Sorry, you are out of time.
Family Nurse Practitioner (FNP) Practice Exam 2
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 60-year-old woman with diabetes presents with worsening fatigue and increased thirst. Her BMP shows a fasting glucose of 320 mg/dL, BUN of 35 mg/dL, and creatinine of 1.6 mg/dL. What is the most concerning potential complication?
Correct Answer: B. Hyperosmolar hyperglycemic state (HHS) Explanation: HHS occurs in type 2 diabetics with very high glucose levels, dehydration, and increased BUN and creatinine due to volume depletion (B). Option (A) is incorrect because hypoglycemia is not expected with a blood glucose of 320 mg/dL. Option (C) is incorrect because DKA is more common in type 1 diabetes and presents with ketonuria and metabolic acidosis, which is not mentioned here. Option (D) is incorrect because Addison’s disease presents with hyponatremia, hyperkalemia, and low cortisol levels rather than hyperglycemia.
2. A 65-year-old female with osteoporosis was prescribed alendronate once weekly. She returns for a follow-up after three months and reports she has taken the medication “most weeks,” but sometimes forgets. A repeat bone density scan shows minimal improvement. What is the most appropriate next step in assessing her compliance with treatment?
Correct Answer: A Reinforcing proper medication adherence and ensuring correct administration (A) is essential because alendronate must be taken consistently and correctly (on an empty stomach with water, remaining upright for 30 minutes) for optimal effectiveness. Discontinuing alendronate and switching to denosumab (B) is unnecessary before ensuring proper adherence. Increasing calcium and vitamin D (C) is helpful but does not replace the need for adherence to osteoporosis medication. Waiting a year to reassess (D) without addressing adherence would delay appropriate intervention.
3. A 55-year-old woman with chronic obstructive pulmonary disease (COPD) is enrolled in a chronic disease self-management program. She reports frequent exacerbations and occasional hospitalizations despite being prescribed a long-acting bronchodilator and inhaled corticosteroid. What is the most important self-management education for this patient?
Correct Answer: A Explanation: Encouraging pulmonary rehabilitation and ensuring proper inhaler technique (A) are essential self-management strategies that improve COPD outcomes by enhancing lung function, reducing exacerbations, and promoting adherence. Switching to oral corticosteroids (B) is not recommended for long-term COPD management due to significant side effects. Avoiding physical activity (C) is incorrect, as exercise is beneficial for COPD patients. Discontinuing inhaled corticosteroids (D) without an alternative management strategy can lead to worsening symptoms.
4. A 68-year-old female with a recent stroke affecting her right side is discharged from the hospital and presents for follow-up. She has persistent right-sided weakness and difficulty performing activities of daily living, including dressing and cooking. What is the most appropriate next step?
Correct Answer: A. Refer to occupational therapy for assistance with activities of daily living Explanation: Patients recovering from a stroke often have difficulty with fine motor tasks and require occupational therapy to regain functional independence (A). Muscle relaxants (B) may be used for spasticity but do not address the underlying functional impairment. Bed rest (C) increases the risk of complications such as deconditioning and deep vein thrombosis. High-dose corticosteroids (D) are not indicated in stroke recovery unless there is underlying cerebral edema, which is not described in this case.
5. A 45-year-old woman presents to the clinic for a routine check-up. She has a family history of type 2 diabetes and hypertension. She has a sedentary lifestyle and a BMI of 30 kg/m簡. Her fasting blood glucose is 110 mg/dL. As her primary care provider, which of the following is the most appropriate preventive counseling strategy?
Correct Answer: C Explanation: The best approach for this patient is to counsel her on dietary modifications and increased physical activity (C), as she has prediabetes and is at high risk for developing type 2 diabetes. Lifestyle modifications, including at least 150 minutes of moderate-intensity exercise per week and a healthy diet, have been shown to significantly reduce the risk of progression to diabetes. Reassuring the patient and waiting one year for follow-up (A) is inappropriate because early intervention is crucial. Initiating metformin (B) may be considered in high-risk individuals, but lifestyle changes should always be the first-line intervention. Bariatric surgery (D) is reserved for patients with a BMI of 40 kg/m² or 35 kg/m² with comorbidities and is not the first-line approach in this case.
6. A 24-year-old pregnant woman at 28 weeks gestation presents with a urinary tract infection (UTI). She denies fever, flank pain, or nausea. Urinalysis confirms significant bacteriuria, and culture is pending. What is the most appropriate initial antibiotic choice?
Correct Answer: B. Nitrofurantoin Explanation: Nitrofurantoin is a preferred first-line antibiotic for uncomplicated UTIs in pregnancy after the first trimester (B). It is safe and effective with minimal risk to the fetus. (A) is incorrect because fluoroquinolones, like ciprofloxacin, are contraindicated in pregnancy due to fetal cartilage toxicity. (C) is incorrect because doxycycline is teratogenic and should be avoided. (D) is incorrect because trimethoprim-sulfamethoxazole is contraindicated in the first trimester due to folate antagonism and in the third trimester due to kernicterus risk.
7. A 26-year-old female presents with a chief complaint of a severe headache that started suddenly while she was at work. She describes it as the "worst headache of her life" and rates it as 9/10 in severity. She also reports nausea, photophobia, and a brief episode of loss of consciousness upon onset. On physical examination, she has mild neck stiffness but no focal neurological deficits. What is the most appropriate next step?
Correct answer: A. Order a non-contrast CT scan of the head Explanation: (A) is the correct answer because this patient’s presentation with a sudden-onset severe headache ("thunderclap headache") raises suspicion for a subarachnoid hemorrhage (SAH), which requires urgent evaluation with a non-contrast CT scan. (B) is incorrect because prescribing sumatriptan assumes the headache is a migraine, but the description does not fit a classic migraine pattern and delaying diagnosis of SAH can be life-threatening. (C) is incorrect because a lumbar puncture (LP) is only necessary if the initial CT scan is negative but suspicion for SAH remains high. LP should not be the first step, as CT can detect most cases of SAH if done within the first 6 hours of symptom onset. (D) is incorrect because high-dose steroids are not indicated in suspected SAH, and an MRI is not the initial imaging modality of choice for an acute hemorrhagic process.
8. A 42-year-old woman presents with fatigue, weight gain, dry skin, and constipation. A thyroid function test reveals a TSH of 8.2 mIU/L (elevated) and a free T4 of 0.7 ng/dL (low). What is the most appropriate diagnosis based on these findings?
Correct Answer: A. Primary hypothyroidism Explanation: Primary hypothyroidism is characterized by an elevated TSH with a low free T4, as seen in this patient, indicating dysfunction at the level of the thyroid gland (A). Option (B) is incorrect because subclinical hypothyroidism presents with an elevated TSH but a normal free T4. Option (C) is incorrect because central hypothyroidism results from pituitary or hypothalamic dysfunction and typically presents with a low or inappropriately normal TSH with a low free T4. Option (D) is incorrect because euthyroid sick syndrome presents with low T3 and normal or low T4 in the setting of acute illness.
9. A 50-year-old male presents with complaints of progressive shortness of breath and fatigue over the past two months. He denies chest pain but reports occasional dizziness and swelling in his legs. He also mentions waking up at night feeling short of breath. On examination, he has bilateral pitting edema and crackles in both lung bases. What is the most likely diagnosis?
Correct answer: B. Congestive heart failure (CHF) Explanation: (B) is the correct answer because this patient’s progressive shortness of breath, orthopnea (waking up feeling breathless), lower extremity edema, and lung crackles are all indicative of CHF. The presence of fluid retention suggests volume overload, which is a hallmark of CHF. (A) is incorrect because COPD typically presents with a chronic cough, wheezing, and a prolonged history of smoking, none of which were mentioned in this case. (C) is incorrect because pulmonary embolism presents acutely with sudden-onset dyspnea, pleuritic chest pain, and tachycardia rather than progressive symptoms. (D) is incorrect because anxiety-related hyperventilation typically presents with transient symptoms, not progressive fluid retention or orthopnea.
10. A 60-year-old female presents with a non-healing ulcer on her left shin that has been present for six months. She has a history of chronic venous insufficiency. Examination reveals a shallow ulcer with an irregular border, granulation tissue at the base, and surrounding hyperpigmentation. What is the most appropriate next step?
Correct Answer: C. Compression therapy and leg elevation are the mainstays of treatment for venous ulcers, which develop due to venous stasis and chronic edema. (A) is incorrect because antibiotics are only indicated if there is clinical evidence of infection, which is not described in this case. (B) is incorrect because a biopsy is typically reserved for ulcers that are non-healing despite appropriate management or when malignancy is suspected. (D) is incorrect because immediate surgical debridement is not the primary treatment for venous ulcers; conservative measures such as compression and wound care should be tried first.
11. A 40-year-old male with no significant medical history presents for a wellness visit. His vital signs are BP 138/88 mmHg, HR 76 bpm, RR 14 breaths/min, temperature 98.2°F (36.8°C), and oxygen saturation 99% on room air. What is the most appropriate classification of his blood pressure according to the American Heart Association (AHA) guidelines?
Correct Answer: C. Hypertension Stage 1 is defined as systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg. This patient’s BP of 138/88 mmHg falls into this category. (A) is incorrect because normal BP is defined as <120/80 mmHg. (B) is incorrect because elevated BP is defined as systolic 120-129 mmHg and diastolic <80 mmHg. (D) is incorrect because Hypertension Stage 2 is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, which does not apply to this patient.
12. A 30-year-old pregnant woman at 16 weeks gestation is found to have a rubella non-immune status during routine prenatal screening. She is concerned about her baby's health and wants to receive the MMR vaccine immediately. What is the most appropriate response?
Correct Answer: A. Explain that the MMR vaccine is contraindicated during pregnancy but can be administered postpartum Explanation: Shared decision-making involves providing accurate information while addressing the patient's concerns (A). The MMR vaccine contains live attenuated viruses and is contraindicated during pregnancy; however, it should be administered postpartum to protect against future infections. (B) is incorrect because administering a live vaccine in pregnancy could pose risks. (C) is incorrect because dismissing the patient's concerns does not align with patient-centered care. (D) is incorrect because the risk of congenital rubella syndrome depends on gestational timing of exposure, and termination should not be recommended based solely on non-immune status.
13. A 30-year-old female with a history of migraines presents with severe headache pain that is not relieved by over-the-counter medications. She denies any neurological deficits but reports nausea and photophobia. She requests an opioid prescription for relief. What is the most appropriate management for her acute migraine?
Correct Answer: A. Sumatriptan Explanation: Sumatriptan (A) is a first-line treatment for acute migraines as it acts as a selective serotonin receptor agonist, effectively relieving headache symptoms by vasoconstriction and reducing inflammation. Opioids such as hydrocodone (B) and morphine (C) are not recommended for migraine treatment due to the risk of dependence and inadequate efficacy in aborting migraine attacks. Naproxen (D) can be used as adjunct therapy but is less effective than triptans for acute migraine relief.
14. A 78-year-old male with a history of Parkinson’s disease presents with acute-onset shortness of breath and mild confusion. His caregiver reports that he has been less active over the past week and has developed swelling in his legs. He denies chest pain or cough. His vital signs include BP 135/80 mmHg, HR 98 bpm, RR 24 breaths/min, and SpO2 88% on room air. What is the most likely diagnosis?
Correct Answer: B. Silent congestive heart failure exacerbation The correct answer is (B) because elderly patients may present with non-specific symptoms such as confusion, fatigue, and dyspnea instead of classic signs of heart failure. His history of reduced activity and new-onset lower extremity edema further supports heart failure exacerbation. (A) is incorrect because Parkinson’s disease exacerbations typically present with worsening motor symptoms rather than respiratory distress. (C) is incorrect because pneumonia would likely present with fever, productive cough, or leukocytosis, none of which are reported. (D) is incorrect because while a deep vein thrombosis could cause leg swelling, it would not explain the respiratory symptoms and hypoxia.
15. A 55-year-old male with hyperlipidemia and smoking history presents with crushing chest pain. His EKG shows ST-segment depressions in leads V1-V4. What is the most likely diagnosis?
Correct Answer: B. Posterior myocardial infarction Explanation: ST-segment depression in leads V1-V4 is a hallmark of posterior myocardial infarction, as these leads are reciprocal to the posterior wall of the heart, which is supplied by the posterior descending artery (B). Option (A) is incorrect because an anterior myocardial infarction presents with ST-elevation in leads V1-V4, not depression. Option (C) is incorrect because a lateral myocardial infarction presents with ST-elevation in leads I, aVL, V5, and V6. Option (D) is incorrect because a right ventricular infarction is best seen in right-sided leads (e.g., V4R).
16. A 35-year-old female with a history of type 1 diabetes presents with nausea, vomiting, and abdominal pain for the past 12 hours. She reports missing her insulin dose the previous night. On examination, she appears dehydrated and has deep, rapid breathing. Laboratory results show a glucose level of 320 mg/dL, an arterial pH of 7.22, and a serum bicarbonate level of 14 mEq/L. What is the most likely diagnosis?
Correct answer: A. Diabetic ketoacidosis (DKA) Explanation: (A) is the correct answer because this patient has hyperglycemia, metabolic acidosis, and dehydration, all hallmark features of DKA, which occurs in type 1 diabetes due to insulin deficiency. (B) is incorrect because HHS is more common in type 2 diabetes and typically presents with much higher glucose levels without significant acidosis. (C) is incorrect because acute pancreatitis presents with severe epigastric pain and elevated lipase, neither of which are mentioned here. (D) is incorrect because lactic acidosis is usually associated with sepsis or hypoperfusion rather than missed insulin doses.
17. A 72-year-old female with a history of chronic obstructive pulmonary disease (COPD) and heart failure presents for follow-up. She has received her influenza and pneumococcal vaccines this year but has never received the herpes zoster vaccine. What is the most appropriate vaccination recommendation?
Correct Answer: A. Administer the recombinant zoster vaccine (RZV) in a two-dose series Explanation: Adults aged ≥50 should receive the recombinant zoster vaccine (RZV) in a two-dose series (A), regardless of prior varicella infection history. The live zoster vaccine (ZVL) (B) is no longer recommended due to its lower efficacy and contraindications in immunocompromised individuals. Deferring vaccination (C) is inappropriate, as chronic conditions like COPD and heart failure increase the risk of complications from herpes zoster. Prior history of shingles is not required for vaccination (D), as prevention is recommended for all eligible adults.
18. A 45-year-old female presents with sudden onset of severe right upper quadrant pain radiating to the right shoulder. She reports nausea and vomiting after eating a fatty meal. On examination, she has significant right upper quadrant tenderness, and Murphy’s sign is positive. What is the most likely diagnosis?
Correct Answer: A. Acute cholecystitis presents with severe right upper quadrant pain, nausea, vomiting, and a positive Murphy’s sign (pain with deep inspiration while palpating the right upper quadrant). (B) is incorrect because acute pancreatitis presents with epigastric pain radiating to the back, rather than localized right upper quadrant tenderness. (C) is incorrect because peptic ulcer disease typically presents with burning epigastric pain that worsens or improves with food intake but does not cause right upper quadrant tenderness or a positive Murphy’s sign. (D) is incorrect because acute appendicitis presents with periumbilical pain migrating to the right lower quadrant, not right upper quadrant pain.
19. A 32-year-old female presents with sudden-onset right lower quadrant abdominal pain and nausea. A urine pregnancy test is positive. What is the most appropriate initial imaging study?
Correct Answer: B. Transvaginal ultrasound Explanation: In a pregnant patient with acute lower abdominal pain, the primary concern is an ectopic pregnancy. A transvaginal ultrasound is the preferred initial imaging study to confirm an intrauterine pregnancy and evaluate for signs of an ectopic pregnancy (B). Option (A) is incorrect because MRI is not used as a first-line test for suspected ectopic pregnancy. Option (C) is incorrect because CT imaging is avoided in pregnant patients due to radiation exposure. Option (D) is incorrect because abdominal X-rays have limited utility in evaluating pregnancy-related conditions.
20. A 34-year-old female is planning to become pregnant and presents for preconception counseling. She has no chronic illnesses but reports that she has never received the measles, mumps, and rubella (MMR) vaccine. What is the most appropriate recommendation?
Correct answer: D. Check rubella titers and determine immunity before vaccination Explanation: (D) is the correct answer because MMR is a live vaccine and should not be given during pregnancy due to the theoretical risk of congenital rubella syndrome. Checking rubella titers will determine if she has immunity and if vaccination is necessary after delivery. (A) is incorrect because MMR is contraindicated in pregnancy or in those trying to conceive within 1 month. (B) is incorrect because vaccination should be based on serologic testing rather than automatic deferral. (C) is incorrect because measles remains a significant health concern, especially with international travel, and rubella poses a severe risk to a fetus if contracted during pregnancy.
21. A 45-year-old female with hypothyroidism presents for a follow-up visit after starting levothyroxine 25 mcg daily one month ago. She reports persistent fatigue, mild weight gain, and cold intolerance. A repeat TSH level is 8.2 mIU/L (elevated). What is the most appropriate next step in managing the effectiveness of her treatment?
Correct Answer: A Increasing the levothyroxine dose and rechecking TSH in 6-8 weeks (A) is the correct approach since the patient's TSH remains elevated, indicating suboptimal thyroid hormone replacement. Hypothyroid treatment should be adjusted based on TSH levels and symptoms, with reevaluation in 6-8 weeks. Continuing the current dose (B) would not be appropriate given persistent symptoms and an elevated TSH. Checking free T3 and T4 (C) may provide additional data but is not routinely necessary for adjusting levothyroxine in primary hypothyroidism. Endocrinology referral (D) is not required unless there is treatment resistance or a complex case.
22. A 55-year-old female with a history of metastatic breast cancer presents to the clinic complaining of increasing lower back pain. She describes the pain as constant, dull, and non-radiating, worsened by movement. She denies recent trauma or fever. On examination, there is localized tenderness over the lumbar spine. What is the most likely cause of her pain?
Correct Answer: C. Spinal cord compression from metastases is the most concerning cause of back pain in a patient with metastatic cancer, especially when pain is progressive and localized. (A) is incorrect because lumbar muscle strain typically results from acute overuse and presents with diffuse rather than localized tenderness. (B) is incorrect because while osteoporotic fractures can cause similar symptoms, the history of metastatic cancer makes spinal metastases a more likely etiology. (D) is incorrect because sciatica typically presents with radicular pain following a dermatomal distribution rather than localized tenderness.
23. A 50-year-old female presents for a routine physical. She has a family history of colon cancer in her father, who was diagnosed at age 55. She is asymptomatic and has never had a colonoscopy. What is the most appropriate screening recommendation?
Correct answer: A. Begin colon cancer screening at age 45 Explanation: (A) is the correct answer because individuals with a first-degree relative diagnosed with colorectal cancer before age 60 should begin screening at age 40 or 10 years before the youngest affected relative’s diagnosis, whichever comes first. (B) is incorrect because delaying screening to age 60 in a patient with a significant family history increases the risk of missed early detection. (C) is incorrect because stool-based testing is an option for average-risk individuals, but those with a strong family history should have colonoscopy as the preferred method. (D) is incorrect because waiting for symptoms before screening for colon cancer is not recommended, as early detection significantly improves outcomes.
24. A 35-year-old woman with major depressive disorder has been prescribed sertraline for the past three months but reports that she often forgets to take it and has not noticed significant improvement in her symptoms. What is the most appropriate response by the nurse practitioner?
Correct Answer: B Explanation: Educating the patient about the importance of consistent medication use and providing strategies to remember doses (B) is the best approach, as antidepressants require regular adherence to be effective. Stopping the medication (A) without addressing adherence may worsen her depression. Switching to a different antidepressant (C) without first ensuring adherence is premature, as sertraline may be effective if taken consistently. Increasing the dose (D) without confirming medication adherence can lead to unnecessary side effects without addressing the underlying issue of missed doses.
25. A 32-year-old female presents to the clinic with complaints of itching, swelling of the lips, and difficulty breathing within 30 minutes of eating shrimp at a restaurant. She has no prior history of food allergies. On examination, she has mild periorbital swelling and scattered urticaria, but her oxygen saturation is 98% on room air, and she is speaking in full sentences. What is the most appropriate initial management?
Correct answer: A. Administer intramuscular epinephrine immediately Explanation: (A) is the correct answer because this patient is exhibiting symptoms of anaphylaxis, which requires immediate administration of intramuscular epinephrine, even if oxygen saturation is normal. Delay in treatment can lead to progression to airway obstruction or cardiovascular collapse. (B) is incorrect because oral antihistamines alone are insufficient to treat anaphylaxis and do not prevent progression to severe symptoms. (C) is incorrect because allergy testing should not delay emergent treatment; the clinical presentation is sufficient for diagnosis. (D) is incorrect because reassurance without treatment could be life-threatening, and patients with food allergies require an epinephrine auto-injector prescription and education on avoidance.
26. A 55-year-old man with no significant medical history presents for a routine check-up. He has no family history of colorectal cancer. He has never had a colonoscopy. What is the most appropriate screening recommendation for this patient?
Correct Answer: B. Perform a colonoscopy now and repeat every 10 years if normal Explanation: The USPSTF recommends colorectal cancer screening starting at age 45 using one of several modalities, with colonoscopy every 10 years being the gold standard (B). Option (A) is incorrect because screening should start at 45, not 60. Option (C) is incorrect because while an annual fecal occult blood test is an option, it is not as comprehensive as a colonoscopy. Option (D) is incorrect because sigmoidoscopy is performed every 5 years, not annually, and does not examine the entire colon.
27. A 19-year-old college student presents with excessive worry about academic performance, difficulty sleeping, muscle tension, and restlessness over the past six months. She reports that she has been feeling this way “for years” but it has worsened with increased academic demands. She denies panic attacks or depressive symptoms. What is the most appropriate next step in management?
Correct Answer: A. Initiate cognitive behavioral therapy (CBT) through mental health counseling Explanation: The patient's symptoms are consistent with generalized anxiety disorder (GAD), and first-line treatment includes cognitive behavioral therapy (CBT) through mental health counseling (A). While benzodiazepines such as alprazolam (B) provide rapid relief, they are not first-line due to their potential for dependence and withdrawal symptoms. An EEG (C) is unnecessary, as there is no indication of a neurological disorder. While stress management techniques (D) may be helpful, they are insufficient as monotherapy in a patient with chronic and functionally impairing anxiety.
28. A 34-year-old female presents with sore throat, fever, and swollen anterior cervical lymph nodes. She has no cough. Her Centor Score is calculated as 3. What is the best next step in management?
Correct Answer: B. Perform a rapid antigen detection test (RADT) The correct answer is (B) because the Centor Criteria help determine the likelihood of Group A Streptococcal (GAS) pharyngitis. A score of 3 suggests an intermediate probability, and testing with RADT is recommended before antibiotic prescription. If positive, antibiotics should be given; if negative, a throat culture may be considered, particularly in children. (A) is incorrect because empiric antibiotics are reserved for scores of 4 or higher. (C) is incorrect because throat culture is primarily used when RADT results are inconclusive or for confirmatory testing in children. (D) is incorrect because symptomatic treatment alone is insufficient when Centor Criteria suggest possible GAS pharyngitis.
29. A 48-year-old female presents with recurrent abdominal pain, bloating, and changes in bowel habits for the past year. She reports periods of constipation alternating with diarrhea. She denies fever, weight loss, or bloody stools. Examination is unremarkable. What is the best initial management?
Correct Answer: A. High-fiber diet and lifestyle modifications Explanation: IBS is a functional gastrointestinal disorder managed with dietary modifications, fiber intake, and stress management (A). Colonoscopy (B) is indicated for alarming symptoms such as weight loss, anemia, or bloody stools, which are absent in this case. Antibiotic therapy (C) is appropriate for infections like diverticulitis but not IBS. Surgical evaluation (D) is unnecessary as there is no indication of an acute surgical abdomen.
30. A 30-year-old single mother of three presents to the clinic with symptoms of anxiety and reports difficulty managing childcare, employment, and financial stress. She states that she often feels overwhelmed and is struggling to afford basic necessities for her children. She denies suicidal ideation but expresses feeling emotionally drained. What is the most appropriate next step?
Correct Answer: B. Refer to social work for financial and childcare assistance Explanation: The patient’s primary concerns are financial hardship and childcare difficulties, which contribute to her emotional distress. Social work can assist with financial aid, childcare resources, and support programs (B). While an SSRI (A) may help with anxiety, it does not address the root cause of her stress. Counseling services (C) are beneficial but may not be accessible without addressing her financial limitations first. Relaxation techniques (D) alone are insufficient for managing significant socioeconomic stressors.
31. A 67-year-old male with a history of smoking and hypertension presents to the emergency department with sudden-onset, severe, tearing chest pain radiating to his back. He appears diaphoretic and has an unequal blood pressure in both arms. His ECG is unremarkable. What is the most likely diagnosis?
Correct Answer: C. Aortic dissection Explanation: Aortic dissection classically presents with sudden-onset, severe, tearing chest pain radiating to the back and can be associated with unequal arm blood pressures (C). MI (A) presents with crushing substernal pain and typically has ECG changes. GERD (B) does not cause tearing pain or hemodynamic instability. Anxiety attack (D) can cause chest discomfort but does not present with blood pressure discrepancies or severe, tearing pain.
32. A 46-year-old female presents for an annual exam. She drinks approximately three beers per night and occasionally has five or more drinks on weekends. She denies withdrawal symptoms or adverse effects on work. According to CDC guidelines, how should this level of alcohol consumption be classified?
Correct answer: C. Heavy alcohol use Explanation: (C) is the correct answer because heavy alcohol use is defined by the CDC as more than one drink per day for women or more than seven drinks per week. This patient regularly exceeds these limits, classifying her alcohol consumption as heavy. (A) is incorrect because moderate drinking is defined as up to one drink per day for women and up to two drinks per day for men, which she exceeds. (B) is incorrect because binge drinking is defined as consuming four or more drinks in a single occasion for women, but her pattern suggests consistent heavy use rather than isolated binge episodes. (D) is incorrect because while she may be at risk for alcohol use disorder, this diagnosis requires further assessment using DSM-5 criteria.
33. A 42-year-old male presents with a white lesion on the lateral side of his tongue that has been present for several months. He reports a history of heavy tobacco and alcohol use. The lesion is non-tender and does not scrape off. What is the most appropriate next step?
Correct Answer: C. This lesion is concerning for leukoplakia, a precancerous condition strongly associated with tobacco and alcohol use. A biopsy is necessary to rule out squamous cell carcinoma. (A) is incorrect because oral candidiasis presents as white plaques that can be scraped off. (B) is incorrect because delaying evaluation could result in missed early diagnosis of malignancy. (D) is incorrect because while smoking cessation is important, biopsy is necessary to confirm or rule out malignancy before simply following up.
34. A 61-year-old male with no significant medical history presents for routine care. He has no urinary symptoms or family history of prostate cancer. He asks whether he should be screened with a PSA test. What is the most appropriate response?
Correct Answer: C. Discuss the risks and benefits, allowing shared decision-making Explanation: The USPSTF recommends shared decision-making for prostate cancer screening in men aged 55-69 (C). The benefits of PSA testing must be weighed against risks such as overdiagnosis and overtreatment. Blanket screening (B) is not recommended. Avoiding screening entirely (A) without discussion is inappropriate. A digital rectal exam alone (D) is not a sufficient screening method.
35. A 65-year-old female with a history of HFrEF and atrial fibrillation presents for routine follow-up. She denies symptoms of heart failure and has been monitoring her weight daily with no significant fluctuations. Current medications include metoprolol succinate, sacubitril/valsartan, spironolactone, and apixaban. Her blood pressure is 104/68 mmHg, and her heart rate is 58 bpm. Which of the following is the best next step in management?
Correct Answer: C. Continue current medications and reinforce home weight monitoring Explanation: This patient has stable heart failure with no signs of decompensation and no alarming symptoms. Continuing current medications (C) is the best approach while reinforcing the importance of home weight monitoring. Reducing metoprolol (A) is unnecessary unless symptomatic bradycardia occurs. Switching sacubitril/valsartan to lisinopril (B) would be a step backward, as sacubitril/valsartan provides superior outcomes in HFrEF. Stopping spironolactone (D) without hyperkalemia or other contraindications is not warranted.
36. A 42-year-old male with a history of depression has been working with a cognitive behavioral therapist. He has struggled with low motivation and lack of interest in activities he once enjoyed. His therapist encourages him to schedule and engage in activities he previously found pleasurable, such as exercise and socializing. This is an example of which CBT technique?
Correct Answer: A. Behavioral activation Explanation: Behavioral activation (A) is a CBT-based intervention that encourages patients to engage in rewarding activities to counteract depressive symptoms. It helps improve mood by reinforcing positive behaviors. Exposure therapy (B) is primarily used for anxiety and phobias, not depression. Systematic desensitization (C) involves gradually exposing patients to fears and is not used for depression. Catharsis (D) is a psychoanalytic concept that refers to emotional release but is not a CBT technique.
37. A 30-year-old female presents with episodes of palpitations, sweating, and headaches that occur intermittently. Her blood pressure is 180/110 mmHg during an episode. Physical examination is otherwise unremarkable. What is the most appropriate initial diagnostic test?
Correct Answer: B. Plasma metanephrines are the most appropriate initial test for pheochromocytoma, a catecholamine-secreting adrenal tumor that presents with episodic hypertension, palpitations, sweating, and headaches. (A) is incorrect because hyperthyroidism can cause palpitations and hypertension but does not typically present with episodic symptoms or headaches. (C) is incorrect because a 24-hour urine cortisol level is used to evaluate Cushing’s syndrome, which presents with central obesity, moon facies, and hyperglycemia rather than episodic hypertension. (D) is incorrect because an electrocardiogram may show tachycardia but does not identify the underlying cause of the patient's symptoms.
38. A 22-year-old female presents for an annual exam. She reports that her older brother was diagnosed with hypertrophic cardiomyopathy (HCM) at age 25. She has no known history of heart disease and denies exertional symptoms. What is the most appropriate next step in her evaluation?
Correct answer: B. Recommend an echocardiogram and ECG screening Explanation: (B) is the correct answer because hypertrophic cardiomyopathy (HCM) is an autosomal dominant condition that can cause sudden cardiac death, especially in young individuals. First-degree relatives should undergo screening with an echocardiogram and ECG. (A) is incorrect because a normal physical exam does not rule out HCM. (C) is incorrect because coronary CT angiography is used to evaluate coronary artery disease, not HCM. (D) is incorrect because stress testing is not the initial diagnostic test for suspected HCM; structural assessment via echocardiogram is preferred.
39. A 72-year-old male with a history of multiple strokes has significant right-sided weakness, dysphagia, and requires enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. His wife is his primary caregiver but is struggling with tube feedings and medication administration. What is the most appropriate next step?
Correct Answer: A. Refer to home health services for PEG tube management and caregiver education Explanation: Home health services provide skilled nursing care to assist with PEG tube management and ensure the caregiver is adequately trained (A). While caregiver education (B) is necessary, professional oversight is needed to prevent complications. Hospice care (C) is not appropriate unless the patient has a terminal condition with a limited prognosis. Encouraging family support (D) is beneficial but does not replace the need for skilled medical assistance.
40. A 27-year-old male presents with worsening lower back pain and stiffness for the past six months. He reports that the pain improves with exercise but worsens with rest. He denies any history of trauma. Examination reveals reduced lumbar spine mobility and tenderness at the sacroiliac joints. What is the most likely diagnosis?
Correct Answer: B. Ankylosing spondylitis is an inflammatory disorder that presents with chronic lower back pain and stiffness that improves with exercise and worsens with rest, often in young males. It is associated with sacroiliitis and reduced spinal mobility. (A) is incorrect because a lumbar herniated disc presents with radicular pain and worsens with activity rather than rest. (C) is incorrect because spinal stenosis presents with pain that worsens with standing and walking but improves with sitting or leaning forward. (D) is incorrect because cauda equina syndrome is a neurosurgical emergency characterized by saddle anesthesia, bowel/bladder dysfunction, and lower extremity weakness.
41. A 52-year-old male patient with a history of hypertension and hyperlipidemia presents to the clinic with complaints of intermittent chest discomfort that occurs with exertion and resolves with rest. He denies radiation of pain, diaphoresis, or shortness of breath. His vital signs are stable, and his ECG in the clinic shows normal sinus rhythm without ST-segment changes. As the primary care provider, what is the most appropriate next step?
Correct Answer: B. Refer to cardiology for further evaluation and possible stress testing Explanation: The patient's symptoms are concerning for stable angina, which requires further assessment to determine the risk of coronary artery disease. The best next step is a cardiology referral for a stress test or further cardiac workup (B). While aspirin therapy and lifestyle modifications are beneficial in cardiovascular disease prevention, they do not address the need for further risk stratification in this case (A). Nitroglycerin may be useful for symptom relief, but it does not substitute for a full cardiac evaluation (C). An echocardiogram evaluates cardiac function but does not directly assess ischemia, making it a less appropriate initial test (D).
42. A 30-year-old male presents with a severe headache that started suddenly while he was exercising at the gym. He describes it as the "worst headache of his life." He also reports nausea and mild neck stiffness. His blood pressure is 160/95 mmHg. On physical examination, there are no focal neurological deficits. What is the most appropriate initial diagnostic test?
Correct answer: A. Non-contrast CT scan of the head Explanation: (A) is the correct answer because a sudden-onset severe headache, often referred to as a "thunderclap headache," is highly concerning for subarachnoid hemorrhage (SAH), which requires immediate evaluation with a non-contrast CT scan. (B) is incorrect because while a lumbar puncture can detect xanthochromia in SAH, it is only performed if the CT scan is inconclusive. (C) is incorrect because an MRI is not the initial test of choice for acute hemorrhagic conditions. (D) is incorrect because an EEG is used to evaluate seizure disorders and is not relevant in this clinical scenario.
43. A 58-year-old African American male with a history of hypertension and type 2 diabetes presents to the clinic for follow-up. His blood pressure today is 152/94 mmHg, and he reports adherence to his current lifestyle modifications. His current medications include metformin for diabetes. Based on current guidelines, which antihypertensive would be the most appropriate first-line therapy for this patient?
Correct Answer: B. Amlodipine Explanation: In African American patients with hypertension, calcium channel blockers (CCBs) like amlodipine (B) or thiazide diuretics are recommended as first-line agents due to better efficacy in reducing blood pressure compared to ACE inhibitors or beta-blockers. Lisinopril (A), an ACE inhibitor, is less effective as monotherapy in African Americans due to lower renin activity and is associated with an increased risk of angioedema in this population. Metoprolol (C), a beta-blocker, is not a first-line choice for hypertension unless there is a compelling indication such as heart failure or post-myocardial infarction. Hydrochlorothiazide (D), a thiazide diuretic, is an alternative first-line option but may not be preferred in a patient with diabetes due to its potential to increase blood glucose levels.
44. A 50-year-old male with metabolic syndrome is advised to lose weight to reduce his cardiovascular risk. He has tried dieting on his own but has not been successful. He states that he needs external accountability and guidance. He has no contraindications to weight loss interventions. What is the most appropriate next step?
Correct Answer: B. Refer to a weight loss support group for accountability and structured education Explanation: Weight loss support groups provide education, accountability, and peer motivation, which improve adherence to lifestyle changes and lead to better long-term outcomes (B). Appetite suppressants (A) may be considered but should not be the first-line intervention without addressing lifestyle behaviors. Intermittent fasting (C) may be an option, but it requires structured guidance, which support groups can provide. Tracking caloric intake (D) is beneficial but may not be effective without external support.
45. A 72-year-old female presents with worsening memory loss over the past year. Her daughter reports that she frequently forgets recent conversations and misplaces household items. On cognitive testing, she has difficulty with short-term recall and executive function but is otherwise alert and oriented. Her gait and motor function are normal. What is the most likely diagnosis?
Correct Answer: A. Alzheimer’s disease is characterized by progressive short-term memory loss and impaired executive function while maintaining alertness and normal motor function in the early stages. (B) is incorrect because vascular dementia presents with stepwise cognitive decline following strokes. (C) is incorrect because Lewy body dementia presents with fluctuating cognition, visual hallucinations, and parkinsonian features. (D) is incorrect because frontotemporal dementia typically presents with early behavioral changes and disinhibition rather than prominent memory loss.
46. A 45-year-old female presents with worsening joint pain and morning stiffness lasting more than one hour over the past six months. She reports fatigue and occasional low-grade fever. On examination, her metacarpophalangeal (MCP) joints and wrists are swollen bilaterally. What is the most likely diagnosis?
Correct answer: B. Rheumatoid arthritis Explanation: (B) is the correct answer because rheumatoid arthritis (RA) presents with chronic symmetrical polyarthritis, prolonged morning stiffness, and systemic symptoms such as fatigue and low-grade fever. MCP joint and wrist involvement are characteristic of RA. (A) is incorrect because osteoarthritis typically affects weight-bearing joints and has morning stiffness lasting less than 30 minutes. (C) is incorrect because gout presents as acute, intensely painful, monoarticular arthritis, often affecting the first metatarsophalangeal (MTP) joint. (D) is incorrect because systemic lupus erythematosus (SLE) can involve arthritis but is typically associated with additional systemic manifestations such as a malar rash, serositis, and renal involvement.
47. A 55-year-old homeless man with uncontrolled diabetes presents with recurrent diabetic ketoacidosis (DKA). He reports difficulty storing and accessing insulin. What is the most appropriate intervention to address his barrier to care?
Correct Answer: C Explanation: The most effective intervention is to connect the patient with social services for housing and medication storage support (C), as his primary barrier is lack of stable housing and storage options. Prescribing oral hypoglycemics (A) may not be appropriate for his condition, as he likely requires insulin. Education on refrigeration (B) does not address his inability to store insulin. Increasing follow-up visits (D) is beneficial but does not resolve the underlying issue of homelessness and medication storage.
48. A 47-year-old male with a long history of gastroesophageal reflux disease (GERD) presents with new-onset dysphagia and unintentional weight loss of 12 pounds over the past two months. He has been compliant with proton pump inhibitor therapy but continues to have worsening symptoms. What is the most appropriate specialist referral?
Correct Answer: A The best referral is to a gastroenterologist for an upper endoscopy (A) to rule out esophageal stricture or malignancy, given his progressive dysphagia and weight loss. An otolaryngologist (B) is not the best first choice, as the symptoms suggest an esophageal, not oropharyngeal, cause. A general surgeon (C) is premature before confirming the diagnosis with endoscopy. A pulmonologist (D) may be involved if aspiration is suspected, but the primary concern here is esophageal pathology.
49. A 55-year-old male with a history of hypertension presents to the emergency department with sudden-onset chest pain that radiates to his back. He describes the pain as severe and tearing. His blood pressure is 190/110 mmHg, and his pulse is weaker in the left arm compared to the right. What is the most likely diagnosis?
Correct Answer: C. Aortic dissection Explanation: Aortic dissection is a life-threatening condition that presents with sudden-onset, severe, tearing chest pain radiating to the back, along with asymmetric pulses or blood pressure differences between extremities (C). Acute pericarditis (A) presents with pleuritic chest pain relieved by sitting forward but does not cause unequal pulses. GERD (B) causes burning, postprandial chest discomfort that does not radiate to the back or cause hemodynamic instability. Costochondritis (D) is a benign musculoskeletal condition causing localized chest pain without systemic symptoms or pulse deficits.
50. A 55-year-old woman presents with a 2 cm pigmented lesion on her back that has recently grown in size. A skin biopsy reveals atypical melanocytes with pagetoid spread and deep dermal invasion. What is the most appropriate diagnosis?
Correct Answer: A. Melanoma Explanation: Melanoma is characterized by atypical melanocytes, pagetoid spread (upward migration of melanocytes), and deep dermal invasion, which are classic histologic features (A). Option (B) is incorrect because basal cell carcinoma has palisading nuclei and does not exhibit melanocyte proliferation. Option (C) is incorrect because seborrheic keratosis is a benign lesion with keratin pseudocysts and does not have pagetoid spread. Option (D) is incorrect because dermatofibromas are benign fibrohistiocytic lesions and do not exhibit atypical melanocytes.
51. A 60-year-old woman with osteoporosis and chronic kidney disease stage 3 presents for follow-up. She recently sustained a vertebral compression fracture. She is on calcium, vitamin D, and alendronate. Her recent DEXA scan shows worsening bone density. What is the most appropriate referral?
Correct Answer: D Given her progressive osteoporosis despite treatment, referral to a rheumatologist for evaluation of secondary causes (D) is most appropriate. Secondary osteoporosis may result from chronic kidney disease, endocrine disorders, or medication side effects. While an endocrinologist (A) may manage osteoporosis, a rheumatologist specializes in systemic bone disorders. Physical therapy (B) is beneficial for fall prevention but does not address the underlying disease progression. A nephrologist (C) manages kidney disease but does not primarily direct osteoporosis treatment.
52. A 70-year-old female with atrial fibrillation is being discharged after hospitalization for a transient ischemic attack (TIA). She has a CHADS2-VASc score of 5 and was started on apixaban. What is the most appropriate follow-up plan?
Correct Answer: A The most appropriate plan is cardiology follow-up within one month and reinforcement of anticoagulation adherence (A), as her high CHADS2-VASc score places her at significant risk for stroke. Aspirin alone (B) is insufficient for stroke prevention in atrial fibrillation. Lifestyle changes (C) are beneficial but do not replace structured follow-up. Stroke rehabilitation (D) is not needed if the patient has had a transient ischemic attack with full symptom resolution.
53. A 72-year-old man with no known medical conditions presents for his annual exam. He is physically active and denies any history of fractures. According to USPSTF guidelines, what is the best screening approach for osteoporosis in men?
Correct Answer: B. No screening is needed unless there are risk factors Explanation: The USPSTF does not routinely recommend osteoporosis screening for men unless they have significant risk factors such as prolonged corticosteroid use, low body weight, or prior fractures (B). Option (A) is incorrect because routine screening is not recommended for all men over 70. Option (C) is incorrect because bone turnover markers are not the gold standard for osteoporosis screening. Option (D) is incorrect because while calcium and vitamin D supplementation may be beneficial, screening should be based on risk factors rather than universal supplementation.
54. A 68-year-old male with a history of diabetes and chronic kidney disease (eGFR 45 mL/min) presents with a blood pressure of 158/92 mmHg. According to JNC-8 guidelines, what is the most appropriate first-line antihypertensive agent for this patient?
Correct Answer: B. Lisinopril The correct answer is (B) because JNC-8 guidelines recommend an ACE inhibitor (such as lisinopril) or an ARB as first-line treatment in hypertensive patients with chronic kidney disease (CKD), regardless of race, due to their nephroprotective effects. (A) is incorrect because while amlodipine, a calcium channel blocker, is a reasonable option for general hypertension, it does not provide the same kidney protection. (C) is incorrect because hydrochlorothiazide may worsen renal function in patients with eGFR <50 mL/min. (D) is incorrect because metoprolol, a beta-blocker, is not a first-line treatment for hypertension unless there is an additional indication, such as heart failure or a history of myocardial infarction.
55. A 28-year-old female presents to the emergency department with sudden-onset severe headache, nausea, and photophobia. She states, “This is the worst headache of my life.” On examination, she has neck stiffness and is unable to tolerate bright lights. What is the most likely diagnosis?
Correct Answer: B. Subarachnoid hemorrhage Explanation: A sudden, severe headache described as "the worst headache of my life," combined with nausea, photophobia, and neck stiffness, is highly concerning for a subarachnoid hemorrhage due to a ruptured cerebral aneurysm. (B) Immediate CT of the head without contrast is warranted, followed by lumbar puncture if the CT is negative. (A) Tension headaches are usually bilateral and described as a band-like pressure, lacking associated photophobia and neurological symptoms. (C) Migraine with aura may present with a severe headache but typically has a gradual onset and associated visual or sensory disturbances rather than abrupt onset. (D) Cluster headaches cause unilateral pain around the eye and autonomic symptoms, but they do not present with meningismus or a "worst-ever" headache description.
56. A 28-year-old pregnant woman at 30 weeks gestation presents for routine prenatal labs. Her CBC reveals hemoglobin of 10.5 g/dL, MCV of 80 fL, and normal serum ferritin levels. What is the most appropriate next step?
Correct Answer: C. Evaluate for hemoglobinopathy with hemoglobin electrophoresis Explanation: Mild anemia in pregnancy is common, but with a normal ferritin level and an MCV on the lower end of normal, it is important to rule out hemoglobinopathies such as thalassemia, which can present with microcytosis (C). Option (A) is incorrect because while mild anemia can occur in pregnancy, further evaluation is needed when there is microcytosis. Option (B) is incorrect because iron supplementation is only needed if iron deficiency is confirmed. Option (D) is incorrect because aplastic anemia presents with pancytopenia rather than isolated anemia.
57. A 50-year-old female with a recent A1C of 7.5% returns for follow-up. She has been on metformin but has not made significant lifestyle changes. Her fasting glucose is 180 mg/dL. What is the best next step in management?
Correct Answer: B. Add a second oral antihyperglycemic agent Explanation: When a patient's A1C remains above target despite monotherapy with metformin, the next step is to add a second antihyperglycemic agent such as a GLP-1 receptor agonist or SGLT2 inhibitor (B). Option (A) is incorrect because increasing the metformin dose alone is unlikely to achieve adequate glycemic control. Option (C) is incorrect because insulin is not typically the first step after metformin failure unless A1C is significantly high (>9-10%). Option (D) is incorrect because delaying treatment adjustments allows further disease progression.
58. A 19-year-old college student presents for a wellness visit. She reports feeling anxious before exams but denies persistent anxiety, panic attacks, or impairment in daily life. She exercises regularly and uses mindfulness techniques. What is the most appropriate next step?
Correct Answer: A. Continue current coping strategies and provide reassurance Explanation: The patient experiences normal situational anxiety, which can be managed with reassurance and continued coping strategies (A). Benzodiazepines (B) are not appropriate due to the risk of dependency. SSRIs (C) are indicated for generalized anxiety disorder, not occasional test anxiety. Discontinuing mindfulness practices (D) is incorrect, as they provide beneficial stress reduction.
59. A 72-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents with worsening shortness of breath over the past three days. He reports increased sputum production and wheezing. On examination, he is using accessory muscles to breathe, and auscultation reveals diffuse expiratory wheezing and diminished breath sounds. His oxygen saturation is 88% on room air. What is the most appropriate initial intervention?
Correct Answer: B. Initiating nebulized albuterol and ipratropium therapy is the most appropriate initial intervention for an acute COPD exacerbation, as bronchodilators help relieve airway obstruction and improve airflow. (A) is incorrect because administering high-flow oxygen at 100% FiO₂ can suppress the hypoxic drive in patients with COPD, leading to CO₂ retention and worsening respiratory acidosis. (C) is incorrect because although antibiotics are sometimes used in COPD exacerbations with purulent sputum, immediate bronchodilator therapy is the priority. (D) is incorrect because while a chest X-ray can help rule out pneumonia, treatment should not be delayed in a patient with a clear clinical picture of a COPD exacerbation.
60. A 65-year-old male presents to the clinic with complaints of progressive exertional dyspnea, lower extremity swelling, and orthopnea over the past two months. He has a history of hypertension and type 2 diabetes mellitus. On physical examination, he has bilateral basilar crackles, jugular venous distension, and pitting edema of both legs. His chest X-ray reveals cardiomegaly and pulmonary congestion. What is the most likely diagnosis?
Correct Answer: B. Heart failure with reduced ejection fraction (HFrEF) Explanation: The patient’s symptoms of exertional dyspnea, orthopnea, and lower extremity edema, along with physical exam findings of crackles, jugular venous distension, and pitting edema, are characteristic of heart failure with reduced ejection fraction (HFrEF). (B) The presence of cardiomegaly and pulmonary congestion on chest X-ray further supports this diagnosis. (A) COPD typically presents with chronic cough, wheezing, and a history of smoking but does not cause significant edema or pulmonary congestion. (C) Pulmonary embolism can cause dyspnea but is more acute in onset and does not present with volume overload signs. (D) Nephrotic syndrome can cause edema but is associated with proteinuria, hypoalbuminemia, and hyperlipidemia, which are not mentioned in this case.
61. A 38-year-old male with generalized anxiety disorder has been taking sertraline 100 mg daily for six weeks but continues to experience significant anxiety symptoms. He denies suicidal ideation but states that his symptoms are affecting his daily life. What is the best next step?
Correct Answer: A Explanation: Increasing sertraline to 150 mg daily (A) is appropriate because the patient has been on an adequate trial of the medication but may require a dose adjustment. Selective serotonin reuptake inhibitors (SSRIs) often require dose titration for optimal efficacy. Discontinuing sertraline and starting buspirone (B) is not recommended as buspirone is less effective for moderate to severe anxiety compared to SSRIs. Switching to fluoxetine (C) is unnecessary, as fluoxetine has a similar mechanism of action and switching too early may prevent the patient from achieving full benefits. Adding alprazolam (D), a benzodiazepine, is not first-line due to its risk of dependence and withdrawal.
62. A 58-year-old male with a history of uncontrolled hypertension presents with sudden-onset tearing chest pain radiating to the back. His blood pressure is 180/100 mmHg. What is the most appropriate imaging study to evaluate his condition?
Correct Answer: A. Transesophageal echocardiogram Explanation: A transesophageal echocardiogram (TEE) is the preferred imaging study for suspected acute aortic dissection in hemodynamically unstable patients, as it provides detailed visualization of the aortic root and ascending aorta (A). Option (B) is incorrect because venous Doppler ultrasound evaluates venous thrombosis, not aortic dissection. Option (C) is incorrect because a transthoracic echocardiogram is less sensitive than TEE for evaluating the aorta. Option (D) is incorrect because while a chest X-ray may show a widened mediastinum, it is not diagnostic.
63. A 50-year-old male with hyperlipidemia is seeking dietary guidance to lower his cholesterol levels. He currently follows a diet high in saturated fats, fried foods, and processed snacks. What is the best dietary modification for this patient?
Correct Answer: A. Increase intake of fiber-rich foods such as oats, beans, and vegetables while reducing saturated fat consumption Explanation: Soluble fiber (A) binds cholesterol in the gut and reduces LDL levels, making foods like oats, beans, and vegetables effective in lowering cholesterol. Reducing saturated fat intake also helps prevent further elevations in LDL cholesterol. A high-fat diet with an emphasis on red meat and dairy (B) can raise cholesterol levels. Avoiding plant-based foods (C) removes important sources of fiber and healthy fats. Eliminating all fats (D) is unnecessary, as healthy fats such as those found in nuts and fish are beneficial for heart health.
64. A 65-year-old male with a history of COPD presents with worsening dyspnea and increased cough over the past five days. He denies fever or chills but reports increased sputum production. On examination, he has diminished breath sounds, scattered wheezing, and prolonged expiration. His oxygen saturation is 89% on room air. What is the most appropriate initial treatment?
Correct Answer: A. Oral antibiotics and systemic corticosteroids Explanation: COPD exacerbation is characterized by worsening dyspnea, cough, and increased sputum production, often triggered by infection. Treatment includes systemic corticosteroids and antibiotics if increased sputum purulence is present (A). Intubation (B) is reserved for severe respiratory failure. Anticoagulation therapy (C) is for PE, which is not suggested in this case. Observation alone (D) is not appropriate as COPD exacerbations require prompt treatment to prevent deterioration.
65. A 75-year-old woman with a history of congestive heart failure presents with increasing dyspnea. Spirometry reveals a normal FEV1/FVC ratio, reduced total lung capacity (TLC), and normal diffusion capacity. What is the most likely cause of her findings?
Correct Answer: A. Congestive heart failure-related restrictive lung disease Explanation: Congestive heart failure can lead to pulmonary congestion and fibrosis, resulting in restrictive lung patterns characterized by normal or high FEV1/FVC ratios and reduced lung volumes (A). Option (B) is incorrect because COPD presents with an obstructive pattern (low FEV1/FVC). Option (C) is incorrect because pulmonary embolism typically presents with acute symptoms and normal lung volumes. Option (D) is incorrect because asthma is an obstructive disease with reversible airflow limitation.
66. A 30-year-old male presents with a sore throat, fever, and fatigue for the past five days. On examination, he has posterior cervical lymphadenopathy and an enlarged spleen. A monospot test is positive. What is the most appropriate next step in management?
Correct Answer: B. Advise rest and avoidance of contact sports Explanation: Infectious mononucleosis, caused by the Epstein-Barr virus (EBV), is characterized by fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Rest and avoidance of contact sports are crucial due to the risk of splenic rupture (B). Amoxicillin (A) should be avoided as it can cause a characteristic rash in EBV-infected patients. Corticosteroids (C) are only indicated in severe cases with airway obstruction. A throat culture (D) is unnecessary because the monospot test is positive, confirming EBV infection.
67. A 52-year-old male with a history of hypertension and obesity presents for an annual wellness exam. His last cholesterol screening was five years ago. Based on the United States Preventive Services Task Force (USPSTF) guidelines, what is the most appropriate screening recommendation for this patient?
Correct Answer: B. Perform lipid screening as he is at increased cardiovascular risk Explanation: The USPSTF recommends lipid screening for adults aged 40-75 years who have risk factors such as hypertension, obesity, smoking, or diabetes to assess cardiovascular risk (B). This patient has multiple risk factors, warranting screening. Option (A) is incorrect because delaying screening until age 65 increases the risk of undiagnosed dyslipidemia. Option (C) is incorrect as coronary artery calcium scoring is not a first-line screening test for hyperlipidemia. Option (D) is incorrect because cholesterol screening is recommended even in asymptomatic individuals with cardiovascular risk factors to prevent future complications.
68. A 70-year-old male with Parkinson’s disease is experiencing visual hallucinations but is otherwise cognitively intact. Which of the following is the most appropriate pharmacologic intervention?
Correct Answer: A. Quetiapine Explanation: Quetiapine (A), an atypical antipsychotic, is the preferred treatment for Parkinson’s disease psychosis as it has a lower risk of worsening motor symptoms compared to first-generation antipsychotics. Haloperidol (B), a first-generation antipsychotic, should be avoided as it can significantly exacerbate Parkinsonian symptoms. Fluoxetine (C), an SSRI, is used for depression but does not address hallucinations. Alprazolam (D), a benzodiazepine, is used for anxiety and is not appropriate for Parkinson’s disease psychosis.
69. A 68-year-old male with a history of atrial fibrillation and type 2 diabetes presents with sudden-onset left-sided weakness and slurred speech that began 30 minutes ago. His blood pressure is 180/100 mmHg, heart rate is irregular at 92 bpm, and he takes apixaban 5 mg BID. What is the most appropriate next step in management?
Correct Answer: A Explanation: Ordering a non-contrast CT and transferring to a stroke center (A) is the most appropriate step in a patient presenting with acute stroke symptoms. The CT scan will help differentiate between ischemic and hemorrhagic stroke. This is critical in determining eligibility for thrombolytic therapy. Administering aspirin (B) is inappropriate before ruling out hemorrhagic stroke. Discontinuing apixaban and initiating heparin (C) is not recommended, as the patient is already anticoagulated, and heparin is not indicated in acute stroke management. Increasing antihypertensives and observing in the clinic (D) delays necessary intervention for a potentially reversible stroke.
70. A 66-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents with a chief complaint of worsening shortness of breath over the past five days. He also reports increased sputum production and a change in sputum color from white to yellow-green. He denies fever or recent travel. On examination, he has prolonged expiration, wheezing, and accessory muscle use. Pulse oximetry shows an oxygen saturation of 90% on room air. What is the most appropriate initial management?
Correct answer: B. Prescribe a short course of oral prednisone and antibiotics Explanation: (B) is the correct answer because this patient meets the criteria for a COPD exacerbation, indicated by worsening dyspnea, increased sputum volume, and purulence. Treatment includes a short course of oral corticosteroids and antibiotics if bacterial infection is suspected. (A) is incorrect because inhaled corticosteroids are used for long-term COPD management but do not address acute exacerbations. (C) is incorrect because non-invasive ventilation is reserved for severe respiratory distress or hypercapnic respiratory failure, which is not evident here. (D) is incorrect because while pneumonia should be ruled out if suspected, treatment for a COPD exacerbation should not be delayed based on the history and clinical presentation.
71. A 47-year-old postmenopausal female presents with complaints of vaginal dryness, dyspareunia, and increased urinary urgency over the past six months. On pelvic examination, the vaginal mucosa appears pale, thin, and dry with loss of rugae. What is the most appropriate treatment?
Correct Answer: C. Vaginal estrogen therapy is the first-line treatment for genitourinary syndrome of menopause (atrophic vaginitis), which presents with vaginal dryness, dyspareunia, and urinary symptoms due to estrogen deficiency. (A) is incorrect because systemic estrogen therapy is not necessary unless the patient has severe systemic menopausal symptoms. (B) is incorrect because while pelvic floor exercises may help with urinary urgency, they do not address the underlying estrogen deficiency causing vaginal atrophy. (D) is incorrect because the symptoms described are due to atrophic changes rather than infection.
72. A 30-year-old female presents with a three-day history of fever, dysuria, and left flank pain. She reports nausea but no vomiting. On examination, she has costovertebral angle (CVA) tenderness on the left. Her temperature is 101.8°F (38.8°C), and urinalysis shows leukocyte esterase and nitrites. What is the most appropriate next step?
Correct answer: B. Admit the patient for IV antibiotics and fluids Explanation: (B) is the correct answer because this patient has pyelonephritis with systemic symptoms (fever, nausea, CVA tenderness) and requires hospitalization for IV antibiotics. (A) is incorrect because outpatient treatment is only appropriate for mild cases without systemic involvement. (C) is incorrect because conservative management is insufficient for an active bacterial infection with fever. (D) is incorrect because a renal ultrasound is only needed if there is suspicion of obstruction or complications.
73. A 60-year-old male with type 2 diabetes mellitus and chronic kidney disease (eGFR 25 mL/min) presents for medication management. His current regimen includes metformin and glipizide, and his A1c is 8.2%. What is the most appropriate adjustment to his treatment plan?
Correct Answer: A. Discontinue metformin and start insulin therapy Explanation: Metformin (A) is contraindicated in patients with an eGFR <30 mL/min due to the increased risk of lactic acidosis, and it should be discontinued in those with an eGFR of 30-45 mL/min if renal function continues to decline. Insulin is often necessary in advanced CKD due to the reduced clearance of many oral antidiabetic agents. Increasing metformin and adding empagliflozin (B) is incorrect because sodium-glucose co-transporter 2 (SGLT2) inhibitors are not recommended for patients with an eGFR below 30 mL/min. Switching glipizide to sitagliptin (C) may be an option, but metformin still needs to be discontinued. Pioglitazone (D) is not recommended due to its risk of fluid retention, which can worsen CKD.
74. A 62-year-old male with a history of type 2 diabetes and hypertension presents for a follow-up visit. He was started on metformin 500 mg BID three months ago, but reports experiencing persistent diarrhea and abdominal discomfort. His HbA1c has improved from 9.2% to 7.8%. How should the Family Nurse Practitioner adjust his medication regimen?
Correct Answer: C Explanation: Reducing the metformin dose to 500 mg daily and gradually titrating as tolerated (C) is the best approach. Metformin is the first-line therapy for type 2 diabetes due to its efficacy in lowering blood glucose and its cardiovascular benefits. However, gastrointestinal side effects are common, especially when initiated at higher doses. Lowering the dose and slowly increasing can improve tolerability. Continuing metformin at the current dose despite the patient's persistent symptoms (A) disregards his discomfort and may lead to nonadherence. Discontinuing metformin and switching to glipizide (B), a sulfonylurea, increases the risk of hypoglycemia and weight gain, making it a less favorable choice. While sitagliptin (D), a DPP-4 inhibitor, may be better tolerated, metformin should not be abandoned unless the patient cannot tolerate it at any dose.
75. A 27-year-old male construction worker presents with recurrent episodes of dizziness and nausea while working outdoors in hot weather. He reports feeling lightheaded and sweating excessively but improves when he takes breaks in the shade. He denies chest pain or palpitations. His blood pressure is 100/60 mmHg, and his pulse is 102 bpm. What is the most likely diagnosis?
Correct answer: A. Heat exhaustion Explanation: (A) is the correct answer because prolonged exposure to high temperatures with excessive sweating can lead to heat exhaustion, characterized by dizziness, nausea, hypotension, and tachycardia. This condition improves with rest, hydration, and cooling measures. (B) is incorrect because orthostatic hypotension presents with symptoms upon standing and is not typically related to heat exposure. (C) is incorrect because cardiac arrhythmias often present with palpitations or syncope rather than heat-induced symptoms. (D) is incorrect because hypoglycemia typically causes tremors, confusion, and hunger, which are not reported in this case.
76. A 62-year-old male with a history of hypertension presents for follow-up. He has been monitoring his blood pressure at home, and his readings average 155/95 mmHg despite adherence to a calcium channel blocker and a low-sodium diet. He denies headaches, dizziness, or chest pain. Which of the following is the most appropriate next step in management?
Correct Answer: C. Add a thiazide diuretic to his current regimen and reassess in one month Explanation: This patient has uncontrolled hypertension with home blood pressure readings persistently above the goal of <130/80 mmHg, necessitating medication adjustment. Adding a thiazide diuretic (C) is appropriate as per guidelines, particularly since combination therapy is often required for optimal blood pressure control. Advising continued lifestyle modifications without adjusting medication (A) is inappropriate when blood pressure remains uncontrolled. Increasing the dose of a calcium channel blocker alone (B) may not be sufficient, as combination therapy often yields better results. A 24-hour ambulatory blood pressure monitor (D) is helpful in suspected white coat hypertension but is unnecessary here since the patient has consistent elevated home readings.
Your score is
Restart Exam
