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Family Nurse Practitioner (FNP) Practice Exam 1
Take your exam preparation to the next level with fully simulated online practice tests designed to replicate the real exam experience. These exams feature realistic questions, timed conditions, and detailed explanations to help you assess your knowledge, identify weak areas, and build confidence before test day.
1. A 52-year-old male presents to the clinic with complaints of persistent fatigue, unintentional weight loss, and intermittent night sweats over the past three months. He has no history of recent travel, fevers, or sick contacts. His physical examination reveals painless cervical lymphadenopathy, mild splenomegaly, and pallor. His complete blood count shows anemia and leukocytosis. Based on the findings, which is the most appropriate next step in management?
Correct Answer: C. Refer for lymph node biopsy to evaluate for malignancy Explanation: The patient's symptoms of fatigue, weight loss, night sweats, painless lymphadenopathy, and splenomegaly raise suspicion for a hematologic malignancy such as lymphoma or leukemia. (C) A lymph node biopsy is essential to confirm the diagnosis and determine the specific type of malignancy. (A) Prescribing antibiotics without evidence of infection is inappropriate and could delay proper diagnosis. (B) Tuberculosis could cause night sweats and lymphadenopathy, but painless nodes, leukocytosis, and splenomegaly make malignancy more likely. (D) Corticosteroids should not be initiated before a definitive diagnosis is made, as they could mask lymphoma and alter biopsy results.
2. A 45-year-old male with a history of seasonal allergic rhinitis presents with worsening nasal congestion, sneezing, and watery eyes for the past two weeks. He reports exposure to pollen and dust at work but denies fever, headache, or facial pain. What is the most appropriate first-line treatment?
Correct answer: A. Intranasal corticosteroids Explanation: (A) is the correct answer because intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis due to their ability to reduce inflammation and nasal congestion. (B) is incorrect because while antihistamines can help with sneezing and watery eyes, diphenhydramine causes sedation and is not recommended as a first-line agent. (C) is incorrect because montelukast is an alternative treatment, primarily used in patients with concurrent asthma or nasal polyps. (D) is incorrect because saline irrigation can provide symptomatic relief but does not address the underlying allergic inflammation.
3. A 48-year-old male with hypertension and obesity presents for a routine exam. His CMP reveals an ALT of 90 U/L and an AST of 75 U/L. He denies alcohol use. What is the most likely diagnosis?
Correct Answer: A. Nonalcoholic fatty liver disease (NAFLD) Explanation: NAFLD is a common cause of elevated liver enzymes in patients with metabolic risk factors such as obesity and hypertension (A). Option (B) is incorrect because acute viral hepatitis typically presents with much higher AST/ALT levels (often >500 U/L). Option (C) is incorrect because cirrhosis typically presents with signs of liver failure such as hypoalbuminemia and coagulopathy, not just elevated liver enzymes. Option (D) is incorrect because Wilson’s disease is a rare genetic disorder that presents with copper accumulation, neurological symptoms, and low ceruloplasmin levels.
4. A 70-year-old female with congestive heart failure (CHF) is being followed after an adjustment in her diuretic regimen. She reports improved shortness of breath but new onset of muscle cramps and generalized weakness. A repeat metabolic panel shows potassium of 3.0 mEq/L (low) and sodium of 135 mEq/L (normal). What is the most appropriate intervention to assess and adjust her treatment?
Correct Answer: C Supplementing with potassium and reassessing electrolytes in one week (C) is the most appropriate step because the patient is experiencing symptoms of hypokalemia, a known side effect of diuretics. Monitoring and correcting electrolyte imbalances is essential in CHF patients to prevent arrhythmias and other complications. Reducing the diuretic dosage (A) may lead to fluid retention, worsening CHF symptoms. Dietary potassium intake alone (B) may not be sufficient to correct a potassium level of 3.0 mEq/L. Discontinuing diuretics entirely (D) could cause fluid overload and worsen CHF management.
5. A 60-year-old male with cirrhosis presents for a follow-up visit. He reports continued alcohol use despite prior recommendations to quit. He denies withdrawal symptoms but drinks daily. Which medication is the best option for alcohol use disorder in this patient?
Correct answer: A. Acamprosate Explanation: (A) is the correct answer because acamprosate is safe for use in patients with liver disease and helps reduce cravings in alcohol use disorder. (B) is incorrect because disulfiram causes an aversive reaction when alcohol is consumed but is not ideal for patients with ongoing drinking behavior. (C) is incorrect because metronidazole is an antibiotic with an alcohol-aversive effect but is not used for alcohol dependence treatment. (D) is incorrect because methadone is used for opioid dependence, not alcohol use disorder.
6. A 3-month-old infant is brought to the clinic by his mother, who reports that he has been irritable, has refused to eat, and has had a high-pitched cry. On physical examination, the infant has a bulging anterior fontanelle, poor eye contact, and intermittent episodes of apnea. What is the most likely diagnosis?
Correct Answer: C. Bacterial meningitis Explanation: A febrile infant with irritability, high-pitched crying, bulging fontanelle, and poor feeding is highly concerning for bacterial meningitis. (C) Infants with meningitis may also present with apnea, lethargy, or seizures. Lumbar puncture is required for diagnosis, and immediate IV antibiotics should be initiated. (A) GERD can cause irritability and feeding difficulties but does not cause bulging fontanelle or neurological symptoms. (B) A viral upper respiratory infection may cause fussiness, but it does not lead to signs of increased intracranial pressure. (D) Infant colic is characterized by excessive crying but does not cause fever, bulging fontanelle, or apnea.
7. A 52-year-old uninsured male presents to the clinic with worsening dyspnea and intermittent chest pain. He was recently diagnosed with congestive heart failure at the emergency department but has been unable to obtain follow-up care due to lack of insurance. He is concerned about the cost of treatment and does not qualify for Medicaid in his state. What is the most appropriate action to address this barrier to care?
Correct Answer: C Explanation: The best approach is to connect the patient with federally qualified health centers (FQHCs) or charity programs (C), which provide care to uninsured individuals at reduced or no cost. Returning to the emergency department (A) does not provide sustainable care and contributes to unnecessary healthcare costs. Enrolling in a clinical trial (B) is not a primary intervention, as it may not be appropriate or immediately available. Prescribing the lowest-cost medication (D) without further evaluation is inappropriate, as the patient's condition requires ongoing management and monitoring beyond pharmacologic intervention.
8. A 24-year-old female who recently tested positive for hepatitis C comes in for vaccination review. She is unsure of her prior vaccination history. What is the most appropriate immunization recommendation for her?
Correct Answer: C. Give both hepatitis A and hepatitis B vaccines today Explanation: Patients with hepatitis C should receive both hepatitis A and B vaccinations (C) due to increased risk of fulminant hepatitis if co-infected. Deferring hepatitis B vaccination (B) is incorrect because protection is needed regardless of hepatitis C treatment status. Administering only hepatitis B vaccine (A) is insufficient, as hepatitis A can also cause severe liver disease in patients with hepatitis C. Only giving hepatitis A vaccine (D) ignores the risk of hepatitis B coinfection, which can worsen liver outcomes.
9. A 6-month-old infant is brought to the clinic for a well-baby visit. The mother is hesitant about vaccinating her child, expressing concerns about vaccine safety and potential side effects. How should the nurse practitioner address the mother’s concerns?
Correct Answer: B Explanation: The best approach is to provide evidence-based information about vaccine safety and address the mother’s concerns (B). Educating caregivers using credible sources, discussing vaccine benefits, and addressing misconceptions are crucial in promoting immunization. Simply agreeing with the mother’s concerns and documenting refusal (A) fails to fulfill the provider’s duty to educate and advocate for the child’s health. Delaying vaccination (C) increases the child’s risk of vaccine-preventable diseases and is not recommended. Informing the mother about legal consequences (D) is incorrect as vaccine refusal is generally allowed under personal, religious, or medical exemptions in many states, and a non-confrontational approach is preferred.
10. A 40-year-old man with newly diagnosed hypertension is referred to a chronic disease self-management program. He expresses frustration about taking medications daily and states that he does not feel any symptoms. What is the best response by the nurse practitioner?
Correct Answer: A Explanation: Educating the patient on the risks of untreated hypertension and emphasizing the role of both lifestyle modifications and medication (A) is the most appropriate response, as uncontrolled hypertension can lead to cardiovascular complications. Reassuring him that missing doses occasionally is not significant (B) is incorrect, as medication adherence is crucial for blood pressure control. Discontinuing antihypertensive therapy (C) or switching to a short-acting agent taken as needed (D) is inappropriate, as consistent control is necessary to prevent long-term complications.
11. A 64-year-old male presents to the clinic for routine follow-up. He reports undergoing coronary artery bypass graft (CABG) surgery five years ago due to severe coronary artery disease. He currently takes aspirin, atorvastatin, metoprolol, and lisinopril. He denies chest pain, dyspnea, or palpitations. His blood pressure is 128/78 mmHg, and his heart rate is 66 bpm. What is the most appropriate next step in his management?
Correct answer: A. Continue current medications and schedule annual follow-up Explanation: (A) is the correct answer because this patient has stable coronary artery disease following CABG, and his current medications (aspirin, statin, beta-blocker, and ACE inhibitor) are appropriate for secondary prevention. Regular follow-up with continued risk factor management is recommended. (B) is incorrect because aspirin is essential for preventing thrombosis in patients with a history of CABG and should not be discontinued unless contraindicated. (C) is incorrect because stress testing is only indicated if the patient has symptoms suggestive of recurrent ischemia, which he does not. (D) is incorrect because atorvastatin dosing should be based on lipid panel results and risk assessment rather than automatic dose escalation.
12. A 72-year-old woman with osteoporosis has been prescribed alendronate but reports that she frequently forgets to take it because she must take it on an empty stomach and remain upright for 30 minutes. What is the best intervention to improve her adherence?
Correct Answer: B Explanation: Educating the patient on the importance of medication adherence and discussing alternative dosing options (B) is the best approach, as weekly or injectable bisphosphonate formulations may improve compliance. Switching to a calcium supplement alone (A) is incorrect because calcium alone does not adequately treat osteoporosis. Recommending that she take the medication with food (C) is inappropriate because alendronate must be taken on an empty stomach for proper absorption. Discontinuing the medication (D) without an alternative treatment plan puts her at increased risk for fractures.
13. A 50-year-old male with major depressive disorder was prescribed sertraline 50 mg daily. At his 8-week follow-up, he reports no significant improvement in mood or anxiety. When asked about his medication use, he admits that he often forgets to take it and sometimes skips doses because he feels it is not working. What is the most appropriate next step in evaluating his compliance with treatment?
Correct Answer: B Reinforcing daily adherence and discussing medication expectations (B) is crucial because SSRIs require consistent use to be effective, and skipping doses can lead to poor response. Increasing the dose (A) without ensuring adherence may not yield better results. Switching to another SSRI (C) is premature if adherence has not been optimized. Referring to psychiatry (D) is not necessary at this stage, as the lack of response is likely due to inconsistent use rather than true treatment resistance.
14. A 67-year-old male with a history of COPD presents with worsening dyspnea and increased sputum production over the past three days. He has been using his albuterol inhaler more frequently with minimal relief. What is the best next step in management?
Correct Answer: A. Prescribe a short course of oral corticosteroids Explanation: This patient has an acute COPD exacerbation, indicated by worsening dyspnea and increased sputum production, and requires oral corticosteroids to reduce airway inflammation and improve symptoms (A). (B) is incorrect because increasing albuterol alone does not address inflammation. (C) is incorrect because long-term oxygen therapy is indicated for patients with chronic hypoxemia (PaO2 ≤ 55 mmHg), which is not mentioned in this case. (D) is incorrect because inhaled corticosteroids are not first-line in COPD exacerbations; they are used in chronic management of COPD with frequent exacerbations.
15. A 30-year-old pregnant woman at 32 weeks gestation presents for a prenatal visit. She denies any symptoms but mentions that her blood pressure was "a little high" at a recent pharmacy check. On examination, her vital signs are BP 142/92 mmHg, HR 82 bpm, RR 18 breaths/min, temperature 98.6°F (37°C), and oxygen saturation 99% on room air. Urinalysis shows trace proteinuria. What is the most likely diagnosis?
Correct Answer: C. Preeclampsia is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks gestation with proteinuria or signs of end-organ dysfunction. The presence of hypertension and proteinuria in this patient suggests preeclampsia. (A) is incorrect because gestational hypertension is defined as new-onset hypertension without proteinuria or end-organ dysfunction. (B) is incorrect because chronic hypertension is diagnosed if hypertension is present before pregnancy or before 20 weeks gestation. (D) is incorrect as eclampsia involves preeclampsia with seizures, which this patient has not developed.
16. A 45-year-old female presents with episodes of palpitations, diaphoresis, and headaches that last for about 20 minutes and resolve spontaneously. Her blood pressure in the clinic is 180/100 mmHg, and her heart rate is 95 bpm. Laboratory results show elevated plasma metanephrines. What is the most likely diagnosis?
Correct Answer: B. Pheochromocytoma Explanation: The classic triad of episodic palpitations, diaphoresis, and headache in a patient with hypertension is highly suggestive of pheochromocytoma, a catecholamine-secreting tumor of the adrenal medulla. (B) The elevated plasma metanephrines confirm excessive catecholamine production. (A) Hyperthyroidism can cause palpitations and tachycardia but is typically associated with weight loss, heat intolerance, and exophthalmos rather than episodic symptoms. (C) Panic disorder can present with similar symptoms, but it does not cause sustained hypertension or elevated catecholamine metabolites. (D) Cushing’s syndrome presents with hypertension but is associated with weight gain, moon facies, and striae rather than episodic symptoms.
17. A 28-year-old female with bipolar disorder presents to the clinic for medication management. She has been stable on lithium for the past year but recently developed tremors and mild confusion. Laboratory results show a lithium level of 1.7 mEq/L. What is the most appropriate next step?
Correct Answer: D. Reduce lithium dose and monitor for symptom improvement Explanation: The therapeutic range for lithium is 0.6-1.2 mEq/L, and levels above 1.5 mEq/L increase the risk of toxicity. The patient’s symptoms and level of 1.7 mEq/L suggest mild toxicity, warranting dose reduction (D). Continuing lithium at the same dose (A) would increase the risk of severe toxicity. Increasing the dose (B) would be dangerous. Aripiprazole (C) is an atypical antipsychotic sometimes used in bipolar disorder, but switching medications is not necessary if lithium toxicity is mild and can be managed by dose adjustment.
18. A 24-year-old female presents with sudden-onset pleuritic chest pain and shortness of breath. She has a history of asthma but denies any recent illness or trauma. On examination, she appears anxious, with an increased respiratory rate and decreased breath sounds on the left side. Tracheal deviation is noted to the right. What is the most likely diagnosis?
Correct Answer: B. Pneumothorax is the most likely diagnosis given the sudden-onset pleuritic chest pain, dyspnea, and decreased breath sounds on one side. The presence of tracheal deviation suggests a tension pneumothorax, which is a medical emergency. (A) is incorrect because a pulmonary embolism typically presents with dyspnea and pleuritic pain but does not cause unilateral absent breath sounds or tracheal deviation. (C) is incorrect because an acute asthma exacerbation presents with wheezing rather than unilateral decreased breath sounds and tracheal shift. (D) is incorrect because pneumonia is associated with fever, cough, and localized crackles, rather than tracheal deviation and absent breath sounds.
19. A 67-year-old man presents with fatigue and peripheral neuropathy. His CBC reveals macrocytic anemia with an MCV of 115 fL and hypersegmented neutrophils. Further workup shows low serum vitamin B12 levels. What is the most likely underlying cause of his anemia?
Correct Answer: B. Pernicious anemia Explanation: Pernicious anemia is an autoimmune disorder that leads to vitamin B12 deficiency due to impaired intrinsic factor production, causing macrocytic anemia with an elevated MCV and hypersegmented neutrophils (B). Option (A) is incorrect because iron deficiency anemia presents with microcytic anemia, not macrocytosis. Option (C) is incorrect because sickle cell anemia presents with hemolysis and sickle-shaped RBCs rather than macrocytosis. Option (D) is incorrect because aplastic anemia is characterized by pancytopenia rather than isolated macrocytic anemia.
20. A 32-year-old female presents with sudden-onset blurry vision, right-sided weakness, and difficulty with balance. She reports a history of similar episodes in the past that resolved spontaneously. On examination, she has hyperreflexia, intention tremor, and reduced vibratory sensation in the right leg. MRI of the brain shows multiple white matter lesions. What is the most likely diagnosis?
Correct Answer: A. Multiple sclerosis is characterized by relapsing-remitting neurological symptoms, hyperreflexia, intention tremor, sensory deficits, and MRI findings of multiple demyelinating lesions in the white matter. (B) is incorrect because myasthenia gravis presents with fatigable muscle weakness without sensory deficits. (C) is incorrect because Guillain-Barré syndrome presents with ascending weakness and areflexia, not hyperreflexia or white matter lesions. (D) is incorrect because B12 deficiency causes subacute combined degeneration of the spinal cord with paresthesia, ataxia, and megaloblastic anemia, but does not cause relapsing-remitting episodes.
21. A 75-year-old female with a history of atrial fibrillation presents with new-onset unilateral vision loss that lasted for 10 minutes and resolved spontaneously. She denies associated pain or weakness. Her physical exam is normal, and an EKG shows atrial fibrillation with a controlled rate. What is the most appropriate specialist referral?
Correct Answer: A A neurologist (A) should evaluate this patient for a transient ischemic attack (TIA), as her symptoms suggest transient retinal ischemia, which increases her stroke risk. An ophthalmologist (B) may be consulted if a retinal artery occlusion is suspected, but in the setting of atrial fibrillation, stroke prevention is the priority. A cardiologist (C) may manage her anticoagulation, but urgent stroke prevention requires neurological evaluation. A vascular surgeon (D) may be needed if carotid stenosis is suspected, but initial assessment should be neurology-led.
22. A 50-year-old male presents with a pruritic rash on his arms and torso. He recently started a new sulfa-based antibiotic for a urinary tract infection. Examination reveals widespread erythematous maculopapular lesions, but no mucosal involvement or systemic symptoms. What is the most likely diagnosis?
Correct Answer: A. Drug-induced exanthematous eruptions are the most common type of drug reaction, presenting with diffuse erythematous maculopapular lesions within days to weeks after medication initiation. (B) is incorrect because Stevens-Johnson syndrome involves mucosal involvement and more severe systemic symptoms, which are not present here. (C) is incorrect because toxic epidermal necrolysis is a severe reaction with widespread epidermal necrosis and systemic involvement, which is not described in this case. (D) is incorrect because erythema nodosum presents with tender, erythematous nodules on the lower extremities, not a widespread maculopapular rash.
23. A 28-year-old male presents with severe right lower quadrant abdominal pain, nausea, and anorexia. He reports the pain started in the periumbilical region and has now migrated to the right lower quadrant. On examination, there is rebound tenderness and guarding in the right lower quadrant. What is the most appropriate next step in management?
Correct Answer: C. Urgent surgical evaluation is necessary as this presentation is highly suggestive of acute appendicitis, which requires prompt intervention to prevent complications such as perforation. (A) is incorrect because while ultrasound can be useful, particularly in children and pregnant women, CT abdomen is the preferred imaging modality for diagnosing appendicitis in non-pregnant adults if needed. (B) is incorrect because providing opioids and discharging the patient without further evaluation could lead to missed diagnosis and complications. (D) is incorrect because a digital rectal exam does not provide significant diagnostic value for appendicitis.
24. A 42-year-old female presents with diffuse musculoskeletal pain, fatigue, and sleep disturbances for the past year. She reports feeling exhausted despite getting eight hours of sleep. On examination, she has multiple tender points over the neck, shoulders, and lower back, but no joint swelling or erythema. Laboratory workup, including inflammatory markers, is normal. What is the most appropriate initial treatment?
Correct Answer: A. Duloxetine is an appropriate first-line treatment for fibromyalgia, which presents with widespread musculoskeletal pain, fatigue, and tender points, without inflammatory markers or joint swelling. (B) is incorrect because prednisone is used for inflammatory conditions such as rheumatoid arthritis and polymyalgia rheumatica but is not effective in fibromyalgia. (C) is incorrect because methotrexate is used for autoimmune diseases like rheumatoid arthritis but has no role in fibromyalgia. (D) is incorrect because hydroxychloroquine is used for systemic lupus erythematosus, not fibromyalgia.
25. A 45-year-old construction worker presents with chronic cough and dyspnea. He has a history of exposure to silica dust. His spirometry shows a normal FEV1/FVC ratio with decreased lung volumes and reduced DLCO. What is the most likely underlying condition?
Correct Answer: A. Silicosis Explanation: Silicosis is a restrictive lung disease caused by long-term inhalation of silica dust, leading to fibrosis and impaired lung compliance. It is characterized by a normal or elevated FEV1/FVC ratio with decreased total lung capacity (A). Option (B) is incorrect because chronic bronchitis is an obstructive lung disease associated with increased mucus production and airway inflammation. Option (C) is incorrect because emphysema presents with an obstructive pattern (low FEV1/FVC) and increased lung compliance. Option (D) is incorrect because asthma is an obstructive disorder with reversible airway obstruction.
26. A 52-year-old male with a history of COPD presents to the clinic with a productive cough, fever of 101°F (38.3°C), and dyspnea for the past three days. On auscultation, decreased breath sounds and crackles are noted in the right lower lung field. A chest X-ray confirms right lower lobe pneumonia. The patient has no known drug allergies and has not recently been hospitalized. What is the most appropriate empiric antibiotic therapy for this patient?
Correct Answer: C. Levofloxacin Explanation: The patient has community-acquired pneumonia (CAP) with risk factors such as COPD, making them more likely to have pneumonia caused by drug-resistant pathogens, including Pseudomonas aeruginosa. Levofloxacin (C) is a respiratory fluoroquinolone that covers Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and atypical organisms, making it an appropriate empiric therapy for CAP in a patient with COPD. Azithromycin (A) alone would not be appropriate due to the patient's comorbid condition, as macrolides have limited efficacy against drug-resistant Streptococcus pneumoniae. Amoxicillin (B) lacks adequate coverage for atypical pathogens and beta-lactamase-producing organisms commonly found in COPD patients. Doxycycline (D) may be used in mild CAP but is not preferred in patients with significant comorbidities.
27. A 35-year-old female presents to the clinic with a chief complaint of fatigue and generalized weakness that has gradually worsened over the past three months. She also reports heavy menstrual periods and frequent headaches. On examination, she appears pale, and her conjunctivae are slightly pale. Laboratory results show hemoglobin of 9.8 g/dL, mean corpuscular volume (MCV) of 72 fL, and ferritin of 8 ng/mL. What is the most appropriate treatment?
Correct answer: A. Oral ferrous sulfate supplementation Explanation: (A) is the correct answer because this patient has microcytic anemia with low ferritin, indicative of iron deficiency anemia (IDA), most likely due to heavy menstrual bleeding. The first-line treatment is oral iron supplementation. (B) is incorrect because IV iron is reserved for cases where oral iron is ineffective or not tolerated. (C) is incorrect because blood transfusion is only indicated for severe anemia (hemoglobin <7 g/dL) or symptomatic anemia with hemodynamic instability. (D) is incorrect because vitamin B12 deficiency causes macrocytic anemia, not microcytic anemia.
28. A 47-year-old female with a BMI of 34 kg/m簡 and hypertension has been monitoring her blood pressure at home for the past two weeks. Her average readings are 140/88 mmHg, and she currently takes lisinopril 10 mg daily. She is otherwise asymptomatic. What is the most appropriate next step?
Correct Answer: B. Increase lisinopril to 20 mg daily and encourage weight loss Explanation: The patient's home blood pressure readings remain above the recommended goal of <130/80 mmHg, indicating the need for medication adjustment. Increasing lisinopril to 20 mg daily (B) is a reasonable next step, as ACE inhibitors are first-line agents, particularly in patients with obesity and metabolic syndrome. Reassuring the patient and continuing current management (A) is inappropriate since her blood pressure is not at goal. Adding a beta-blocker (C) is not first-line unless the patient has a compelling indication such as heart failure or a history of myocardial infarction. Discontinuing lisinopril and switching to a calcium channel blocker (D) is unnecessary since increasing the ACE inhibitor dosage is a more effective approach.
29. A 60-year-old male with a history of cirrhosis presents with confusion and lethargy. His family reports that he has not been adherent to his lactulose regimen. His vital signs are stable, but he demonstrates asterixis on exam. His ammonia level is elevated. What is the most appropriate next step?
Correct Answer: B Explanation: Administering lactulose and considering admission (B) is appropriate because this patient has hepatic encephalopathy, evidenced by confusion and asterixis. Lactulose is essential for reducing ammonia levels, and admission may be necessary to ensure proper treatment and monitoring. Restarting lactulose and discharging home (A) is risky, as the patient is already symptomatic and may not be able to manage treatment independently. Prescribing rifaximin (C) is beneficial for preventing recurrent encephalopathy but is not a first-line treatment for acute episodes. Discontinuing lactulose (D) is inappropriate, as it is a primary treatment for hepatic encephalopathy.
30. A 55-year-old male presents with chest pressure that started while walking and resolved after resting for five minutes. He has a history of diabetes and hyperlipidemia. His ECG shows normal sinus rhythm without ST changes. What is the most likely diagnosis?
Correct Answer: A. Stable angina Explanation: Stable angina is characterized by exertional chest pain that resolves with rest and is associated with coronary artery disease risk factors such as diabetes and hyperlipidemia (A). MI (B) presents with more prolonged, severe pain and does not resolve with rest. Panic attack (C) is not triggered by exertion and is often accompanied by autonomic symptoms. GERD (D) causes burning pain worsened by food intake and lying down, not exertion-related chest discomfort.
31. A 59-year-old male with a history of heart failure presents for a medication review. He has been on carvedilol, furosemide, and lisinopril but continues to have NYHA class III symptoms. His blood pressure is 122/76 mmHg, and his potassium is 4.2 mEq/L. His most recent echocardiogram shows an ejection fraction of 30%. Which of the following medications should be added to his regimen?
Correct Answer: B. Spironolactone Explanation: Spironolactone (B) is indicated for patients with HFrEF and persistent NYHA class II-IV symptoms despite optimal medical therapy, as it reduces mortality and hospitalizations. Digoxin (A) can help with symptoms but does not improve survival and is reserved for refractory cases. Amlodipine (C) is a calcium channel blocker that does not improve outcomes in heart failure and may worsen symptoms due to negative inotropic effects. Hydrochlorothiazide (D) is less effective than loop diuretics for fluid management in heart failure and does not provide mortality benefits.
32. A 55-year-old uninsured male presents for follow-up after being diagnosed with type 2 diabetes mellitus two months ago. He has been unable to afford his prescribed medication, which includes a GLP-1 receptor agonist. His A1c has increased to 9.2%, and he reports difficulty affording healthy foods. What is the best approach to address his care while considering his socioeconomic factors?
Correct Answer: A. Prescribe a more affordable alternative such as metformin and refer him to a community food assistance program Explanation: Addressing a patient’s socioeconomic barriers includes providing cost-effective treatment options and ensuring access to essential resources (A). Metformin is an affordable first-line therapy for diabetes, and connecting the patient with a food assistance program improves dietary access. (B) is incorrect because advising the patient to seek financial aid without providing immediate, cost-effective alternatives does not address his urgent needs. (C) is incorrect because dietary changes alone are unlikely to adequately manage his diabetes at this stage. (D) is incorrect because encouraging a patient to borrow money is not an ethical or sustainable approach to care.
33. A 60-year-old male presents with weak urine stream, incomplete bladder emptying, and nocturia. Digital rectal examination reveals a smooth, enlarged prostate. His prostate-specific antigen (PSA) level is within normal limits. What is the most appropriate initial treatment?
Correct Answer: A. Tamsulosin, an alpha-blocker, is the first-line treatment for benign prostatic hyperplasia (BPH), which presents with urinary hesitancy, weak stream, and nocturia with a smooth, enlarged prostate. (B) is incorrect because a prostate biopsy is indicated for suspected prostate cancer, which presents with an irregular, nodular prostate or elevated PSA. (C) is incorrect because prostatitis presents with perineal pain, fever, and prostate tenderness, which this patient lacks. (D) is incorrect because increasing fluid intake may worsen nocturia, and dietary fiber does not address urinary obstruction symptoms.
34. A 67-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents with worsening dyspnea and purulent sputum production over the last two days. His vital signs are BP 135/85 mmHg, HR 98 bpm, RR 22 breaths/min, SpO2 90% on room air, and temperature 37.8°C (100°F). Based on clinical guidelines and the GOLD criteria, what is the most appropriate next step?
Correct Answer: A. Prescribe oral corticosteroids and short-acting bronchodilators The correct answer is (A) because in patients with an acute COPD exacerbation without signs of severe infection or respiratory failure, oral corticosteroids (e.g., prednisone 40 mg for 5 days) and bronchodilators (e.g., albuterol, ipratropium) are the first-line treatments. (B) is incorrect because IV antibiotics are not immediately needed unless there are signs of pneumonia or systemic infection. (C) is incorrect because while a chest X-ray may be done to rule out pneumonia, it is not the primary management step for an uncomplicated exacerbation. (D) is incorrect because an ABG is only necessary in cases of severe respiratory distress or suspected respiratory failure.
35. A 58-year-old male with a 40-pack-year smoking history presents with hemoptysis and unintentional weight loss. His physical exam is unremarkable. What is the most appropriate initial imaging study?
Correct Answer: A. Chest X-ray Explanation: The first-line imaging study for evaluating hemoptysis in a high-risk patient is a chest X-ray to assess for lung masses, infections, or other pulmonary pathology (A). Option (B) is incorrect because while CT imaging is more sensitive for detecting lung malignancies, a chest X-ray is the appropriate initial test before considering further imaging. Option (C) is incorrect because MRI is not routinely used in lung cancer screening. Option (D) is incorrect because pulmonary ultrasound is primarily used for evaluating pleural effusions and does not provide detailed lung parenchyma assessment.
36. A 64-year-old postmenopausal woman presents for a wellness visit. She has a history of smoking, rheumatoid arthritis, and long-term corticosteroid use. She has never had osteoporosis screening. What is the most appropriate next step?
Correct Answer: A. Perform a DEXA scan now due to multiple risk factors Explanation: The USPSTF recommends osteoporosis screening in postmenopausal women younger than 65 if they have additional risk factors, including smoking, corticosteroid use, and rheumatoid arthritis (A). Option (B) is incorrect because delaying screening in a high-risk individual may result in undiagnosed osteoporosis. Option (C) is incorrect because bisphosphonates should not be prescribed without first confirming osteoporosis. Option (D) is incorrect because CT scans are not the standard for osteoporosis screening; DEXA scans are the preferred method.
37. A 55-year-old female with a history of hypertension and hyperlipidemia presents with intermittent headaches and dizziness. Her blood pressure in the clinic is 168/102 mmHg. She is currently taking hydrochlorothiazide 25 mg daily. According to JNC-8 guidelines, what is the most appropriate next step in management?
Correct Answer: B. Add an ACE inhibitor or calcium channel blocker The correct answer is (B) because JNC-8 recommends that if a patient's blood pressure remains above 140/90 mmHg despite monotherapy, a second antihypertensive agent should be added. Preferred options include an ACE inhibitor, ARB, calcium channel blocker, or another diuretic. (A) is incorrect because increasing hydrochlorothiazide to 50 mg has diminishing effects and may increase the risk of side effects such as electrolyte disturbances. (C) is incorrect because beta-blockers are not first-line for hypertension unless there is a compelling indication, such as heart failure or previous myocardial infarction. (D) is incorrect because a blood pressure of 168/102 mmHg indicates Stage 2 hypertension, which requires immediate adjustment of therapy rather than continued monitoring.
38. A 38-year-old female presents with a six-month history of episodic palpitations, sweating, and headaches. She reports that these episodes occur suddenly and last for about 15–20 minutes before resolving. Her blood pressure in the clinic is 162/98 mmHg. She denies caffeine use or stimulant medications. What is the most likely diagnosis?
Correct answer: C. Pheochromocytoma Explanation: (C) is the correct answer because pheochromocytoma is a catecholamine-secreting tumor that causes episodic hypertension, palpitations, sweating, and headaches, which match the patient’s symptoms. (A) is incorrect because anxiety disorders do not typically cause episodic hypertension and are often associated with chronic worry rather than sudden episodes of symptoms. (B) is incorrect because hyperthyroidism presents with persistent symptoms such as weight loss, heat intolerance, and tremors rather than episodic attacks. (D) is incorrect because paroxysmal atrial fibrillation can cause palpitations, but it does not explain the associated headaches and sweating.
39. A 34-year-old pregnant woman at 34 weeks' gestation presents to the clinic complaining of new-onset right upper quadrant pain, nausea, and headache for the past two days. She denies fever or dysuria but has noticed increased swelling in her hands and face. Blood pressure is 162/102 mmHg, and urinalysis reveals 3+ proteinuria. Laboratory results show low platelets, elevated liver enzymes, and hemolysis. What is the most appropriate next step?
Correct answer: D. Administer IV magnesium sulfate and prepare for urgent delivery Explanation: (A) is the correct answer because this patient exhibits signs of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe complication of preeclampsia. The primary management includes seizure prophylaxis with IV magnesium sulfate and expedited delivery, as maternal and fetal risks increase with prolonged gestation. (B) is incorrect because oral antihypertensives alone are inadequate for treating severe preeclampsia with HELLP; prompt delivery is necessary. (C) is incorrect because while gallbladder disease can present with right upper quadrant pain, the combination of hypertension, proteinuria, and lab abnormalities strongly suggests HELLP syndrome rather than biliary pathology. (D) is incorrect because corticosteroids do not alter the disease course in HELLP; definitive treatment is delivery.
40. A 30-year-old female presents for a well-woman exam. She has no history of abnormal Pap smears and no HPV vaccination. Her last Pap test was three years ago and was normal. She asks whether she needs cervical cancer screening. What is the most appropriate recommendation?
Correct Answer: A. Repeat a Pap test today and every three years if normal Explanation: Women aged 21-29 should have a Pap test every three years (A). HPV testing alone (B) is not recommended for her age group. Delaying until 35 (C) is inappropriate, as screening begins at 21. Annual screening (D) is unnecessary, as the USPSTF recommends less frequent testing.
41. A 34-year-old female patient with a BMI of 32 kg/m簡 presents with complaints of polyuria, polydipsia, and unexplained weight loss over the past three months. A fasting blood glucose test is 195 mg/dL, and a repeat test confirms similar results. What is the most appropriate next step in the management of this patient?
Correct Answer: A. Start metformin and refer to endocrinology Explanation: A fasting blood glucose ≥ 126 mg/dL on two separate occasions confirms diabetes mellitus, and the first-line treatment in a newly diagnosed type 2 diabetes patient is metformin (A). Endocrinology referral is appropriate for guidance on management, particularly if there are concerns about type 1 diabetes or an atypical presentation. Delaying treatment by waiting another three months is inappropriate and may lead to complications (B). Immediate insulin therapy is generally reserved for patients with severe hyperglycemia (≥ 300 mg/dL) or significant symptoms suggestive of type 1 diabetes (C). An HbA1c test is helpful for long-term monitoring but is not necessary to diagnose diabetes when two fasting glucose readings are ≥ 126 mg/dL (D).
42. A 65-year-old female with a history of hypertension and obesity is interested in making lifestyle changes to improve her cardiovascular health. She asks about the most effective dietary approach. Which of the following is the best recommendation?
Correct Answer: A. Follow a DASH (Dietary Approaches to Stop Hypertension) diet rich in fruits, vegetables, whole grains, and low-fat dairy Explanation: The DASH diet (A) has been proven to reduce blood pressure and improve cardiovascular health through high intake of fruits, vegetables, whole grains, and low-fat dairy while limiting sodium and saturated fats. A diet high in processed foods and sodium (B) worsens hypertension and cardiovascular disease risk. A diet primarily composed of red meat and saturated fats (C) increases LDL cholesterol and cardiovascular risk. Avoiding all carbohydrates (D) is not necessary, as whole grains and fiber-rich foods are essential for a balanced diet and heart health.
43. A 65-year-old male with hypertension and benign prostatic hyperplasia (BPH) has been on hydrochlorothiazide 25 mg daily and tamsulosin 0.4 mg daily for the past three months. He reports persistent nocturia and difficulty initiating urination. His blood pressure today is 138/82 mmHg. What is the most appropriate medication adjustment?
Correct Answer: D Explanation: Adding finasteride 5 mg daily (D) is the best option because the patient’s persistent BPH symptoms indicate that alpha-blockade alone (tamsulosin) is insufficient. Finasteride, a 5-alpha reductase inhibitor, helps reduce prostate size and improve urinary symptoms over time. Increasing hydrochlorothiazide (A) does not address BPH symptoms and may increase side effects like electrolyte imbalances. Discontinuing tamsulosin and starting finasteride alone (B) is not recommended, as finasteride takes months to show effects, whereas tamsulosin provides immediate symptom relief. Switching hydrochlorothiazide to losartan (C) may be reasonable for blood pressure but does not address the patient’s primary concern.
44. A 38-year-old male presents with intermittent cramping abdominal pain, bloating, and diarrhea for the past six months. He reports weight loss and notices that symptoms worsen after consuming bread and pasta. Examination reveals mild abdominal distension but no tenderness. What is the most appropriate next step?
Correct Answer: A. The tissue transglutaminase (tTG) IgA antibody test is the best initial test for celiac disease, which presents with chronic diarrhea, bloating, weight loss, and worsened symptoms with gluten ingestion. (B) is incorrect because anti-diarrheal medication and fiber do not address the underlying cause of symptoms. (C) is incorrect because colonoscopy is not the first-line test for suspected celiac disease, which primarily affects the small intestine rather than the colon. (D) is incorrect because Clostridioides difficile infection typically occurs after recent antibiotic use and presents with watery, foul-smelling diarrhea rather than chronic symptoms related to gluten intake.
45. A 58-year-old woman presents with fever, cough, and shortness of breath for three days. She has a history of hypertension but no chronic lung disease. On examination, she has crackles and decreased breath sounds in the right lower lung field. Her oxygen saturation is 94% on room air. A chest X-ray reveals a right lower lobe infiltrate. What is the most likely diagnosis?
Correct Answer: C. Pneumonia Explanation: Pneumonia presents with fever, cough, shortness of breath, and focal lung findings such as crackles and decreased breath sounds, often confirmed by an infiltrate on chest X-ray (C). COPD (A) typically presents with chronic symptoms and airflow obstruction, rather than acute infection. PE (B) usually presents with sudden dyspnea, tachycardia, and pleuritic chest pain, not fever and lung infiltrates. Congestive heart failure (D) presents with bilateral lung findings and peripheral edema rather than a focal infiltrate.
46. A 65-year-old female with a history of type 2 diabetes mellitus presents with new-onset burning pain and tingling in both feet for the past three months. The symptoms are worse at night and improve with activity. On examination, she has decreased vibratory sensation and absent ankle reflexes. What is the most likely diagnosis?
Correct answer: A. Diabetic peripheral neuropathy Explanation: (A) is the correct answer because diabetic peripheral neuropathy typically presents with burning pain, tingling, and sensory loss in a stocking-glove distribution, along with absent reflexes. (B) is incorrect because lumbar radiculopathy would present with unilateral pain radiating from the lower back down the leg rather than symmetric sensory loss. (C) is incorrect because peripheral arterial disease presents with claudication and diminished pulses rather than sensory neuropathy. (D) is incorrect because multiple sclerosis usually presents with asymmetric neurological deficits and is not common in this demographic.
47. A 29-year-old woman presents with weight loss, heat intolerance, and palpitations. Her thyroid function tests show TSH <0.01 mIU/L (low) and free T4 of 2.5 ng/dL (elevated). What is the most likely diagnosis?
Correct Answer: A. Graves' disease Explanation: Graves' disease is the most common cause of hyperthyroidism and is characterized by a suppressed TSH and elevated free T4, as seen in this patient (A). Option (B) is incorrect because subclinical hyperthyroidism presents with a low TSH but normal free T4 levels. Option (C) is incorrect because Hashimoto’s thyroiditis is a cause of hypothyroidism, not hyperthyroidism. Option (D) is incorrect because euthyroid sick syndrome does not present with a suppressed TSH and elevated free T4.
48. A 48-year-old woman with no significant medical history presents with intermittent palpitations and exertional shortness of breath. An electrocardiogram reveals frequent premature ventricular contractions (PVCs). What is the most appropriate next imaging study?
Correct Answer: A. Transthoracic echocardiogram Explanation: A transthoracic echocardiogram is the best next step in evaluating PVCs and exertional dyspnea, as it assesses left ventricular function, structural abnormalities, and potential cardiomyopathies (A). Option (B) is incorrect because a carotid Doppler ultrasound is used to assess for carotid artery stenosis, not palpitations. Option (C) is incorrect because venous Doppler ultrasound is used for DVT assessment. Option (D) is incorrect because a CT scan of the chest is not indicated for PVC evaluation unless pulmonary embolism is suspected.
49. A 22-year-old female presents to the clinic with dysuria, urinary frequency, and suprapubic discomfort for two days. She denies fever, flank pain, or nausea. A urine dipstick is positive for leukocyte esterase and nitrites. What is the most likely diagnosis?
Correct Answer: A. Acute cystitis Explanation: Acute cystitis is a non-life-threatening urinary tract infection characterized by dysuria, urinary frequency, and suprapubic discomfort, with positive leukocyte esterase and nitrites on urinalysis (A). Pyelonephritis (B) presents with fever, flank pain, and systemic symptoms, making it a more serious infection. Urolithiasis (C) causes severe flank pain but does not typically present with dysuria and urinary frequency alone. Bladder cancer (D) can cause hematuria but is uncommon in young patients with an acute presentation.
50. A 72-year-old male with a history of hypertension and coronary artery disease presents with increasing shortness of breath over the past two weeks. On physical examination, you note jugular venous distension (JVD), bilateral crackles in the lungs, and 2+ pitting edema in the lower extremities. Auscultation reveals an S3 heart sound. What is the most likely diagnosis?
Correct Answer: B. Heart failure with reduced ejection fraction (HFrEF) is suggested by JVD, crackles, lower extremity edema, and an S3 heart sound, which is associated with volume overload and reduced ventricular compliance. (A) is incorrect because COPD exacerbation would present with wheezing, prolonged expiratory phase, and hyperresonance rather than pulmonary congestion and S3. (C) is incorrect because pulmonary embolism presents with acute onset dyspnea, pleuritic chest pain, and tachycardia rather than progressive symptoms with volume overload signs. (D) is incorrect because aortic stenosis classically presents with exertional syncope, angina, and dyspnea with a systolic crescendo-decrescendo murmur at the right upper sternal border.
51. A 50-year-old male with a history of type 2 diabetes and chronic alcohol use disorder presents with vague abdominal discomfort, fatigue, and recent weight loss. He has no fever, nausea, or vomiting. On examination, he appears thin and slightly jaundiced. His abdomen is soft with mild right upper quadrant tenderness. What is the most likely diagnosis?
Correct Answer: B. Silent hepatic cirrhosis The correct answer is (B) because patients with chronic alcohol use and diabetes are at high risk for cirrhosis, which can present subtly with fatigue, weight loss, and mild jaundice rather than overt signs of liver failure. (A) is incorrect because chronic pancreatitis is more commonly associated with severe epigastric pain radiating to the back. (C) is incorrect because peptic ulcer disease typically causes episodic burning pain relieved by food or antacids. (D) is incorrect because small bowel obstruction would present with nausea, vomiting, and absent or high-pitched bowel sounds.
52. A 70-year-old male with a history of peptic ulcer disease and chronic hip pain presents for medication management. He has been taking ibuprofen daily but now reports worsening epigastric pain. What is the most appropriate next step in pain management?
Correct Answer: A. Switch to acetaminophen Explanation: Acetaminophen (A) is the safest option for this patient because it provides analgesia without increasing gastrointestinal bleeding risk. Continuing ibuprofen with omeprazole (B) may reduce gastric irritation but does not eliminate the risk of NSAID-related ulcer complications. Oxycodone (C) is not an appropriate first-line choice for chronic hip pain due to the risk of dependence. Increasing the ibuprofen dosage (D) would likely worsen the patient's gastrointestinal symptoms and is contraindicated in peptic ulcer disease.
53. A 75-year-old female with Parkinson’s disease presents for follow-up. She has worsening mobility issues and difficulty with daily activities, including dressing and preparing meals. She reports frequent falls and has recently been hospitalized for a hip contusion. Her son lives nearby but works full-time. What is the most appropriate intervention?
Correct Answer: A. Refer to home health services for assistance with daily activities and fall prevention Explanation: The patient’s worsening functional status and fall risk necessitate home health services for daily assistance and safety modifications (A). While dopamine agonists (B) can help with Parkinson’s symptoms, they do not address the immediate risk of falls and functional limitations. Using a walker and installing grab bars (C) are helpful but do not replace the need for professional assistance. Outpatient physical therapy (D) is beneficial, but the patient’s mobility issues may make home-based care more appropriate.
54. A 56-year-old male with type 2 diabetes mellitus presents for a follow-up visit. His most recent HbA1C was 9.2%, and he reports occasional tingling in his feet. On examination, he has diminished monofilament sensation in both feet. Which of the following is the most appropriate next step in managing his condition?
Correct Answer: C. Increase the intensity of glycemic control and perform a comprehensive foot exam Explanation: The patient has uncontrolled diabetes with an HbA1C above the target goal of <7% and symptoms of diabetic neuropathy, evidenced by tingling and diminished monofilament sensation (C). Increasing the intensity of glycemic control is essential to reduce the progression of diabetic complications, and a comprehensive foot exam is warranted to assess for ulcerations, deformities, or signs of infection. Rechecking HbA1C in six months without intervention (A) is inappropriate, as tighter glycemic control is needed now. Initiating gabapentin (B) may help with neuropathic symptoms, but discontinuing metformin is not appropriate unless there is an indication such as renal impairment or lactic acidosis risk. Vitamin B12 deficiency can cause neuropathy, especially in metformin users, but (D) alone is insufficient in the management of diabetic neuropathy without addressing glycemic control.
55. A 45-year-old female with a BMI of 31 kg/m² presents for a routine visit. She reports a sedentary lifestyle due to long work hours and limited time for exercise. She expresses interest in starting a weight loss plan but is unsure where to begin. What is the most evidence-based initial recommendation?
Correct answer: B. Recommend at least 150 minutes of moderate-intensity exercise per week and dietary modifications Explanation: (B) is the correct answer because current guidelines recommend at least 150 minutes of moderate-intensity aerobic activity per week combined with dietary modifications for effective weight management. Exercise improves cardiovascular health and supports long-term weight loss. (A) is incorrect because pharmacologic therapy is only considered when lifestyle interventions fail or in cases of severe obesity (BMI ≥30 kg/m² or ≥27 kg/m² with comorbidities). (C) is incorrect because while intermittent fasting may promote weight loss, it is not superior to a well-balanced calorie-restricted diet combined with exercise. (D) is incorrect because avoiding all carbohydrates is not necessary; rather, a focus on portion control and consuming complex carbohydrates is a healthier approach.
56. A 50-year-old man with obesity and newly diagnosed obstructive sleep apnea (OSA) presents for follow-up. He was prescribed continuous positive airway pressure (CPAP) therapy but reports poor adherence, stating that the mask feels uncomfortable. What is the best intervention for this patient?
Correct Answer: B Poor CPAP adherence is a common problem, and referral to a sleep specialist for mask adjustment and desensitization strategies (B) is the most effective approach. Many patients tolerate CPAP better after proper fit and comfort modifications. Encouraging weight loss (A) is important but does not address his immediate CPAP adherence issue. Discontinuing CPAP and switching to an oral appliance (C) without specialist evaluation is premature. Adjusting CPAP pressure without assessing fit and comfort (D) may worsen his compliance issues.
57. A 51-year-old woman with no family history of breast cancer asks if she needs a mammogram. She has no breast complaints and no known risk factors. According to the USPSTF guidelines, what is the best recommendation?
Correct Answer: C. Biennial mammograms starting at age 50 Explanation: The USPSTF recommends biennial mammograms for average-risk women aged 50-74 (C). Option (A) is incorrect because mammograms are recommended for routine screening, not just when symptoms develop. Option (B) is incorrect because annual mammograms are not universally recommended for average-risk women. Option (D) is incorrect because MRI screening is only recommended for high-risk women, such as those with BRCA mutations or strong family history.
58. A 42-year-old male with a history of opioid use disorder presents to the clinic stating that he has been struggling with cravings and is at risk of relapse. He recently completed an inpatient detoxification program and is motivated to maintain sobriety. What is the most appropriate next step?
Correct Answer: A. Refer to a psychiatrist for medication-assisted treatment Explanation: The patient is at high risk for relapse and requires specialized treatment through a psychiatrist for medication-assisted therapy, which may include buprenorphine, methadone, or naltrexone (A). While self-help groups (B) provide additional support, they are not sufficient alone for opioid use disorder. Although naltrexone (C) may be used, psychiatric evaluation is needed to determine the most appropriate medication. Cognitive behavioral therapy (D) is an essential component of treatment but is most effective when combined with medication-assisted therapy.
59. A 48-year-old female with a history of anxiety presents with palpitations and shortness of breath. Her EKG shows a regular rhythm with narrow QRS complexes, a ventricular rate of 160 bpm, and P waves that are difficult to distinguish from the T waves. What is the most likely diagnosis?
Correct Answer: B. Supraventricular tachycardia (SVT) Explanation: SVT is a narrow-complex tachycardia with a rapid, regular rhythm and P waves that are either absent or difficult to differentiate from T waves due to the fast rate (B). Option (A) is incorrect because atrial fibrillation presents with an irregularly irregular rhythm and absent P waves. Option (C) is incorrect because ventricular tachycardia has wide QRS complexes, not narrow. Option (D) is incorrect because sinus tachycardia typically has a visible P wave before each QRS and does not exceed 150-160 bpm in most cases.
60. A 35-year-old male presents for an initial visit. He states that his father and two paternal uncles were diagnosed with early-onset Alzheimer’s disease before age 55. He is concerned about his risk of developing the disease. What is the most appropriate next step?
Correct answer: A. Refer for genetic counseling and APOE testing Explanation: (A) is the correct answer because early-onset Alzheimer’s disease (before age 65) is often linked to genetic mutations such as those in the APP, PSEN1, and PSEN2 genes. Genetic counseling can help assess his risk and guide future monitoring. (B) is incorrect because brain MRI is not useful for diagnosing Alzheimer’s disease in asymptomatic individuals. (C) is incorrect because lifestyle modifications may help reduce risk but do not replace appropriate genetic assessment for early-onset familial Alzheimer’s. (D) is incorrect because delaying evaluation until symptoms appear could lead to missed opportunities for early intervention and planning.
61. A 68-year-old male with a history of osteoarthritis presents with chronic knee pain that limits his mobility. He has tried NSAIDs with minimal relief and is interested in non-pharmacologic options. Which of the following is the most appropriate next step in managing his condition?
Correct Answer: B. Physical therapy Explanation: Physical therapy (B) is the first-line non-pharmacologic intervention for osteoarthritis as it helps improve joint mobility, strengthen muscles, and reduce pain through targeted exercises. Acupuncture (A) may provide some pain relief but does not address joint function. Therapeutic ultrasound (C) has limited evidence for osteoarthritis pain relief. TENS (D) may be helpful for short-term pain relief but does not improve long-term joint function like physical therapy does.
62. A 50-year-old male with a history of alcohol use disorder and cirrhosis presents for follow-up after being discharged from the hospital for complications related to liver disease. He reports difficulty keeping up with his medical appointments and managing his medications. He also states that he is at risk of losing his job due to frequent absences. What is the most appropriate next step?
Correct Answer: A. Refer to case management for coordination of medical care and employment support Explanation: The patient has multiple complex needs, including medical care, medication management, and employment concerns. Case management can help coordinate care, provide resources for medication access, and assist with workplace accommodations (A). While joining an alcohol recovery program (B) is beneficial, it does not address his immediate need for medical and employment support. Prescribing medications (C) is necessary but does not resolve the underlying barriers to adherence and follow-up care. Advising him to rest and reduce stress (D) does not address his practical challenges in managing his condition.
63. A 52-year-old male with hypertension and a 20-pack-year smoking history presents for a routine check-up. His lipid panel reveals total cholesterol of 240 mg/dL, LDL of 160 mg/dL, HDL of 35 mg/dL, and triglycerides of 180 mg/dL. Based on current guidelines, what is the most appropriate management?
Correct Answer: A. Initiate high-intensity statin therapy Explanation: This patient has multiple cardiovascular risk factors, including hypertension and smoking, along with an LDL of 160 mg/dL, which places him at increased risk for atherosclerotic cardiovascular disease (ASCVD). Current guidelines recommend high-intensity statin therapy for individuals with an LDL ≥190 mg/dL or for those aged 40-75 with an LDL ≥70 mg/dL and additional risk factors (A). Option (B) is incorrect because lifestyle modifications alone are insufficient for his risk profile. Option (C) is incorrect because fibrates are used primarily for triglycerides >500 mg/dL, not LDL reduction. Option (D) is incorrect because intervention is necessary to prevent cardiovascular events.
64. A 68-year-old male with a history of hypertension and atrial fibrillation presents to the emergency department with sudden-onset right-sided weakness and difficulty speaking that began one hour ago. He denies headache, fever, or recent trauma. On examination, he has right facial droop, 1/5 strength in his right upper and lower extremities, and expressive aphasia. What is the most likely diagnosis?
Correct Answer: A. Ischemic stroke Explanation: The sudden onset of focal neurological deficits such as unilateral weakness, facial droop, and aphasia in a high-risk patient suggests an ischemic stroke (A). Migraine with aura (B) can cause transient neurological symptoms but typically presents with preceding visual disturbances and headache rather than isolated motor deficits. Seizure with postictal weakness (C) may mimic stroke but is usually accompanied by a witnessed convulsion or altered consciousness before the weakness. Transient global amnesia (D) is a benign condition causing a temporary loss of memory without motor deficits, making it unlikely in this case.
65. A 38-year-old woman with no known medical history presents for a routine check-up. She asks whether she needs to be screened for type 2 diabetes. According to the American Diabetes Association (ADA), which of the following is the most appropriate response?
Correct Answer: C. Screening is recommended if she has a BMI ≥25 kg/m² with additional risk factors Explanation: The ADA recommends diabetes screening in adults aged 35-70 who are overweight (BMI ≥25 kg/m²) or obese, especially if they have additional risk factors such as hypertension, dyslipidemia, or family history (C). Option (A) is incorrect because waiting for symptoms may lead to delayed diagnosis and complications. Option (B) is incorrect because the threshold for screening based on BMI is lower than 35 kg/m². Option (D) is incorrect because screening may begin earlier than 45 years in those with risk factors.
66. A 72-year-old female with hypertension and type 2 diabetes presents for a wellness visit. She states she received the herpes zoster vaccine about 7 years ago but is unsure which formulation. What is the best recommendation regarding zoster vaccination?
Correct answer: B. Recommend two doses of recombinant zoster vaccine (RZV) Explanation: (B) is the correct answer because the recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 and older, even if they previously received the live zoster vaccine (Zostavax). Since Zostavax is no longer recommended, she should receive the two-dose series of RZV for optimal protection. (A) is incorrect because the live zoster vaccine (ZVL) has lower efficacy, and the newer recombinant vaccine is recommended regardless of prior ZVL administration. (C) is incorrect because ZVL is no longer recommended and should not be boosted. (D) is incorrect because diabetes is not a contraindication to the zoster vaccine; rather, it increases the risk of complications from herpes zoster, making vaccination more important.
67. A 62-year-old male presents with chronic cough, progressive dyspnea, and unintentional weight loss over the past four months. He has a 40-pack-year smoking history. Chest X-ray reveals a mass in the right lung. What is the most likely diagnosis?
Correct answer: B. Lung cancer Explanation: (B) is the correct answer because lung cancer is highly suspected in a patient with a significant smoking history, chronic cough, progressive dyspnea, weight loss, and a lung mass on imaging. (A) is incorrect because tuberculosis typically presents with night sweats, fever, and cavitary lesions rather than a solitary mass. (C) is incorrect because pulmonary fibrosis presents with chronic dyspnea and restrictive lung patterns but does not typically cause a lung mass. (D) is incorrect because COPD presents with airflow limitation and hyperinflation but does not cause a solitary lung mass.
68. A 25-year-old female presents for a preconception visit. Her brother has sickle cell disease, but she has never been tested. She is concerned about the risk to her future child. What is the most appropriate next step?
Correct answer: A. Order a hemoglobin electrophoresis test Explanation: (A) is the correct answer because individuals with a family history of sickle cell disease should be tested for sickle cell trait via hemoglobin electrophoresis before conception to assess the risk of passing the disease to offspring. (B) is incorrect because sickle cell disease is inherited in an autosomal recessive manner, meaning both parents must be carriers for the child to be affected. (C) is incorrect because testing the patient first is more efficient; if she is negative for sickle cell trait, her partner does not need testing. (D) is incorrect because sickle cell carrier status is usually asymptomatic, and genetic counseling should be done before conception, not only if symptoms develop.
69. A 45-year-old female with a history of heart failure with reduced ejection fraction (HFrEF) presents to the clinic for routine follow-up. Her current medications include furosemide and metoprolol succinate. Her blood pressure today is 138/88 mmHg. Which of the following antihypertensive medications should be added to provide mortality benefit in this patient?
Correct Answer: B. Lisinopril Explanation: Patients with heart failure with reduced ejection fraction (HFrEF) benefit from ACE inhibitors like lisinopril (B), which improve survival by reducing afterload and preventing ventricular remodeling. Amlodipine (A), a calcium channel blocker, does not provide mortality benefit in heart failure and is typically avoided due to its potential to cause peripheral edema. Hydrochlorothiazide (C) is a thiazide diuretic that primarily aids in volume management but does not reduce mortality in HFrEF. Clonidine (D) is a centrally acting alpha-agonist used for resistant hypertension but is not appropriate in HFrEF due to its potential for rebound hypertension and lack of mortality benefit.
70. A 64-year-old man with hypertension and hyperlipidemia presents with a severe headache, blurred vision, and confusion that started suddenly. His blood pressure is 220/110 mmHg. On physical examination, papilledema is noted. What is the most appropriate next step in management?
Correct Answer: B. Emergent lowering of blood pressure with IV antihypertensives Explanation: The patient presents with hypertensive emergency, characterized by severe hypertension with end-organ damage (e.g., papilledema, confusion). This requires immediate blood pressure reduction with IV antihypertensives (B). Oral antihypertensives (A) are insufficient in hypertensive emergency. Observation (C) risks worsening organ damage. Lifestyle modifications (D) are for chronic management, not acute emergencies.
71. A 72-year-old male is brought to the emergency department by his daughter, who reports that he suddenly became confused and disoriented two hours ago. His past medical history includes hypertension and atrial fibrillation. On examination, he is lethargic, unable to follow commands, and has right-sided weakness. His blood pressure is 185/100 mmHg. What is the most appropriate next step?
Correct Answer: B. A non-contrast CT scan of the head is the most appropriate next step in evaluating a sudden change in level of consciousness with focal neurological deficits to differentiate between ischemic and hemorrhagic stroke. (A) is incorrect because aspirin should not be given until hemorrhage is ruled out. (C) is incorrect because intravenous heparin is not the first-line treatment for suspected acute stroke without imaging confirmation. (D) is incorrect because lumbar puncture is not the initial step in evaluating acute stroke; it is typically reserved for cases of suspected meningitis or subarachnoid hemorrhage when the CT scan is inconclusive.
72. A 55-year-old male presents with gradually worsening left knee pain over the past year. The pain is worse after activity and improves with rest. He denies trauma, fever, or morning stiffness lasting more than 30 minutes. On examination, there is crepitus with passive movement and mild joint effusion. What is the most likely diagnosis?
Correct answer: A. Osteoarthritis Explanation: (A) is the correct answer because osteoarthritis presents with chronic joint pain that worsens with activity and improves with rest, along with crepitus and mild effusion. (B) is incorrect because rheumatoid arthritis typically presents with prolonged morning stiffness and symmetric joint involvement. (C) is incorrect because gout presents with acute, intensely painful, swollen joints rather than gradual worsening. (D) is incorrect because septic arthritis presents with acute onset severe pain, fever, and joint erythema.
73. A 45-year-old female with type 2 diabetes mellitus is started on metformin. Two weeks later, she reports persistent nausea, diarrhea, and abdominal discomfort. Her renal function is normal. What is the most appropriate next step?
Correct Answer: B. Change metformin to an extended-release formulation Explanation: Gastrointestinal side effects are common with metformin (B), particularly in the immediate-release form. Switching to an extended-release formulation can improve tolerability. Discontinuing metformin and switching to glimepiride (A), a sulfonylurea, is not ideal because sulfonylureas increase the risk of hypoglycemia and weight gain. Continuing metformin (C) without any modification may not improve the patient’s symptoms. Starting insulin therapy (D) is unnecessary at this stage as the patient is not experiencing severe hyperglycemia.
74. A 45-year-old female with a history of hypertension and chronic kidney disease stage 3 is taking lisinopril 10 mg daily. She reports a persistent dry cough but no shortness of breath or signs of infection. Her blood pressure today is well-controlled at 128/78 mmHg. What is the most appropriate change to her medication regimen?
Correct Answer: B Explanation: Switching lisinopril to losartan (B) is appropriate because this patient is experiencing an ACE inhibitor-induced dry cough, which is a well-known side effect due to bradykinin accumulation. Losartan, an angiotensin receptor blocker (ARB), provides similar renal and cardiovascular benefits without causing cough. Increasing lisinopril (A) would not address the side effect and may exacerbate the patient's discomfort. Discontinuing lisinopril in favor of hydrochlorothiazide (C) removes the renal-protective effects of an ACE inhibitor or ARB, which are recommended in CKD. Continuing lisinopril despite the bothersome cough (D) is inappropriate because the cough is unlikely to resolve while the medication is continued.
75. A 42-year-old construction worker presents with chronic lower back pain that worsens with prolonged standing. He denies any recent trauma, radiation of pain, or neurological symptoms. Physical exam shows normal reflexes and motor strength but tenderness over the lumbar paraspinal muscles. What is the most appropriate initial management?
Correct Answer: A. Refer to physical therapy for core strengthening exercises Explanation: Chronic mechanical lower back pain is best managed with physical therapy focused on core strengthening and proper body mechanics (A). Opioids (B) should be avoided due to their high risk of dependence and lack of long-term effectiveness for chronic pain. MRI (C) is unnecessary in the absence of red flags such as neurological deficits or trauma. Bed rest (D) is discouraged as it can worsen deconditioning and prolong recovery.
76. A 42-year-old female with a history of generalized anxiety disorder (GAD) has been stable on sertraline for two years. She asks about discontinuing the medication since she feels well. What is the most appropriate response?
Correct Answer: B. Gradually taper sertraline while monitoring for relapse Explanation: Discontinuing sertraline should be done gradually with monitoring for relapse (B) to minimize withdrawal effects and assess symptom recurrence. Stopping abruptly (A) risks withdrawal symptoms. Continuing indefinitely (C) is not necessary for all patients. Benzodiazepines (D) are not first-line for long-term management of GAD.
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