NRNP 6675 MIDTERM EXAM ACTUAL 2026/2027 | PMHNP
Comprehensive Q&A with Explanations | 100% Verified
Answers | Pass Guaranteed - A+ Graded
Section 1: Neurobiology & Psychopharmacology Fundamentals (Q1-20)
Q1. Which neurotransmitter pathway is primarily associated with the therapeutic effects
of selective serotonin reuptake inhibitors (SSRIs)?
A. Dopaminergic mesolimbic pathway
B. Noradrenergic locus coeruleus pathway
C. Serotonergic raphe nuclei pathway [CORRECT]
D. GABAergic interneuron pathway
Rationale: SSRIs block the serotonin transporter (SERT) at the presynaptic membrane of
serotonergic neurons originating in the raphe nuclei, increasing synaptic serotonin
availability. The mesolimbic pathway is dopaminergic, and GABA is inhibitory.
"Correct Answer: C"
Q2. A 45-year-old patient on fluoxetine 40 mg daily is started on tramadol for chronic
back pain. The PMHNP is most concerned about which interaction?
A. Increased risk of serotonin syndrome [CORRECT]
B. Decreased tramadol analgesic effect
C. Increased risk of QT prolongation
D. Decreased fluoxetine efficacy
Rationale: Fluoxetine is a potent CYP2D6 inhibitor and serotonergic agent; tramadol has
serotonergic properties via inhibition of serotonin reuptake. Combined use significantly
increases serotonin syndrome risk. Fluoxetine can reduce tramadol's analgesic effect
,(by inhibiting CYP2D6 conversion to active metabolite M1), but serotonin syndrome is
the most acute life-threatening concern.
"Correct Answer: A"
Q3. A patient with treatment-resistant depression undergoes pharmacogenomic testing.
Results show CYP2D6 poor metabolizer status. Which antidepressant would the
PMHNP most likely AVOID?
A. Sertraline
B. Citalopram
C. Venlafaxine [CORRECT]
D. Mirtazapine
Rationale: Venlafaxine is primarily metabolized by CYP2D6; poor metabolizers have
significantly elevated levels and increased side effects. Sertraline and citalopram are
primarily CYP3A4/CYP2C19 substrates, and mirtazapine is metabolized by multiple CYP
enzymes with less dependence on 2D6.
"Correct Answer: C"
Q4. The mechanism of action of bupropion involves inhibition of which neurotransmitter
reuptake transporters?
A. Serotonin and norepinephrine
B. Dopamine and norepinephrine [CORRECT]
C. Serotonin and dopamine
D. GABA and glutamate
Rationale: Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) with
minimal serotonergic activity, making it useful for depression with fatigue, ADHD, and
smoking cessation but not for anxiety disorders.
,"Correct Answer: B"
Q5. A patient on clozapine develops fever, sore throat, and malaise. Lab results reveal
an absolute neutrophil count (ANC) of 800/mm³. What is the appropriate PMHNP
action?
A. Continue clozapine and monitor weekly
B. Discontinue clozapine immediately; do not rechallenge unless benefits clearly
outweigh risks [CORRECT]
C. Reduce clozapine dose by 50%
D. Start granulocyte colony-stimulating factor (G-CSF) and continue clozapine
Rationale: An ANC of 800/mm³ falls in the severe neutropenia range (500-999/mm³,
orange zone per REMS); clozapine must be discontinued immediately and rechallenge is
generally contraindicated unless exceptional circumstances exist with full informed
consent.
"Correct Answer: B"
Q6. A patient with bipolar disorder is started on aripiprazole while taking
carbamazepine. The PMHNP should:
A. Decrease the aripiprazole dose because carbamazepine inhibits CYP3A4
B. Increase the aripiprazole dose because carbamazepine is a CYP3A4 inducer
[CORRECT]
C. No dose adjustment is needed
D. Discontinue carbamazepine
Rationale: Carbamazepine is a potent CYP3A4 inducer that significantly reduces
aripiprazole levels; the aripiprazole dose should be doubled when used concomitantly
with strong CYP3A4 inducers like carbamazepine.
"Correct Answer: B"
, Q7. A patient with bipolar disorder is started on lithium carbonate. Which baseline
laboratory studies are REQUIRED before initiating therapy?
A. CBC, comprehensive metabolic panel, TSH, ECG, and pregnancy test [CORRECT]
B. CBC and urinalysis only
C. TSH and lipid panel only
D. ECG and chest X-ray only
Rationale: Lithium requires baseline CBC (to monitor for leukocytosis later), CMP with
creatinine/eGFR and electrolytes (lithium is renally cleared), TSH (lithium affects
thyroid), ECG (especially if >40 or cardiac history), and pregnancy test if applicable.
Lithium is cleared renally and affects multiple organ systems.
"Correct Answer: A"
Q8. Pharmacogenomic testing reveals a patient is a CYP2C19 rapid metabolizer. Which
medication may require a higher-than-standard dose to achieve therapeutic effect?
A. Sertraline
B. Escitalopram [CORRECT]
C. Fluoxetine
D. Paroxetine
Rationale: Escitalopram is primarily metabolized by CYP2C19 and CYP3A4; rapid
metabolizers may have subtherapeutic levels at standard doses. Sertraline and
fluoxetine are less dependent on CYP2C19, and paroxetine is primarily CYP2D6.
"Correct Answer: B"
Q9. The primary mechanism of action of vortioxetine differs from other SSRIs because
it also acts as a:
Comprehensive Q&A with Explanations | 100% Verified
Answers | Pass Guaranteed - A+ Graded
Section 1: Neurobiology & Psychopharmacology Fundamentals (Q1-20)
Q1. Which neurotransmitter pathway is primarily associated with the therapeutic effects
of selective serotonin reuptake inhibitors (SSRIs)?
A. Dopaminergic mesolimbic pathway
B. Noradrenergic locus coeruleus pathway
C. Serotonergic raphe nuclei pathway [CORRECT]
D. GABAergic interneuron pathway
Rationale: SSRIs block the serotonin transporter (SERT) at the presynaptic membrane of
serotonergic neurons originating in the raphe nuclei, increasing synaptic serotonin
availability. The mesolimbic pathway is dopaminergic, and GABA is inhibitory.
"Correct Answer: C"
Q2. A 45-year-old patient on fluoxetine 40 mg daily is started on tramadol for chronic
back pain. The PMHNP is most concerned about which interaction?
A. Increased risk of serotonin syndrome [CORRECT]
B. Decreased tramadol analgesic effect
C. Increased risk of QT prolongation
D. Decreased fluoxetine efficacy
Rationale: Fluoxetine is a potent CYP2D6 inhibitor and serotonergic agent; tramadol has
serotonergic properties via inhibition of serotonin reuptake. Combined use significantly
increases serotonin syndrome risk. Fluoxetine can reduce tramadol's analgesic effect
,(by inhibiting CYP2D6 conversion to active metabolite M1), but serotonin syndrome is
the most acute life-threatening concern.
"Correct Answer: A"
Q3. A patient with treatment-resistant depression undergoes pharmacogenomic testing.
Results show CYP2D6 poor metabolizer status. Which antidepressant would the
PMHNP most likely AVOID?
A. Sertraline
B. Citalopram
C. Venlafaxine [CORRECT]
D. Mirtazapine
Rationale: Venlafaxine is primarily metabolized by CYP2D6; poor metabolizers have
significantly elevated levels and increased side effects. Sertraline and citalopram are
primarily CYP3A4/CYP2C19 substrates, and mirtazapine is metabolized by multiple CYP
enzymes with less dependence on 2D6.
"Correct Answer: C"
Q4. The mechanism of action of bupropion involves inhibition of which neurotransmitter
reuptake transporters?
A. Serotonin and norepinephrine
B. Dopamine and norepinephrine [CORRECT]
C. Serotonin and dopamine
D. GABA and glutamate
Rationale: Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) with
minimal serotonergic activity, making it useful for depression with fatigue, ADHD, and
smoking cessation but not for anxiety disorders.
,"Correct Answer: B"
Q5. A patient on clozapine develops fever, sore throat, and malaise. Lab results reveal
an absolute neutrophil count (ANC) of 800/mm³. What is the appropriate PMHNP
action?
A. Continue clozapine and monitor weekly
B. Discontinue clozapine immediately; do not rechallenge unless benefits clearly
outweigh risks [CORRECT]
C. Reduce clozapine dose by 50%
D. Start granulocyte colony-stimulating factor (G-CSF) and continue clozapine
Rationale: An ANC of 800/mm³ falls in the severe neutropenia range (500-999/mm³,
orange zone per REMS); clozapine must be discontinued immediately and rechallenge is
generally contraindicated unless exceptional circumstances exist with full informed
consent.
"Correct Answer: B"
Q6. A patient with bipolar disorder is started on aripiprazole while taking
carbamazepine. The PMHNP should:
A. Decrease the aripiprazole dose because carbamazepine inhibits CYP3A4
B. Increase the aripiprazole dose because carbamazepine is a CYP3A4 inducer
[CORRECT]
C. No dose adjustment is needed
D. Discontinue carbamazepine
Rationale: Carbamazepine is a potent CYP3A4 inducer that significantly reduces
aripiprazole levels; the aripiprazole dose should be doubled when used concomitantly
with strong CYP3A4 inducers like carbamazepine.
"Correct Answer: B"
, Q7. A patient with bipolar disorder is started on lithium carbonate. Which baseline
laboratory studies are REQUIRED before initiating therapy?
A. CBC, comprehensive metabolic panel, TSH, ECG, and pregnancy test [CORRECT]
B. CBC and urinalysis only
C. TSH and lipid panel only
D. ECG and chest X-ray only
Rationale: Lithium requires baseline CBC (to monitor for leukocytosis later), CMP with
creatinine/eGFR and electrolytes (lithium is renally cleared), TSH (lithium affects
thyroid), ECG (especially if >40 or cardiac history), and pregnancy test if applicable.
Lithium is cleared renally and affects multiple organ systems.
"Correct Answer: A"
Q8. Pharmacogenomic testing reveals a patient is a CYP2C19 rapid metabolizer. Which
medication may require a higher-than-standard dose to achieve therapeutic effect?
A. Sertraline
B. Escitalopram [CORRECT]
C. Fluoxetine
D. Paroxetine
Rationale: Escitalopram is primarily metabolized by CYP2C19 and CYP3A4; rapid
metabolizers may have subtherapeutic levels at standard doses. Sertraline and
fluoxetine are less dependent on CYP2C19, and paroxetine is primarily CYP2D6.
"Correct Answer: B"
Q9. The primary mechanism of action of vortioxetine differs from other SSRIs because
it also acts as a:
