552 Practice Questions with Rationales
1) CYP3A4 inducer and escitalopram
A patient stable on escitalopram (a CYP3A4 substrate) starts a new medication that is a strong
CYP3A4 inducer. What is the most likely outcome?
A) Escitalopram levels increase, toxicity risk rises
B) Escitalopram levels decrease, efficacy may drop
C) Escitalopram levels stay the same
D) Escitalopram becomes more sedating
Answer: B
Rationale: Inducers increase enzyme activity, increasing metabolism of substrates and lowering
serum levels, which can reduce clinical effect.
2) CYP inhibitor effect
A patient takes a medication that is a CYP2D6 substrate. You add a strong CYP2D6 inhibitor.
What happens?
A) Substrate levels increase
B) Substrate levels decrease
C) Substrate converts to an inactive metabolite faster
D) No interaction occurs
Answer: A
Rationale: Inhibitors slow metabolism of substrates, raising drug exposure and adverse effect
risk.
3) STEPs framework
A PMHNP is choosing between two effective medications. One requires frequent lab monitoring
and is expensive; the other is affordable and simple to take. Which STEPs domain is most
relevant?
A) Safety
B) Tolerability
C) Efficacy
D) Practicality
Answer: D
Rationale: Practicality includes cost, access, route, and monitoring burden, all of which
influence adherence.
4) Acute agitation in psychosis
An acutely psychotic patient is violent and cannot take oral meds. Best next medication
approach?
A) IM haloperidol, consider adding lorazepam
, B) PO SSRI and reassurance
C) IM benztropine alone
D) Start lithium immediately
Answer: A
Rationale: Acute agitation with psychosis often requires IM antipsychotic for rapid behavioral
control; lorazepam can be paired for sedation and anxiety.
5) D2 occupancy concept
A patient develops EPS after an antipsychotic dose increase. The best mechanistic explanation is:
A) D2 occupancy fell below therapeutic range
B) D2 occupancy rose above the EPS threshold
C) 5-HT2A blockade increased too much
D) Muscarinic blockade increased too much
Answer: B
Rationale: EPS risk increases when D2 blockade is excessive, classically above the threshold
that produces motor side effects.
6) Parkinsonism vs akathisia vs TD
A patient on a high-potency antipsychotic has tremor, rigidity, bradykinesia, and pill-rolling. Best
diagnosis?
A) Akathisia
B) Drug-induced parkinsonism
C) Tardive dyskinesia
D) Acute dystonia
Answer: B
Rationale: Parkinsonism is characterized by rigidity, tremor, bradykinesia. Akathisia is
restlessness. TD is choreiform movements. Dystonia is sustained painful contraction.
7) Treating drug-induced parkinsonism
Best symptomatic treatment for drug-induced parkinsonism from antipsychotics?
A) Propranolol
B) Benztropine or amantadine
C) Cyproheptadine
D) Sodium bicarbonate
Answer: B
Rationale: Anticholinergics (benztropine) and amantadine commonly treat antipsychotic-
induced parkinsonism.
8) Akathisia treatment
1) CYP3A4 inducer and escitalopram
A patient stable on escitalopram (a CYP3A4 substrate) starts a new medication that is a strong
CYP3A4 inducer. What is the most likely outcome?
A) Escitalopram levels increase, toxicity risk rises
B) Escitalopram levels decrease, efficacy may drop
C) Escitalopram levels stay the same
D) Escitalopram becomes more sedating
Answer: B
Rationale: Inducers increase enzyme activity, increasing metabolism of substrates and lowering
serum levels, which can reduce clinical effect.
2) CYP inhibitor effect
A patient takes a medication that is a CYP2D6 substrate. You add a strong CYP2D6 inhibitor.
What happens?
A) Substrate levels increase
B) Substrate levels decrease
C) Substrate converts to an inactive metabolite faster
D) No interaction occurs
Answer: A
Rationale: Inhibitors slow metabolism of substrates, raising drug exposure and adverse effect
risk.
3) STEPs framework
A PMHNP is choosing between two effective medications. One requires frequent lab monitoring
and is expensive; the other is affordable and simple to take. Which STEPs domain is most
relevant?
A) Safety
B) Tolerability
C) Efficacy
D) Practicality
Answer: D
Rationale: Practicality includes cost, access, route, and monitoring burden, all of which
influence adherence.
4) Acute agitation in psychosis
An acutely psychotic patient is violent and cannot take oral meds. Best next medication
approach?
A) IM haloperidol, consider adding lorazepam
, B) PO SSRI and reassurance
C) IM benztropine alone
D) Start lithium immediately
Answer: A
Rationale: Acute agitation with psychosis often requires IM antipsychotic for rapid behavioral
control; lorazepam can be paired for sedation and anxiety.
5) D2 occupancy concept
A patient develops EPS after an antipsychotic dose increase. The best mechanistic explanation is:
A) D2 occupancy fell below therapeutic range
B) D2 occupancy rose above the EPS threshold
C) 5-HT2A blockade increased too much
D) Muscarinic blockade increased too much
Answer: B
Rationale: EPS risk increases when D2 blockade is excessive, classically above the threshold
that produces motor side effects.
6) Parkinsonism vs akathisia vs TD
A patient on a high-potency antipsychotic has tremor, rigidity, bradykinesia, and pill-rolling. Best
diagnosis?
A) Akathisia
B) Drug-induced parkinsonism
C) Tardive dyskinesia
D) Acute dystonia
Answer: B
Rationale: Parkinsonism is characterized by rigidity, tremor, bradykinesia. Akathisia is
restlessness. TD is choreiform movements. Dystonia is sustained painful contraction.
7) Treating drug-induced parkinsonism
Best symptomatic treatment for drug-induced parkinsonism from antipsychotics?
A) Propranolol
B) Benztropine or amantadine
C) Cyproheptadine
D) Sodium bicarbonate
Answer: B
Rationale: Anticholinergics (benztropine) and amantadine commonly treat antipsychotic-
induced parkinsonism.
8) Akathisia treatment
