,LMR Georgette PMHNP Board Exam Review
(2027) – High-Yield Board Prep (Questions
1. Where is norepinephrine primarily synthesized in the central nervous system?
A) Raphe nuclei
B) Locus coeruleus
C) Substantia nigra
D) Nucleus accumbens
*B) Locus coeruleus *
Rationale: The locus coeruleus, located in the pons, is the primary site for norepinephrine
synthesis in the brain. This pathway is crucial for arousal, attention, and the stress
response. The raphe nuclei synthesize serotonin, while the substantia nigra synthesizes
dopamine .
2. Which dopamine pathway is primarily associated with the positive symptoms
(hallucinations, delusions) of schizophrenia?
A) Mesocortical pathway
B) Nigrostriatal pathway
C) Tuberoinfundibular pathway
D) Mesolimbic pathway
*D) Mesolimbic pathway *
Rationale: The mesolimbic pathway projects from the Ventral Tegmental Area (VTA) to the
nucleus accumbens. Excess dopamine activity here is linked to positive symptoms.
Hypoactivity in the mesocortical pathway is linked to negative symptoms .
,3. A patient of Asian descent is being considered for carbamazepine (Tegretol)
therapy. Which genetic screening must be prioritized to prevent Stevens-Johnson
Syndrome (SJS)?
A) CYP2D6 genotyping
B) HLA-B*1502 allele
C) Serum sodium level
D) Complete Blood Count (CBC)
B) HLA-B1502 allele *
Rationale: The HLA-B1502 allele is strongly associated with an increased risk of Stevens-
Johnson Syndrome and Toxic Epidermal Necrolysis in patients of Asian descent taking
carbamazepine. Screening is mandatory before initiation .*
4. A patient with major depressive disorder has failed two adequate trials of SSRIs.
Pharmacogenomic testing reveals a CYP2C19 poor metabolizer phenotype. Which
antidepressant selection is most appropriate?
A) Escitalopram 10 mg daily, monitoring for increased side effects
B) Citalopram 40 mg daily, with dose reduction due to prolonged half-life
C) Sertraline 100 mg daily, as it is primarily metabolized by CYP3A4
D) Venlafaxine XR 75 mg daily, avoiding CYP2C19 metabolism
*C) Sertraline 100 mg daily, as it is primarily metabolized by CYP3A4 *
Rationale: Sertraline is not significantly metabolized by CYP2C19; it uses CYP2B6 and 3A4.
Escitalopram and citalopram are both metabolized by CYP2C19; in poor metabolizers,
they accumulate, increasing QTc risk (citalopram) or side effects. Venlafaxine is
metabolized by CYP2D6, not relevant. Therefore, sertraline is a safe choice .
5. What is the therapeutic range for lithium in maintenance treatment of bipolar
disorder?
A) 0.6 – 1.2 mEq/L
B) 4 – 12 mcg/mL
, C) 50 – 125 mcg/mL
D) 1.5 – 2.0 mEq/L
*A) 0.6 – 1.2 mEq/L *
Rationale: For maintenance treatment of bipolar disorder, lithium levels should be kept
between 0.6 and 1.2 mEq/L. Acute mania may require levels up to 1.5 mEq/L, but levels
above 1.5 mEq/L indicate toxicity .
6. At what lithium level should treatment be immediately discontinued due to
toxicity risk?
A) 0.8 mEq/L
B) 1.0 mEq/L
C) 1.2 mEq/L
D) 1.5 mEq/L
*D) 1.5 mEq/L *
Rationale: Once lithium reaches 1.5 mEq/L, immediate discontinuation is required. Levels
of 1.3-1.4 mEq/L warrant close monitoring for signs of toxicity .
7. Which drug class increases lithium levels by reducing renal clearance?
A) Antihypertensives (beta-blockers)
B) Antibiotics (penicillins)
C) NSAIDs, hydrochlorothiazide, and ACE inhibitors
D) Antidepressants (SSRIs)
*C) NSAIDs, hydrochlorothiazide, and ACE inhibitors *
Rationale: NSAIDs, thiazide diuretics, and ACE inhibitors can increase lithium levels by
reducing renal clearance. Dehydration and hyponatremia also increase lithium levels .
(2027) – High-Yield Board Prep (Questions
1. Where is norepinephrine primarily synthesized in the central nervous system?
A) Raphe nuclei
B) Locus coeruleus
C) Substantia nigra
D) Nucleus accumbens
*B) Locus coeruleus *
Rationale: The locus coeruleus, located in the pons, is the primary site for norepinephrine
synthesis in the brain. This pathway is crucial for arousal, attention, and the stress
response. The raphe nuclei synthesize serotonin, while the substantia nigra synthesizes
dopamine .
2. Which dopamine pathway is primarily associated with the positive symptoms
(hallucinations, delusions) of schizophrenia?
A) Mesocortical pathway
B) Nigrostriatal pathway
C) Tuberoinfundibular pathway
D) Mesolimbic pathway
*D) Mesolimbic pathway *
Rationale: The mesolimbic pathway projects from the Ventral Tegmental Area (VTA) to the
nucleus accumbens. Excess dopamine activity here is linked to positive symptoms.
Hypoactivity in the mesocortical pathway is linked to negative symptoms .
,3. A patient of Asian descent is being considered for carbamazepine (Tegretol)
therapy. Which genetic screening must be prioritized to prevent Stevens-Johnson
Syndrome (SJS)?
A) CYP2D6 genotyping
B) HLA-B*1502 allele
C) Serum sodium level
D) Complete Blood Count (CBC)
B) HLA-B1502 allele *
Rationale: The HLA-B1502 allele is strongly associated with an increased risk of Stevens-
Johnson Syndrome and Toxic Epidermal Necrolysis in patients of Asian descent taking
carbamazepine. Screening is mandatory before initiation .*
4. A patient with major depressive disorder has failed two adequate trials of SSRIs.
Pharmacogenomic testing reveals a CYP2C19 poor metabolizer phenotype. Which
antidepressant selection is most appropriate?
A) Escitalopram 10 mg daily, monitoring for increased side effects
B) Citalopram 40 mg daily, with dose reduction due to prolonged half-life
C) Sertraline 100 mg daily, as it is primarily metabolized by CYP3A4
D) Venlafaxine XR 75 mg daily, avoiding CYP2C19 metabolism
*C) Sertraline 100 mg daily, as it is primarily metabolized by CYP3A4 *
Rationale: Sertraline is not significantly metabolized by CYP2C19; it uses CYP2B6 and 3A4.
Escitalopram and citalopram are both metabolized by CYP2C19; in poor metabolizers,
they accumulate, increasing QTc risk (citalopram) or side effects. Venlafaxine is
metabolized by CYP2D6, not relevant. Therefore, sertraline is a safe choice .
5. What is the therapeutic range for lithium in maintenance treatment of bipolar
disorder?
A) 0.6 – 1.2 mEq/L
B) 4 – 12 mcg/mL
, C) 50 – 125 mcg/mL
D) 1.5 – 2.0 mEq/L
*A) 0.6 – 1.2 mEq/L *
Rationale: For maintenance treatment of bipolar disorder, lithium levels should be kept
between 0.6 and 1.2 mEq/L. Acute mania may require levels up to 1.5 mEq/L, but levels
above 1.5 mEq/L indicate toxicity .
6. At what lithium level should treatment be immediately discontinued due to
toxicity risk?
A) 0.8 mEq/L
B) 1.0 mEq/L
C) 1.2 mEq/L
D) 1.5 mEq/L
*D) 1.5 mEq/L *
Rationale: Once lithium reaches 1.5 mEq/L, immediate discontinuation is required. Levels
of 1.3-1.4 mEq/L warrant close monitoring for signs of toxicity .
7. Which drug class increases lithium levels by reducing renal clearance?
A) Antihypertensives (beta-blockers)
B) Antibiotics (penicillins)
C) NSAIDs, hydrochlorothiazide, and ACE inhibitors
D) Antidepressants (SSRIs)
*C) NSAIDs, hydrochlorothiazide, and ACE inhibitors *
Rationale: NSAIDs, thiazide diuretics, and ACE inhibitors can increase lithium levels by
reducing renal clearance. Dehydration and hyponatremia also increase lithium levels .
