NR 546 / NR546 Midterm Exam (Latest 2026) Tested
Questions with Revised Answers, (A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 29-year-old woman with TRD (failed sertraline 200 mg & duloxetine 90 mg)
reports 3-week worsening mood after starting augmentation with aripiprazole 5 mg.
PHQ-9 22. She now feels “flat” and has gained 4 lb. Labs: fasting glucose 104 mg/dL,
prolactin 8 ng/mL.
Question: Best next medication adjustment?
Options:
A. Increase aripiprazole to 15 mg
B. Switch aripiprazole to brexpiprazole 1 mg daily
C. Add lithium 300 mg BID
D. Cross-taper to bupropion XL 300 mg
(Correct: B)
Rationale:
, ● Answer: Switch aripiprazole to brexpiprazole 1 mg daily
● Why (2026 Standard): Brexpiprazole has lower D2 intrinsic activity (45% vs 80%)
& balanced 5-HT1A/2A, reducing “flattening” & weight gain while maintaining
antidepressant augmentation (APA TRD 2025).
● Errors: Increasing aripiprazole worsens dopamine over-blockade & apathy;
lithium adds toxicity risk without clear bipolarity; bupropion alone insufficient after
two SSRI/SNRI failures.
Q002:
Type: Expert MCQ
Scenario: 67-year-old man with vascular depression, eGFR 38 mL/min, on donepezil 5
mg daily, newly started on sertraline 50 mg, presents with myoclonus, diaphoresis, and
agitation 10 days later. VS stable.
Question: Immediate action?
Options:
A. Increase sertraline to 100 mg
B. Switch to duloxetine 30 mg
C. Stop sertraline & monitor for 24 h
D. Add lorazepam 1 mg q8h
(Correct: C)
Rationale:
, ● Answer: Stop sertraline & monitor for 24 h
● Why (2026 Standard): Reduced clearance → serotonin syndrome; stopping
offending agent is first-line (Neuropsych 2026).
● Errors: Escalation worsens toxicity; duloxetine also renally cleared; benzos mask
but don’t treat hyper-serotonergic state.
Q003:
Type: NGN - Psychopharm
Scenario: 19-year-old college freshman with ADHD, CYP2D6 ultra-rapid metabolizer
(UM), on methylphenidate IR 10 mg TID with 2-h efficacy loss. Heart rate 98 bpm, BP
118/76 mmHg.
Question: Best evidence-based switch?
Options:
A. Amphetamine XR 20 mg daily
B. Atomoxetine 40 mg daily
C. Lisdexamfetamine 30 mg daily
D. Clonidine XR 0.1 mg nightly
(Correct: C)
Rationale:
, ● Answer: Lisdexamfetamine 30 mg daily
● Why (2026 Standard: Pro-drug bypasses CYP2D6; provides 13-h coverage in
UM phenotype (CPIC 2025).
● Errors: MPH still CYP-independent but short duration; atomoxetine relies on 2D6
→ subtherapeutic in UM; clonidine lacks robust ADHD monotherapy data.
Q004:
Type: Expert MCQ
Scenario: 34-year-old woman with bipolar I depression, on lithium 900 mg (level 0.8
mEq/L), lurasidone 40 mg hs, reports 4-week emergent suicidality, HbA1c 5.2%, weight
stable.
Question: Best add-on?
Options:
A. Quetiapine IR 50 mg
B. Lamotrigine 25 mg starter pack
C. Bupropion 150 mg
D. Risperidone 1 mg
(Correct: B)
Rationale:
Questions with Revised Answers, (A+ Guarantee)
Q001:
Type: NGN - Psychopharm
Scenario: 29-year-old woman with TRD (failed sertraline 200 mg & duloxetine 90 mg)
reports 3-week worsening mood after starting augmentation with aripiprazole 5 mg.
PHQ-9 22. She now feels “flat” and has gained 4 lb. Labs: fasting glucose 104 mg/dL,
prolactin 8 ng/mL.
Question: Best next medication adjustment?
Options:
A. Increase aripiprazole to 15 mg
B. Switch aripiprazole to brexpiprazole 1 mg daily
C. Add lithium 300 mg BID
D. Cross-taper to bupropion XL 300 mg
(Correct: B)
Rationale:
, ● Answer: Switch aripiprazole to brexpiprazole 1 mg daily
● Why (2026 Standard): Brexpiprazole has lower D2 intrinsic activity (45% vs 80%)
& balanced 5-HT1A/2A, reducing “flattening” & weight gain while maintaining
antidepressant augmentation (APA TRD 2025).
● Errors: Increasing aripiprazole worsens dopamine over-blockade & apathy;
lithium adds toxicity risk without clear bipolarity; bupropion alone insufficient after
two SSRI/SNRI failures.
Q002:
Type: Expert MCQ
Scenario: 67-year-old man with vascular depression, eGFR 38 mL/min, on donepezil 5
mg daily, newly started on sertraline 50 mg, presents with myoclonus, diaphoresis, and
agitation 10 days later. VS stable.
Question: Immediate action?
Options:
A. Increase sertraline to 100 mg
B. Switch to duloxetine 30 mg
C. Stop sertraline & monitor for 24 h
D. Add lorazepam 1 mg q8h
(Correct: C)
Rationale:
, ● Answer: Stop sertraline & monitor for 24 h
● Why (2026 Standard): Reduced clearance → serotonin syndrome; stopping
offending agent is first-line (Neuropsych 2026).
● Errors: Escalation worsens toxicity; duloxetine also renally cleared; benzos mask
but don’t treat hyper-serotonergic state.
Q003:
Type: NGN - Psychopharm
Scenario: 19-year-old college freshman with ADHD, CYP2D6 ultra-rapid metabolizer
(UM), on methylphenidate IR 10 mg TID with 2-h efficacy loss. Heart rate 98 bpm, BP
118/76 mmHg.
Question: Best evidence-based switch?
Options:
A. Amphetamine XR 20 mg daily
B. Atomoxetine 40 mg daily
C. Lisdexamfetamine 30 mg daily
D. Clonidine XR 0.1 mg nightly
(Correct: C)
Rationale:
, ● Answer: Lisdexamfetamine 30 mg daily
● Why (2026 Standard: Pro-drug bypasses CYP2D6; provides 13-h coverage in
UM phenotype (CPIC 2025).
● Errors: MPH still CYP-independent but short duration; atomoxetine relies on 2D6
→ subtherapeutic in UM; clonidine lacks robust ADHD monotherapy data.
Q004:
Type: Expert MCQ
Scenario: 34-year-old woman with bipolar I depression, on lithium 900 mg (level 0.8
mEq/L), lurasidone 40 mg hs, reports 4-week emergent suicidality, HbA1c 5.2%, weight
stable.
Question: Best add-on?
Options:
A. Quetiapine IR 50 mg
B. Lamotrigine 25 mg starter pack
C. Bupropion 150 mg
D. Risperidone 1 mg
(Correct: B)
Rationale:
