NRNP 6675 Midterm Exam Questions with Answers|PMHNP Care Across
the Lifespan II| Walden University
1. A PMHNP explains to a patient how sertraline works. Which statement
best describes its primary mechanism of action?
A. Inhibits monoamine oxidase, preventing breakdown of serotonin
B. Antagonizes postsynaptic 5-HT2A receptors
C. Blocks presynaptic alpha-2 autoreceptors to increase norepinephrine
and serotonin release
D. Blocks the presynaptic serotonin transporter (SERT), increasing synaptic
serotonin
Answer: D. Blocks the presynaptic serotonin transporter (SERT),
increasing synaptic serotonin
Rationale: SSRIs selectively inhibit SERT. The clinical effect is delayed
(about 2–6 weeks) because autoreceptor desensitization and downstream
receptor adaptation must occur. Inhibiting MAO describes MAOIs; 5-HT2A
antagonism describes trazodone/nefazodone; alpha-2 blockade describes
mirtazapine.
2. A 34-year-old taking sertraline 200 mg daily is given linezolid for an
MRSA infection. Twelve hours later he is agitated, diaphoretic, and
febrile (39.2 °C), with diarrhea, tremor, hyperreflexia, and inducible ankle
clonus. What is the most likely diagnosis?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome
C. Anticholinergic toxicity
D. Malignant hyperthermia
Answer: A. Serotonin syndrome
Rationale: Linezolid is a weak, reversible MAOI and, combined with an SSRI,
can precipitate serotonin syndrome. Hallmarks are rapid onset (usually within
24 hours), clonus, hyperreflexia, diaphoresis, and GI hyperactivity.
Management: stop serotonergic agents, supportive care, benzodiazepines for
agitation, and cyproheptadine (5-HT2A antagonist) for moderate cases.
Anticholinergic toxicity causes dry skin, not diaphoresis.
NRNP 6675 Midterm Exam – Page 1
,3. A patient taking fluoxetine 40 mg/day needs to be switched to
phenelzine (an MAOI). What is the minimum washout period after
stopping fluoxetine?
A. 24 hours
B. 5 weeks
C. 1 week
D. 2 weeks
Answer: B. 5 weeks
Rationale: Fluoxetine and its active metabolite norfluoxetine have very long
half-lives, so at least 5 weeks is required to avoid serotonin syndrome. Most
other SSRIs require about 2 weeks before starting an MAOI, and an MAOI
must also be stopped for at least 2 weeks before starting an SSRI.
4. A 15-year-old begins fluoxetine for major depressive disorder. The NP
reviews the FDA boxed warning with the family. Which monitoring plan
is most appropriate?
A. Reassess only at the 3-month visit
B. Avoid antidepressants in all patients younger than 25 years
C. Close monitoring for new or worsening suicidal thoughts, agitation, or
behavior change—especially in the first weeks and after dose changes—
with parent involvement
D. Obtain a baseline ECG and weekly serum drug levels
Answer: C. Close monitoring for new or worsening suicidal thoughts,
agitation, or behavior change—especially in the first weeks and after
dose changes—with parent involvement
Rationale: The boxed warning applies to patients ≤24 years of age and
reflects a small increase in suicidal thinking/behavior (not completed suicide)
versus placebo. The benefits of treating moderate-to-severe depression
usually outweigh the risk, but frequent contact (e.g., weekly initially) and
family education are expected. Serum levels and routine ECGs are not
required for fluoxetine.
NRNP 6675 Midterm Exam – Page 2
,5. Which antidepressant is FDA-approved for the treatment of major
depressive disorder in a 10-year-old child?
A. Fluoxetine
B. Sertraline
C. Escitalopram
D. Venlafaxine
Answer: A. Fluoxetine
Rationale: Fluoxetine is approved for MDD in patients 8 years and older (and
OCD in patients 7 and older). Escitalopram is approved for MDD starting at
age 12. Sertraline is approved for pediatric OCD (age 6+) but not MDD.
Venlafaxine is not approved for pediatric use.
6. A patient who abruptly stopped paroxetine 3 days ago reports
dizziness, "electric shock" sensations, nausea, irritability, and flu-like
symptoms. What is the best explanation and management?
A. SSRI discontinuation syndrome; reinstate the medication and taper
slowly (or bridge with fluoxetine)
B. Relapse of major depression; double the previous dose
C. Serotonin syndrome; give cyproheptadine
D. Bipolar switch; start lithium
Answer: A. SSRI discontinuation syndrome; reinstate the medication
and taper slowly (or bridge with fluoxetine)
Rationale: Paroxetine has a short half-life and no active metabolites, making
it the SSRI most associated with discontinuation symptoms (dizziness,
sensory disturbances, nausea, insomnia, irritability, flu-like symptoms; onset
within days). Symptoms are self-limited but distressing; reinstating and
tapering slowly resolves them. Fluoxetine's long half-life makes it least likely
to cause the syndrome.
NRNP 6675 Midterm Exam – Page 3
, 7. A 78-year-old woman started sertraline 3 weeks ago and now
presents with confusion, lethargy, headache, and a serum sodium of
122 mEq/L. What is the most likely cause?
A. Lithium toxicity
B. SIADH induced by the SSRI
C. Neuroleptic malignant syndrome
D. Primary hypothyroidism
Answer: B. SIADH induced by the SSRI
Rationale: Older adults, women, those with low body weight, and patients on
diuretics are at the highest risk of SSRI-associated hyponatremia (SIADH),
typically within the first weeks. Check serum and urine osmolality and urine
sodium, stop the SSRI, and consider fluid restriction. Baseline and early (2–4
week) sodium checks are prudent in older adults.
8. Which patient should NOT be prescribed bupropion?
A. A 28-year-old woman with bulimia nervosa
B. A 40-year-old smoker with major depression
C. A 55-year-old with depression, fatigue, and obesity
D. A 35-year-old with comorbid ADHD and depression
Answer: A. A 28-year-old woman with bulimia nervosa
Rationale: Bupropion lowers the seizure threshold. It is contraindicated in
seizure disorders, in bulimia nervosa and anorexia nervosa (purging,
electrolyte disturbances), and with abrupt alcohol or benzodiazepine
discontinuation. It is useful for smoking cessation, depression without sexual
side effects or weight gain, and ADHD (off-label).
NRNP 6675 Midterm Exam – Page 4
the Lifespan II| Walden University
1. A PMHNP explains to a patient how sertraline works. Which statement
best describes its primary mechanism of action?
A. Inhibits monoamine oxidase, preventing breakdown of serotonin
B. Antagonizes postsynaptic 5-HT2A receptors
C. Blocks presynaptic alpha-2 autoreceptors to increase norepinephrine
and serotonin release
D. Blocks the presynaptic serotonin transporter (SERT), increasing synaptic
serotonin
Answer: D. Blocks the presynaptic serotonin transporter (SERT),
increasing synaptic serotonin
Rationale: SSRIs selectively inhibit SERT. The clinical effect is delayed
(about 2–6 weeks) because autoreceptor desensitization and downstream
receptor adaptation must occur. Inhibiting MAO describes MAOIs; 5-HT2A
antagonism describes trazodone/nefazodone; alpha-2 blockade describes
mirtazapine.
2. A 34-year-old taking sertraline 200 mg daily is given linezolid for an
MRSA infection. Twelve hours later he is agitated, diaphoretic, and
febrile (39.2 °C), with diarrhea, tremor, hyperreflexia, and inducible ankle
clonus. What is the most likely diagnosis?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome
C. Anticholinergic toxicity
D. Malignant hyperthermia
Answer: A. Serotonin syndrome
Rationale: Linezolid is a weak, reversible MAOI and, combined with an SSRI,
can precipitate serotonin syndrome. Hallmarks are rapid onset (usually within
24 hours), clonus, hyperreflexia, diaphoresis, and GI hyperactivity.
Management: stop serotonergic agents, supportive care, benzodiazepines for
agitation, and cyproheptadine (5-HT2A antagonist) for moderate cases.
Anticholinergic toxicity causes dry skin, not diaphoresis.
NRNP 6675 Midterm Exam – Page 1
,3. A patient taking fluoxetine 40 mg/day needs to be switched to
phenelzine (an MAOI). What is the minimum washout period after
stopping fluoxetine?
A. 24 hours
B. 5 weeks
C. 1 week
D. 2 weeks
Answer: B. 5 weeks
Rationale: Fluoxetine and its active metabolite norfluoxetine have very long
half-lives, so at least 5 weeks is required to avoid serotonin syndrome. Most
other SSRIs require about 2 weeks before starting an MAOI, and an MAOI
must also be stopped for at least 2 weeks before starting an SSRI.
4. A 15-year-old begins fluoxetine for major depressive disorder. The NP
reviews the FDA boxed warning with the family. Which monitoring plan
is most appropriate?
A. Reassess only at the 3-month visit
B. Avoid antidepressants in all patients younger than 25 years
C. Close monitoring for new or worsening suicidal thoughts, agitation, or
behavior change—especially in the first weeks and after dose changes—
with parent involvement
D. Obtain a baseline ECG and weekly serum drug levels
Answer: C. Close monitoring for new or worsening suicidal thoughts,
agitation, or behavior change—especially in the first weeks and after
dose changes—with parent involvement
Rationale: The boxed warning applies to patients ≤24 years of age and
reflects a small increase in suicidal thinking/behavior (not completed suicide)
versus placebo. The benefits of treating moderate-to-severe depression
usually outweigh the risk, but frequent contact (e.g., weekly initially) and
family education are expected. Serum levels and routine ECGs are not
required for fluoxetine.
NRNP 6675 Midterm Exam – Page 2
,5. Which antidepressant is FDA-approved for the treatment of major
depressive disorder in a 10-year-old child?
A. Fluoxetine
B. Sertraline
C. Escitalopram
D. Venlafaxine
Answer: A. Fluoxetine
Rationale: Fluoxetine is approved for MDD in patients 8 years and older (and
OCD in patients 7 and older). Escitalopram is approved for MDD starting at
age 12. Sertraline is approved for pediatric OCD (age 6+) but not MDD.
Venlafaxine is not approved for pediatric use.
6. A patient who abruptly stopped paroxetine 3 days ago reports
dizziness, "electric shock" sensations, nausea, irritability, and flu-like
symptoms. What is the best explanation and management?
A. SSRI discontinuation syndrome; reinstate the medication and taper
slowly (or bridge with fluoxetine)
B. Relapse of major depression; double the previous dose
C. Serotonin syndrome; give cyproheptadine
D. Bipolar switch; start lithium
Answer: A. SSRI discontinuation syndrome; reinstate the medication
and taper slowly (or bridge with fluoxetine)
Rationale: Paroxetine has a short half-life and no active metabolites, making
it the SSRI most associated with discontinuation symptoms (dizziness,
sensory disturbances, nausea, insomnia, irritability, flu-like symptoms; onset
within days). Symptoms are self-limited but distressing; reinstating and
tapering slowly resolves them. Fluoxetine's long half-life makes it least likely
to cause the syndrome.
NRNP 6675 Midterm Exam – Page 3
, 7. A 78-year-old woman started sertraline 3 weeks ago and now
presents with confusion, lethargy, headache, and a serum sodium of
122 mEq/L. What is the most likely cause?
A. Lithium toxicity
B. SIADH induced by the SSRI
C. Neuroleptic malignant syndrome
D. Primary hypothyroidism
Answer: B. SIADH induced by the SSRI
Rationale: Older adults, women, those with low body weight, and patients on
diuretics are at the highest risk of SSRI-associated hyponatremia (SIADH),
typically within the first weeks. Check serum and urine osmolality and urine
sodium, stop the SSRI, and consider fluid restriction. Baseline and early (2–4
week) sodium checks are prudent in older adults.
8. Which patient should NOT be prescribed bupropion?
A. A 28-year-old woman with bulimia nervosa
B. A 40-year-old smoker with major depression
C. A 55-year-old with depression, fatigue, and obesity
D. A 35-year-old with comorbid ADHD and depression
Answer: A. A 28-year-old woman with bulimia nervosa
Rationale: Bupropion lowers the seizure threshold. It is contraindicated in
seizure disorders, in bulimia nervosa and anorexia nervosa (purging,
electrolyte disturbances), and with abrupt alcohol or benzodiazepine
discontinuation. It is useful for smoking cessation, depression without sexual
side effects or weight gain, and ADHD (off-label).
NRNP 6675 Midterm Exam – Page 4
