1
NRNP 6675 FINAL EXAM LATEST 2026/2027 |
Advanced PMHNP Clinical Practice | Most
Comprehensive | 100% Verified Answers | Updated |
Pass Guaranteed - A+ Graded
Section 1: Advanced Psychopharmacology - Complex Medication Regimens (Q1-
18)
Question 1 A 34-year-old patient with bipolar I disorder, currently manic with
psychotic features, has failed lithium monotherapy due to intolerable tremor and
polyuria. The patient requires an antimanic agent with demonstrated efficacy for
acute mania and maintenance therapy, plus robust antidepressant properties for
future depressive episodes. Which medication best meets these criteria? A.
Lamotrigine monotherapy B. Quetiapine extended-release C. Lurasidone
monotherapy D. Valproic acid monotherapy
B. Quetiapine extended-release [CORRECT]
Rationale: Quetiapine XR is FDA-approved for acute mania, bipolar maintenance, and
bipolar depression, making it uniquely suitable for patients requiring both antimanic
and antidepressant efficacy across mood episodes. Lamotrigine is primarily for
depression prevention, lurasidone lacks acute mania indication as monotherapy, and
valproic acid lacks robust antidepressant data. Quetiapine also addresses psychotic
features without requiring additional antipsychotic polypharmacy.
Correct Answer: B
Question 2 A 29-year-old with treatment-resistant major depressive disorder has
failed trials of sertraline 200 mg, venlafaxine XR 225 mg, and augmentation with
lithium 900 mg. The patient remains severely depressed with suicidal ideation but no
active plan. Which intervention is most appropriate according to current STAR*D and
ANCC guidelines? A. Switch to escitalopram 20 mg monotherapy B. Initiate
esketamine nasal spray with REMS enrollment C. Add aripiprazole 2 mg daily to
current antidepressant D. Refer immediately for ECT without further pharmacologic
trials
,2
B. Initiate esketamine nasal spray with REMS enrollment [CORRECT]
Rationale: After failure of two antidepressant trials and lithium augmentation, the
patient meets criteria for treatment-resistant depression. Esketamine is FDA-
approved for TRD with suicidal ideation and requires REMS enrollment due to
dissociation and sedation risks. ECT is appropriate for TRD but esketamine is less
invasive and can be initiated in outpatient settings with proper monitoring.
Aripiprazole augmentation is typically used earlier in the algorithm.
Correct Answer: B
Question 3 A 42-year-old with schizophrenia has failed trials of risperidone,
olanzapine, and aripiprazole due to persistent positive symptoms and intolerable
metabolic effects. The PMHNP considers clozapine initiation. Which baseline
laboratory requirement must be completed before the first dose can be dispensed?
A. Comprehensive metabolic panel and fasting lipid panel B. Absolute neutrophil
count (ANC) and registration in the Clozapine REMS program C. Liver function tests
and serum creatinine D. Thyroid function tests and prolactin level
B. Absolute neutrophil count (ANC) and registration in the Clozapine REMS program
[CORRECT]
Rationale: Clozapine carries a black box warning for agranulocytosis and is available
only through the Clozapine REMS program. An ANC must be obtained prior to
initiation, and the prescriber, pharmacy, and patient must all be enrolled in REMS.
While metabolic monitoring is essential for all SGAs, the ANC and REMS enrollment
are non-negotiable prerequisites specific to clozapine that prevent dispensing.
Correct Answer: B
Question 4 A 38-year-old patient with bipolar I disorder in a depressive episode is
currently on lithium 1200 mg (level 0.8 mEq/L) and reports persistent anhedonia and
fatigue. The PMHNP considers augmentation. Which agent has the strongest
evidence for bipolar depression augmentation without inducing mania? A. Bupropion
XL 150 mg B. Lamotrigine titrated to 200 mg C. Fluoxetine 20 mg D. Methylphenidate
10 mg
B. Lamotrigine titrated to 200 mg [CORRECT]
Rationale: Lamotrigine is FDA-approved for bipolar I maintenance to delay mood
episodes, with strongest evidence for preventing depressive relapse. Unlike
,3
antidepressants, lamotrigine carries minimal risk of mood elevation or cycle
acceleration. Bupropion and fluoxetine carry significant mania induction risk in
bipolar I, and methylphenidate lacks robust evidence for bipolar depression and may
worsen mood cycling.
Correct Answer: B
Question 5 A 55-year-old with chronic schizophrenia on clozapine 400 mg daily has
been stable for 18 months. The patient reports constipation for 3 weeks, abdominal
distension, and has not had a bowel movement in 5 days. Vital signs show
tachycardia 112 bpm. Which action is most critical? A. Reduce clozapine to 300 mg
and add docusate sodium B. Obtain abdominal X-ray and initiate aggressive bowel
regimen immediately C. Switch to olanzapine 20 mg due to clozapine GI toxicity D.
Recommend increased dietary fiber and hydration alone
B. Obtain abdominal X-ray and initiate aggressive bowel regimen immediately
[CORRECT]
Rationale: Clozapine-induced constipation is the leading cause of clozapine-related
mortality, often progressing to paralytic ileus, bowel obstruction, and fatal
complications. Tachycardia with abdominal distension and obstipation requires
immediate imaging to rule out obstruction and aggressive bowel regimen (docusate,
senna, polyethylene glycol, possible lubiprostone). Reducing the dose alone or
switching medications is insufficient for acute management.
Correct Answer: B
Question 6 A 26-year-old with bipolar II disorder presents with a current depressive
episode. The patient has rapid cycling (4 episodes in 12 months). Which medication
strategy is most consistent with current evidence and safety guidelines? A. Initiate
fluoxetine 20 mg with lithium 900 mg B. Initiate lamotrigine titration with quetiapine
XR 300 mg C. Initiate venlafaxine XR 150 mg with valproic acid D. Initiate
carbamazepine 400 mg with bupropion XL 300 mg
B. Initiate lamotrigine titration with quetiapine XR 300 mg [CORRECT]
Rationale: In bipolar II with rapid cycling, lamotrigine is preferred for depression
prevention and quetiapine provides acute antidepressant and antimanic effects
without destabilizing mood cycles. Antidepressants (fluoxetine, venlafaxine,
bupropion) are generally contraindicated in rapid-cycling bipolar disorder due to
, 4
cycle acceleration and mood destabilization risks. Carbamazepine has significant
drug interactions and teratogenicity concerns.
Correct Answer: B
Question 7 A 45-year-old with MDD and comorbid generalized anxiety disorder has
been on escitalopram 20 mg for 8 weeks with partial response. The PMHNP
considers augmentation. Which combination provides complementary mechanisms
for both depression and anxiety without significant CYP450 interaction? A. Add
fluoxetine 20 mg daily B. Add buspirone 15 mg twice daily C. Add bupropion XL 150
mg daily D. Add mirtazapine 15 mg nightly
B. Add buspirone 15 mg twice daily [CORRECT]
Rationale: Buspirone is a 5-HT1A partial agonist FDA-approved for GAD that
augments SSRIs for depression and anxiety through complementary serotonergic
mechanisms. It has minimal CYP450 interactions and does not worsen anxiety
activation. Adding fluoxetine (another SSRI) is redundant and increases serotonin
syndrome risk. Bupropion lacks anxiolytic properties and may worsen anxiety.
Mirtazapine is reasonable but causes sedation and weight gain.
Correct Answer: B
Question 8 A 62-year-old with TRD on sertraline 150 mg and aripiprazole 5 mg
reports continued anhedonia. The PMHNP considers switching the augmentation
agent to brexpiprazole. What is the primary pharmacologic advantage of
brexpiprazole over aripiprazole in this population? A. Greater D2 receptor
antagonism reducing psychosis risk B. Lower intrinsic D2 partial agonist activity
causing less akathisia and activation C. Stronger 5-HT2A antagonism for faster
antidepressant onset D. Potent H1 antagonism for improved sleep architecture
B. Lower intrinsic D2 partial agonist activity causing less akathisia and activation
[CORRECT]
Rationale: Brexpiprazole is a D2 partial agonist with lower intrinsic activity at D2
receptors compared to aripiprazole, resulting in reduced akathisia, restlessness, and
activation while maintaining antidepressant efficacy through 5-HT1A partial agonism
and 5-HT2A antagonism. This improved tolerability profile is particularly
advantageous in older adults and those sensitive to aripiprazole's activating side
effects.
NRNP 6675 FINAL EXAM LATEST 2026/2027 |
Advanced PMHNP Clinical Practice | Most
Comprehensive | 100% Verified Answers | Updated |
Pass Guaranteed - A+ Graded
Section 1: Advanced Psychopharmacology - Complex Medication Regimens (Q1-
18)
Question 1 A 34-year-old patient with bipolar I disorder, currently manic with
psychotic features, has failed lithium monotherapy due to intolerable tremor and
polyuria. The patient requires an antimanic agent with demonstrated efficacy for
acute mania and maintenance therapy, plus robust antidepressant properties for
future depressive episodes. Which medication best meets these criteria? A.
Lamotrigine monotherapy B. Quetiapine extended-release C. Lurasidone
monotherapy D. Valproic acid monotherapy
B. Quetiapine extended-release [CORRECT]
Rationale: Quetiapine XR is FDA-approved for acute mania, bipolar maintenance, and
bipolar depression, making it uniquely suitable for patients requiring both antimanic
and antidepressant efficacy across mood episodes. Lamotrigine is primarily for
depression prevention, lurasidone lacks acute mania indication as monotherapy, and
valproic acid lacks robust antidepressant data. Quetiapine also addresses psychotic
features without requiring additional antipsychotic polypharmacy.
Correct Answer: B
Question 2 A 29-year-old with treatment-resistant major depressive disorder has
failed trials of sertraline 200 mg, venlafaxine XR 225 mg, and augmentation with
lithium 900 mg. The patient remains severely depressed with suicidal ideation but no
active plan. Which intervention is most appropriate according to current STAR*D and
ANCC guidelines? A. Switch to escitalopram 20 mg monotherapy B. Initiate
esketamine nasal spray with REMS enrollment C. Add aripiprazole 2 mg daily to
current antidepressant D. Refer immediately for ECT without further pharmacologic
trials
,2
B. Initiate esketamine nasal spray with REMS enrollment [CORRECT]
Rationale: After failure of two antidepressant trials and lithium augmentation, the
patient meets criteria for treatment-resistant depression. Esketamine is FDA-
approved for TRD with suicidal ideation and requires REMS enrollment due to
dissociation and sedation risks. ECT is appropriate for TRD but esketamine is less
invasive and can be initiated in outpatient settings with proper monitoring.
Aripiprazole augmentation is typically used earlier in the algorithm.
Correct Answer: B
Question 3 A 42-year-old with schizophrenia has failed trials of risperidone,
olanzapine, and aripiprazole due to persistent positive symptoms and intolerable
metabolic effects. The PMHNP considers clozapine initiation. Which baseline
laboratory requirement must be completed before the first dose can be dispensed?
A. Comprehensive metabolic panel and fasting lipid panel B. Absolute neutrophil
count (ANC) and registration in the Clozapine REMS program C. Liver function tests
and serum creatinine D. Thyroid function tests and prolactin level
B. Absolute neutrophil count (ANC) and registration in the Clozapine REMS program
[CORRECT]
Rationale: Clozapine carries a black box warning for agranulocytosis and is available
only through the Clozapine REMS program. An ANC must be obtained prior to
initiation, and the prescriber, pharmacy, and patient must all be enrolled in REMS.
While metabolic monitoring is essential for all SGAs, the ANC and REMS enrollment
are non-negotiable prerequisites specific to clozapine that prevent dispensing.
Correct Answer: B
Question 4 A 38-year-old patient with bipolar I disorder in a depressive episode is
currently on lithium 1200 mg (level 0.8 mEq/L) and reports persistent anhedonia and
fatigue. The PMHNP considers augmentation. Which agent has the strongest
evidence for bipolar depression augmentation without inducing mania? A. Bupropion
XL 150 mg B. Lamotrigine titrated to 200 mg C. Fluoxetine 20 mg D. Methylphenidate
10 mg
B. Lamotrigine titrated to 200 mg [CORRECT]
Rationale: Lamotrigine is FDA-approved for bipolar I maintenance to delay mood
episodes, with strongest evidence for preventing depressive relapse. Unlike
,3
antidepressants, lamotrigine carries minimal risk of mood elevation or cycle
acceleration. Bupropion and fluoxetine carry significant mania induction risk in
bipolar I, and methylphenidate lacks robust evidence for bipolar depression and may
worsen mood cycling.
Correct Answer: B
Question 5 A 55-year-old with chronic schizophrenia on clozapine 400 mg daily has
been stable for 18 months. The patient reports constipation for 3 weeks, abdominal
distension, and has not had a bowel movement in 5 days. Vital signs show
tachycardia 112 bpm. Which action is most critical? A. Reduce clozapine to 300 mg
and add docusate sodium B. Obtain abdominal X-ray and initiate aggressive bowel
regimen immediately C. Switch to olanzapine 20 mg due to clozapine GI toxicity D.
Recommend increased dietary fiber and hydration alone
B. Obtain abdominal X-ray and initiate aggressive bowel regimen immediately
[CORRECT]
Rationale: Clozapine-induced constipation is the leading cause of clozapine-related
mortality, often progressing to paralytic ileus, bowel obstruction, and fatal
complications. Tachycardia with abdominal distension and obstipation requires
immediate imaging to rule out obstruction and aggressive bowel regimen (docusate,
senna, polyethylene glycol, possible lubiprostone). Reducing the dose alone or
switching medications is insufficient for acute management.
Correct Answer: B
Question 6 A 26-year-old with bipolar II disorder presents with a current depressive
episode. The patient has rapid cycling (4 episodes in 12 months). Which medication
strategy is most consistent with current evidence and safety guidelines? A. Initiate
fluoxetine 20 mg with lithium 900 mg B. Initiate lamotrigine titration with quetiapine
XR 300 mg C. Initiate venlafaxine XR 150 mg with valproic acid D. Initiate
carbamazepine 400 mg with bupropion XL 300 mg
B. Initiate lamotrigine titration with quetiapine XR 300 mg [CORRECT]
Rationale: In bipolar II with rapid cycling, lamotrigine is preferred for depression
prevention and quetiapine provides acute antidepressant and antimanic effects
without destabilizing mood cycles. Antidepressants (fluoxetine, venlafaxine,
bupropion) are generally contraindicated in rapid-cycling bipolar disorder due to
, 4
cycle acceleration and mood destabilization risks. Carbamazepine has significant
drug interactions and teratogenicity concerns.
Correct Answer: B
Question 7 A 45-year-old with MDD and comorbid generalized anxiety disorder has
been on escitalopram 20 mg for 8 weeks with partial response. The PMHNP
considers augmentation. Which combination provides complementary mechanisms
for both depression and anxiety without significant CYP450 interaction? A. Add
fluoxetine 20 mg daily B. Add buspirone 15 mg twice daily C. Add bupropion XL 150
mg daily D. Add mirtazapine 15 mg nightly
B. Add buspirone 15 mg twice daily [CORRECT]
Rationale: Buspirone is a 5-HT1A partial agonist FDA-approved for GAD that
augments SSRIs for depression and anxiety through complementary serotonergic
mechanisms. It has minimal CYP450 interactions and does not worsen anxiety
activation. Adding fluoxetine (another SSRI) is redundant and increases serotonin
syndrome risk. Bupropion lacks anxiolytic properties and may worsen anxiety.
Mirtazapine is reasonable but causes sedation and weight gain.
Correct Answer: B
Question 8 A 62-year-old with TRD on sertraline 150 mg and aripiprazole 5 mg
reports continued anhedonia. The PMHNP considers switching the augmentation
agent to brexpiprazole. What is the primary pharmacologic advantage of
brexpiprazole over aripiprazole in this population? A. Greater D2 receptor
antagonism reducing psychosis risk B. Lower intrinsic D2 partial agonist activity
causing less akathisia and activation C. Stronger 5-HT2A antagonism for faster
antidepressant onset D. Potent H1 antagonism for improved sleep architecture
B. Lower intrinsic D2 partial agonist activity causing less akathisia and activation
[CORRECT]
Rationale: Brexpiprazole is a D2 partial agonist with lower intrinsic activity at D2
receptors compared to aripiprazole, resulting in reduced akathisia, restlessness, and
activation while maintaining antidepressant efficacy through 5-HT1A partial agonism
and 5-HT2A antagonism. This improved tolerability profile is particularly
advantageous in older adults and those sensitive to aripiprazole's activating side
effects.
