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Question 1

A 74-year-old with COPD has resting oxygen saturation 86% on room air when stable. What therapy should be evaluated?

1. Daily oral steroids indefinitely
2. Chronic high-dose opioids for dyspnea first
3. Avoid vaccination
4. Long-term oxygen therapy qualification ✅

Question 2

A 34-year-old has epigastric pain, positive urea breath test, and no alarm features. What is the appropriate plan?

1. No treatment unless hematemesis occurs
2. Long-term NSAID therapy
3. Eradication therapy for Helicobacter pylori ✅
4. Immediate colectomy referral

Question 3

A 72-year-old started gabapentin for neuropathy and reports dizziness and gait instability. What should the NP consider?

1. Add zolpidem
2. Ignore because neuropathy improved
3. Dose adjustment or alternative therapy due to fall risk ✅
4. Increase dose rapidly despite falls

Question 4

A 13-year-old overweight boy has hip pain referred to the knee and walks with an antalgic gait. Internal rotation is limited. What should the NP do?

1. Recommend stretching and sports participation
2. Prescribe oral antibiotics
3. Make the patient non-weight-bearing and arrange urgent orthopedic evaluation ✅
4. Treat as knee sprain with bracing only

Question 5

A 78-year-old with insomnia asks for medication. He drinks caffeine at 7 pm and naps daily. What is the best initial approach?

1. Start chronic benzodiazepine nightly
2. Advise alcohol at bedtime
3. Prescribe diphenhydramine
4. Sleep hygiene and behavioral interventions before sedative-hypnotics ✅

Question 6

A 2-week-old has forceful nonbilious vomiting after feeds, persistent hunger, and poor weight gain. The abdomen is soft. What is the most likely diagnosis?

1. Hypertrophic pyloric stenosis ✅
2. Milk protein allergy
3. Gastroesophageal reflux
4. Malrotation with volvulus

Question 7

A 35-year-old has an enlarging asymmetric pigmented lesion with irregular border and color variation. Which approach is most appropriate?

1. Use ABCDE criteria and arrange biopsy/dermatology referral ✅
2. Treat with topical steroid for 5-10 days and re-evaluate
3. Cryotherapy is ideal to minimize incision and bleeding
4. Consider a retinoid cream

Question 8

An 8-year-old has periorbital edema, cola-colored urine, hypertension, and low C3 after a recent impetigo infection. What is the most likely diagnosis?

1. Nephrolithiasis
2. IgA nephropathy
3. Minimal change disease
4. Poststreptococcal glomerulonephritis ✅

Question 9

A 76-year-old man has BPH with acute urinary retention and suprapubic pain. What is the priority?

1. Urgent bladder decompression ✅
2. Advise fluid restriction for 1 week
3. Start pelvic floor exercises only
4. Schedule PSA in 6 months only

Question 10

A 53-year-old with suspected polymyalgia rheumatica (PMR) has bilateral shoulder/hip girdle pain and elevated ESR. She also reports new temporal headache and jaw claudication. What is the best action?

1. Routine physical therapy for PMR
2. Treat with colchicine as an anti-inflammatory
3. Refer for ophthalmology for giant cell arteritis rule out ✅
4. Wait for amaurosis fugax before treatment since it is confirmatory of the diagnosis

Question 11

A 79-year-old woman has dysuria, urgency, fever, and flank pain. What assessment finding supports pyelonephritis?

1. Stress incontinence with cough
2. WBC casts in urinalysis ✅
3. Frequent urinary tract infections
4. Vaginal dryness only

Question 12

A 72-year-old woman has osteoporosis on DEXA and a wrist fracture. What should treatment include?

1. Physical therapy if no improvement in 6 months
2. Use of chronic steroids to support bone growth
3. Avoid weight-bearing activity
4. calcium/vitamin D and bisphosphonates ✅

Question 13

A 46-year-old has new thunderclap headache described as the worst headache of life. Neuro exam is normal. What is the best plan?

1. Treat as tension headache with reassurance
2. Begin migraine prophylaxis only
3. Schedule routine neurology visit in 3 months
4. Emergency evaluation for subarachnoid hemorrhage ✅

Question 14

A 29-year-old has fatigue, spoon nails, and heavy menses. Hemoglobin is 9.8 g/dL with low MCV. What test best confirms iron deficiency?

1. Ferritin level ✅
2. D-dimer
3. HLA-B27
4. Serum sodium

Question 15

A 31-year-old treated for H. pylori asks how cure will be confirmed. What is the best response?

1. Repeat antibody testing after initiating antibiotics
2. No follow-up testing is recommended if symptoms subside
3. Perform test of cure with urea breath or stool antigen after therapy and after holding PPI appropriately ✅
4. No need to confirm cure since this is done by symptom improvement only

Question 16

A 74-year-old woman has hypercalcemia, kidney stones, constipation, and elevated parathyroid hormone. What is the likely diagnosis?

1. Hypoparathyroidism
2. Primary hyperparathyroidism ✅
3. Addison disease
4. SIADH

Question 17

A 14-year-old has weight loss, polyuria, polydipsia, abdominal pain, and fruity breath. Respirations are deep and rapid. Which initial test is most important?

1. Thyroid ultrasound
2. Serum prolactin
3. Point-of-care glucose and ketone assessment ✅
4. Fasting lipid panel

Question 18

A 27-year-old at 32 weeks gestation reports headache, visual spots, and right upper quadrant pain. BP is 162/104 mm Hg and urine protein is positive. What is the likely diagnosis?

1. Normal third-trimester discomfort
2. Hyperemesis gravidarum
3. Preeclampsia with severe features ✅
4. Gestational diabetes

Question 19

A 27-year-old treated for pyelonephritis calls after 72 hours with persistent fever and flank pain. What is the best action?

1. Consider gram positive coverage strategy
2. Stop antibiotics immediately and refer to urology
3. Reassure that fever for 2 weeks is expected with pyelonephritis
4. Urgent reassessment for resistant organism ✅

Question 20

A 76-year-old has exertional syncope, systolic crescendo-decrescendo murmur at right upper sternal border, and delayed carotid upstroke. What condition is suspected?

1. Pericarditis
2. Mitral stenosis
3. Tricuspid regurgitation
4. Aortic stenosis ✅

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