NRNP 6675 Final Exam Latest
2026/2027: 100 Qs & Ans [Verified
Answers] Plus Rationales | Instant
PDF Download
This practice exam covers pharmacology, DSM-5-TR criteria,
psychotherapy models, medical mimics, ethics, and legal
standards most frequently tested on NRNP 6665. Focus on
high-yield topics: lithium toxicity, serotonin syndrome, NMS,
antipsychotic mechanisms, diagnostic thresholds (mania vs
hypomania), and duty to warn.
Domain 1: Foundational Neuroscience & Psychopharmacology
(Qs 1-20)
1. A 34-year-old with major depressive disorder (MDD) has failed
two SSRIs. You consider adding aripiprazole. Its primary
mechanism of action is:
• A. Partial agonism at D2 and 5-HT1A receptors
*Rationale: Aripiprazole is a dopamine (D2) and serotonin (5-
HT1A) partial agonist and 5-HT2A antagonist. This "dopamine
system stabilizer" mechanism is FDA-approved as adjunctive
treatment for MDD. Full agonists or antagonists do not explain its
unique profile.*
• B. Full antagonism at D2 receptors
• C. MAO-A inhibition
• D. Selective norepinephrine reuptake inhibition
2. A patient on clozapine reports drooling, constipation, and
sedation. These are most attributable to:
,• D. Histamine H1 and muscarinic M1 antagonism
*Rationale: Clozapine has high affinity for H1 (sedation, weight
gain) and M1 (constipation, dry mouth, drooling) receptors.
Alpha-1 antagonism causes orthostasis; D2 blockade causes EPS,
but clozapine has low D2 affinity.*
• A. D2 receptor blockade
• B. Norepinephrine reuptake inhibition
• C. 5-HT2C inverse agonism
3. Which anticonvulsant requires baseline and serial LFTs, CBC
with differential, and serum drug levels due to risk of
hepatotoxicity and hematologic effects?
• C. Valproate (valproic acid)
*Rationale: Valproate carries black box warnings for
hepatotoxicity (especially children <2 years) and pancreatitis. It
also causes thrombocytopenia and requires level monitoring (50–
100 mcg/mL).*
• A. Lamotrigine
• B. Gabapentin
• D. Levetiracetam
4. A patient on phenelzine (MAOI) presents with occipital
headache, palpitations, and dilated pupils 30 minutes after eating
aged cheese. The most likely cause is:
• B. Hypertensive crisis from reduced tyramine metabolism
Rationale: MAOIs irreversibly inhibit MAO-A and MAO-B, preventing
dietary tyramine breakdown. Tyramine displaces norepinephrine
from vesicles, causing a surge in blood pressure. Aged cheese is high
in tyramine.
• A. Serotonin syndrome
• B. Hypertensive crisis from reduced tyramine metabolism
• C. Cholinergic crisis
• D. Neuroleptic malignant syndrome (NMS)
, 5. Lithium’s narrow therapeutic index requires monitoring. A
level of 1.8 mEq/L in a patient with confusion and coarse tremor
indicates:
• C. Early lithium toxicity
*Rationale: Therapeutic lithium level is 0.6–1.2 mEq/L (acute
mania 0.8–1.2). Levels >1.5 mEq/L often cause early toxicity
(ataxia, coarse tremor, nausea, confusion). Levels >2.5 mEq/L can
cause seizures, coma, death.*
• A. Subtherapeutic level
• B. Maintenance level
• C. Early lithium toxicity
• D. Normal lab error
6. A 72-year-old with Parkinson’s disease develops hallucinations
after starting pramipexole. Which antipsychotic is safest?
• B. Pimavanserin
*Rationale: Pimavanserin is a selective 5-HT2A inverse agonist
with no dopaminergic blockade, approved for Parkinson’s disease
psychosis. Quetiapine low-dose is second-line; all other options
worsen motor symptoms.*
• A. Haloperidol
• B. Pimavanserin
• C. Risperidone
• D. Aripiprazole
7. The serotonin syndrome triad includes:
• A. Neuromuscular excitation, autonomic instability, altered
mental status
Rationale: Classic triad: mental status changes (agitation,
confusion), autonomic instability (hyperthermia, tachycardia,
diaphoresis), and neuromuscular excitation (clonus, rigidity,
hyperreflexia). This differs from NMS (bradyreflexia, lead-pipe
rigidity).
• A. Neuromuscular excitation, autonomic instability, altered
mental status
, • B. Fever, lead-pipe rigidity, bradyreflexia
• C. Dry mouth, urinary retention, ileus
• D. Hypertension, bradycardia, miosis
8. Which CYP enzyme is responsible for converting most prodrug
opioids (codeine, tramadol) to active metabolites?
• C. CYP2D6
*Rationale: CYP2D6 poor metabolizers (7–10% of population) get
minimal analgesia from codeine; ultra-rapid metabolizers risk
toxicity. CYP3A4 metabolizes fentanyl, methadone.*
• A. CYP1A2
• B. CYP3A4
• C. CYP2D6
• D. CYP2C19
9. A patient on carbamazepine develops rash, fever, and
eosinophilia. The most concerning differential is:
• D. Drug reaction with eosinophilia and systemic symptoms
(DRESS)
Rationale: DRESS is a severe hypersensitivity reaction with rash,
fever, lymphadenopathy, eosinophilia, and internal organ
involvement (liver, kidney). Carbamazepine is high-risk. Requires
immediate discontinuation and hospitalization.
• A. Benign exanthem
• B. Acneiform rash
• C. Stevens-Johnson syndrome
• D. DRESS syndrome
10. A patient taking fluoxetine and olanzapine for bipolar
depression develops significant weight gain. The mechanism most
responsible is:
• B. 5-HT2C and H1 antagonism
*Rationale: Olanzapine has potent H1 (histamine) antagonism
(sedation, weight gain) and 5-HT2C antagonism (disinhibits
feeding, weight gain). Fluoxetine alone is weight-neutral to
2026/2027: 100 Qs & Ans [Verified
Answers] Plus Rationales | Instant
PDF Download
This practice exam covers pharmacology, DSM-5-TR criteria,
psychotherapy models, medical mimics, ethics, and legal
standards most frequently tested on NRNP 6665. Focus on
high-yield topics: lithium toxicity, serotonin syndrome, NMS,
antipsychotic mechanisms, diagnostic thresholds (mania vs
hypomania), and duty to warn.
Domain 1: Foundational Neuroscience & Psychopharmacology
(Qs 1-20)
1. A 34-year-old with major depressive disorder (MDD) has failed
two SSRIs. You consider adding aripiprazole. Its primary
mechanism of action is:
• A. Partial agonism at D2 and 5-HT1A receptors
*Rationale: Aripiprazole is a dopamine (D2) and serotonin (5-
HT1A) partial agonist and 5-HT2A antagonist. This "dopamine
system stabilizer" mechanism is FDA-approved as adjunctive
treatment for MDD. Full agonists or antagonists do not explain its
unique profile.*
• B. Full antagonism at D2 receptors
• C. MAO-A inhibition
• D. Selective norepinephrine reuptake inhibition
2. A patient on clozapine reports drooling, constipation, and
sedation. These are most attributable to:
,• D. Histamine H1 and muscarinic M1 antagonism
*Rationale: Clozapine has high affinity for H1 (sedation, weight
gain) and M1 (constipation, dry mouth, drooling) receptors.
Alpha-1 antagonism causes orthostasis; D2 blockade causes EPS,
but clozapine has low D2 affinity.*
• A. D2 receptor blockade
• B. Norepinephrine reuptake inhibition
• C. 5-HT2C inverse agonism
3. Which anticonvulsant requires baseline and serial LFTs, CBC
with differential, and serum drug levels due to risk of
hepatotoxicity and hematologic effects?
• C. Valproate (valproic acid)
*Rationale: Valproate carries black box warnings for
hepatotoxicity (especially children <2 years) and pancreatitis. It
also causes thrombocytopenia and requires level monitoring (50–
100 mcg/mL).*
• A. Lamotrigine
• B. Gabapentin
• D. Levetiracetam
4. A patient on phenelzine (MAOI) presents with occipital
headache, palpitations, and dilated pupils 30 minutes after eating
aged cheese. The most likely cause is:
• B. Hypertensive crisis from reduced tyramine metabolism
Rationale: MAOIs irreversibly inhibit MAO-A and MAO-B, preventing
dietary tyramine breakdown. Tyramine displaces norepinephrine
from vesicles, causing a surge in blood pressure. Aged cheese is high
in tyramine.
• A. Serotonin syndrome
• B. Hypertensive crisis from reduced tyramine metabolism
• C. Cholinergic crisis
• D. Neuroleptic malignant syndrome (NMS)
, 5. Lithium’s narrow therapeutic index requires monitoring. A
level of 1.8 mEq/L in a patient with confusion and coarse tremor
indicates:
• C. Early lithium toxicity
*Rationale: Therapeutic lithium level is 0.6–1.2 mEq/L (acute
mania 0.8–1.2). Levels >1.5 mEq/L often cause early toxicity
(ataxia, coarse tremor, nausea, confusion). Levels >2.5 mEq/L can
cause seizures, coma, death.*
• A. Subtherapeutic level
• B. Maintenance level
• C. Early lithium toxicity
• D. Normal lab error
6. A 72-year-old with Parkinson’s disease develops hallucinations
after starting pramipexole. Which antipsychotic is safest?
• B. Pimavanserin
*Rationale: Pimavanserin is a selective 5-HT2A inverse agonist
with no dopaminergic blockade, approved for Parkinson’s disease
psychosis. Quetiapine low-dose is second-line; all other options
worsen motor symptoms.*
• A. Haloperidol
• B. Pimavanserin
• C. Risperidone
• D. Aripiprazole
7. The serotonin syndrome triad includes:
• A. Neuromuscular excitation, autonomic instability, altered
mental status
Rationale: Classic triad: mental status changes (agitation,
confusion), autonomic instability (hyperthermia, tachycardia,
diaphoresis), and neuromuscular excitation (clonus, rigidity,
hyperreflexia). This differs from NMS (bradyreflexia, lead-pipe
rigidity).
• A. Neuromuscular excitation, autonomic instability, altered
mental status
, • B. Fever, lead-pipe rigidity, bradyreflexia
• C. Dry mouth, urinary retention, ileus
• D. Hypertension, bradycardia, miosis
8. Which CYP enzyme is responsible for converting most prodrug
opioids (codeine, tramadol) to active metabolites?
• C. CYP2D6
*Rationale: CYP2D6 poor metabolizers (7–10% of population) get
minimal analgesia from codeine; ultra-rapid metabolizers risk
toxicity. CYP3A4 metabolizes fentanyl, methadone.*
• A. CYP1A2
• B. CYP3A4
• C. CYP2D6
• D. CYP2C19
9. A patient on carbamazepine develops rash, fever, and
eosinophilia. The most concerning differential is:
• D. Drug reaction with eosinophilia and systemic symptoms
(DRESS)
Rationale: DRESS is a severe hypersensitivity reaction with rash,
fever, lymphadenopathy, eosinophilia, and internal organ
involvement (liver, kidney). Carbamazepine is high-risk. Requires
immediate discontinuation and hospitalization.
• A. Benign exanthem
• B. Acneiform rash
• C. Stevens-Johnson syndrome
• D. DRESS syndrome
10. A patient taking fluoxetine and olanzapine for bipolar
depression develops significant weight gain. The mechanism most
responsible is:
• B. 5-HT2C and H1 antagonism
*Rationale: Olanzapine has potent H1 (histamine) antagonism
(sedation, weight gain) and 5-HT2C antagonism (disinhibits
feeding, weight gain). Fluoxetine alone is weight-neutral to
