Western Governors University
CCN: NURS 6800
Course Number: D116
Course Title: Advanced Pharmacology for the Advanced Practice
Nurse
Exam: Final Assessment
Date:2026
A PMHNP is treating a patient with Schizophrenia who smokes one pack of cigarettes per day. The patient
is stabilized on Clozapine. If the patient suddenly stops smoking, what is the most likely pharmacological
outcome?
A. Clozapine levels will decrease, leading to a relapse of psychosis.
B. Clozapine levels will increase, raising the risk of seizures and toxicity.
C. There will be no change because Clozapine is not metabolized by the liver.
D. The patient will develop an immediate allergy to the medication.
Answer: B.
Rationale: Polycyclic aromatic hydrocarbons in cigarette smoke induce the CYP1A2 enzyme. When a
patient stops smoking, the induction ceases, which slows the metabolism of Clozapine (a 1A2 substrate),
leading to potentially dangerous increases in serum drug levels.
A patient with Bipolar I Disorder is prescribed Lithium Carbonate. During a follow up, the patient mentions
they have started taking Ibuprofen daily for back pain. What is the priority concern for the NP?
A. Increased risk of gastrointestinal bleeding.
B. Decreased effectiveness of Lithium leading to mania.
C. Reduced renal clearance of Lithium leading to toxicity.
D. Development of a skin rash known as Stevens Johnson Syndrome.
Answer: C.
Rationale: NSAIDs like Ibuprofen reduce renal blood flow and prostaglandin synthesis, which can lead to a
significant increase in Lithium levels. Lithium has a narrow therapeutic index, and this combination
frequently precipitates toxicity.
True or False: The mechanism of action for most Second Generation Antipsychotics (SGAs) involves both
D2 receptor antagonism and 5-HT2A receptor antagonism.
Answer: True.
Rationale: Unlike First Generation Antipsychotics which primarily block D2 receptors, SGAs block
serotonin 5-HT2A receptors. This typically results in a lower risk of extrapyramidal symptoms and may
help improve negative symptoms of schizophrenia.
Fill in the blank: The constellation of symptoms including hyperreflexia, autonomic instability, and
myoclonus resulting from excessive synaptic serotonin is known as ________.
Answer: Serotonin Syndrome.
Rationale: Serotonin Syndrome is a potentially fatal condition often caused by combining medications like
SSRIs, SNRIs, MAOIs, or certain pain medications like Tramadol.
An elderly patient with dementia is experiencing severe agitation. The NP considers prescribing an
,antipsychotic. What is the most critical regulatory "black box" warning the NP must discuss with the
family?
A. Risk of permanent memory loss.
B. Increased risk of mortality due to cardiovascular events or infections.
C. Risk of developing severe addiction to the medication.
D. Increased risk of autoimmune disorders.
Answer: B.
Rationale: The FDA has issued a boxed warning for all antipsychotics used in elderly patients with dementia
related psychosis, noting an increased risk of death, primarily from heart failure, sudden death, or
pneumonia.
A patient on Lamotrigine for bipolar depression misses five consecutive days of dosing. What is the most
appropriate pharmacological action for the PMHNP to take?
A. Resume the previous maintenance dose immediately.
B. Double the next dose to reach steady state faster.
C. Restart the titration schedule from the initial starting dose.
D. Switch the patient to Valproate permanently.
Answer: C.
Rationale: Lamotrigine requires a very slow titration to minimize the risk of a life threatening rash (Stevens
Johnson Syndrome). If the medication is held for more than five half lives (about five days), the titration
must be restarted from the beginning to maintain safety.
True or False: Bupropion is an ideal choice for a patient with a history of Bulimia Nervosa or a seizure
disorder.
Answer: False.
Rationale: Bupropion is contraindicated in patients with eating disorders or seizure disorders because it
lowers the seizure threshold, especially in patients prone to electrolyte imbalances or those with a history of
purging.
Fill in the blank: In the treatment of ADHD, atomoxetine (Strattera) functions as a selective ________
reuptake inhibitor.
Answer: Norepinephrine.
Rationale: Unlike stimulants that affect dopamine and norepinephrine, atomoxetine specifically targets the
norepinephrine transporter, making it a non stimulant option with a lower potential for abuse.
A patient is experiencing "Lead Pipe" muscle rigidity, a temperature of 104 degrees F, and altered mental
status after their first dose of Haloperidol. Which medication should the NP prepare to administer?
A. Benztropine.
B. Dantrolene.
C. Lorazepam.
D. Propranolol.
Answer: B.
Rationale: These symptoms indicate Neuroleptic Malignant Syndrome (NMS), a medical emergency.
Dantrolene, a muscle relaxant, or Bromocriptine, a dopamine agonist, are used to treat the underlying
muscle rigidity and dopamine blockade.
A PMHNP is prescribing an SSRI for a patient who is an ultra rapid metabolizer at the CYP2D6 enzyme.
What is the most likely clinical result?
A. The patient will likely experience severe side effects at low doses.
B. The medication may be ineffective because it is cleared from the system too quickly.
C. The patient will have a higher risk of Serotonin Syndrome.
D. The medication's half life will be significantly prolonged.
Answer: B.
Rationale: Ultra rapid metabolizers break down substrates of a specific enzyme much faster than the general
population. This leads to subtherapeutic blood levels and a lack of clinical response to standard doses.
, True or False: Discontinuation Syndrome, characterized by flu like symptoms and "brain zaps," is most
common with antidepressants that have a very long half life, such as Fluoxetine.
Answer: False.
Rationale: Discontinuation syndrome is more common with drugs that have a short half life, like Paroxetine
or Venlafaxine. Fluoxetine has a very long half life (and an active metabolite), meaning it essentially "self
tapers" out of the body.
Fill in the blank: The specific Absolute Neutrophil Count (ANC) threshold for initiating Clozapine therapy
is greater than or equal to ________ /uL.
Answer: 1500.
Rationale: Due to the risk of severe neutropenia, the REMS program requires a baseline ANC of at least
1500 (or 1000 for those with documented Benign Ethnic Neutropenia) before Clozapine can be started.
A patient taking Phenelzine (an MAOI) presents with a pounding headache and a blood pressure of 210/120
mmHg after eating at an Italian restaurant. What is the most likely cause?
A. Serotonin Syndrome.
B. Hypertensive Crisis due to Tyramine ingestion.
C. Acute panic attack.
D. Normal side effect of the medication.
Answer: B.
Rationale: MAOIs inhibit the breakdown of tyramine in the gut. Tyramine promotes the release of
norepinephrine. When found in high concentrations (aged cheeses, cured meats), it can cause massive
vasoconstriction and a hypertensive crisis.
Which medication is considered the first line pharmacological treatment for a patient with Akathisia?
A. Diphenhydramine.
B. Benztropine.
C. Propranolol.
D. Diazepam.
Answer: C.
Rationale: Akathisia is a subjective feeling of inner restlessness. While anticholinergics work for dystonia
and parkinsonism, beta blockers like Propranolol are the gold standard for treating akathisia.
True or False: Varenicline (Chantix) is a nicotinic receptor partial agonist that can be used for smoking
cessation but requires monitoring for neuropsychiatric side effects.
Answer: True.
Rationale: By partially stimulating the Alpha 4 Beta 2 receptors and blocking nicotine, Varenicline reduces
cravings and prevents the "reward" associated with smoking.
Fill in the blank: When prescribing typical antipsychotics, the primary neurobiological cause of
Extrapyramidal Symptoms (EPS) is the blockade of D2 receptors in the ________ pathway.
Answer: Nigrostriatal.
Rationale: There are four major dopamine pathways. Blockade in the mesolimbic pathway reduces
psychosis, but blockade in the nigrostriatal pathway leads to motor side effects and EPS.
A patient with Major Depressive Disorder and Chronic Neuropathic Pain would benefit most from which
class of antidepressant?
A. SSRI (e.g., Escitalopram).
B. SNRI (e.g., Duloxetine).
C. SARI (e.g., Trazodone).
D. NDRI (e.g., Bupropion).
Answer: B.
Rationale: SNRIs inhibit the reuptake of both serotonin and norepinephrine. Norepinephrine modulation in
the descending spinal tracts is known to help mitigate pain signals, making SNRIs effective for both mood
and physical pain.
A NP is reviewing the lab work for a patient on Valproate. Which labs are most critical for monitoring the
CCN: NURS 6800
Course Number: D116
Course Title: Advanced Pharmacology for the Advanced Practice
Nurse
Exam: Final Assessment
Date:2026
A PMHNP is treating a patient with Schizophrenia who smokes one pack of cigarettes per day. The patient
is stabilized on Clozapine. If the patient suddenly stops smoking, what is the most likely pharmacological
outcome?
A. Clozapine levels will decrease, leading to a relapse of psychosis.
B. Clozapine levels will increase, raising the risk of seizures and toxicity.
C. There will be no change because Clozapine is not metabolized by the liver.
D. The patient will develop an immediate allergy to the medication.
Answer: B.
Rationale: Polycyclic aromatic hydrocarbons in cigarette smoke induce the CYP1A2 enzyme. When a
patient stops smoking, the induction ceases, which slows the metabolism of Clozapine (a 1A2 substrate),
leading to potentially dangerous increases in serum drug levels.
A patient with Bipolar I Disorder is prescribed Lithium Carbonate. During a follow up, the patient mentions
they have started taking Ibuprofen daily for back pain. What is the priority concern for the NP?
A. Increased risk of gastrointestinal bleeding.
B. Decreased effectiveness of Lithium leading to mania.
C. Reduced renal clearance of Lithium leading to toxicity.
D. Development of a skin rash known as Stevens Johnson Syndrome.
Answer: C.
Rationale: NSAIDs like Ibuprofen reduce renal blood flow and prostaglandin synthesis, which can lead to a
significant increase in Lithium levels. Lithium has a narrow therapeutic index, and this combination
frequently precipitates toxicity.
True or False: The mechanism of action for most Second Generation Antipsychotics (SGAs) involves both
D2 receptor antagonism and 5-HT2A receptor antagonism.
Answer: True.
Rationale: Unlike First Generation Antipsychotics which primarily block D2 receptors, SGAs block
serotonin 5-HT2A receptors. This typically results in a lower risk of extrapyramidal symptoms and may
help improve negative symptoms of schizophrenia.
Fill in the blank: The constellation of symptoms including hyperreflexia, autonomic instability, and
myoclonus resulting from excessive synaptic serotonin is known as ________.
Answer: Serotonin Syndrome.
Rationale: Serotonin Syndrome is a potentially fatal condition often caused by combining medications like
SSRIs, SNRIs, MAOIs, or certain pain medications like Tramadol.
An elderly patient with dementia is experiencing severe agitation. The NP considers prescribing an
,antipsychotic. What is the most critical regulatory "black box" warning the NP must discuss with the
family?
A. Risk of permanent memory loss.
B. Increased risk of mortality due to cardiovascular events or infections.
C. Risk of developing severe addiction to the medication.
D. Increased risk of autoimmune disorders.
Answer: B.
Rationale: The FDA has issued a boxed warning for all antipsychotics used in elderly patients with dementia
related psychosis, noting an increased risk of death, primarily from heart failure, sudden death, or
pneumonia.
A patient on Lamotrigine for bipolar depression misses five consecutive days of dosing. What is the most
appropriate pharmacological action for the PMHNP to take?
A. Resume the previous maintenance dose immediately.
B. Double the next dose to reach steady state faster.
C. Restart the titration schedule from the initial starting dose.
D. Switch the patient to Valproate permanently.
Answer: C.
Rationale: Lamotrigine requires a very slow titration to minimize the risk of a life threatening rash (Stevens
Johnson Syndrome). If the medication is held for more than five half lives (about five days), the titration
must be restarted from the beginning to maintain safety.
True or False: Bupropion is an ideal choice for a patient with a history of Bulimia Nervosa or a seizure
disorder.
Answer: False.
Rationale: Bupropion is contraindicated in patients with eating disorders or seizure disorders because it
lowers the seizure threshold, especially in patients prone to electrolyte imbalances or those with a history of
purging.
Fill in the blank: In the treatment of ADHD, atomoxetine (Strattera) functions as a selective ________
reuptake inhibitor.
Answer: Norepinephrine.
Rationale: Unlike stimulants that affect dopamine and norepinephrine, atomoxetine specifically targets the
norepinephrine transporter, making it a non stimulant option with a lower potential for abuse.
A patient is experiencing "Lead Pipe" muscle rigidity, a temperature of 104 degrees F, and altered mental
status after their first dose of Haloperidol. Which medication should the NP prepare to administer?
A. Benztropine.
B. Dantrolene.
C. Lorazepam.
D. Propranolol.
Answer: B.
Rationale: These symptoms indicate Neuroleptic Malignant Syndrome (NMS), a medical emergency.
Dantrolene, a muscle relaxant, or Bromocriptine, a dopamine agonist, are used to treat the underlying
muscle rigidity and dopamine blockade.
A PMHNP is prescribing an SSRI for a patient who is an ultra rapid metabolizer at the CYP2D6 enzyme.
What is the most likely clinical result?
A. The patient will likely experience severe side effects at low doses.
B. The medication may be ineffective because it is cleared from the system too quickly.
C. The patient will have a higher risk of Serotonin Syndrome.
D. The medication's half life will be significantly prolonged.
Answer: B.
Rationale: Ultra rapid metabolizers break down substrates of a specific enzyme much faster than the general
population. This leads to subtherapeutic blood levels and a lack of clinical response to standard doses.
, True or False: Discontinuation Syndrome, characterized by flu like symptoms and "brain zaps," is most
common with antidepressants that have a very long half life, such as Fluoxetine.
Answer: False.
Rationale: Discontinuation syndrome is more common with drugs that have a short half life, like Paroxetine
or Venlafaxine. Fluoxetine has a very long half life (and an active metabolite), meaning it essentially "self
tapers" out of the body.
Fill in the blank: The specific Absolute Neutrophil Count (ANC) threshold for initiating Clozapine therapy
is greater than or equal to ________ /uL.
Answer: 1500.
Rationale: Due to the risk of severe neutropenia, the REMS program requires a baseline ANC of at least
1500 (or 1000 for those with documented Benign Ethnic Neutropenia) before Clozapine can be started.
A patient taking Phenelzine (an MAOI) presents with a pounding headache and a blood pressure of 210/120
mmHg after eating at an Italian restaurant. What is the most likely cause?
A. Serotonin Syndrome.
B. Hypertensive Crisis due to Tyramine ingestion.
C. Acute panic attack.
D. Normal side effect of the medication.
Answer: B.
Rationale: MAOIs inhibit the breakdown of tyramine in the gut. Tyramine promotes the release of
norepinephrine. When found in high concentrations (aged cheeses, cured meats), it can cause massive
vasoconstriction and a hypertensive crisis.
Which medication is considered the first line pharmacological treatment for a patient with Akathisia?
A. Diphenhydramine.
B. Benztropine.
C. Propranolol.
D. Diazepam.
Answer: C.
Rationale: Akathisia is a subjective feeling of inner restlessness. While anticholinergics work for dystonia
and parkinsonism, beta blockers like Propranolol are the gold standard for treating akathisia.
True or False: Varenicline (Chantix) is a nicotinic receptor partial agonist that can be used for smoking
cessation but requires monitoring for neuropsychiatric side effects.
Answer: True.
Rationale: By partially stimulating the Alpha 4 Beta 2 receptors and blocking nicotine, Varenicline reduces
cravings and prevents the "reward" associated with smoking.
Fill in the blank: When prescribing typical antipsychotics, the primary neurobiological cause of
Extrapyramidal Symptoms (EPS) is the blockade of D2 receptors in the ________ pathway.
Answer: Nigrostriatal.
Rationale: There are four major dopamine pathways. Blockade in the mesolimbic pathway reduces
psychosis, but blockade in the nigrostriatal pathway leads to motor side effects and EPS.
A patient with Major Depressive Disorder and Chronic Neuropathic Pain would benefit most from which
class of antidepressant?
A. SSRI (e.g., Escitalopram).
B. SNRI (e.g., Duloxetine).
C. SARI (e.g., Trazodone).
D. NDRI (e.g., Bupropion).
Answer: B.
Rationale: SNRIs inhibit the reuptake of both serotonin and norepinephrine. Norepinephrine modulation in
the descending spinal tracts is known to help mitigate pain signals, making SNRIs effective for both mood
and physical pain.
A NP is reviewing the lab work for a patient on Valproate. Which labs are most critical for monitoring the
