NR 546 / NR546 Midterm actual Exam (Latest
2026) Tested Questions with Revised Answers,
(A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 27-year-old woman with MDD, inadequate response to 8-week escitalopram 20
mg. PHQ-9 18. CYP2C19 *2/*2 (poor metabolizer). Current meds: escitalopram 20 mg,
occasional zolpidem.
Question: Most evidence-based next step?
Options:
A. Increase escitalopram to 30 mg daily
B. Switch to sertraline 50 mg
C. Augment with aripiprazole 2 mg
D. Cross-taper to venlafaxine XR 37.5 mg
(Correct: C)
Rationale:
● Answer: Augment with aripiprazole 2 mg
● Why (2026 Standard): APA/TRD 2025: after one failed SSRI, atypical
antipsychotic augmentation has strongest evidence. CYP2C19 PM status does not
, block aripiprazole pathway; partial DA agonism ↑ prefrontal dopamine →
pro-cognitive & antidepressant effect.
● Errors: Escital 30 mg (A) exceeds FDA max & QTc risk; sertraline (B) still
CYP2C19 substrate; venlafaxine (D) requires long taper & similar SNRI
side-effect burden.
Q002:
Type: Expert MCQ
Scenario: 19-year-old man with first-episode psychosis, BMI 18.5, QTc 455 ms. Needs
antipsychotic.
Question: First-line choice?
Options:
A. Olanzapine 10 mg
B. Risperidone 4 mg
C. Aripiprazole 10 mg
D. Haloperidol 5 mg
(Correct: C)
Rationale:
● Answer: Aripiprazole 10 mg
● Why (2026 Standard): Lowest weight gain & QTc liability; partial agonism ↓
hyperprolactinemia—critical in teens to preserve bone density.
● Errors: Olanzapine (A) weight gain; risperidone (B) ↑QTc & prolactin; haloperidol
(D) ↑EPS, QTc.
Q003:
,Type: NGN - Psychopharm
Scenario: 34-year-old woman with bipolar-I, stable on lithium 1200 mg, level 0.9 mEq/L.
GFR 45 mL/min, urine osmolality 120 mOsm/kg, Na 132 mEq/L.
Question: Best prescribing action?
Options:
A. Continue lithium, add amiloride 5 mg
B. Switch to valproate ER 500 mg
C. Reduce lithium to 900 mg
D. Add hydrochlorothiazide 25 mg
(Correct: B)
Rationale:
● Answer: Switch to valproate ER 500 mg
● Why (2026 Standard): GFR <60 + nephrogenic DI (dilute urine) = stage 3b CKD
risk; valproate not renally cleared, equal mania relapse prevention.
● Errors: Amiloride (A) may help DI but not CKD progression; thiazide (D) worsens
Na↓ & renal stress.
Q004:
Type: Expert MCQ
Scenario: 66-year-old man with MDD, on duloxetine 60 mg; develops urinary retention,
hesitancy.
Question: Best next step?
, Options:
A. Add tamsulosin 0.4 mg
B. Reduce duloxetine to 30 mg
C. Switch to desvenlafaxine 50 mg
D. Stop duloxetine, start mirtazapine 15 mg
(Correct: D)
Rationale:
● Answer: Stop duloxetine, start mirtazapine 15 mg
● Why (2026 Standard): SNRI α1-adrenergic blockade → bladder neck relaxation
failure; mirtazapine enhances 5-HT2/3 antagonism + NA/5-HT release without
adrenergic affinity → preserves continence, sleep, appetite.
● Errors: Tamsulosin (A) adds hypotension; desvenlafaxine (C) similar SNRI
profile.
Q005:
Type: NGN - Psychopharm
Scenario: 24-year-old woman with PTSD, nightmares, on sertraline 100 mg ×8 weeks.
Nightmare severity 7/10.
Question: Evidence-based add-on?
Options:
A. Prazosin 1 mg qHS
B. Trazodone 50 mg qHS
2026) Tested Questions with Revised Answers,
(A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 27-year-old woman with MDD, inadequate response to 8-week escitalopram 20
mg. PHQ-9 18. CYP2C19 *2/*2 (poor metabolizer). Current meds: escitalopram 20 mg,
occasional zolpidem.
Question: Most evidence-based next step?
Options:
A. Increase escitalopram to 30 mg daily
B. Switch to sertraline 50 mg
C. Augment with aripiprazole 2 mg
D. Cross-taper to venlafaxine XR 37.5 mg
(Correct: C)
Rationale:
● Answer: Augment with aripiprazole 2 mg
● Why (2026 Standard): APA/TRD 2025: after one failed SSRI, atypical
antipsychotic augmentation has strongest evidence. CYP2C19 PM status does not
, block aripiprazole pathway; partial DA agonism ↑ prefrontal dopamine →
pro-cognitive & antidepressant effect.
● Errors: Escital 30 mg (A) exceeds FDA max & QTc risk; sertraline (B) still
CYP2C19 substrate; venlafaxine (D) requires long taper & similar SNRI
side-effect burden.
Q002:
Type: Expert MCQ
Scenario: 19-year-old man with first-episode psychosis, BMI 18.5, QTc 455 ms. Needs
antipsychotic.
Question: First-line choice?
Options:
A. Olanzapine 10 mg
B. Risperidone 4 mg
C. Aripiprazole 10 mg
D. Haloperidol 5 mg
(Correct: C)
Rationale:
● Answer: Aripiprazole 10 mg
● Why (2026 Standard): Lowest weight gain & QTc liability; partial agonism ↓
hyperprolactinemia—critical in teens to preserve bone density.
● Errors: Olanzapine (A) weight gain; risperidone (B) ↑QTc & prolactin; haloperidol
(D) ↑EPS, QTc.
Q003:
,Type: NGN - Psychopharm
Scenario: 34-year-old woman with bipolar-I, stable on lithium 1200 mg, level 0.9 mEq/L.
GFR 45 mL/min, urine osmolality 120 mOsm/kg, Na 132 mEq/L.
Question: Best prescribing action?
Options:
A. Continue lithium, add amiloride 5 mg
B. Switch to valproate ER 500 mg
C. Reduce lithium to 900 mg
D. Add hydrochlorothiazide 25 mg
(Correct: B)
Rationale:
● Answer: Switch to valproate ER 500 mg
● Why (2026 Standard): GFR <60 + nephrogenic DI (dilute urine) = stage 3b CKD
risk; valproate not renally cleared, equal mania relapse prevention.
● Errors: Amiloride (A) may help DI but not CKD progression; thiazide (D) worsens
Na↓ & renal stress.
Q004:
Type: Expert MCQ
Scenario: 66-year-old man with MDD, on duloxetine 60 mg; develops urinary retention,
hesitancy.
Question: Best next step?
, Options:
A. Add tamsulosin 0.4 mg
B. Reduce duloxetine to 30 mg
C. Switch to desvenlafaxine 50 mg
D. Stop duloxetine, start mirtazapine 15 mg
(Correct: D)
Rationale:
● Answer: Stop duloxetine, start mirtazapine 15 mg
● Why (2026 Standard): SNRI α1-adrenergic blockade → bladder neck relaxation
failure; mirtazapine enhances 5-HT2/3 antagonism + NA/5-HT release without
adrenergic affinity → preserves continence, sleep, appetite.
● Errors: Tamsulosin (A) adds hypotension; desvenlafaxine (C) similar SNRI
profile.
Q005:
Type: NGN - Psychopharm
Scenario: 24-year-old woman with PTSD, nightmares, on sertraline 100 mg ×8 weeks.
Nightmare severity 7/10.
Question: Evidence-based add-on?
Options:
A. Prazosin 1 mg qHS
B. Trazodone 50 mg qHS
