NURS 663 EXAM 1 QUESTIONS AND
ANSWERS 2026/2027
1. A 35-year-old female with major depressive disorder has failed trials of two
SSRIs. Her PMHNP decides to initiate venlafaxine. Which of the following is the
most important baseline assessment prior to starting this medication?
A. Serum creatinine
B. Electrocardiogram (EKG)
C. Liver function tests
D. Complete blood count
Correct Answer: B. Venlafaxine can cause dose-dependent increases in blood
pressure and has been associated with QT prolongation. An EKG is recommended
to establish a baseline for cardiac conduction, particularly in patients with
cardiovascular risk factors. While renal and hepatic function are important, the
most critical baseline assessment for venlafaxine is cardiac monitoring.
2. A patient with bipolar I disorder is being started on lithium. The PMHNP
understands that lithium's mechanism of action is primarily related to which of the
following?
A. Blockade of dopamine D2 receptors
B. Inhibition of inositol monophosphatase and modulation of second messenger
systems
C. Enhancement of GABA activity at the GABA-A receptor
D. Blockade of serotonin reuptake transporters
Correct Answer: B. Lithium's precise mechanism is not fully understood, but it is
believed to work by inhibiting inositol monophosphatase, which affects the
1
,phosphatidylinositol second messenger system. This modulates neurotransmitter
signaling and contributes to its mood-stabilizing effects. Lithium does not directly
block dopamine D2 receptors (antipsychotics do), enhance GABA
(benzodiazepines do), or block serotonin reuptake (SSRIs do).
3. Which of the following SSRIs has the longest half-life and is most likely to
cause activation or agitation?
A. Sertraline
B. Paroxetine
C. Fluoxetine
D. Escitalopram
Correct Answer: C. Fluoxetine has a long half-life of approximately 1-3 days for
the parent drug and 7-15 days for its active metabolite, norfluoxetine. This long
half-life makes it more activating and can cause agitation or insomnia, particularly
when initiated. The long half-life also results in a smoother discontinuation but can
prolong adverse effects if they occur.
4. A patient with generalized anxiety disorder is started on buspirone. The PMHNP
counsels the patient that this medication differs from benzodiazepines in which
important way?
A. It has immediate anxiolytic effects within hours
B. It has no abuse potential and does not cause sedation
C. It acts as a positive allosteric modulator of GABA-A receptors
D. It is eliminated exclusively by the kidneys
Correct Answer: B. Buspirone is a non-benzodiazepine anxiolytic that acts as a
partial agonist at serotonin 5-HT1A receptors. It has no abuse potential, does not
cause sedation, and does not produce tolerance or withdrawal. Unlike
benzodiazepines, it takes 2-4 weeks to achieve therapeutic effect. It does not act on
GABA receptors, and its elimination is primarily hepatic.
2
,5. A 28-year-old male with bipolar II disorder presents with hypomanic symptoms.
The PMHNP considers initiating lamotrigine. Which statement about lamotrigine
is correct?
A. It can be started at 100 mg daily for rapid symptom control
B. It is first-line treatment for acute mania
C. It requires slow titration due to risk of Stevens-Johnson syndrome
D. It has no drug-drug interactions
Correct Answer: C. Lamotrigine requires slow titration to minimize the risk of
Stevens-Johnson syndrome, a potentially life-threatening rash. The recommended
starting dose is 25 mg daily for two weeks, then 50 mg daily for two weeks, with
gradual further increases. It is not first-line for acute mania (it is more effective for
maintenance and bipolar depression), and it does have drug interactions.
6. A patient on carbamazepine for bipolar disorder is being evaluated for potential
drug interactions. Carbamazepine is primarily metabolized by which cytochrome
P450 enzyme?
A. CYP2D6
B. CYP3A4
C. CYP1A2
D. CYP2C9
Correct Answer: B. Carbamazepine is primarily metabolized by CYP3A4. It is a
potent inducer of CYP3A4, which can lead to significant drug-drug interactions by
increasing the metabolism of many other medications. This autoinduction also
means that carbamazepine can induce its own metabolism, requiring dose
adjustments over time.
7. Which of the following is the most common cause of death in patients with
anorexia nervosa?
A. Cardiac arrest
B. Suicide
3
, C. Sepsis
D. Liver failure
Correct Answer: B. While medical complications of anorexia nervosa are
significant, suicide is the most common cause of death in this population. The high
rate of comorbid depression and the psychological distress associated with the
disorder contribute to this elevated risk. Cardiac complications are a major medical
concern but are not the leading cause of mortality.
8. A patient with schizophrenia is being started on clozapine. Which laboratory
monitoring parameter is most critical for this medication?
A. Serum glucose
B. Absolute neutrophil count (ANC)
C. Liver function tests
D. Serum creatinine
Correct Answer: B. Clozapine carries a black box warning for agranulocytosis, a
severe drop in neutrophils that can be fatal. The absolute neutrophil count (ANC)
must be monitored regularly (weekly for the first six months, then biweekly) per
REMS requirements. While glucose, liver, and renal function are also monitored,
ANC monitoring is the most critical for patient safety.
9. A 45-year-old female with major depressive disorder and insomnia is started on
trazodone. The PMHNP explains that trazodone's primary mechanism at low doses
is:
A. Serotonin reuptake inhibition
B. Histamine H1 receptor antagonism
C. 5-HT2A receptor antagonism
D. Alpha-1 adrenergic receptor antagonism
Correct Answer: C. At low doses (50-100 mg), trazodone acts primarily as a 5-
HT2A receptor antagonist and weak serotonin reuptake inhibitor. This mechanism
contributes to its sedating properties without significant serotonin syndrome risk at
4
ANSWERS 2026/2027
1. A 35-year-old female with major depressive disorder has failed trials of two
SSRIs. Her PMHNP decides to initiate venlafaxine. Which of the following is the
most important baseline assessment prior to starting this medication?
A. Serum creatinine
B. Electrocardiogram (EKG)
C. Liver function tests
D. Complete blood count
Correct Answer: B. Venlafaxine can cause dose-dependent increases in blood
pressure and has been associated with QT prolongation. An EKG is recommended
to establish a baseline for cardiac conduction, particularly in patients with
cardiovascular risk factors. While renal and hepatic function are important, the
most critical baseline assessment for venlafaxine is cardiac monitoring.
2. A patient with bipolar I disorder is being started on lithium. The PMHNP
understands that lithium's mechanism of action is primarily related to which of the
following?
A. Blockade of dopamine D2 receptors
B. Inhibition of inositol monophosphatase and modulation of second messenger
systems
C. Enhancement of GABA activity at the GABA-A receptor
D. Blockade of serotonin reuptake transporters
Correct Answer: B. Lithium's precise mechanism is not fully understood, but it is
believed to work by inhibiting inositol monophosphatase, which affects the
1
,phosphatidylinositol second messenger system. This modulates neurotransmitter
signaling and contributes to its mood-stabilizing effects. Lithium does not directly
block dopamine D2 receptors (antipsychotics do), enhance GABA
(benzodiazepines do), or block serotonin reuptake (SSRIs do).
3. Which of the following SSRIs has the longest half-life and is most likely to
cause activation or agitation?
A. Sertraline
B. Paroxetine
C. Fluoxetine
D. Escitalopram
Correct Answer: C. Fluoxetine has a long half-life of approximately 1-3 days for
the parent drug and 7-15 days for its active metabolite, norfluoxetine. This long
half-life makes it more activating and can cause agitation or insomnia, particularly
when initiated. The long half-life also results in a smoother discontinuation but can
prolong adverse effects if they occur.
4. A patient with generalized anxiety disorder is started on buspirone. The PMHNP
counsels the patient that this medication differs from benzodiazepines in which
important way?
A. It has immediate anxiolytic effects within hours
B. It has no abuse potential and does not cause sedation
C. It acts as a positive allosteric modulator of GABA-A receptors
D. It is eliminated exclusively by the kidneys
Correct Answer: B. Buspirone is a non-benzodiazepine anxiolytic that acts as a
partial agonist at serotonin 5-HT1A receptors. It has no abuse potential, does not
cause sedation, and does not produce tolerance or withdrawal. Unlike
benzodiazepines, it takes 2-4 weeks to achieve therapeutic effect. It does not act on
GABA receptors, and its elimination is primarily hepatic.
2
,5. A 28-year-old male with bipolar II disorder presents with hypomanic symptoms.
The PMHNP considers initiating lamotrigine. Which statement about lamotrigine
is correct?
A. It can be started at 100 mg daily for rapid symptom control
B. It is first-line treatment for acute mania
C. It requires slow titration due to risk of Stevens-Johnson syndrome
D. It has no drug-drug interactions
Correct Answer: C. Lamotrigine requires slow titration to minimize the risk of
Stevens-Johnson syndrome, a potentially life-threatening rash. The recommended
starting dose is 25 mg daily for two weeks, then 50 mg daily for two weeks, with
gradual further increases. It is not first-line for acute mania (it is more effective for
maintenance and bipolar depression), and it does have drug interactions.
6. A patient on carbamazepine for bipolar disorder is being evaluated for potential
drug interactions. Carbamazepine is primarily metabolized by which cytochrome
P450 enzyme?
A. CYP2D6
B. CYP3A4
C. CYP1A2
D. CYP2C9
Correct Answer: B. Carbamazepine is primarily metabolized by CYP3A4. It is a
potent inducer of CYP3A4, which can lead to significant drug-drug interactions by
increasing the metabolism of many other medications. This autoinduction also
means that carbamazepine can induce its own metabolism, requiring dose
adjustments over time.
7. Which of the following is the most common cause of death in patients with
anorexia nervosa?
A. Cardiac arrest
B. Suicide
3
, C. Sepsis
D. Liver failure
Correct Answer: B. While medical complications of anorexia nervosa are
significant, suicide is the most common cause of death in this population. The high
rate of comorbid depression and the psychological distress associated with the
disorder contribute to this elevated risk. Cardiac complications are a major medical
concern but are not the leading cause of mortality.
8. A patient with schizophrenia is being started on clozapine. Which laboratory
monitoring parameter is most critical for this medication?
A. Serum glucose
B. Absolute neutrophil count (ANC)
C. Liver function tests
D. Serum creatinine
Correct Answer: B. Clozapine carries a black box warning for agranulocytosis, a
severe drop in neutrophils that can be fatal. The absolute neutrophil count (ANC)
must be monitored regularly (weekly for the first six months, then biweekly) per
REMS requirements. While glucose, liver, and renal function are also monitored,
ANC monitoring is the most critical for patient safety.
9. A 45-year-old female with major depressive disorder and insomnia is started on
trazodone. The PMHNP explains that trazodone's primary mechanism at low doses
is:
A. Serotonin reuptake inhibition
B. Histamine H1 receptor antagonism
C. 5-HT2A receptor antagonism
D. Alpha-1 adrenergic receptor antagonism
Correct Answer: C. At low doses (50-100 mg), trazodone acts primarily as a 5-
HT2A receptor antagonist and weak serotonin reuptake inhibitor. This mechanism
contributes to its sedating properties without significant serotonin syndrome risk at
4
