NURS 661 EXAM 2 —a COMPLETE QUESTIONS &
ANSWERS (2025/2026)
Introduction
NURS 661 is the cornerstone didactic course for graduate psychiatric-mental health nursing students
advancing toward nurse-practitioner practice. Exam 2 evaluates mastery of evidence-based biological
and psychotherapeutic interventions across the lifespan. Domains tested include advanced
psychopharmacology (mechanisms, kinetics, adverse effects, interactions), neurobiological
underpinnings of DSM-5-TR disorders, evidence-based psychotherapy models, crisis and safety
planning, culturally responsive care, and the ethical / legal scope of the psychiatric-mental health NP.
Every question below is original, board-exam aligned, and written for the 2025/2026 academic year
to support A-level performance.
Question 1
Which second-generation antipsychotic possesses the highest affinity for the 5-HT2A receptor
relative to D2 and carries the lowest risk of dose-dependent prolactin elevation?
A. Risperidone
B. Olanzapine
C. Ziprasidone
D. Aripiprazole
Answer: D. Aripiprazole
Rationale: Aripiprazole is a D2 partial agonist with high 5-HT2A antagonism. Partial agonism stabilizes
dopamine pathways, preventing sustained prolactin elevation. Risperidone and olanzapine are
potent D2 blockers; ziprasidone’s ratio is lower.
Question 2
A 26-year-old with MDD begins sertraline 50 mg daily. After 6 weeks, Hamilton-D-17 score drops
from 22 to 18. Which neuroplastic change is most closely linked to this partial response?
A. Down-regulation of β-adrenergic receptors
B. Increased hippocampal BDNF expression
C. Decreased 5-HT1A autoreceptor density
D. Up-regulation of GABA-A subunits
Answer: B. Increased hippocampal BDNF expression
Rationale: SSRIs gradually raise brain-derived neurotrophic factor, promoting synaptogenesis and
neurogenesis—correlating with mood improvement. β-down-regulation occurs faster; 5-HT1A
changes are earlier; GABA up-regulation is less specific.
Question 3
pg. 1
, (Case) A patient on lithium 900 mg nightly for bipolar I presents with coarse tremor, nausea, and
serum lithium 1.4 mEq/L (normal 0.6–1.0). Which kinetic factor most likely explains this elevation?
A. Introduction of ibuprofen two weeks ago
B. Switch from twice-daily to once-daily dosing
C. Initiation of high-dose vitamin D
D. Patient began a low-sodium diet
Answer: A. Introduction of ibuprofen two weeks ago
Rationale: NSAIDs reduce renal blood flow and lithium clearance, raising levels within days. Once-
daily dosing does not alter steady-state AUC; vitamin D lacks kinetic interaction; low-sodium
increases reabsorption but NSAIDs have larger effect.
Question 4
Which cytochrome P450 enzyme contributes most to the primary active metabolite of clozapine?
A. CYP1A2
B. CYP2D6
C. CYP3A4
D. CYP2C19
Answer: A. CYP1A2
Rationale: CYP1A2 forms norclozapine, which retains some efficacy. 3A4 contributes, but 1A2 is
dominant. Smoking induces 1A2, often requiring higher doses.
Question 5
During initiation of brexpiprazole, which monitoring parameter is unique compared with other
atypical antipsychotics?
A. Fasting lipid panel
B. A1C
C. Baseline CYP2D6 genotype
D. Prolactin
Answer: C. Baseline CYP2D6 genotype
Rationale: Brexpiprazole’s FDA labeling recommends genotype-guided dosing (reduce starting dose
by half in CYP2D6 poor metabolizers). Lipids, A1C, and prolactin are standard for all.
Question 6
(Case) A 34-year-old with treatment-resistant MDD receives intravenous ketamine 0.5 mg/kg. Within
2 hours, mood improves dramatically. Which receptor mechanism is most directly responsible for the
rapid antidepressant effect?
A. NMDA-receptor antagonism → increased glutamate burst → AMPA potentiation
B. Direct 5-HT2A agonism
C. Mu-opioid receptor agonism
D. GABA-A positive modulation
pg. 2
ANSWERS (2025/2026)
Introduction
NURS 661 is the cornerstone didactic course for graduate psychiatric-mental health nursing students
advancing toward nurse-practitioner practice. Exam 2 evaluates mastery of evidence-based biological
and psychotherapeutic interventions across the lifespan. Domains tested include advanced
psychopharmacology (mechanisms, kinetics, adverse effects, interactions), neurobiological
underpinnings of DSM-5-TR disorders, evidence-based psychotherapy models, crisis and safety
planning, culturally responsive care, and the ethical / legal scope of the psychiatric-mental health NP.
Every question below is original, board-exam aligned, and written for the 2025/2026 academic year
to support A-level performance.
Question 1
Which second-generation antipsychotic possesses the highest affinity for the 5-HT2A receptor
relative to D2 and carries the lowest risk of dose-dependent prolactin elevation?
A. Risperidone
B. Olanzapine
C. Ziprasidone
D. Aripiprazole
Answer: D. Aripiprazole
Rationale: Aripiprazole is a D2 partial agonist with high 5-HT2A antagonism. Partial agonism stabilizes
dopamine pathways, preventing sustained prolactin elevation. Risperidone and olanzapine are
potent D2 blockers; ziprasidone’s ratio is lower.
Question 2
A 26-year-old with MDD begins sertraline 50 mg daily. After 6 weeks, Hamilton-D-17 score drops
from 22 to 18. Which neuroplastic change is most closely linked to this partial response?
A. Down-regulation of β-adrenergic receptors
B. Increased hippocampal BDNF expression
C. Decreased 5-HT1A autoreceptor density
D. Up-regulation of GABA-A subunits
Answer: B. Increased hippocampal BDNF expression
Rationale: SSRIs gradually raise brain-derived neurotrophic factor, promoting synaptogenesis and
neurogenesis—correlating with mood improvement. β-down-regulation occurs faster; 5-HT1A
changes are earlier; GABA up-regulation is less specific.
Question 3
pg. 1
, (Case) A patient on lithium 900 mg nightly for bipolar I presents with coarse tremor, nausea, and
serum lithium 1.4 mEq/L (normal 0.6–1.0). Which kinetic factor most likely explains this elevation?
A. Introduction of ibuprofen two weeks ago
B. Switch from twice-daily to once-daily dosing
C. Initiation of high-dose vitamin D
D. Patient began a low-sodium diet
Answer: A. Introduction of ibuprofen two weeks ago
Rationale: NSAIDs reduce renal blood flow and lithium clearance, raising levels within days. Once-
daily dosing does not alter steady-state AUC; vitamin D lacks kinetic interaction; low-sodium
increases reabsorption but NSAIDs have larger effect.
Question 4
Which cytochrome P450 enzyme contributes most to the primary active metabolite of clozapine?
A. CYP1A2
B. CYP2D6
C. CYP3A4
D. CYP2C19
Answer: A. CYP1A2
Rationale: CYP1A2 forms norclozapine, which retains some efficacy. 3A4 contributes, but 1A2 is
dominant. Smoking induces 1A2, often requiring higher doses.
Question 5
During initiation of brexpiprazole, which monitoring parameter is unique compared with other
atypical antipsychotics?
A. Fasting lipid panel
B. A1C
C. Baseline CYP2D6 genotype
D. Prolactin
Answer: C. Baseline CYP2D6 genotype
Rationale: Brexpiprazole’s FDA labeling recommends genotype-guided dosing (reduce starting dose
by half in CYP2D6 poor metabolizers). Lipids, A1C, and prolactin are standard for all.
Question 6
(Case) A 34-year-old with treatment-resistant MDD receives intravenous ketamine 0.5 mg/kg. Within
2 hours, mood improves dramatically. Which receptor mechanism is most directly responsible for the
rapid antidepressant effect?
A. NMDA-receptor antagonism → increased glutamate burst → AMPA potentiation
B. Direct 5-HT2A agonism
C. Mu-opioid receptor agonism
D. GABA-A positive modulation
pg. 2
