NR 668 CEA/NR 668 CEA ACTUAL EXAM 2026-2027 COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES(VERIFIED ANSWERS) GUARANTEED PASS A+
Question 1
A 72-year-old male with a 10-year history of Parkinson’s disease presents with worsening confusion,
visual hallucinations, and fluctuating attention over the past 3 days. His current medications include
carbidopa/levodopa and pramipexole. What is the most appropriate next step?
A. Increase carbidopa/levodopa dose
B. Add quetiapine
C. Reduce or discontinue pramipexole
D. Start rivastigmine
Rationale: Dopamine agonists (pramipexole) are strongly associated with hallucinations and confusion
in elderly Parkinson’s patients. Reducing or discontinuing the agonist is first-line before adding
antipsychotics or changing carbidopa/levodopa.
Question 2
A 45-year-old female with major depressive disorder has failed trials of sertraline, venlafaxine, and
bupropion. She is now started on phenelzine. Which dietary instruction is most critical?
A. Avoid grapefruit juice
B. Avoid aged cheeses and red wine
C. Increase fluid intake
D. Take with high-fat meals
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Tyramine-rich foods (aged cheeses,
cured meats, red wine) can cause hypertensive crisis. Grapefruit affects CYP3A4, relevant to some but
not primarily MAOIs.
,Question 3
A 28-year-old male presents with a first episode of mania with psychotic features. He has no prior
psychiatric history. What is the initial treatment of choice?
A. Lithium monotherapy
B. Atypical antipsychotic monotherapy
C. Valproate plus SSRI
D. Electroconvulsive therapy
Rationale: For acute mania with psychosis, an atypical antipsychotic (e.g., risperidone, olanzapine) is
recommended for rapid symptom control. Lithium has a slower onset. ECT is for refractory cases.
Question 4
A 60-year-old female with Alzheimer’s disease is started on donepezil. One week later, her family
reports she is sleeping 14 hours per day and has a heart rate of 52 bpm. What is the most appropriate
action?
A. Increase donepezil to therapeutic dose
B. Add modafinil
C. Hold donepezil and evaluate for bradycardia
D. Continue donepezil and monitor
Rationale: Donepezil can cause symptomatic bradycardia. Heart rate 52 with hypersomnia suggests
cholinergic excess. Holding the medication and evaluating (EKG, vital signs) is safest.
Question 5
A patient with bipolar I disorder on lithium for 2 years develops polyuria and polydipsia. Serum
lithium level is 0.8 mEq/L. What is the most likely diagnosis?
A. Diabetes mellitus
B. Nephrogenic diabetes insipidus
C. Psychogenic polydipsia
D. Hypercalcemia
Rationale: Lithium inhibits ADH action in the collecting duct, causing nephrogenic diabetes insipidus.
Serum lithium is therapeutic. Polyuria is not due to hyperglycemia or calcium.
,Question 6
A 34-year-old woman with panic disorder on paroxetine reports停药 (discontinuation) due to
pregnancy. She now has dizziness, nausea, and “electric shock” sensations. What is the diagnosis?
A. Relapse of panic disorder
B. Serotonin syndrome
C. SSRI discontinuation syndrome
D. Vestibular neuritis
Rationale: Abrupt SSRI cessation causes flu-like symptoms, sensory disturbances (electric shocks),
and GI distress. Onset is days after stopping. Serotonin syndrome requires excess serotonin.
Question 7
A patient with schizophrenia on clozapine has a white blood cell count of 2800/mm³. What is the
immediate action?
A. Continue clozapine and repeat CBC in 1 week
B. Increase clozapine dose
C. Stop clozapine and initiate REMS protocol
D. Add filgrastim
Rationale: WBC <3000/mm³ is moderate neutropenia per clozapine REMS. Clozapine must be
interrupted, and the patient monitored per protocol. Filgrastim is not first-line.
Question 8
Which medication is most likely to cause weight gain and new-onset diabetes?
A. Haloperidol
B. Fluphenazine
C. Olanzapine
D. Ziprasidone
Rationale: Olanzapine has high metabolic risk (weight gain, dyslipidemia, hyperglycemia).
Ziprasidone is weight-neutral. Haloperidol and fluphenazine are lower risk.
, Question 9
A 22-year-old male with ADHD is on mixed amphetamine salts. He reports palpitations and blood
pressure of 150/95 mmHg. What is the next step?
A. Add propranolol
B. Discontinue stimulant and assess for underlying hypertension
C. Increase dose to improve focus
D. Switch to atomoxetine immediately
Rationale: Significant hypertension on stimulants requires stopping the drug and evaluating primary
hypertension or stimulant-induced effect. Atomoxetine can also increase BP.
Question 10
A 50-year-old male with alcohol use disorder is prescribed naltrexone. Which statement indicates a
need for further teaching?
A. “I should not take opioids for pain while on this.”
B. “This will reduce my craving for alcohol.”
C. “I can drink alcohol while on this to test if it works.”
D. “It may cause nausea, especially at first.”
Rationale: Naltrexone reduces craving and blocks opioid receptors, but drinking is not required for
effect and undermines treatment. Patients should aim for abstinence.
Question 11
A patient on valproate for bipolar disorder has routine labs. Which abnormality is most specific to
valproate?
A. Hyponatremia
B. Hyperammonemia
C. Hypocalcemia
D. Elevated creatinine
Rationale: Valproate can cause hyperammonemia, even with normal LFTs, due to inhibition of urea
cycle enzymes. Hyponatremia is more common with carbamazepine or SSRIs.
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES(VERIFIED ANSWERS) GUARANTEED PASS A+
Question 1
A 72-year-old male with a 10-year history of Parkinson’s disease presents with worsening confusion,
visual hallucinations, and fluctuating attention over the past 3 days. His current medications include
carbidopa/levodopa and pramipexole. What is the most appropriate next step?
A. Increase carbidopa/levodopa dose
B. Add quetiapine
C. Reduce or discontinue pramipexole
D. Start rivastigmine
Rationale: Dopamine agonists (pramipexole) are strongly associated with hallucinations and confusion
in elderly Parkinson’s patients. Reducing or discontinuing the agonist is first-line before adding
antipsychotics or changing carbidopa/levodopa.
Question 2
A 45-year-old female with major depressive disorder has failed trials of sertraline, venlafaxine, and
bupropion. She is now started on phenelzine. Which dietary instruction is most critical?
A. Avoid grapefruit juice
B. Avoid aged cheeses and red wine
C. Increase fluid intake
D. Take with high-fat meals
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Tyramine-rich foods (aged cheeses,
cured meats, red wine) can cause hypertensive crisis. Grapefruit affects CYP3A4, relevant to some but
not primarily MAOIs.
,Question 3
A 28-year-old male presents with a first episode of mania with psychotic features. He has no prior
psychiatric history. What is the initial treatment of choice?
A. Lithium monotherapy
B. Atypical antipsychotic monotherapy
C. Valproate plus SSRI
D. Electroconvulsive therapy
Rationale: For acute mania with psychosis, an atypical antipsychotic (e.g., risperidone, olanzapine) is
recommended for rapid symptom control. Lithium has a slower onset. ECT is for refractory cases.
Question 4
A 60-year-old female with Alzheimer’s disease is started on donepezil. One week later, her family
reports she is sleeping 14 hours per day and has a heart rate of 52 bpm. What is the most appropriate
action?
A. Increase donepezil to therapeutic dose
B. Add modafinil
C. Hold donepezil and evaluate for bradycardia
D. Continue donepezil and monitor
Rationale: Donepezil can cause symptomatic bradycardia. Heart rate 52 with hypersomnia suggests
cholinergic excess. Holding the medication and evaluating (EKG, vital signs) is safest.
Question 5
A patient with bipolar I disorder on lithium for 2 years develops polyuria and polydipsia. Serum
lithium level is 0.8 mEq/L. What is the most likely diagnosis?
A. Diabetes mellitus
B. Nephrogenic diabetes insipidus
C. Psychogenic polydipsia
D. Hypercalcemia
Rationale: Lithium inhibits ADH action in the collecting duct, causing nephrogenic diabetes insipidus.
Serum lithium is therapeutic. Polyuria is not due to hyperglycemia or calcium.
,Question 6
A 34-year-old woman with panic disorder on paroxetine reports停药 (discontinuation) due to
pregnancy. She now has dizziness, nausea, and “electric shock” sensations. What is the diagnosis?
A. Relapse of panic disorder
B. Serotonin syndrome
C. SSRI discontinuation syndrome
D. Vestibular neuritis
Rationale: Abrupt SSRI cessation causes flu-like symptoms, sensory disturbances (electric shocks),
and GI distress. Onset is days after stopping. Serotonin syndrome requires excess serotonin.
Question 7
A patient with schizophrenia on clozapine has a white blood cell count of 2800/mm³. What is the
immediate action?
A. Continue clozapine and repeat CBC in 1 week
B. Increase clozapine dose
C. Stop clozapine and initiate REMS protocol
D. Add filgrastim
Rationale: WBC <3000/mm³ is moderate neutropenia per clozapine REMS. Clozapine must be
interrupted, and the patient monitored per protocol. Filgrastim is not first-line.
Question 8
Which medication is most likely to cause weight gain and new-onset diabetes?
A. Haloperidol
B. Fluphenazine
C. Olanzapine
D. Ziprasidone
Rationale: Olanzapine has high metabolic risk (weight gain, dyslipidemia, hyperglycemia).
Ziprasidone is weight-neutral. Haloperidol and fluphenazine are lower risk.
, Question 9
A 22-year-old male with ADHD is on mixed amphetamine salts. He reports palpitations and blood
pressure of 150/95 mmHg. What is the next step?
A. Add propranolol
B. Discontinue stimulant and assess for underlying hypertension
C. Increase dose to improve focus
D. Switch to atomoxetine immediately
Rationale: Significant hypertension on stimulants requires stopping the drug and evaluating primary
hypertension or stimulant-induced effect. Atomoxetine can also increase BP.
Question 10
A 50-year-old male with alcohol use disorder is prescribed naltrexone. Which statement indicates a
need for further teaching?
A. “I should not take opioids for pain while on this.”
B. “This will reduce my craving for alcohol.”
C. “I can drink alcohol while on this to test if it works.”
D. “It may cause nausea, especially at first.”
Rationale: Naltrexone reduces craving and blocks opioid receptors, but drinking is not required for
effect and undermines treatment. Patients should aim for abstinence.
Question 11
A patient on valproate for bipolar disorder has routine labs. Which abnormality is most specific to
valproate?
A. Hyponatremia
B. Hyperammonemia
C. Hypocalcemia
D. Elevated creatinine
Rationale: Valproate can cause hyperammonemia, even with normal LFTs, due to inhibition of urea
cycle enzymes. Hyponatremia is more common with carbamazepine or SSRIs.
