WGU D344 PMHNP OBJECTIVE
ASSESSMENT OA ULTIMATE EXAM PREP
150 HIGH YIELD CLINICAL QUESTIONS
WITH DIRECT ANSWERS and
RATIONALES GRADED A+
WGU D344: PMHNP Advanced Advanced
Psychopharmacology Practice Exam
1. A 32-year-old female patient diagnosed with bipolar I
disorder presents to the outpatient clinic expressing her
desire to become pregnant in the near future. She is
currently stabilized on a maintenance regimen of lithium
carbonate 900 mg daily, with a recent therapeutic serum
level of 0.8 mEq/L. Which of the following structural fetal
abnormalities is most strongly associated with first-
trimester lithium exposure, and what is the standard
monitoring protocol during pregnancy?
A. Neural tube defects; monitored via maternal alpha-
fetoprotein screening at 16 weeks gestation
B. Ebstein’s anomaly; monitored via fetal
echocardiography at 18 to 20 weeks gestation
C. Cleft lip and palate; monitored via high-resolution
structural ultrasound at 12 weeks gestation
D. Tetralogy of Fallot; monitored via electronic fetal heart
rate monitoring in the third trimester
Correct Answer: B. Rationale: Lithium exposure
during the first trimester carries a well-documented risk
of cardiovascular malformations, specifically Ebstein's
anomaly (displacement of the tricuspid valve leaflets into
the right ventricle). While the absolute risk is lower than
, historically estimated, it remains significantly higher
than the general population baseline. Fetal
echocardiography at 18 to 20 weeks is the gold standard
for screening for this specific structural heart defect.
2. A 45-year-old male with chronic schizophrenia has been
treated with clozapine for the past two years due to
treatment-resistant auditory hallucinations. His recent
absolute neutrophil count (ANC) drops from a baseline of
1,800/µL to 1,250/µL on routine laboratory monitoring.
According to the Clozapine Risk Evaluation and Mitigation
Strategy (REMS) registry guidelines, what is the correct
clinical action for this patient?
A. Immediately discontinue clozapine, initiate
prophylactic antibiotics, and admit to an inpatient medical
unit.
B. Maintain current clozapine dosing, but increase lab
draws to twice-weekly until the ANC rises above 1,500/µL.
C. Continue clozapine therapy but increase
monitoring frequency to three times weekly until
ANC is greater than or equal to 1,500/µL.
D. Reduce the clozapine dose by 50% and order a bone
marrow biopsy to rule out idiopathic aplastic anemia.
Correct Answer: C. Rationale: In a regular patient
(non-benign ethnic neutropenia), an ANC between
1,000–1,499/µL represents mild neutropenia. Under
Clozapine REMS guidelines, the medication is continued,
but laboratory monitoring must be increased to 3 times
weekly until the ANC returns to ≥ 1,500/µL, at which
point the patient can return to their previous monitoring
frequency.
3. A 68-year-old female patient with a history of recurrent
major depressive disorder presents with new-onset severe
cognitive slowing, profound psychomotor retardation, and
somatic delusions of poverty. She has failed adequate 6-
, week trials of two different Selective Serotonin Reuptake
Inhibitors (SSRIs) and one Serotonin-Norepinephrine
Reuptake Inhibitor (SNRI). Given her presentation of
severe psychotic depression and history of medication
resistance, what is the most appropriate next-line
treatment strategy?
A. Initiation of Electroconvulsive Therapy (ECT)
B. Augmentation of the current SNRI with low-dose
buspirone
C. Switching to a Monoamine Oxidase Inhibitor (MAOI)
such as phenelzine
D. Initiation of high-dose intravenous ketamine infusions
over two weeks
Correct Answer: A. Rationale: For severe major
depressive disorder with psychotic features, especially in
the elderly or when treatment resistance is demonstrated,
Electroconvulsive Therapy (ECT) is considered a first-
line, highly effective intervention. It works more rapidly
and effectively than pharmacological switching or simple
non-psychotic augmentation strategies for delusional
depression.
4. A 24-year-old male is brought to the emergency
department after a witnessed generalized tonic-clonic
seizure. His outpatient medication list includes bupropion
XL 450 mg daily for major depressive disorder, which was
titrated up rapidly by an outside provider two weeks ago.
He has no prior history of epilepsy. Which neurobiological
mechanism explains how bupropion lowers the seizure
threshold?
A. Potent antagonism of central GABA-A receptors leading
to uninhibited glutamate release
B. Blockade of voltage-gated sodium channels in the
hippocampal formation
C. Inhibition of norepinephrine and dopamine
, reuptake, which can alter cortical excitability at
high concentrations
D. Direct agonism at NMDA receptors causing massive
intracellular calcium influx
Correct Answer: C. Rationale: Bupropion is an
inhibitor of the norepinephrine and dopamine
transporters (NDRI). At doses exceeding 450 mg/day, or
when titrated too quickly, it significantly lowers the
seizure threshold due to altered catecholaminergic
cortical excitability. It does not possess direct GABA
antagonistic or NMDA agonistic properties.
5. A 29-year-old female patient with obsessive-compulsive
disorder (OCD) has been taking sertraline 200 mg daily
for 12 weeks with only minimal reduction in her checking
and washing rituals. She reports strict adherence to the
medication. What is the next most appropriate
pharmacotherapeutic step according to evidence-based
guidelines for treatment-resistant OCD?
A. Discontinue sertraline and immediately switch to a
maximum dose of fluoxetine.
B. Augment the current dose of sertraline with a
low-dose atypical antipsychotic such as
aripiprazole or risperidone.
C. Add low-dose trazodone at bedtime to enhance
serotonergic neurotransmission.
D. Discontinue sertraline and initiate monotherapy with
the tricyclic antidepressant clomipramine at 250 mg daily.
Correct Answer: B. Rationale: When a patient with
OCD shows an inadequate response to a maximum dose
of an SSRI after a full 12-week trial, guidelines
recommend augmenting the SSRI with a low-dose
atypical antipsychotic (e.g., risperidone or aripiprazole)
before completely switching mechanisms or moving to
high-side-effect options like clomipramine monotherapy.
ASSESSMENT OA ULTIMATE EXAM PREP
150 HIGH YIELD CLINICAL QUESTIONS
WITH DIRECT ANSWERS and
RATIONALES GRADED A+
WGU D344: PMHNP Advanced Advanced
Psychopharmacology Practice Exam
1. A 32-year-old female patient diagnosed with bipolar I
disorder presents to the outpatient clinic expressing her
desire to become pregnant in the near future. She is
currently stabilized on a maintenance regimen of lithium
carbonate 900 mg daily, with a recent therapeutic serum
level of 0.8 mEq/L. Which of the following structural fetal
abnormalities is most strongly associated with first-
trimester lithium exposure, and what is the standard
monitoring protocol during pregnancy?
A. Neural tube defects; monitored via maternal alpha-
fetoprotein screening at 16 weeks gestation
B. Ebstein’s anomaly; monitored via fetal
echocardiography at 18 to 20 weeks gestation
C. Cleft lip and palate; monitored via high-resolution
structural ultrasound at 12 weeks gestation
D. Tetralogy of Fallot; monitored via electronic fetal heart
rate monitoring in the third trimester
Correct Answer: B. Rationale: Lithium exposure
during the first trimester carries a well-documented risk
of cardiovascular malformations, specifically Ebstein's
anomaly (displacement of the tricuspid valve leaflets into
the right ventricle). While the absolute risk is lower than
, historically estimated, it remains significantly higher
than the general population baseline. Fetal
echocardiography at 18 to 20 weeks is the gold standard
for screening for this specific structural heart defect.
2. A 45-year-old male with chronic schizophrenia has been
treated with clozapine for the past two years due to
treatment-resistant auditory hallucinations. His recent
absolute neutrophil count (ANC) drops from a baseline of
1,800/µL to 1,250/µL on routine laboratory monitoring.
According to the Clozapine Risk Evaluation and Mitigation
Strategy (REMS) registry guidelines, what is the correct
clinical action for this patient?
A. Immediately discontinue clozapine, initiate
prophylactic antibiotics, and admit to an inpatient medical
unit.
B. Maintain current clozapine dosing, but increase lab
draws to twice-weekly until the ANC rises above 1,500/µL.
C. Continue clozapine therapy but increase
monitoring frequency to three times weekly until
ANC is greater than or equal to 1,500/µL.
D. Reduce the clozapine dose by 50% and order a bone
marrow biopsy to rule out idiopathic aplastic anemia.
Correct Answer: C. Rationale: In a regular patient
(non-benign ethnic neutropenia), an ANC between
1,000–1,499/µL represents mild neutropenia. Under
Clozapine REMS guidelines, the medication is continued,
but laboratory monitoring must be increased to 3 times
weekly until the ANC returns to ≥ 1,500/µL, at which
point the patient can return to their previous monitoring
frequency.
3. A 68-year-old female patient with a history of recurrent
major depressive disorder presents with new-onset severe
cognitive slowing, profound psychomotor retardation, and
somatic delusions of poverty. She has failed adequate 6-
, week trials of two different Selective Serotonin Reuptake
Inhibitors (SSRIs) and one Serotonin-Norepinephrine
Reuptake Inhibitor (SNRI). Given her presentation of
severe psychotic depression and history of medication
resistance, what is the most appropriate next-line
treatment strategy?
A. Initiation of Electroconvulsive Therapy (ECT)
B. Augmentation of the current SNRI with low-dose
buspirone
C. Switching to a Monoamine Oxidase Inhibitor (MAOI)
such as phenelzine
D. Initiation of high-dose intravenous ketamine infusions
over two weeks
Correct Answer: A. Rationale: For severe major
depressive disorder with psychotic features, especially in
the elderly or when treatment resistance is demonstrated,
Electroconvulsive Therapy (ECT) is considered a first-
line, highly effective intervention. It works more rapidly
and effectively than pharmacological switching or simple
non-psychotic augmentation strategies for delusional
depression.
4. A 24-year-old male is brought to the emergency
department after a witnessed generalized tonic-clonic
seizure. His outpatient medication list includes bupropion
XL 450 mg daily for major depressive disorder, which was
titrated up rapidly by an outside provider two weeks ago.
He has no prior history of epilepsy. Which neurobiological
mechanism explains how bupropion lowers the seizure
threshold?
A. Potent antagonism of central GABA-A receptors leading
to uninhibited glutamate release
B. Blockade of voltage-gated sodium channels in the
hippocampal formation
C. Inhibition of norepinephrine and dopamine
, reuptake, which can alter cortical excitability at
high concentrations
D. Direct agonism at NMDA receptors causing massive
intracellular calcium influx
Correct Answer: C. Rationale: Bupropion is an
inhibitor of the norepinephrine and dopamine
transporters (NDRI). At doses exceeding 450 mg/day, or
when titrated too quickly, it significantly lowers the
seizure threshold due to altered catecholaminergic
cortical excitability. It does not possess direct GABA
antagonistic or NMDA agonistic properties.
5. A 29-year-old female patient with obsessive-compulsive
disorder (OCD) has been taking sertraline 200 mg daily
for 12 weeks with only minimal reduction in her checking
and washing rituals. She reports strict adherence to the
medication. What is the next most appropriate
pharmacotherapeutic step according to evidence-based
guidelines for treatment-resistant OCD?
A. Discontinue sertraline and immediately switch to a
maximum dose of fluoxetine.
B. Augment the current dose of sertraline with a
low-dose atypical antipsychotic such as
aripiprazole or risperidone.
C. Add low-dose trazodone at bedtime to enhance
serotonergic neurotransmission.
D. Discontinue sertraline and initiate monotherapy with
the tricyclic antidepressant clomipramine at 250 mg daily.
Correct Answer: B. Rationale: When a patient with
OCD shows an inadequate response to a maximum dose
of an SSRI after a full 12-week trial, guidelines
recommend augmenting the SSRI with a low-dose
atypical antipsychotic (e.g., risperidone or aripiprazole)
before completely switching mechanisms or moving to
high-side-effect options like clomipramine monotherapy.
