1
NRNP 6675 MIDTERM EXAM ACTUAL 2026/2027 |
Advanced PMHNP Clinical Practice | Most Comprehensive |
100% Verified Answers | Pass Guaranteed - A+ Graded
[Section 1: Psychopharmacology - Antidepressants & Mood Stabilizers (Q1-18)]
Q1. A 42-year-old patient presents with major depressive disorder, generalized
anxiety disorder, and chronic insomnia. The PMHNP must select an initial
antidepressant that addresses both mood and anxiety symptoms without
exacerbating sleep disruption. Which medication is the most appropriate first-line
choice?
A. Fluoxetine 20mg daily due to its strong noradrenergic activation and minimal
impact on sleep architecture
B. Paroxetine 20mg daily because its potent anticholinergic and antihistaminic
properties promote sedation
C. Escitalopram 10mg daily given its high selectivity for the serotonin transporter and
favorable anxiolytic profile with low propensity for sleep disruption
D. Bupropion XL 150mg daily owing to its dopaminergic mechanism and energizing
effects in comorbid anxiety
C. Escitalopram 10mg daily given its high selectivity for the serotonin transporter and
favorable anxiolytic profile with low propensity for sleep disruption [CORRECT]
Rationale: Escitalopram is FDA-approved for both MDD and GAD and demonstrates
superior efficacy for anxiety symptoms compared to many SSRIs. Fluoxetine and
bupropion are activating and may worsen insomnia, while paroxetine's
anticholinergic burden increases discontinuation syndrome risk, falls, and cognitive
impairment, making it suboptimal as a first-line agent in this profile.
Correct Answer: C
Q2. Which neurotransmitter mechanism primarily explains the therapeutic effect of
selective serotonin reuptake inhibitors (SSRIs) in major depressive disorder?
,2
A. Blockade of NMDA glutamate receptors in the prefrontal cortex
B. Inhibition of the presynaptic serotonin transporter (SERT), increasing synaptic 5-HT
availability
C. Direct agonism at postsynaptic 5-HT1A and 5-HT2A receptors
D. Inhibition of monoamine oxidase enzymes in the presynaptic terminal
B. Inhibition of the presynaptic serotonin transporter (SERT), increasing synaptic 5-HT
availability [CORRECT]
Rationale: SSRIs exert their antidepressant effect by competitively inhibiting SERT,
thereby increasing serotonin concentration in the synaptic cleft and enhancing
postsynaptic receptor activation over time. NMDA antagonism describes ketamine,
direct agonism is not the primary SSRI mechanism, and MAO inhibition characterizes
MAOIs, not SSRIs.
Correct Answer: B
Q3. A 38-year-old patient on sertraline 100mg daily is prescribed tramadol for
postoperative pain. Three days later, the patient presents with confusion,
hyperthermia (38.9°C), diaphoresis, tremor, and bilateral inducible clonus. What is the
immediate priority intervention?
A. Discontinue sertraline and tramadol, initiate supportive care, and administer
cyproheptadine 12mg orally
B. Add lorazepam 2mg IV every 4 hours for agitation and continue both medications
at reduced doses
C. Switch sertraline to fluoxetine 40mg daily to outcompete tramadol for hepatic
metabolism
D. Initiate haloperidol 5mg IM for delirium and maintain the current analgesic
regimen
A. Discontinue sertraline and tramadol, initiate supportive care, and administer
cyproheptadine 12mg orally [CORRECT]
Rationale: The presentation is classic serotonin syndrome (Hunter criteria: clonus +
autonomic instability + hyperthermia). The immediate priority is cessation of all
serotonergic agents, supportive measures including hydration and cooling, and
,3
cyproheptadine as a serotonin antagonist. Continuing serotonergic agents or adding
antipsychotics worsens morbidity and may precipitate neuroleptic malignant
syndrome.
Correct Answer: A
Q4. A patient newly started on phenelzine 45mg daily asks which food item is safe to
consume. Which dietary choice demonstrates appropriate patient education
regarding MAOI tyramine restrictions?
A. Aged cheddar cheese with red wine
B. Fermented sauerkraut and draft beer
C. Fresh mozzarella cheese with pasteurized yogurt
D. Smoked salmon and soy sauce
C. Fresh mozzarella cheese with pasteurized yogurt [CORRECT]
Rationale: MAOIs inhibit tyramine metabolism, and hypertensive crisis can result from
high-tyramine foods. Aged cheeses, fermented products, draft beer, smoked meats,
and soy sauce are contraindicated. Fresh mozzarella and pasteurized dairy products
contain negligible tyramine and are safe alternatives.
Correct Answer: C
Q5. A 55-year-old patient with bipolar disorder has been stable on lithium carbonate
900mg BID for 18 months. The patient develops osteoarthritis and begins taking
ibuprofen 600mg TID. At the 3-week follow-up, the patient reports nausea, ataxia,
and coarse tremor. The lithium level is 2.1 mEq/L. What is the primary mechanism
underlying this drug-drug interaction?
A. Ibuprofen induces cytochrome P450 3A4, accelerating lithium hepatic metabolism
B. NSAIDs reduce renal prostaglandin synthesis, decreasing glomerular filtration rate
and lithium clearance
C. Ibuprofen displaces lithium from albumin binding sites, increasing free lithium
, 4
fraction
D. NSAIDs enhance intestinal lithium absorption via P-glycoprotein inhibition
B. NSAIDs reduce renal prostaglandin synthesis, decreasing glomerular filtration rate
and lithium clearance [CORRECT]
Rationale: Most NSAIDs (except aspirin and sulindac) reduce renal blood flow by
inhibiting prostaglandin-mediated afferent arteriolar vasodilation, thereby decreasing
lithium clearance and precipitating toxicity. Lithium is not hepatically metabolized by
CYP3A4, is not protein-bound, and NSAIDs do not significantly alter intestinal P-
glycoprotein transport of lithium.
Correct Answer: B
Q6. A 67-year-old patient is brought to the emergency department after an
intentional overdose of amitriptyline 1500mg. The ECG reveals sinus tachycardia with
QRS widening to 120ms. Which intervention is the evidence-based antidote for this
TCA cardiotoxicity?
A. Naloxone 2mg IV for respiratory depression reversal
B. Sodium bicarbonate 1-2 mEq/kg IV push to alkalinize serum and narrow QRS
C. Flumazenil 0.2mg IV for potential benzodiazepine co-ingestion
D. Atropine 1mg IV for anticholinergic tachycardia management
B. Sodium bicarbonate 1-2 mEq/kg IV push to alkalinize serum and narrow QRS
[CORRECT]
Rationale: TCA overdose produces sodium channel blockade (class IA effect),
manifesting as QRS widening, hypotension, and arrhythmias. Sodium bicarbonate
alkalinizes serum (pH >7.50), increases extracellular sodium to overcome channel
blockade, and is the standard antidote. Naloxone addresses opioids, flumazenil is
contraindicated in polypharmacy overdose, and atropine does not reverse TCA
cardiotoxicity.
Correct Answer: B
NRNP 6675 MIDTERM EXAM ACTUAL 2026/2027 |
Advanced PMHNP Clinical Practice | Most Comprehensive |
100% Verified Answers | Pass Guaranteed - A+ Graded
[Section 1: Psychopharmacology - Antidepressants & Mood Stabilizers (Q1-18)]
Q1. A 42-year-old patient presents with major depressive disorder, generalized
anxiety disorder, and chronic insomnia. The PMHNP must select an initial
antidepressant that addresses both mood and anxiety symptoms without
exacerbating sleep disruption. Which medication is the most appropriate first-line
choice?
A. Fluoxetine 20mg daily due to its strong noradrenergic activation and minimal
impact on sleep architecture
B. Paroxetine 20mg daily because its potent anticholinergic and antihistaminic
properties promote sedation
C. Escitalopram 10mg daily given its high selectivity for the serotonin transporter and
favorable anxiolytic profile with low propensity for sleep disruption
D. Bupropion XL 150mg daily owing to its dopaminergic mechanism and energizing
effects in comorbid anxiety
C. Escitalopram 10mg daily given its high selectivity for the serotonin transporter and
favorable anxiolytic profile with low propensity for sleep disruption [CORRECT]
Rationale: Escitalopram is FDA-approved for both MDD and GAD and demonstrates
superior efficacy for anxiety symptoms compared to many SSRIs. Fluoxetine and
bupropion are activating and may worsen insomnia, while paroxetine's
anticholinergic burden increases discontinuation syndrome risk, falls, and cognitive
impairment, making it suboptimal as a first-line agent in this profile.
Correct Answer: C
Q2. Which neurotransmitter mechanism primarily explains the therapeutic effect of
selective serotonin reuptake inhibitors (SSRIs) in major depressive disorder?
,2
A. Blockade of NMDA glutamate receptors in the prefrontal cortex
B. Inhibition of the presynaptic serotonin transporter (SERT), increasing synaptic 5-HT
availability
C. Direct agonism at postsynaptic 5-HT1A and 5-HT2A receptors
D. Inhibition of monoamine oxidase enzymes in the presynaptic terminal
B. Inhibition of the presynaptic serotonin transporter (SERT), increasing synaptic 5-HT
availability [CORRECT]
Rationale: SSRIs exert their antidepressant effect by competitively inhibiting SERT,
thereby increasing serotonin concentration in the synaptic cleft and enhancing
postsynaptic receptor activation over time. NMDA antagonism describes ketamine,
direct agonism is not the primary SSRI mechanism, and MAO inhibition characterizes
MAOIs, not SSRIs.
Correct Answer: B
Q3. A 38-year-old patient on sertraline 100mg daily is prescribed tramadol for
postoperative pain. Three days later, the patient presents with confusion,
hyperthermia (38.9°C), diaphoresis, tremor, and bilateral inducible clonus. What is the
immediate priority intervention?
A. Discontinue sertraline and tramadol, initiate supportive care, and administer
cyproheptadine 12mg orally
B. Add lorazepam 2mg IV every 4 hours for agitation and continue both medications
at reduced doses
C. Switch sertraline to fluoxetine 40mg daily to outcompete tramadol for hepatic
metabolism
D. Initiate haloperidol 5mg IM for delirium and maintain the current analgesic
regimen
A. Discontinue sertraline and tramadol, initiate supportive care, and administer
cyproheptadine 12mg orally [CORRECT]
Rationale: The presentation is classic serotonin syndrome (Hunter criteria: clonus +
autonomic instability + hyperthermia). The immediate priority is cessation of all
serotonergic agents, supportive measures including hydration and cooling, and
,3
cyproheptadine as a serotonin antagonist. Continuing serotonergic agents or adding
antipsychotics worsens morbidity and may precipitate neuroleptic malignant
syndrome.
Correct Answer: A
Q4. A patient newly started on phenelzine 45mg daily asks which food item is safe to
consume. Which dietary choice demonstrates appropriate patient education
regarding MAOI tyramine restrictions?
A. Aged cheddar cheese with red wine
B. Fermented sauerkraut and draft beer
C. Fresh mozzarella cheese with pasteurized yogurt
D. Smoked salmon and soy sauce
C. Fresh mozzarella cheese with pasteurized yogurt [CORRECT]
Rationale: MAOIs inhibit tyramine metabolism, and hypertensive crisis can result from
high-tyramine foods. Aged cheeses, fermented products, draft beer, smoked meats,
and soy sauce are contraindicated. Fresh mozzarella and pasteurized dairy products
contain negligible tyramine and are safe alternatives.
Correct Answer: C
Q5. A 55-year-old patient with bipolar disorder has been stable on lithium carbonate
900mg BID for 18 months. The patient develops osteoarthritis and begins taking
ibuprofen 600mg TID. At the 3-week follow-up, the patient reports nausea, ataxia,
and coarse tremor. The lithium level is 2.1 mEq/L. What is the primary mechanism
underlying this drug-drug interaction?
A. Ibuprofen induces cytochrome P450 3A4, accelerating lithium hepatic metabolism
B. NSAIDs reduce renal prostaglandin synthesis, decreasing glomerular filtration rate
and lithium clearance
C. Ibuprofen displaces lithium from albumin binding sites, increasing free lithium
, 4
fraction
D. NSAIDs enhance intestinal lithium absorption via P-glycoprotein inhibition
B. NSAIDs reduce renal prostaglandin synthesis, decreasing glomerular filtration rate
and lithium clearance [CORRECT]
Rationale: Most NSAIDs (except aspirin and sulindac) reduce renal blood flow by
inhibiting prostaglandin-mediated afferent arteriolar vasodilation, thereby decreasing
lithium clearance and precipitating toxicity. Lithium is not hepatically metabolized by
CYP3A4, is not protein-bound, and NSAIDs do not significantly alter intestinal P-
glycoprotein transport of lithium.
Correct Answer: B
Q6. A 67-year-old patient is brought to the emergency department after an
intentional overdose of amitriptyline 1500mg. The ECG reveals sinus tachycardia with
QRS widening to 120ms. Which intervention is the evidence-based antidote for this
TCA cardiotoxicity?
A. Naloxone 2mg IV for respiratory depression reversal
B. Sodium bicarbonate 1-2 mEq/kg IV push to alkalinize serum and narrow QRS
C. Flumazenil 0.2mg IV for potential benzodiazepine co-ingestion
D. Atropine 1mg IV for anticholinergic tachycardia management
B. Sodium bicarbonate 1-2 mEq/kg IV push to alkalinize serum and narrow QRS
[CORRECT]
Rationale: TCA overdose produces sodium channel blockade (class IA effect),
manifesting as QRS widening, hypotension, and arrhythmias. Sodium bicarbonate
alkalinizes serum (pH >7.50), increases extracellular sodium to overcome channel
blockade, and is the standard antidote. Naloxone addresses opioids, flumazenil is
contraindicated in polypharmacy overdose, and atropine does not reverse TCA
cardiotoxicity.
Correct Answer: B
