NR 546 / NR546 Midterm Exam (Latest
2026) Tested Questions with Revised
Answers, (A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 28-year-old woman with TRD (failed sertraline 200 mg 8 wks, augmentation
aripiprazole 5 mg 6 wks). PHQ-9 22, no psychosis. CYP2D6 ultra-rapid metabolizer
(UM). Vital signs stable.
Question: Next evidence-based pharmacotherapy?
Options:
A. Increase aripiprazole to 15 mg daily
B. Switch to intranasal esketamine 56 mg bi-weekly
C. Add lithium 600 mg hs
D. Cross-taper to venlafaxine 225 mg
(Correct: B)
Rationale:
● Answer: Intranasal esketamine 56 mg bi-weekly
● Why (2026 Standard): TRD with ≥2 failures qualifies for esketamine per APA
2026; rapid NMDA-antagonist benefit independent of CYP2D6.
, ● Errors: Aripiprazole UM needs ↓dose not ↑; lithium lacks antidepressant
monotherapy evidence here; venlafaxine still SSRI-like, likely fail.
Q002:
Type: Expert MCQ
Scenario: 45-year-old man on clozapine 400 mg hs for TRS. WBC 2.8 K/µL (baseline
5.2), neutrophils 1.2 K/µL, repeated ×2. Afebrile.
Question: Immediate PMHNP action?
Options:
A. Continue clozapine and add filgrastim
B. Hold clozapine and obtain hematology consult
C. Reduce to 300 mg and monitor weekly
D. Switch to olanzapine 20 mg
(Correct: B)
Rationale:
● Answer: Hold clozapine and obtain hematology consult
● Why (2026 Standard): ANC <1.5 or WBC <3.0 mandates immediate
discontinuation per Clozapine REMS 2026 to prevent agranulocytosis.
● Errors: Continuing risks life; dose reduction unsafe once cytopenic; switch agent
premature without work-up.
Q003:
Type: NGN - Psychopharm
,Scenario: 19-year-old college male, new ADHD dx. EKG shows QTc 490 ms. No meds.
HR 58.
Question: Stimulant choice?
Options:
A. Lisdexamfetamine 30 mg qAM
B. Methylphenidate LA 20 mg qAM
C. Atomoxetine 40 mg qAM
D. Clonidine 0.1 mg bid
(Correct: C)
Rationale:
● Answer: Atomoxetine 40 mg qAM
● Why (2026 Standard): QTc >480 contraindicates amphetamines per 2026 AACAP
guidelines; atomoxetine non-stimulant, minimal QT effect.
● Errors: Amphetamines ↑QTc; methylphenidate also sympathomimetic; clonidine
efficacy monotherapy <stimulants.
Q004:
Type: Expert MCQ
Scenario: 66-year-old woman with late-life MDD started on paroxetine 10 mg. Day 10
presents with delirium, urinary retention, dry mouth.
Question: Best pharmacokinetic explanation?
Options:
, A. CYP2D6 poor metabolizer with anticholinergic accumulation
B. CYP3A4 rapid metabolizer
C. Renal clearance decreased by 50%
D. Protein-binding displacement
(Correct: A)
Rationale:
● Answer: CYP2D6 poor metabolizer with anticholinergic accumulation
● Why (2026 Standard): Paroxetine potent anticholinergic; poor metabolizers
↑plasma levels 3-fold → anticholinergic toxicity in elderly.
● Errors: 3A4 not major for paroxetine; renal not primary; protein binding rarely
clinical issue.
Q005:
Type: NGN - Psychopharm
Scenario: 32-year-old woman 32 wks pregnant, stable on lamotrigine 150 mg bid for
bipolar depression. Last seizure 4 yrs ago. Level 4.5 µg/mL (goal 3-15).
Question: Plan?
Options:
A. Increase dose 50% at 36 wks
B. Switch to valproate 500 mg
C. Add lithium 300 mg
D. Maintain current dose
2026) Tested Questions with Revised
Answers, (A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 28-year-old woman with TRD (failed sertraline 200 mg 8 wks, augmentation
aripiprazole 5 mg 6 wks). PHQ-9 22, no psychosis. CYP2D6 ultra-rapid metabolizer
(UM). Vital signs stable.
Question: Next evidence-based pharmacotherapy?
Options:
A. Increase aripiprazole to 15 mg daily
B. Switch to intranasal esketamine 56 mg bi-weekly
C. Add lithium 600 mg hs
D. Cross-taper to venlafaxine 225 mg
(Correct: B)
Rationale:
● Answer: Intranasal esketamine 56 mg bi-weekly
● Why (2026 Standard): TRD with ≥2 failures qualifies for esketamine per APA
2026; rapid NMDA-antagonist benefit independent of CYP2D6.
, ● Errors: Aripiprazole UM needs ↓dose not ↑; lithium lacks antidepressant
monotherapy evidence here; venlafaxine still SSRI-like, likely fail.
Q002:
Type: Expert MCQ
Scenario: 45-year-old man on clozapine 400 mg hs for TRS. WBC 2.8 K/µL (baseline
5.2), neutrophils 1.2 K/µL, repeated ×2. Afebrile.
Question: Immediate PMHNP action?
Options:
A. Continue clozapine and add filgrastim
B. Hold clozapine and obtain hematology consult
C. Reduce to 300 mg and monitor weekly
D. Switch to olanzapine 20 mg
(Correct: B)
Rationale:
● Answer: Hold clozapine and obtain hematology consult
● Why (2026 Standard): ANC <1.5 or WBC <3.0 mandates immediate
discontinuation per Clozapine REMS 2026 to prevent agranulocytosis.
● Errors: Continuing risks life; dose reduction unsafe once cytopenic; switch agent
premature without work-up.
Q003:
Type: NGN - Psychopharm
,Scenario: 19-year-old college male, new ADHD dx. EKG shows QTc 490 ms. No meds.
HR 58.
Question: Stimulant choice?
Options:
A. Lisdexamfetamine 30 mg qAM
B. Methylphenidate LA 20 mg qAM
C. Atomoxetine 40 mg qAM
D. Clonidine 0.1 mg bid
(Correct: C)
Rationale:
● Answer: Atomoxetine 40 mg qAM
● Why (2026 Standard): QTc >480 contraindicates amphetamines per 2026 AACAP
guidelines; atomoxetine non-stimulant, minimal QT effect.
● Errors: Amphetamines ↑QTc; methylphenidate also sympathomimetic; clonidine
efficacy monotherapy <stimulants.
Q004:
Type: Expert MCQ
Scenario: 66-year-old woman with late-life MDD started on paroxetine 10 mg. Day 10
presents with delirium, urinary retention, dry mouth.
Question: Best pharmacokinetic explanation?
Options:
, A. CYP2D6 poor metabolizer with anticholinergic accumulation
B. CYP3A4 rapid metabolizer
C. Renal clearance decreased by 50%
D. Protein-binding displacement
(Correct: A)
Rationale:
● Answer: CYP2D6 poor metabolizer with anticholinergic accumulation
● Why (2026 Standard): Paroxetine potent anticholinergic; poor metabolizers
↑plasma levels 3-fold → anticholinergic toxicity in elderly.
● Errors: 3A4 not major for paroxetine; renal not primary; protein binding rarely
clinical issue.
Q005:
Type: NGN - Psychopharm
Scenario: 32-year-old woman 32 wks pregnant, stable on lamotrigine 150 mg bid for
bipolar depression. Last seizure 4 yrs ago. Level 4.5 µg/mL (goal 3-15).
Question: Plan?
Options:
A. Increase dose 50% at 36 wks
B. Switch to valproate 500 mg
C. Add lithium 300 mg
D. Maintain current dose
