young
adults during early treatment. While stimulants carry warnings regarding
cardiovascular events (mostly related to pre-existing heart defects) and
atomoxetine carries a warning regarding liver injury, the prominent Black Box
Warning distinguishing it in pediatric guidelines is the risk of suicidality.
A patient with Schizophrenia is currently on Haloperidol. He presents to the
emergency department with fever, muscle rigidity, autonomic instability, and elevated
creatine kinase (CK). What is the FIRST intervention the PMHNP should anticipate?
A) Administer Benztropine (Cogentin) IM
B) Stop the antipsychotic immediately
C) Administer Bromocriptine
D) Switch to Clozapine
Answer: B
4. Rationale: The patient presents with Neuroleptic Malignant Syndrome (NMS),
a life-threatening complication of antipsychotic use. The first and most critical
step is the immediate discontinuation of the offending antipsychotic
medication. Supportive care (hydration, cooling) is initiated immediately.
Pharmacological interventions like bromocriptine (dopamine agonist) or
dantrolene may be used, but stopping the drug is the priority. Benztropine is
used for extrapyramidal symptoms (EPS) but is not the primary treatment for
NMS.
A 45-year-old female with Panic Disorder requests a medication she can take "as
needed" for her panic attacks because they are infrequent. She is concerned about
addiction. Which medication is the BEST choice for PRN use given her concerns?
A) Alprazolam (Xanax)
B) Lorazepam (Ativan)
C) Clonazepam (Klonopin)
D) Buspirone (Buspar)
Answer: B
5. Rationale: While all benzodiazepines carry a risk of dependence, lorazepam
is often preferred for PRN use in patients with addiction concerns because it
has no active metabolites, leading to a shorter half-life and reduced risk of
accumulation compared to clonazepam or diazepam. Alprazolam has a
particularly high abuse potential and severe discontinuation syndrome.
Buspirone is an excellent non-benzodiazepine option for anxiety but takes 2-4
weeks to work and is ineffective for immediate PRN relief of a panic attack.
When prescribing Lamotrigine (Lamictal) for Bipolar Depression, what is the most
critical instruction the PMHNP must give the patient to prevent a potentially fatal
rash?
,A) Avoid grapefruit juice
B) Do not take with food
C) Adhere strictly to the dosage titration schedule
D) Wear sunscreen at all times
Answer: C
6. Rationale: Lamotrigine carries a risk of Stevens-Johnson Syndrome (SJS)
and Toxic Epidermal Necrolysis (TEN). The risk of this severe rash is strongly
correlated with rapid dosage escalation. Patients must be instructed to adhere
strictly to the slow titration schedule and to report any rash immediately. While
stopping the drug is required if a rash occurs, prevention via slow titration is
paramount.
A patient with Major Depressive Disorder has failed to achieve remission after
adequate trials of two different SSRIs. According to the STAR*D algorithm and
current guidelines, what is the most appropriate NEXT step?
A) Switch to an MAOI
B) Augment with an atypical antipsychotic
C) Switch to a different SSRI
D) Initiate Electroconvulsive Therapy (ECT)
Answer: B
7. Rationale: For patients who have not responded to an adequate trial of one
antidepressant (Stage 1), switching to a different class or augmenting is
appropriate. However, after failure of two adequate trials (Stage 2/3),
augmentation strategies such as adding an atypical antipsychotic (e.g., Abilify,
Rexulti) or Lithium are strongly supported by evidence. Switching to an MAOI
is generally considered a later-stage option (Stage 4 or 5) due to dietary and
drug interactions. ECT is reserved for severe, psychotic, or
treatment-resistant depression (TRD), but augmentation is typically tried
before ECT in non-emergent TRD.
Which of the following laboratory values must be monitored regularly for a patient
taking Valproate (Depakote)?
A) Complete Blood Count (CBC) and Liver Function Tests (LFTs)
B) Thyroid Stimulating Hormone (TSH) and BUN
C) Prolactin levels and Lipid panel
D) Serum sodium and Potassium
Answer: A
8. Rationale: Valproate carries a risk of hepatotoxicity (liver damage) and
thrombocytopenia (low platelets). Therefore, LFTs and CBCs must be
monitored, especially during the first 6 months of therapy. While valproate can
cause weight gain (implicating lipids), CBC and LFTs are the safety-critical
, labs required to watch for fatal toxicities. Lithium requires monitoring of TSH,
BUN, and Creatinine.
A patient with Schizophrenia is experiencing auditory hallucinations and delusions
but has severe tardive dyskinesia (TD) from previous typical antipsychotics. Which
medication is FDA-approved specifically for this condition?
A) Quetiapine (Seroquel)
B) Clozapine (Clozaril)
C) Ziprasidone (Geodon)
D) Risperidone (Risperdal)
Answer: B
9. Rationale: Clozapine is the only antipsychotic with an FDA indication for
treatment-resistant schizophrenia and for reducing the risk of suicidal
behavior. Crucially, it is also the only antipsychotic shown to have minimal risk
of causing tardive dyskinesia and can actually improve existing symptoms of
TD. It is used when other antipsychotics fail or cause intolerable EPS/TD,
though it requires monitoring for agranulocytosis via the Clozapine REMS
program.
A 28-year-old female presents with symptoms of PTSD, including nightmares and
flashbacks. She has a history of substance use disorder. Which medication is
FDA-approved for PTSD and has a favorable profile regarding abuse potential?
A) Alprazolam (Xanax)
B) Sertraline (Zoloft)
C) Prazosin (Minipress)
D) Clonidine (Catapres)
Answer: B
10.Rationale: Sertraline and Paroxetine are the only two FDA-approved
medications for PTSD. They are SSRIs and have no abuse potential, making
them safe for a patient with a history of substance use. Prazosin is frequently
used off-label for nightmares (often with good evidence), but it is not
FDA-approved for the broad condition of PTSD. Benzodiazepines like
alprazolam are generally avoided in PTSD due to abuse potential and
evidence suggesting they may hinder recovery.
What is the mechanism of action of Selective Serotonin Reuptake Inhibitors
(SSRIs)?
A) Blocking the reuptake of serotonin and norepinephrine
B) Blocking the reuptake of serotonin
C) Blocking the reuptake of dopamine
D) Inhibiting the enzyme monoamine oxidase
Answer: B
NURSING – 2025 FINAL EXAM (ALREADY GRADED)
A 32-year-old patient presents with symptoms of major depressive disorder (MDD).
She has a history of hypersomnia and weight gain with previous medication trials.
Which antidepressant would be the MOST appropriate first-line choice considering
her history and side effect profile?
A) Fluoxetine (Prozac)
B) Bupropion (Wellbutrin)
C) Mirtazapine (Remeron)
D) Paroxetine (Paxil)
Answer: B
1. Rationale: Bupropion is a dopamine-norepinephrine reuptake inhibitor (DNRI)
that is weight-neutral or associated with weight loss and does not typically
cause sedation/hypersomnia; in fact, it is often activating. Fluoxetine and
Paroxetine are SSRIs that can cause initial activation but are generally
weight-neutral or associated with weight gain long-term. Mirtazapine is
well-known for causing significant weight gain and sedation due to its
antihistamine effects, which would exacerbate this patient's specific history of
hypersomnia and weight gain.
A PMHNP is initiating treatment for a patient with Bipolar I Disorder, acute manic
episode with mixed features. The patient has a history of renal insufficiency. Which
mood stabilizer is CONTRAINDICATED in this patient?
A) Lithium
B) Valproate (Depakote)
C) Lamotrigine (Lamictal)
D) Carbamazepine (Tegretol)
Answer: A
2. Rationale: Lithium is primarily excreted unchanged by the kidneys. In patients
with renal insufficiency, the risk of lithium toxicity increases significantly
because clearance is reduced. Valproate is metabolized by the liver (though
caution is needed), Lamotrigine is metabolized by the liver (glucuronidation),
and Carbamazepine is hepatically metabolized. Lithium requires strict renal
function monitoring and is contraindicated in severe renal disease.
Which of the following is a BLACK BOX WARNING for Atomoxetine (Strattera) used
in the treatment of ADHD?
A) Sudden death and serious cardiovascular events
B) Severe liver injury
C) Suicidal ideation in children and adolescents
D) Tardive dyskinesia
Answer: C
, 3. Rationale: Atomoxetine carries a Black Box Warning for the increased risk of
suicidal thinking and behavior (suicidality) in children, adolescents, and young
adults during early treatment. While stimulants carry warnings regarding
cardiovascular events (mostly related to pre-existing heart defects) and
atomoxetine carries a warning regarding liver injury, the prominent Black Box
Warning distinguishing it in pediatric guidelines is the risk of suicidality.
A patient with Schizophrenia is currently on Haloperidol. He presents to the
emergency department with fever, muscle rigidity, autonomic instability, and elevated
creatine kinase (CK). What is the FIRST intervention the PMHNP should anticipate?
A) Administer Benztropine (Cogentin) IM
B) Stop the antipsychotic immediately
C) Administer Bromocriptine
D) Switch to Clozapine
Answer: B
4. Rationale: The patient presents with Neuroleptic Malignant Syndrome (NMS),
a life-threatening complication of antipsychotic use. The first and most critical
step is the immediate discontinuation of the offending antipsychotic
medication. Supportive care (hydration, cooling) is initiated immediately.
Pharmacological interventions like bromocriptine (dopamine agonist) or
dantrolene may be used, but stopping the drug is the priority. Benztropine is
used for extrapyramidal symptoms (EPS) but is not the primary treatment for
NMS.
A 45-year-old female with Panic Disorder requests a medication she can take "as
needed" for her panic attacks because they are infrequent. She is concerned about
addiction. Which medication is the BEST choice for PRN use given her concerns?
A) Alprazolam (Xanax)
B) Lorazepam (Ativan)
C) Clonazepam (Klonopin)
D) Buspirone (Buspar)
Answer: B
5. Rationale: While all benzodiazepines carry a risk of dependence, lorazepam
is often preferred for PRN use in patients with addiction concerns because it
has no active metabolites, leading to a shorter half-life and reduced risk of
accumulation compared to clonazepam or diazepam. Alprazolam has a
particularly high abuse potential and severe discontinuation syndrome.
Buspirone is an excellent non-benzodiazepine option for anxiety but takes 2-4
weeks to work and is ineffective for immediate PRN relief of a panic attack.
When prescribing Lamotrigine (Lamictal) for Bipolar Depression, what is the most
critical instruction the PMHNP must give the patient to prevent a potentially fatal
rash?
,A) Avoid grapefruit juice
B) Do not take with food
C) Adhere strictly to the dosage titration schedule
D) Wear sunscreen at all times
Answer: C
6. Rationale: Lamotrigine carries a risk of Stevens-Johnson Syndrome (SJS)
and Toxic Epidermal Necrolysis (TEN). The risk of this severe rash is strongly
correlated with rapid dosage escalation. Patients must be instructed to adhere
strictly to the slow titration schedule and to report any rash immediately. While
stopping the drug is required if a rash occurs, prevention via slow titration is
paramount.
A patient with Major Depressive Disorder has failed to achieve remission after
adequate trials of two different SSRIs. According to the STAR*D algorithm and
current guidelines, what is the most appropriate NEXT step?
A) Switch to an MAOI
B) Augment with an atypical antipsychotic
C) Switch to a different SSRI
D) Initiate Electroconvulsive Therapy (ECT)
Answer: B
7. Rationale: For patients who have not responded to an adequate trial of one
antidepressant (Stage 1), switching to a different class or augmenting is
appropriate. However, after failure of two adequate trials (Stage 2/3),
augmentation strategies such as adding an atypical antipsychotic (e.g., Abilify,
Rexulti) or Lithium are strongly supported by evidence. Switching to an MAOI
is generally considered a later-stage option (Stage 4 or 5) due to dietary and
drug interactions. ECT is reserved for severe, psychotic, or
treatment-resistant depression (TRD), but augmentation is typically tried
before ECT in non-emergent TRD.
Which of the following laboratory values must be monitored regularly for a patient
taking Valproate (Depakote)?
A) Complete Blood Count (CBC) and Liver Function Tests (LFTs)
B) Thyroid Stimulating Hormone (TSH) and BUN
C) Prolactin levels and Lipid panel
D) Serum sodium and Potassium
Answer: A
8. Rationale: Valproate carries a risk of hepatotoxicity (liver damage) and
thrombocytopenia (low platelets). Therefore, LFTs and CBCs must be
monitored, especially during the first 6 months of therapy. While valproate can
cause weight gain (implicating lipids), CBC and LFTs are the safety-critical
, labs required to watch for fatal toxicities. Lithium requires monitoring of TSH,
BUN, and Creatinine.
A patient with Schizophrenia is experiencing auditory hallucinations and delusions
but has severe tardive dyskinesia (TD) from previous typical antipsychotics. Which
medication is FDA-approved specifically for this condition?
A) Quetiapine (Seroquel)
B) Clozapine (Clozaril)
C) Ziprasidone (Geodon)
D) Risperidone (Risperdal)
Answer: B
9. Rationale: Clozapine is the only antipsychotic with an FDA indication for
treatment-resistant schizophrenia and for reducing the risk of suicidal
behavior. Crucially, it is also the only antipsychotic shown to have minimal risk
of causing tardive dyskinesia and can actually improve existing symptoms of
TD. It is used when other antipsychotics fail or cause intolerable EPS/TD,
though it requires monitoring for agranulocytosis via the Clozapine REMS
program.
A 28-year-old female presents with symptoms of PTSD, including nightmares and
flashbacks. She has a history of substance use disorder. Which medication is
FDA-approved for PTSD and has a favorable profile regarding abuse potential?
A) Alprazolam (Xanax)
B) Sertraline (Zoloft)
C) Prazosin (Minipress)
D) Clonidine (Catapres)
Answer: B
10.Rationale: Sertraline and Paroxetine are the only two FDA-approved
medications for PTSD. They are SSRIs and have no abuse potential, making
them safe for a patient with a history of substance use. Prazosin is frequently
used off-label for nightmares (often with good evidence), but it is not
FDA-approved for the broad condition of PTSD. Benzodiazepines like
alprazolam are generally avoided in PTSD due to abuse potential and
evidence suggesting they may hinder recovery.
What is the mechanism of action of Selective Serotonin Reuptake Inhibitors
(SSRIs)?
A) Blocking the reuptake of serotonin and norepinephrine
B) Blocking the reuptake of serotonin
C) Blocking the reuptake of dopamine
D) Inhibiting the enzyme monoamine oxidase
Answer: B
