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NRNP 6675 MIDTERM EXAM LATEST 2026/2027 | Advanced
PMHNP Clinical Practice | Most Comprehensive | 100%
Verified Updated | Pass Guaranteed - A+ Graded
Section 1: Psychopharmacology - Antidepressants (SSRIs, SNRIs, TCAs, MAOIs)
(Q1-12)
Q1. A 28-year-old patient with major depressive disorder has been taking fluoxetine
20mg daily for 8 months with partial response. The psychiatric-mental health nurse
practitioner (PMHNP) decides to switch to phenelzine 15mg TID. What is the
minimum washout period required between discontinuing fluoxetine and initiating
phenelzine?
A. 3 days
B. 2 weeks
C. 4 weeks
D. 5 weeks
C. 5 weeks [CORRECT]
Rationale: Fluoxetine has a long elimination half-life (1–3 days) and its active
metabolite norfluoxetine persists for 4–16 days, potentiating CYP2D6 inhibition and
serotonin accumulation; a 5-week washout is mandatory per FDA labeling to prevent
life-threatening serotonin syndrome when switching to an irreversible MAOI.
Correct Answer: C
Q2. A 52-year-old patient with generalized anxiety disorder has been taking
venlafaxine XR 225mg daily for 6 months. At a routine follow-up, blood pressure is
158/96 mmHg (baseline 122/78 mmHg). All other medications and diet are
unchanged. What is the most appropriate initial intervention?
A. Add lisinopril 10mg daily and recheck in 2 weeks
B. Reduce venlafaxine to 150mg XR and monitor BP closely
,2
C. Discontinue venlafaxine immediately and switch to sertraline
D. Order renal ultrasound and 24-hour urine catecholamines
B. Reduce venlafaxine to 150mg XR and monitor BP closely [CORRECT]
Rationale: Venlafaxine causes dose-dependent norepinephrine reuptake inhibition at
doses ≥150mg/day, producing hypertension in 5–10% of patients; dose reduction
typically resolves the effect, whereas adding an antihypertensive masks the
pharmacologic cause.
Correct Answer: B
Q3. A 39-year-old patient on sertraline 100mg daily is prescribed tramadol 50mg
Q6h PRN for lower back pain by an outside provider. Three days later, the patient
presents to the emergency department with agitation, hyperthermia (104.2°F),
diaphoresis, ocular clonus, and hyperreflexia. What is the most likely diagnosis?
A. Neuroleptic malignant syndrome
B. Serotonin syndrome
C. Malignant hyperthermia
D. Thyroid storm
B. Serotonin syndrome [CORRECT]
Rationale: Tramadol inhibits serotonin reuptake and enhances release; combined
with an SSRI, it produces excessive serotonergic activity manifesting as the classic
triad of mental status changes, autonomic instability, and neuromuscular
abnormalities (clonus, hyperreflexia).
Correct Answer: B
Q4. A 45-year-old patient is brought to the emergency department after ingesting
approximately 50 tablets of amitriptyline 50mg in a suicide attempt. ECG reveals
sinus tachycardia with QRS duration 120ms. What is the antidotal treatment of
choice?
,3
A. Naloxone 2mg IV
B. Sodium bicarbonate 1–2 mEq/kg IV
C. Flumazenil 0.2mg IV
D. Physostigmine 1mg IV
B. Sodium bicarbonate 1–2 mEq/kg IV [CORRECT]
Rationale: TCA overdose produces sodium channel blockade causing QRS widening,
hypotension, and arrhythmias; sodium bicarbonate alkalinizes serum (pH goal 7.50–
7.55), reducing free drug and overcoming the sodium channel antagonism.
Correct Answer: B
Q5. A patient newly started on phenelzine 15mg TID asks the PMHNP about dietary
restrictions. Which food item poses the greatest risk of a hypertensive crisis if
consumed?
A. Fresh mozzarella cheese
B. Aged cheddar cheese
C. Plain yogurt
D. Cottage cheese
B. Aged cheddar cheese [CORRECT]
Rationale: Aged and fermented foods contain high levels of tyramine, which is
normally metabolized by MAO-A in the gut; irreversible MAOIs block this protection,
allowing tyramine to displace norepinephrine from vesicles, producing a potentially
fatal hypertensive crisis.
Correct Answer: B
Q6. A 34-year-old patient who has taken paroxetine 40mg daily for 3 years for panic
disorder abruptly stops the medication due to cost. Four days later, she reports
dizziness, electric shock sensations in her head, nausea, irritability, and insomnia.
What is the most accurate explanation?
, 4
A. Recurrence of panic disorder
B. SSRI discontinuation syndrome
C. Serotonin syndrome
D. Conversion disorder
B. SSRI discontinuation syndrome [CORRECT]
Rationale: Paroxetine has the shortest half-life among SSRIs (≈21 hours) and lacks an
active metabolite, making it the most frequently associated with discontinuation
syndrome characterized by sensory disturbances, GI symptoms, and mood lability
upon abrupt cessation.
Correct Answer: B
Q7. A 67-year-old patient with a history of coronary artery disease and MDD is being
considered for pharmacotherapy. Which SSRI at standard therapeutic doses carries
the lowest risk of QTc prolongation and is therefore preferred in this patient?
A. Citalopram 40mg daily
B. Escitalopram 20mg daily
C. Fluoxetine 60mg daily
D. Sertraline 200mg daily
B. Escitalopram 20mg daily [CORRECT]
Rationale: Citalopram exhibits dose-dependent QT prolongation via hERG potassium
channel blockade, prompting an FDA warning and a 20mg maximum in patients >60
years; escitalopram, the purified S-enantiomer, demonstrates significantly less QT
effect at equivalent antidepressant doses.
Correct Answer: B
Q8. A 58-year-old patient with type 2 diabetes presents with MDD and reports
burning pain in both feet consistent with diabetic peripheral neuropathy. Which
antidepressant would address both conditions with FDA-approved indications?
NRNP 6675 MIDTERM EXAM LATEST 2026/2027 | Advanced
PMHNP Clinical Practice | Most Comprehensive | 100%
Verified Updated | Pass Guaranteed - A+ Graded
Section 1: Psychopharmacology - Antidepressants (SSRIs, SNRIs, TCAs, MAOIs)
(Q1-12)
Q1. A 28-year-old patient with major depressive disorder has been taking fluoxetine
20mg daily for 8 months with partial response. The psychiatric-mental health nurse
practitioner (PMHNP) decides to switch to phenelzine 15mg TID. What is the
minimum washout period required between discontinuing fluoxetine and initiating
phenelzine?
A. 3 days
B. 2 weeks
C. 4 weeks
D. 5 weeks
C. 5 weeks [CORRECT]
Rationale: Fluoxetine has a long elimination half-life (1–3 days) and its active
metabolite norfluoxetine persists for 4–16 days, potentiating CYP2D6 inhibition and
serotonin accumulation; a 5-week washout is mandatory per FDA labeling to prevent
life-threatening serotonin syndrome when switching to an irreversible MAOI.
Correct Answer: C
Q2. A 52-year-old patient with generalized anxiety disorder has been taking
venlafaxine XR 225mg daily for 6 months. At a routine follow-up, blood pressure is
158/96 mmHg (baseline 122/78 mmHg). All other medications and diet are
unchanged. What is the most appropriate initial intervention?
A. Add lisinopril 10mg daily and recheck in 2 weeks
B. Reduce venlafaxine to 150mg XR and monitor BP closely
,2
C. Discontinue venlafaxine immediately and switch to sertraline
D. Order renal ultrasound and 24-hour urine catecholamines
B. Reduce venlafaxine to 150mg XR and monitor BP closely [CORRECT]
Rationale: Venlafaxine causes dose-dependent norepinephrine reuptake inhibition at
doses ≥150mg/day, producing hypertension in 5–10% of patients; dose reduction
typically resolves the effect, whereas adding an antihypertensive masks the
pharmacologic cause.
Correct Answer: B
Q3. A 39-year-old patient on sertraline 100mg daily is prescribed tramadol 50mg
Q6h PRN for lower back pain by an outside provider. Three days later, the patient
presents to the emergency department with agitation, hyperthermia (104.2°F),
diaphoresis, ocular clonus, and hyperreflexia. What is the most likely diagnosis?
A. Neuroleptic malignant syndrome
B. Serotonin syndrome
C. Malignant hyperthermia
D. Thyroid storm
B. Serotonin syndrome [CORRECT]
Rationale: Tramadol inhibits serotonin reuptake and enhances release; combined
with an SSRI, it produces excessive serotonergic activity manifesting as the classic
triad of mental status changes, autonomic instability, and neuromuscular
abnormalities (clonus, hyperreflexia).
Correct Answer: B
Q4. A 45-year-old patient is brought to the emergency department after ingesting
approximately 50 tablets of amitriptyline 50mg in a suicide attempt. ECG reveals
sinus tachycardia with QRS duration 120ms. What is the antidotal treatment of
choice?
,3
A. Naloxone 2mg IV
B. Sodium bicarbonate 1–2 mEq/kg IV
C. Flumazenil 0.2mg IV
D. Physostigmine 1mg IV
B. Sodium bicarbonate 1–2 mEq/kg IV [CORRECT]
Rationale: TCA overdose produces sodium channel blockade causing QRS widening,
hypotension, and arrhythmias; sodium bicarbonate alkalinizes serum (pH goal 7.50–
7.55), reducing free drug and overcoming the sodium channel antagonism.
Correct Answer: B
Q5. A patient newly started on phenelzine 15mg TID asks the PMHNP about dietary
restrictions. Which food item poses the greatest risk of a hypertensive crisis if
consumed?
A. Fresh mozzarella cheese
B. Aged cheddar cheese
C. Plain yogurt
D. Cottage cheese
B. Aged cheddar cheese [CORRECT]
Rationale: Aged and fermented foods contain high levels of tyramine, which is
normally metabolized by MAO-A in the gut; irreversible MAOIs block this protection,
allowing tyramine to displace norepinephrine from vesicles, producing a potentially
fatal hypertensive crisis.
Correct Answer: B
Q6. A 34-year-old patient who has taken paroxetine 40mg daily for 3 years for panic
disorder abruptly stops the medication due to cost. Four days later, she reports
dizziness, electric shock sensations in her head, nausea, irritability, and insomnia.
What is the most accurate explanation?
, 4
A. Recurrence of panic disorder
B. SSRI discontinuation syndrome
C. Serotonin syndrome
D. Conversion disorder
B. SSRI discontinuation syndrome [CORRECT]
Rationale: Paroxetine has the shortest half-life among SSRIs (≈21 hours) and lacks an
active metabolite, making it the most frequently associated with discontinuation
syndrome characterized by sensory disturbances, GI symptoms, and mood lability
upon abrupt cessation.
Correct Answer: B
Q7. A 67-year-old patient with a history of coronary artery disease and MDD is being
considered for pharmacotherapy. Which SSRI at standard therapeutic doses carries
the lowest risk of QTc prolongation and is therefore preferred in this patient?
A. Citalopram 40mg daily
B. Escitalopram 20mg daily
C. Fluoxetine 60mg daily
D. Sertraline 200mg daily
B. Escitalopram 20mg daily [CORRECT]
Rationale: Citalopram exhibits dose-dependent QT prolongation via hERG potassium
channel blockade, prompting an FDA warning and a 20mg maximum in patients >60
years; escitalopram, the purified S-enantiomer, demonstrates significantly less QT
effect at equivalent antidepressant doses.
Correct Answer: B
Q8. A 58-year-old patient with type 2 diabetes presents with MDD and reports
burning pain in both feet consistent with diabetic peripheral neuropathy. Which
antidepressant would address both conditions with FDA-approved indications?
