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NRNP 6675 FINAL EXAM ACTUAL 2026/2027 | PMHNP
Comprehensive Q&A with Explanations | 100%
Verified Updated Answers | Pass Guaranteed - A+
Graded
Section 1: Complex Psychopharmacology & Polypharmacy Management (Q1-20)
Q1. A 34-year-old patient with major depressive disorder is prescribed tramadol for
chronic back pain by their primary care provider while already taking sertraline 100
mg daily. Within 48 hours, the patient presents to the emergency department with
confusion, hyperreflexia, clonus, and temperature of 39.2°C. Which neurotoxic
syndrome is most likely developing? A. Neuroleptic malignant syndrome B. Serotonin
syndrome [CORRECT] C. Malignant hyperthermia D. Anticholinergic toxicity
Rationale: Serotonin syndrome is characterized by the triad of mental status changes,
autonomic instability, and neuromuscular abnormalities (clonus, hyperreflexia)
resulting from excessive serotonergic activity. The combination of an SSRI (sertraline)
and tramadol—which has SNRI properties and is a weak opioid—precipitates this
potentially fatal syndrome. NMS presents with lead-pipe rigidity and bradyreflexia,
while anticholinergic toxicity shows "mad as a hatter, blind as a bat, red as a beet, hot
as a hare, dry as a bone."
Correct Answer: B
Q2. A PMHNP reviews pharmacogenomic testing for a patient starting nortriptyline.
The report indicates the patient is a CYP2D6 poor metabolizer. Which clinical
implication is most accurate? A. The patient will require higher doses of nortriptyline
to achieve therapeutic effect B. The patient is at increased risk for nortriptyline
toxicity due to reduced clearance [CORRECT] C. The patient will metabolize
nortriptyline normally because it is primarily metabolized by CYP3A4 D. The patient
should avoid nortriptyline and use codeine instead
Rationale: Nortriptyline is primarily metabolized by CYP2D6. Poor metabolizers have
significantly reduced clearance, leading to elevated plasma levels and increased risk
of adverse effects including cardiotoxicity and anticholinergic symptoms. Dose
reduction or alternative agents are recommended. Codeine is also metabolized by
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CYP2D6 to morphine, so poor metabolizers would have inadequate analgesia with
codeine.
Correct Answer: B
Q3. A 28-year-old patient on clozapine 400 mg daily reports smoking cessation after
10 years of heavy tobacco use. Two weeks later, the patient presents with sedation,
dizziness, and orthostatic hypotension. Which cytochrome P450 mechanism explains
this change? A. Tobacco is a CYP3A4 inhibitor; cessation increases clozapine levels B.
Tobacco is a CYP1A2 inducer; cessation increases clozapine levels due to reduced
metabolism [CORRECT] C. Tobacco is a CYP2D6 inducer; cessation decreases
clozapine levels D. Tobacco is a CYP2C19 inhibitor; cessation has no effect on
clozapine
Rationale: Polycyclic aromatic hydrocarbons in tobacco smoke induce CYP1A2, which
metabolizes clozapine and olanzapine. Smoking cessation removes this induction,
reducing clozapine clearance by up to 50% and potentially causing toxicity. The dose
should be reduced by approximately 30-40% when patients stop smoking.
Correct Answer: B
Q4. A patient with bipolar disorder taking carbamazepine 800 mg daily is started on
aripiprazole 10 mg daily. After 4 weeks, the patient reports increased restlessness
and akathisia despite a low aripiprazole dose. Which pharmacokinetic interaction is
most likely responsible? A. Carbamazepine inhibits CYP3A4, increasing aripiprazole
levels B. Carbamazepine induces CYP3A4, decreasing aripiprazole levels and
necessitating dose adjustment C. Carbamazepine induces CYP3A4, decreasing
aripiprazole levels and causing paradoxical activation symptoms [CORRECT] D.
Carbamazepine inhibits CYP2D6, increasing aripiprazole levels
Rationale: Carbamazepine is a potent CYP3A4 inducer. Aripiprazole is metabolized
primarily by CYP2D6 and CYP3A4. Strong CYP3A4 induction by carbamazepine
significantly reduces aripiprazole plasma levels, potentially leading to subtherapeutic
dosing and paradoxical activation symptoms including akathisia. The aripiprazole
dose should be doubled when co-administered with strong CYP3A4 inducers.
Correct Answer: C
Q5. A patient with treatment-resistant depression is being considered for phenelzine.
The PMHNP counsels the patient on dietary restrictions. Which food item is SAFE to
,3
consume while taking an irreversible MAOI? A. Aged cheddar cheese B. Fermented
soy sauce C. Fresh mozzarella cheese [CORRECT] D. Smoked salmon
Rationale: Fresh mozzarella is a non-aged cheese with low tyramine content and is
generally safe with MAOIs. Aged cheeses, fermented products (soy sauce,
sauerkraut), cured/smoked meats, and tap beers contain high tyramine levels that
can precipitate hypertensive crisis due to inhibition of MAO-A in the gut and
platelets. Patients must avoid foods with >6 mg tyramine per serving.
Correct Answer: C
Q6. A patient taking ziprasidone 80 mg BID presents for a routine EKG. The QTc
interval is measured at 520 ms. Which action is most appropriate? A. Continue
ziprasidone and recheck in 6 months B. Discontinue ziprasidone immediately and
obtain cardiology consultation [CORRECT] C. Reduce ziprasidone to 40 mg BID and
add citalopram D. Switch to haloperidol without further monitoring
Rationale: Ziprasidone is associated with dose-dependent QTc prolongation. A QTc
≥500 ms or an increase >60 ms from baseline warrants immediate discontinuation
and cardiology evaluation due to risk of torsades de pointes. Citalopram also
prolongs QTc and is contraindicated. Haloperidol has a black box warning for QTc
prolongation and requires monitoring.
Correct Answer: B
Q7. A 45-year-old patient with schizophrenia is prescribed clozapine. The baseline
absolute neutrophil count (ANC) is 4,200/mm³. After 3 weeks, the ANC is 1,800/mm³.
According to Clozapine REMS, which action is required? A. Continue clozapine with
weekly monitoring B. Interrupt clozapine therapy and monitor ANC daily until
≥1,000/mm³, then resume with twice-weekly monitoring [CORRECT] C. Permanently
discontinue clozapine D. Reduce dose by 50% and monitor monthly
Rationale: Per Clozapine REMS, an ANC between 500-999/mm³ (moderate
neutropenia) requires interruption of therapy, daily ANC monitoring until
≥1,000/mm³, and resumption with twice-weekly monitoring. ANC <500/mm³
requires permanent discontinuation. ANC 1,000-1,499 requires weekly monitoring
but continuation.
Correct Answer: B
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Q8. A patient with ADHD is taking mixed amphetamine salts 30 mg daily. The patient
is diagnosed with depression and the PMHNP considers adding an antidepressant.
Which combination poses the highest risk for hypertensive crisis? A. Sertraline and
amphetamine B. Bupropion and amphetamine C. Tranylcypromine and amphetamine
[CORRECT] D. Mirtazapine and amphetamine
Rationale: The combination of an MAOI (tranylcypromine) with amphetamines is
absolutely contraindicated due to the risk of hypertensive crisis, hyperthermia, and
serotonin syndrome from enhanced catecholamine and serotonin release. While
bupropion and amphetamines both increase norepinephrine and dopamine, the
MAOI-amphetamine combination carries the most immediate life-threatening risk.
Correct Answer: C
Q9. A patient with generalized anxiety disorder is taking buspirone 15 mg BID. The
patient is started on erythromycin for a respiratory infection. Which interaction is
most concerning? A. Erythromycin inhibits CYP3A4, increasing buspirone levels and
risk of serotonin syndrome B. Erythromycin inhibits CYP3A4, increasing buspirone
levels and risk of dizziness and hypotension [CORRECT] C. Erythromycin induces
CYP2D6, decreasing buspirone levels D. No significant interaction exists between
these agents
Rationale: Buspirone is metabolized primarily by CYP3A4. Erythromycin is a potent
CYP3A4 inhibitor that can significantly increase buspirone plasma concentrations,
leading to enhanced adverse effects including dizziness, nausea, and hypotension.
Dose reduction or temporary discontinuation of buspirone should be considered.
Correct Answer: B
Q10. A patient with schizophrenia is prescribed a long-acting injectable
antipsychotic. The PMHNP selects paliperidone palmitate. Which statement
regarding administration is correct? A. It requires oral antipsychotic supplementation
for the first 21 days B. It requires deltoid administration for the first two doses, then
gluteal [CORRECT] C. It can be administered subcutaneously D. It requires monthly
dosing only with no loading option
Rationale: Paliperidone palmitate requires initiation with deltoid injections (day 1 and
day 8) to achieve therapeutic plasma levels rapidly, followed by monthly gluteal or
NRNP 6675 FINAL EXAM ACTUAL 2026/2027 | PMHNP
Comprehensive Q&A with Explanations | 100%
Verified Updated Answers | Pass Guaranteed - A+
Graded
Section 1: Complex Psychopharmacology & Polypharmacy Management (Q1-20)
Q1. A 34-year-old patient with major depressive disorder is prescribed tramadol for
chronic back pain by their primary care provider while already taking sertraline 100
mg daily. Within 48 hours, the patient presents to the emergency department with
confusion, hyperreflexia, clonus, and temperature of 39.2°C. Which neurotoxic
syndrome is most likely developing? A. Neuroleptic malignant syndrome B. Serotonin
syndrome [CORRECT] C. Malignant hyperthermia D. Anticholinergic toxicity
Rationale: Serotonin syndrome is characterized by the triad of mental status changes,
autonomic instability, and neuromuscular abnormalities (clonus, hyperreflexia)
resulting from excessive serotonergic activity. The combination of an SSRI (sertraline)
and tramadol—which has SNRI properties and is a weak opioid—precipitates this
potentially fatal syndrome. NMS presents with lead-pipe rigidity and bradyreflexia,
while anticholinergic toxicity shows "mad as a hatter, blind as a bat, red as a beet, hot
as a hare, dry as a bone."
Correct Answer: B
Q2. A PMHNP reviews pharmacogenomic testing for a patient starting nortriptyline.
The report indicates the patient is a CYP2D6 poor metabolizer. Which clinical
implication is most accurate? A. The patient will require higher doses of nortriptyline
to achieve therapeutic effect B. The patient is at increased risk for nortriptyline
toxicity due to reduced clearance [CORRECT] C. The patient will metabolize
nortriptyline normally because it is primarily metabolized by CYP3A4 D. The patient
should avoid nortriptyline and use codeine instead
Rationale: Nortriptyline is primarily metabolized by CYP2D6. Poor metabolizers have
significantly reduced clearance, leading to elevated plasma levels and increased risk
of adverse effects including cardiotoxicity and anticholinergic symptoms. Dose
reduction or alternative agents are recommended. Codeine is also metabolized by
,2
CYP2D6 to morphine, so poor metabolizers would have inadequate analgesia with
codeine.
Correct Answer: B
Q3. A 28-year-old patient on clozapine 400 mg daily reports smoking cessation after
10 years of heavy tobacco use. Two weeks later, the patient presents with sedation,
dizziness, and orthostatic hypotension. Which cytochrome P450 mechanism explains
this change? A. Tobacco is a CYP3A4 inhibitor; cessation increases clozapine levels B.
Tobacco is a CYP1A2 inducer; cessation increases clozapine levels due to reduced
metabolism [CORRECT] C. Tobacco is a CYP2D6 inducer; cessation decreases
clozapine levels D. Tobacco is a CYP2C19 inhibitor; cessation has no effect on
clozapine
Rationale: Polycyclic aromatic hydrocarbons in tobacco smoke induce CYP1A2, which
metabolizes clozapine and olanzapine. Smoking cessation removes this induction,
reducing clozapine clearance by up to 50% and potentially causing toxicity. The dose
should be reduced by approximately 30-40% when patients stop smoking.
Correct Answer: B
Q4. A patient with bipolar disorder taking carbamazepine 800 mg daily is started on
aripiprazole 10 mg daily. After 4 weeks, the patient reports increased restlessness
and akathisia despite a low aripiprazole dose. Which pharmacokinetic interaction is
most likely responsible? A. Carbamazepine inhibits CYP3A4, increasing aripiprazole
levels B. Carbamazepine induces CYP3A4, decreasing aripiprazole levels and
necessitating dose adjustment C. Carbamazepine induces CYP3A4, decreasing
aripiprazole levels and causing paradoxical activation symptoms [CORRECT] D.
Carbamazepine inhibits CYP2D6, increasing aripiprazole levels
Rationale: Carbamazepine is a potent CYP3A4 inducer. Aripiprazole is metabolized
primarily by CYP2D6 and CYP3A4. Strong CYP3A4 induction by carbamazepine
significantly reduces aripiprazole plasma levels, potentially leading to subtherapeutic
dosing and paradoxical activation symptoms including akathisia. The aripiprazole
dose should be doubled when co-administered with strong CYP3A4 inducers.
Correct Answer: C
Q5. A patient with treatment-resistant depression is being considered for phenelzine.
The PMHNP counsels the patient on dietary restrictions. Which food item is SAFE to
,3
consume while taking an irreversible MAOI? A. Aged cheddar cheese B. Fermented
soy sauce C. Fresh mozzarella cheese [CORRECT] D. Smoked salmon
Rationale: Fresh mozzarella is a non-aged cheese with low tyramine content and is
generally safe with MAOIs. Aged cheeses, fermented products (soy sauce,
sauerkraut), cured/smoked meats, and tap beers contain high tyramine levels that
can precipitate hypertensive crisis due to inhibition of MAO-A in the gut and
platelets. Patients must avoid foods with >6 mg tyramine per serving.
Correct Answer: C
Q6. A patient taking ziprasidone 80 mg BID presents for a routine EKG. The QTc
interval is measured at 520 ms. Which action is most appropriate? A. Continue
ziprasidone and recheck in 6 months B. Discontinue ziprasidone immediately and
obtain cardiology consultation [CORRECT] C. Reduce ziprasidone to 40 mg BID and
add citalopram D. Switch to haloperidol without further monitoring
Rationale: Ziprasidone is associated with dose-dependent QTc prolongation. A QTc
≥500 ms or an increase >60 ms from baseline warrants immediate discontinuation
and cardiology evaluation due to risk of torsades de pointes. Citalopram also
prolongs QTc and is contraindicated. Haloperidol has a black box warning for QTc
prolongation and requires monitoring.
Correct Answer: B
Q7. A 45-year-old patient with schizophrenia is prescribed clozapine. The baseline
absolute neutrophil count (ANC) is 4,200/mm³. After 3 weeks, the ANC is 1,800/mm³.
According to Clozapine REMS, which action is required? A. Continue clozapine with
weekly monitoring B. Interrupt clozapine therapy and monitor ANC daily until
≥1,000/mm³, then resume with twice-weekly monitoring [CORRECT] C. Permanently
discontinue clozapine D. Reduce dose by 50% and monitor monthly
Rationale: Per Clozapine REMS, an ANC between 500-999/mm³ (moderate
neutropenia) requires interruption of therapy, daily ANC monitoring until
≥1,000/mm³, and resumption with twice-weekly monitoring. ANC <500/mm³
requires permanent discontinuation. ANC 1,000-1,499 requires weekly monitoring
but continuation.
Correct Answer: B
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Q8. A patient with ADHD is taking mixed amphetamine salts 30 mg daily. The patient
is diagnosed with depression and the PMHNP considers adding an antidepressant.
Which combination poses the highest risk for hypertensive crisis? A. Sertraline and
amphetamine B. Bupropion and amphetamine C. Tranylcypromine and amphetamine
[CORRECT] D. Mirtazapine and amphetamine
Rationale: The combination of an MAOI (tranylcypromine) with amphetamines is
absolutely contraindicated due to the risk of hypertensive crisis, hyperthermia, and
serotonin syndrome from enhanced catecholamine and serotonin release. While
bupropion and amphetamines both increase norepinephrine and dopamine, the
MAOI-amphetamine combination carries the most immediate life-threatening risk.
Correct Answer: C
Q9. A patient with generalized anxiety disorder is taking buspirone 15 mg BID. The
patient is started on erythromycin for a respiratory infection. Which interaction is
most concerning? A. Erythromycin inhibits CYP3A4, increasing buspirone levels and
risk of serotonin syndrome B. Erythromycin inhibits CYP3A4, increasing buspirone
levels and risk of dizziness and hypotension [CORRECT] C. Erythromycin induces
CYP2D6, decreasing buspirone levels D. No significant interaction exists between
these agents
Rationale: Buspirone is metabolized primarily by CYP3A4. Erythromycin is a potent
CYP3A4 inhibitor that can significantly increase buspirone plasma concentrations,
leading to enhanced adverse effects including dizziness, nausea, and hypotension.
Dose reduction or temporary discontinuation of buspirone should be considered.
Correct Answer: B
Q10. A patient with schizophrenia is prescribed a long-acting injectable
antipsychotic. The PMHNP selects paliperidone palmitate. Which statement
regarding administration is correct? A. It requires oral antipsychotic supplementation
for the first 21 days B. It requires deltoid administration for the first two doses, then
gluteal [CORRECT] C. It can be administered subcutaneously D. It requires monthly
dosing only with no loading option
Rationale: Paliperidone palmitate requires initiation with deltoid injections (day 1 and
day 8) to achieve therapeutic plasma levels rapidly, followed by monthly gluteal or
