1
NRNP 6675 FINAL EXAM ACTUAL 2026/2027 | Advanced
PMHNP Clinical Practice | Most Comprehensive Board-
Style Certification | 100% Verified Answers | Pass
Guaranteed - A+ Graded
Section 1: Advanced Psychopharmacology - Complex Regimens
& Monitoring (Questions 1-20)
Question 1
A 34-year-old patient with treatment-resistant major depressive disorder has failed
trials of sertraline 200 mg, venlafaxine 225 mg, and bupropion XL 300 mg, each for
≥8 weeks at adequate doses. Current PHQ-9 score is 18. The patient refuses ECT. A
pharmacogenomic test reveals CYP2D6 poor metabolizer status and normal CYP2C19
activity. Which augmentation strategy is most appropriate?
A. Add aripiprazole 2 mg daily, titrating to 5-15 mg
B. Add brexpiprazole 0.5 mg daily, titrating to 2-4 mg
C. Add bupropion IR 100 mg twice daily to current bupropion XL
D. Add quetiapine XR 50 mg nightly, titrating to 300 mg
Rationale: Brexpiprazole is FDA-approved for adjunctive treatment of MDD with a
favorable metabolic profile and minimal CYP2D6 interaction at standard doses,
making it ideal for this CYP2D6 poor metabolizer who has failed multiple
antidepressants. Aripiprazole is also effective but has more CYP2D6 interaction;
adding bupropion is redundant and increases seizure risk; quetiapine is not first-line
for MDD augmentation due to metabolic adverse effects.
Correct Answer: B
Question 2
,2
A 28-year-old woman with bipolar I disorder presents for maintenance therapy after
a recent manic episode requiring hospitalization. She is euthymic on lithium 900 mg
daily (level 0.8 mEq/L) and quetiapine 400 mg nightly. She desires pregnancy within 6
months. Which medication adjustment best aligns with current guidelines?
A. Continue lithium and quetiapine; add high-dose folate 4 mg daily
B. Taper lithium over 4 weeks; maintain quetiapine monotherapy
C. Transition to lamotrigine monotherapy; taper lithium and quetiapine
D. Switch to valproate monotherapy; discontinue lithium and quetiapine
Rationale: Lamotrigine has the most robust pregnancy safety data for bipolar
maintenance with the lowest teratogenic risk among mood stabilizers, making it the
preferred agent for planned pregnancy. Continuing lithium carries a 0.05-0.1% risk of
Ebstein's anomaly; valproate has a 6-10% neural tube defect risk and is
contraindicated; quetiapine monotherapy lacks robust maintenance data compared
to lamotrigine.
Correct Answer: C
Question 3
A 42-year-old male with schizophrenia is initiated on clozapine after failing two
adequate antipsychotic trials. Baseline ANC is 4,200/μL. At week 4, ANC is 2,800/μL.
According to the REMS program and current FDA monitoring protocols, what is the
appropriate clinical action?
A. Continue clozapine; repeat ANC in 1 week; no interruption required
B. Interrupt clozapine immediately; do not resume unless ANC ≥3,000/μL
C. Interrupt clozapine; may resume if ANC ≥2,000/μL with enhanced monitoring
D. Interrupt clozapine permanently; do not rechallenge due to moderate leukopenia
Rationale: An ANC between 2,000-3,000/μL represents moderate leukopenia
requiring immediate clozapine interruption; rechallenge is permitted if ANC recovers
to ≥2,000/μL with weekly monitoring for 4 weeks, then return to regular schedule.
Continuing with ANC 2,800 is prohibited; permanent discontinuation is reserved for
ANC <1,000/μL or severe granulocytopenia.
,3
Correct Answer: C
Question 4
A 56-year-old patient with psychotic depression is prescribed a combination of
olanzapine 15 mg and fluoxetine 40 mg (Symbyax equivalent). After 3 weeks, the
patient develops fever 38.8°C, muscle rigidity, altered mental status, and autonomic
instability with diaphoresis and tachycardia. CK is 1,200 U/L. Which diagnostic
distinction is most critical?
A. This is serotonin syndrome; discontinue fluoxetine only and add cyproheptadine
B. This is neuroleptic malignant syndrome; discontinue olanzapine and initiate
dantrolene
C. This is malignant catatonia; initiate lorazepam challenge 2 mg IV and consider ECT
D. This is severe anticholinergic toxicity; administer physostigmine 1 mg IV
Rationale: The combination of antipsychotic + SSRI with hyperthermia, rigidity,
autonomic instability, and elevated CK in the context of psychotic depression is most
consistent with NMS, requiring discontinuation of the offending antipsychotic and
supportive care with dantrolene if severe. Serotonin syndrome typically presents with
clonus and hyperreflexia rather than lead-pipe rigidity; malignant catatonia would
show waxy flexibility and negativism; anticholinergic toxicity presents with dry, hot
skin and absent sweating.
Correct Answer: B
Question 5
A pharmacogenomic report for a 31-year-old patient with MDD shows CYP2D6 *1/*4
(intermediate metabolizer) and CYP2C19 *2/*2 (poor metabolizer). The patient
previously experienced severe sedation on escitalopram 10 mg. Which
antidepressant selection best accounts for these pharmacogenomic findings?
, 4
A. Sertraline 50 mg daily; titrate based on clinical response
B. Venlafaxine 37.5 mg daily; monitor for early adverse effects
C. Vortioxetine 10 mg daily; reduce dose by 50%
D. Mirtazapine 15 mg nightly; standard dosing appropriate
Rationale: Vortioxetine is primarily metabolized by CYP2D6 with minor CYP2C19
contribution; in a CYP2D6 intermediate metabolizer with CYP2C19 poor metabolizer
status, standard doses may produce excessive levels, warranting 50% dose reduction.
Sertraline is metabolized by multiple CYPs including 2C19, making it unpredictable;
venlafaxine relies heavily on CYP2D6 and would require caution; mirtazapine is
metabolized by CYP1A2, 2D6, and 3A4 but sedation is dose-dependent and not
primarily PGx-driven.
Correct Answer: C
Question 6
A 38-year-old patient with bipolar II disorder on lamotrigine 200 mg daily presents
with a diffuse pruritic rash 10 days after dose escalation from 100 mg. There is no
mucosal involvement, fever, or systemic symptoms. Which management strategy is
most appropriate?
A. Discontinue lamotrigine permanently; do not rechallenge due to SJS risk
B. Hold lamotrigine; if rash resolves, may rechallenge at 12.5 mg with ultra-slow
titration
C. Continue lamotrigine at current dose; add diphenhydramine 25 mg every 6 hours
D. Discontinue lamotrigine; switch to immediate lithium monotherapy
Rationale: A benign, non-mucosal rash without systemic symptoms in a patient
responding to lamotrigine may permit cautious rechallenge with ultra-slow titration
(12.5 mg weekly) after complete resolution, as discontinuation often leads to loss of
an effective mood stabilizer. Permanent discontinuation is reserved for mucosal
involvement, blistering, or systemic symptoms; continuing through a developing rash
risks progression to SJS/TEN; switching to lithium is unnecessary if the rash is benign
and the patient is stable.
Correct Answer: B
NRNP 6675 FINAL EXAM ACTUAL 2026/2027 | Advanced
PMHNP Clinical Practice | Most Comprehensive Board-
Style Certification | 100% Verified Answers | Pass
Guaranteed - A+ Graded
Section 1: Advanced Psychopharmacology - Complex Regimens
& Monitoring (Questions 1-20)
Question 1
A 34-year-old patient with treatment-resistant major depressive disorder has failed
trials of sertraline 200 mg, venlafaxine 225 mg, and bupropion XL 300 mg, each for
≥8 weeks at adequate doses. Current PHQ-9 score is 18. The patient refuses ECT. A
pharmacogenomic test reveals CYP2D6 poor metabolizer status and normal CYP2C19
activity. Which augmentation strategy is most appropriate?
A. Add aripiprazole 2 mg daily, titrating to 5-15 mg
B. Add brexpiprazole 0.5 mg daily, titrating to 2-4 mg
C. Add bupropion IR 100 mg twice daily to current bupropion XL
D. Add quetiapine XR 50 mg nightly, titrating to 300 mg
Rationale: Brexpiprazole is FDA-approved for adjunctive treatment of MDD with a
favorable metabolic profile and minimal CYP2D6 interaction at standard doses,
making it ideal for this CYP2D6 poor metabolizer who has failed multiple
antidepressants. Aripiprazole is also effective but has more CYP2D6 interaction;
adding bupropion is redundant and increases seizure risk; quetiapine is not first-line
for MDD augmentation due to metabolic adverse effects.
Correct Answer: B
Question 2
,2
A 28-year-old woman with bipolar I disorder presents for maintenance therapy after
a recent manic episode requiring hospitalization. She is euthymic on lithium 900 mg
daily (level 0.8 mEq/L) and quetiapine 400 mg nightly. She desires pregnancy within 6
months. Which medication adjustment best aligns with current guidelines?
A. Continue lithium and quetiapine; add high-dose folate 4 mg daily
B. Taper lithium over 4 weeks; maintain quetiapine monotherapy
C. Transition to lamotrigine monotherapy; taper lithium and quetiapine
D. Switch to valproate monotherapy; discontinue lithium and quetiapine
Rationale: Lamotrigine has the most robust pregnancy safety data for bipolar
maintenance with the lowest teratogenic risk among mood stabilizers, making it the
preferred agent for planned pregnancy. Continuing lithium carries a 0.05-0.1% risk of
Ebstein's anomaly; valproate has a 6-10% neural tube defect risk and is
contraindicated; quetiapine monotherapy lacks robust maintenance data compared
to lamotrigine.
Correct Answer: C
Question 3
A 42-year-old male with schizophrenia is initiated on clozapine after failing two
adequate antipsychotic trials. Baseline ANC is 4,200/μL. At week 4, ANC is 2,800/μL.
According to the REMS program and current FDA monitoring protocols, what is the
appropriate clinical action?
A. Continue clozapine; repeat ANC in 1 week; no interruption required
B. Interrupt clozapine immediately; do not resume unless ANC ≥3,000/μL
C. Interrupt clozapine; may resume if ANC ≥2,000/μL with enhanced monitoring
D. Interrupt clozapine permanently; do not rechallenge due to moderate leukopenia
Rationale: An ANC between 2,000-3,000/μL represents moderate leukopenia
requiring immediate clozapine interruption; rechallenge is permitted if ANC recovers
to ≥2,000/μL with weekly monitoring for 4 weeks, then return to regular schedule.
Continuing with ANC 2,800 is prohibited; permanent discontinuation is reserved for
ANC <1,000/μL or severe granulocytopenia.
,3
Correct Answer: C
Question 4
A 56-year-old patient with psychotic depression is prescribed a combination of
olanzapine 15 mg and fluoxetine 40 mg (Symbyax equivalent). After 3 weeks, the
patient develops fever 38.8°C, muscle rigidity, altered mental status, and autonomic
instability with diaphoresis and tachycardia. CK is 1,200 U/L. Which diagnostic
distinction is most critical?
A. This is serotonin syndrome; discontinue fluoxetine only and add cyproheptadine
B. This is neuroleptic malignant syndrome; discontinue olanzapine and initiate
dantrolene
C. This is malignant catatonia; initiate lorazepam challenge 2 mg IV and consider ECT
D. This is severe anticholinergic toxicity; administer physostigmine 1 mg IV
Rationale: The combination of antipsychotic + SSRI with hyperthermia, rigidity,
autonomic instability, and elevated CK in the context of psychotic depression is most
consistent with NMS, requiring discontinuation of the offending antipsychotic and
supportive care with dantrolene if severe. Serotonin syndrome typically presents with
clonus and hyperreflexia rather than lead-pipe rigidity; malignant catatonia would
show waxy flexibility and negativism; anticholinergic toxicity presents with dry, hot
skin and absent sweating.
Correct Answer: B
Question 5
A pharmacogenomic report for a 31-year-old patient with MDD shows CYP2D6 *1/*4
(intermediate metabolizer) and CYP2C19 *2/*2 (poor metabolizer). The patient
previously experienced severe sedation on escitalopram 10 mg. Which
antidepressant selection best accounts for these pharmacogenomic findings?
, 4
A. Sertraline 50 mg daily; titrate based on clinical response
B. Venlafaxine 37.5 mg daily; monitor for early adverse effects
C. Vortioxetine 10 mg daily; reduce dose by 50%
D. Mirtazapine 15 mg nightly; standard dosing appropriate
Rationale: Vortioxetine is primarily metabolized by CYP2D6 with minor CYP2C19
contribution; in a CYP2D6 intermediate metabolizer with CYP2C19 poor metabolizer
status, standard doses may produce excessive levels, warranting 50% dose reduction.
Sertraline is metabolized by multiple CYPs including 2C19, making it unpredictable;
venlafaxine relies heavily on CYP2D6 and would require caution; mirtazapine is
metabolized by CYP1A2, 2D6, and 3A4 but sedation is dose-dependent and not
primarily PGx-driven.
Correct Answer: C
Question 6
A 38-year-old patient with bipolar II disorder on lamotrigine 200 mg daily presents
with a diffuse pruritic rash 10 days after dose escalation from 100 mg. There is no
mucosal involvement, fever, or systemic symptoms. Which management strategy is
most appropriate?
A. Discontinue lamotrigine permanently; do not rechallenge due to SJS risk
B. Hold lamotrigine; if rash resolves, may rechallenge at 12.5 mg with ultra-slow
titration
C. Continue lamotrigine at current dose; add diphenhydramine 25 mg every 6 hours
D. Discontinue lamotrigine; switch to immediate lithium monotherapy
Rationale: A benign, non-mucosal rash without systemic symptoms in a patient
responding to lamotrigine may permit cautious rechallenge with ultra-slow titration
(12.5 mg weekly) after complete resolution, as discontinuation often leads to loss of
an effective mood stabilizer. Permanent discontinuation is reserved for mucosal
involvement, blistering, or systemic symptoms; continuing through a developing rash
risks progression to SJS/TEN; switching to lithium is unnecessary if the rash is benign
and the patient is stable.
Correct Answer: B
