NR 546 / NR546 Midterm actual Exam (Latest 2026)
Tested Questions with Revised Answers, (A+
Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 28-year-old woman with MDD, PHQ-9 19, 6-week postpartum, breastfeeding.
Medications: sertraline 50 mg/day x 4 weeks, PHQ-9 decreased to 14. Reports persistent
insomnia and low energy.
Question: Most appropriate next step?
Options:
A. Increase sertraline to 100 mg
B. Add mirtazapine 15 mg HS
C. Switch to paroxetine 20 mg
D. Add zolpidem 10 mg HS
(Correct: B)
Rationale:
● Answer: Add mirtazapine 15 mg HS
● **Why (2026 Standard):) Mirtazapine augments sertraline via α2-antagonism
↑NE/5-HT, safe in lactation (minimal milk), improves sleep/appetite.
, ● Errors: Paroxetine more milk transfer; zolpidem short-acting no antidepressant
synergy; dose increase alone may worsen insomnia.
Q002:
Type: Expert MCQ
Scenario: 45-year-old man with TRD on venlafaxine XR 300 mg, Mirtazapine 45 mg,
lithium 900 mg (level 0.7). PHQ-9 18. Genotype: CYP2D6 ultrarapid.
Question: Best augmentation?
Options:
A. Aripiprazole 5 mg
B. Bupropion 150 mg
C. Lamotrigine 200 mg
D. Lithium ↑ to 1200 mg
(Correct: A)
Rationale:
● Answer: Aripiprazole 5 mg
● **Why (2026 Standard):) APA 2026 TRD pathway: 3rd-line atypical
antipsychotic; partial D2 agonism ↑frontal DA, 5-HT1A partial agonism; CYP2D6
UM needs higher dose but start low titrate.
● Errors: Bupropion CYP2D6 UM rapid clearance ↓levels; lamotrigine slow; lithium
already therapeutic.
Q003:
Type: NGN - Psychopharm
,Scenario: 19-year-old college male with first-episode psychosis, PANSS 92, BMI 18.
Initiated olanzapine 10 mg HS; 4-week PANSS 60 but gained 6 kg.
Question: Best intervention?
Options:
A. Switch to lurasidone 40 mg
B. Add metformin 500 mg BID
C. Reduce olanzapine to 5 mg
D. Add lorazepam 1 mg HS
(Correct: A)
Rationale:
● Answer: Switch to lurasidone 40 mg
● **Why (2026 Standard):) Lurasidone weight-neutral, minimal metabolic impact;
D2/5-HT2A antagonist effective for FEP continuation.
● Errors: Metformin only delays; dose reduction risks relapse; lorazepam no
antipsychotic benefit.
Q004:
Type: Expert MCQ
Scenario: 32-year-old woman GAD, on sertraline 100 mg, continues anxiety 18 on
GAD-7, no depression.
Question: Next evidence-based add-on?
Options:
, A. Pregabalin 150 mg BID
B. Hydroxyzine 25 mg TID
C. Buspirone 5 mg TID
D. Propranolol 40 mg BID
(Correct: A)
Rationale:
● Answer: Pregabalin 150 mg BID
● **Why (2026 Standard):) APA 2026 GAD: pregabalin α2δ ligand ↓glutamate;
multiple RCTs show 50% response vs placebo 30%.
● Errors: Buspirone weak; hydroxyzine anticholinergic; propranolol somatic only.
Q005:
Type: NGN - Psychopharm
Scenario: 60-year-old man BPI depression, on lithium 900 mg (level 0.9), quetiapine 200
mg HS. Reports tremor, polyuria, polydipsia. Labs: eGFR 45, Na 150 mEq/L.
Question: Best action?
Options:
A. Reduce lithium to 600 mg
B. Switch quetiapine to lurasidone
C. Add amiloride 5 mg
D. Stop lithium, start lamotrigine
Tested Questions with Revised Answers, (A+
Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 28-year-old woman with MDD, PHQ-9 19, 6-week postpartum, breastfeeding.
Medications: sertraline 50 mg/day x 4 weeks, PHQ-9 decreased to 14. Reports persistent
insomnia and low energy.
Question: Most appropriate next step?
Options:
A. Increase sertraline to 100 mg
B. Add mirtazapine 15 mg HS
C. Switch to paroxetine 20 mg
D. Add zolpidem 10 mg HS
(Correct: B)
Rationale:
● Answer: Add mirtazapine 15 mg HS
● **Why (2026 Standard):) Mirtazapine augments sertraline via α2-antagonism
↑NE/5-HT, safe in lactation (minimal milk), improves sleep/appetite.
, ● Errors: Paroxetine more milk transfer; zolpidem short-acting no antidepressant
synergy; dose increase alone may worsen insomnia.
Q002:
Type: Expert MCQ
Scenario: 45-year-old man with TRD on venlafaxine XR 300 mg, Mirtazapine 45 mg,
lithium 900 mg (level 0.7). PHQ-9 18. Genotype: CYP2D6 ultrarapid.
Question: Best augmentation?
Options:
A. Aripiprazole 5 mg
B. Bupropion 150 mg
C. Lamotrigine 200 mg
D. Lithium ↑ to 1200 mg
(Correct: A)
Rationale:
● Answer: Aripiprazole 5 mg
● **Why (2026 Standard):) APA 2026 TRD pathway: 3rd-line atypical
antipsychotic; partial D2 agonism ↑frontal DA, 5-HT1A partial agonism; CYP2D6
UM needs higher dose but start low titrate.
● Errors: Bupropion CYP2D6 UM rapid clearance ↓levels; lamotrigine slow; lithium
already therapeutic.
Q003:
Type: NGN - Psychopharm
,Scenario: 19-year-old college male with first-episode psychosis, PANSS 92, BMI 18.
Initiated olanzapine 10 mg HS; 4-week PANSS 60 but gained 6 kg.
Question: Best intervention?
Options:
A. Switch to lurasidone 40 mg
B. Add metformin 500 mg BID
C. Reduce olanzapine to 5 mg
D. Add lorazepam 1 mg HS
(Correct: A)
Rationale:
● Answer: Switch to lurasidone 40 mg
● **Why (2026 Standard):) Lurasidone weight-neutral, minimal metabolic impact;
D2/5-HT2A antagonist effective for FEP continuation.
● Errors: Metformin only delays; dose reduction risks relapse; lorazepam no
antipsychotic benefit.
Q004:
Type: Expert MCQ
Scenario: 32-year-old woman GAD, on sertraline 100 mg, continues anxiety 18 on
GAD-7, no depression.
Question: Next evidence-based add-on?
Options:
, A. Pregabalin 150 mg BID
B. Hydroxyzine 25 mg TID
C. Buspirone 5 mg TID
D. Propranolol 40 mg BID
(Correct: A)
Rationale:
● Answer: Pregabalin 150 mg BID
● **Why (2026 Standard):) APA 2026 GAD: pregabalin α2δ ligand ↓glutamate;
multiple RCTs show 50% response vs placebo 30%.
● Errors: Buspirone weak; hydroxyzine anticholinergic; propranolol somatic only.
Q005:
Type: NGN - Psychopharm
Scenario: 60-year-old man BPI depression, on lithium 900 mg (level 0.9), quetiapine 200
mg HS. Reports tremor, polyuria, polydipsia. Labs: eGFR 45, Na 150 mEq/L.
Question: Best action?
Options:
A. Reduce lithium to 600 mg
B. Switch quetiapine to lurasidone
C. Add amiloride 5 mg
D. Stop lithium, start lamotrigine
