NR607 PRE-DIAGNOSTIC EXAM (Chamberlain)
NEWEST 2025/ 2026 ACTUAL EXAM| COMPLETE
REAL EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
GRADED A+ (BRAND NEW!!)
1. A 32-year-old individual with a history of major depressive disorder (MDD) has been on
escitalopram 20 mg daily for 12 weeks with minimal improvement. The patient reports persistent
depressed mood, anhedonia, and significant weight gain. Which of the following next-step
strategies is most appropriate based on current evidence for treatment-resistant depression?
A. Augment with aripiprazole 2 mg daily.
B. Switch to venlafaxine XR 75 mg daily.
C. Augment with bupropion XL 150 mg daily.
D. Augment with triiodothyronine (T3) 25 mcg daily.
Answer: A
Rationale: For treatment-resistant depression after an adequate SSRI trial, augmentation with a
second-generation antipsychotic (e.g., aripiprazole) is first-line per STAR*D and CANMAT guidelines.
Bupropion augmentation is also effective but less evidence for weight gain. T3 augmentation is
second-line. Switching to another agent is reasonable but aripiprazole is the most evidence-based
augmentation strategy.
2. Which of the following best describes the mechanism by which lamotrigine exerts its
mood-stabilizing effects in bipolar I disorder?
A. Blockade of voltage-gated sodium channels and inhibition of glutamate release.
B. Agonism at GABA-A receptors and enhancement of chloride ion influx.
C. Inhibition of dopamine D2 receptors in the mesolimbic pathway.
D. Antagonism at NMDA receptors and reduction of intracellular calcium.
Answer: A
Rationale: Lamotrigine stabilizes mood primarily by blocking voltage-gated sodium channels, which
reduces presynaptic glutamate release and attenuates excitatory neurotransmission. This mechanism is
distinct from lithium (inositol depletion) and valproate (GABA enhancement). Options B and C describe
mechanisms of benzodiazepines and antipsychotics, respectively.
Page 1
,3. A 45-year-old patient with schizophrenia has been adherent to clozapine 300 mg daily for 6
months but continues to experience persistent auditory hallucinations and negative symptoms.
Clozapine levels are therapeutic. Which of the following augmentation strategies is most supported
by evidence?
A. Addition of aripiprazole 10 mg daily.
B. Addition of electroconvulsive therapy (ECT).
C. Increase clozapine to 450 mg daily.
D. Addition of lamotrigine 100 mg daily.
Answer: A
Rationale: For clozapine-resistant schizophrenia, augmentation with a second antipsychotic (e.g.,
aripiprazole) is recommended by guidelines, though evidence is modest. ECT is an option but less
evidence. Increasing clozapine above 300 mg may be considered but levels are already therapeutic.
Lamotrigine augmentation has limited evidence.
4. Which neurotransmitter system is primarily implicated in the pathophysiology of
obsessive-compulsive disorder (OCD), and what is the corresponding first-line pharmacotherapy
target?
A. Dopamine; D2 receptor blockade.
B. Serotonin; 5-HT reuptake inhibition.
C. Norepinephrine; alpha-2 agonism.
D. Glutamate; NMDA antagonism.
Answer: B
Rationale: OCD is strongly linked to dysregulation of the serotonin system, particularly in
cortico-striato-thalamo-cortical circuits. First-line pharmacotherapy is SSRIs (e.g., fluoxetine,
fluvoxamine) which inhibit serotonin reuptake. Dopamine and glutamate play secondary roles.
Clomipramine (a tricyclic with potent SRI activity) is also first-line.
5. A 28-year-old patient with generalized anxiety disorder (GAD) has been on paroxetine 40 mg
daily for 8 weeks with partial response but reports significant sexual dysfunction. Which of the
following medication adjustments is most appropriate?
A. Switch to buspirone 15 mg twice daily.
B. Add sildenafil 50 mg as needed.
C. Switch to sertraline 100 mg daily.
D. Add mirtazapine 15 mg at bedtime.
Answer: A
Rationale: For SSRI-induced sexual dysfunction, switching to a non-SSRI anxiolytic like buspirone is a
rational choice, as buspirone is effective for GAD and has minimal sexual side effects. Sildenafil treats
dysfunction but does not address the need for continued anxiolysis. Mirtazapine may help but is
sedating. Sertraline also causes sexual dysfunction.
6. Which of the following best explains the efficacy of phenelzine in treating atypical depression,
particularly in patients with rejection sensitivity and hypersomnia?
Page 2
,A. Irreversible inhibition of monoamine oxidase A and B, leading to increased norepinephrine and serotonin.
B. Selective inhibition of serotonin reuptake with minimal effect on dopamine.
C. Dual inhibition of norepinephrine and dopamine reuptake.
D. Partial agonism at 5-HT1A receptors and antagonism at 5-HT2 receptors.
Answer: A
Rationale: Phenelzine is an irreversible MAOI that inhibits both MAO-A and MAO-B, increasing levels of
norepinephrine, serotonin, and dopamine. This broad action is particularly effective for atypical
depression, which often responds better to MAOIs than to SSRIs or SNRIs. Option B describes SSRIs, C
describes bupropion, and D describes vilazodone.
7. A 55-year-old patient with alcohol use disorder (AUD) and cirrhosis (Child-Pugh class B) is
seeking pharmacotherapy for relapse prevention. Which of the following medications is safest and
most appropriate?
A. Naltrexone 50 mg daily.
B. Acamprosate 666 mg three times daily.
C. Disulfiram 250 mg daily.
D. Baclofen 10 mg three times daily.
Answer: D
Rationale: Baclofen is primarily hepatically metabolized but has been studied in AUD with cirrhosis and
is considered safe with dose adjustment. Naltrexone is hepatically metabolized and contraindicated in
acute hepatitis or liver failure. Acamprosate is renally excreted but not recommended in cirrhosis due to
lack of data. Disulfiram is hepatotoxic and contraindicated.
8. A 22-year-old patient with ADHD, predominantly inattentive presentation, has failed a trial of
methylphenidate extended-release due to intolerable appetite suppression and insomnia. Which of
the following is the most appropriate next step?
A. Switch to dexmethylphenidate 10 mg daily.
B. Switch to lisdexamfetamine 30 mg daily.
C. Switch to atomoxetine 40 mg daily.
D. Switch to guanfacine extended-release 1 mg daily.
Answer: C
Rationale: Atomoxetine, a selective norepinephrine reuptake inhibitor, is a non-stimulant option for
ADHD and is less likely to cause appetite suppression or insomnia. It is particularly useful when
stimulants are not tolerated. Dexmethylphenidate and lisdexamfetamine are stimulants and may cause
similar side effects. Guanfacine is effective but primarily for hyperactivity/impulsivity.
9. Which of the following best describes the primary neurobiological mechanism underlying the
efficacy of prazosin in treating nightmares associated with PTSD?
A. Selective antagonism of alpha-1 adrenergic receptors in the central nervous system.
B. Inhibition of norepinephrine reuptake at the synaptic cleft.
C. Agonism at alpha-2 adrenergic autoreceptors, reducing norepinephrine release.
D. Blockade of beta-adrenergic receptors in the amygdala.
Page 3
, Answer: A
Rationale: Prazosin is an alpha-1 adrenergic receptor antagonist that reduces central noradrenergic
hyperactivity, which is implicated in trauma-related nightmares and hyperarousal. It does not affect
reuptake (option B) or act on alpha-2 or beta receptors. Clonidine (alpha-2 agonist) and propranolol
(beta-blocker) have different mechanisms.
10. A 35-year-old patient with borderline personality disorder (BPD) presents with chronic feelings
of emptiness, unstable relationships, and recurrent self-harm. Which psychotherapy modality has
the strongest evidence base for reducing self-harm and suicide attempts in BPD?
A. Dialectical behavior therapy (DBT).
B. Cognitive behavioral therapy (CBT).
C. Transference-focused psychotherapy (TFP).
D. Mentalization-based treatment (MBT).
Answer: A
Rationale: DBT is the most extensively studied and effective psychotherapy for BPD, particularly for
reducing self-harm, suicide attempts, and hospitalizations. It combines individual therapy, group skills
training, and phone coaching. While CBT, TFP, and MBT have evidence, DBT remains the gold standard
for these specific outcomes.
11. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe headache, palpitations, and diaphoresis. Blood pressure is 220/130 mm Hg. Which
of the following diagnostic tests is most appropriate to differentiate hypertensive emergency from
hypertensive urgency?
A. Serum creatinine and urinalysis
B. Electrocardiogram
C. Chest X-ray
D. Plasma metanephrines
Answer: D
Rationale: In this presentation, hypertensive emergency is suspected, and pheochromocytoma must be
excluded. Plasma metanephrines have high sensitivity for pheochromocytoma. Serum creatinine and
urinalysis assess renal function but are not diagnostic for the cause. ECG and chest X-ray evaluate
end-organ damage but do not differentiate etiology.
12. A 60-year-old patient with chronic kidney disease (GFR 25 mL/min) is started on an ACE
inhibitor for hypertension. Which of the following best describes the expected change in serum
potassium and the underlying mechanism?
A. Hyperkalemia due to decreased aldosterone secretion
B. Hypokalemia due to increased aldosterone secretion
C. Hyperkalemia due to increased potassium reabsorption in distal tubule
D. Hypokalemia due to decreased potassium reabsorption in proximal tubule
Answer: A
Rationale: ACE inhibitors reduce angiotensin II, leading to decreased aldosterone release. Aldosterone
normally promotes potassium excretion; its reduction causes hyperkalemia, especially in CKD. Options
B, C, and D are incorrect because ACE inhibitors do not increase aldosterone or directly affect
Page 4
NEWEST 2025/ 2026 ACTUAL EXAM| COMPLETE
REAL EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
GRADED A+ (BRAND NEW!!)
1. A 32-year-old individual with a history of major depressive disorder (MDD) has been on
escitalopram 20 mg daily for 12 weeks with minimal improvement. The patient reports persistent
depressed mood, anhedonia, and significant weight gain. Which of the following next-step
strategies is most appropriate based on current evidence for treatment-resistant depression?
A. Augment with aripiprazole 2 mg daily.
B. Switch to venlafaxine XR 75 mg daily.
C. Augment with bupropion XL 150 mg daily.
D. Augment with triiodothyronine (T3) 25 mcg daily.
Answer: A
Rationale: For treatment-resistant depression after an adequate SSRI trial, augmentation with a
second-generation antipsychotic (e.g., aripiprazole) is first-line per STAR*D and CANMAT guidelines.
Bupropion augmentation is also effective but less evidence for weight gain. T3 augmentation is
second-line. Switching to another agent is reasonable but aripiprazole is the most evidence-based
augmentation strategy.
2. Which of the following best describes the mechanism by which lamotrigine exerts its
mood-stabilizing effects in bipolar I disorder?
A. Blockade of voltage-gated sodium channels and inhibition of glutamate release.
B. Agonism at GABA-A receptors and enhancement of chloride ion influx.
C. Inhibition of dopamine D2 receptors in the mesolimbic pathway.
D. Antagonism at NMDA receptors and reduction of intracellular calcium.
Answer: A
Rationale: Lamotrigine stabilizes mood primarily by blocking voltage-gated sodium channels, which
reduces presynaptic glutamate release and attenuates excitatory neurotransmission. This mechanism is
distinct from lithium (inositol depletion) and valproate (GABA enhancement). Options B and C describe
mechanisms of benzodiazepines and antipsychotics, respectively.
Page 1
,3. A 45-year-old patient with schizophrenia has been adherent to clozapine 300 mg daily for 6
months but continues to experience persistent auditory hallucinations and negative symptoms.
Clozapine levels are therapeutic. Which of the following augmentation strategies is most supported
by evidence?
A. Addition of aripiprazole 10 mg daily.
B. Addition of electroconvulsive therapy (ECT).
C. Increase clozapine to 450 mg daily.
D. Addition of lamotrigine 100 mg daily.
Answer: A
Rationale: For clozapine-resistant schizophrenia, augmentation with a second antipsychotic (e.g.,
aripiprazole) is recommended by guidelines, though evidence is modest. ECT is an option but less
evidence. Increasing clozapine above 300 mg may be considered but levels are already therapeutic.
Lamotrigine augmentation has limited evidence.
4. Which neurotransmitter system is primarily implicated in the pathophysiology of
obsessive-compulsive disorder (OCD), and what is the corresponding first-line pharmacotherapy
target?
A. Dopamine; D2 receptor blockade.
B. Serotonin; 5-HT reuptake inhibition.
C. Norepinephrine; alpha-2 agonism.
D. Glutamate; NMDA antagonism.
Answer: B
Rationale: OCD is strongly linked to dysregulation of the serotonin system, particularly in
cortico-striato-thalamo-cortical circuits. First-line pharmacotherapy is SSRIs (e.g., fluoxetine,
fluvoxamine) which inhibit serotonin reuptake. Dopamine and glutamate play secondary roles.
Clomipramine (a tricyclic with potent SRI activity) is also first-line.
5. A 28-year-old patient with generalized anxiety disorder (GAD) has been on paroxetine 40 mg
daily for 8 weeks with partial response but reports significant sexual dysfunction. Which of the
following medication adjustments is most appropriate?
A. Switch to buspirone 15 mg twice daily.
B. Add sildenafil 50 mg as needed.
C. Switch to sertraline 100 mg daily.
D. Add mirtazapine 15 mg at bedtime.
Answer: A
Rationale: For SSRI-induced sexual dysfunction, switching to a non-SSRI anxiolytic like buspirone is a
rational choice, as buspirone is effective for GAD and has minimal sexual side effects. Sildenafil treats
dysfunction but does not address the need for continued anxiolysis. Mirtazapine may help but is
sedating. Sertraline also causes sexual dysfunction.
6. Which of the following best explains the efficacy of phenelzine in treating atypical depression,
particularly in patients with rejection sensitivity and hypersomnia?
Page 2
,A. Irreversible inhibition of monoamine oxidase A and B, leading to increased norepinephrine and serotonin.
B. Selective inhibition of serotonin reuptake with minimal effect on dopamine.
C. Dual inhibition of norepinephrine and dopamine reuptake.
D. Partial agonism at 5-HT1A receptors and antagonism at 5-HT2 receptors.
Answer: A
Rationale: Phenelzine is an irreversible MAOI that inhibits both MAO-A and MAO-B, increasing levels of
norepinephrine, serotonin, and dopamine. This broad action is particularly effective for atypical
depression, which often responds better to MAOIs than to SSRIs or SNRIs. Option B describes SSRIs, C
describes bupropion, and D describes vilazodone.
7. A 55-year-old patient with alcohol use disorder (AUD) and cirrhosis (Child-Pugh class B) is
seeking pharmacotherapy for relapse prevention. Which of the following medications is safest and
most appropriate?
A. Naltrexone 50 mg daily.
B. Acamprosate 666 mg three times daily.
C. Disulfiram 250 mg daily.
D. Baclofen 10 mg three times daily.
Answer: D
Rationale: Baclofen is primarily hepatically metabolized but has been studied in AUD with cirrhosis and
is considered safe with dose adjustment. Naltrexone is hepatically metabolized and contraindicated in
acute hepatitis or liver failure. Acamprosate is renally excreted but not recommended in cirrhosis due to
lack of data. Disulfiram is hepatotoxic and contraindicated.
8. A 22-year-old patient with ADHD, predominantly inattentive presentation, has failed a trial of
methylphenidate extended-release due to intolerable appetite suppression and insomnia. Which of
the following is the most appropriate next step?
A. Switch to dexmethylphenidate 10 mg daily.
B. Switch to lisdexamfetamine 30 mg daily.
C. Switch to atomoxetine 40 mg daily.
D. Switch to guanfacine extended-release 1 mg daily.
Answer: C
Rationale: Atomoxetine, a selective norepinephrine reuptake inhibitor, is a non-stimulant option for
ADHD and is less likely to cause appetite suppression or insomnia. It is particularly useful when
stimulants are not tolerated. Dexmethylphenidate and lisdexamfetamine are stimulants and may cause
similar side effects. Guanfacine is effective but primarily for hyperactivity/impulsivity.
9. Which of the following best describes the primary neurobiological mechanism underlying the
efficacy of prazosin in treating nightmares associated with PTSD?
A. Selective antagonism of alpha-1 adrenergic receptors in the central nervous system.
B. Inhibition of norepinephrine reuptake at the synaptic cleft.
C. Agonism at alpha-2 adrenergic autoreceptors, reducing norepinephrine release.
D. Blockade of beta-adrenergic receptors in the amygdala.
Page 3
, Answer: A
Rationale: Prazosin is an alpha-1 adrenergic receptor antagonist that reduces central noradrenergic
hyperactivity, which is implicated in trauma-related nightmares and hyperarousal. It does not affect
reuptake (option B) or act on alpha-2 or beta receptors. Clonidine (alpha-2 agonist) and propranolol
(beta-blocker) have different mechanisms.
10. A 35-year-old patient with borderline personality disorder (BPD) presents with chronic feelings
of emptiness, unstable relationships, and recurrent self-harm. Which psychotherapy modality has
the strongest evidence base for reducing self-harm and suicide attempts in BPD?
A. Dialectical behavior therapy (DBT).
B. Cognitive behavioral therapy (CBT).
C. Transference-focused psychotherapy (TFP).
D. Mentalization-based treatment (MBT).
Answer: A
Rationale: DBT is the most extensively studied and effective psychotherapy for BPD, particularly for
reducing self-harm, suicide attempts, and hospitalizations. It combines individual therapy, group skills
training, and phone coaching. While CBT, TFP, and MBT have evidence, DBT remains the gold standard
for these specific outcomes.
11. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe headache, palpitations, and diaphoresis. Blood pressure is 220/130 mm Hg. Which
of the following diagnostic tests is most appropriate to differentiate hypertensive emergency from
hypertensive urgency?
A. Serum creatinine and urinalysis
B. Electrocardiogram
C. Chest X-ray
D. Plasma metanephrines
Answer: D
Rationale: In this presentation, hypertensive emergency is suspected, and pheochromocytoma must be
excluded. Plasma metanephrines have high sensitivity for pheochromocytoma. Serum creatinine and
urinalysis assess renal function but are not diagnostic for the cause. ECG and chest X-ray evaluate
end-organ damage but do not differentiate etiology.
12. A 60-year-old patient with chronic kidney disease (GFR 25 mL/min) is started on an ACE
inhibitor for hypertension. Which of the following best describes the expected change in serum
potassium and the underlying mechanism?
A. Hyperkalemia due to decreased aldosterone secretion
B. Hypokalemia due to increased aldosterone secretion
C. Hyperkalemia due to increased potassium reabsorption in distal tubule
D. Hypokalemia due to decreased potassium reabsorption in proximal tubule
Answer: A
Rationale: ACE inhibitors reduce angiotensin II, leading to decreased aldosterone release. Aldosterone
normally promotes potassium excretion; its reduction causes hyperkalemia, especially in CKD. Options
B, C, and D are incorrect because ACE inhibitors do not increase aldosterone or directly affect
Page 4
