NP Certification Q&A

A 51 year old woman who works as a real estate agent presents for an office visit with a chief complaint of severe vasomotor symptoms reporting, "I can't sleep through the night without being drenched in sweat. I have at least four hot flashes a day. Sometimes while I'm working with clients. I need some help. What do you think about hormone therapy? " Her LMP was approximately 13 months ago and she's without chronic health problems. 

When considering postmenopause hormone therapy, which of the following is the most accurate statement?

A. The use of hormone therapy post menopause is associated with a significant increase in cardiovascular and cancer risk.

B. The use of select low dose SSRIs for the management of vasomotor symptoms is as effective as hormone therapy.

C. Short duration lower dose hormone therapy offers an effective form of therapy for menopausal vasomotor symptoms.

D. Hormone therapy postmenopause offers an effective treatment for osteoporosis.

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Which of the following best describes the use of contraception for a 26 year old woman who has migraine without aura, usually three episodes per month controlled with high dose ibuprofen who is otherwise well states. "I want to get on some birth control that's really reliable for the next three years while I'm in graduate school."

A. All combined hormonal contraceptive forms are contraindicated with any type of migraine.

B. Combined hormonal contraception is acceptable for use in this clinical situation.

C. Progestin-only contraceptive methods should be avoided in migraine with or without aura due to the increased risk for elevated blood pressure.

D. Barrier contraceptive methods are preferred in this situation.

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A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he has not taken his high blood pressure medicines, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the last three months due to, quote, running out of medication and not getting to the pharmacy, close quote. Today's blood pressure is 192 over 120, and he's without complaint, denying shortness of breath, chest pain, or visual changes. He states, "I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a half an hour." His physical exam shows no acute distress, grade one hypertensive retinopathy, and S4 heart sound. His neck veins are within normal limit, chest is clear, no peripheral edema with a resting heart rate of 73. Respiratory rate 16, 12 lead ECG is within normal limits. His BMI is 33. 

Which of the following is the next best step in the patient's care?

A. Administer in-office oral clonidine and reassess blood pressure in 1 hour. 

B. Activate EMS with prompt transfer to emergency department

C. Restart prior blood pressure medications with follow-up within the next month

D. Advise restricting dietary sodium and weight loss to help with BP control. 

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A 56 year old man with a 10 year history of hypertension presents for a primary care visit, stating he's not taking his hypertension med, a calcium channel blocker, an angiotensin converting enzyme inhibitor, and a thiazide diuretic for the past three months due to  "running out of the medication and not getting to the pharmacy." Today, his blood pressure is 192 over 120 and he has no complaint, denying shortness of breath, chest pain or visual changes. He states, "I just came in today for a visit since I ran out of my blood pressure refills. I need to get back to work in a half an hour." When considering the diagnosis of asymptomatic markedly elevated blood pressure, the clinician would predict his physical exam is normal with the exception of which of the following.

A. S4 heart sound

B. Grade 3 HTN retinopathy

C. Neck vein distension

D. Murmur of aortic regurgitation

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Which of the following two patients with asymptomatic bacteria, or abbreviated ABS, should receive antimicrobial therapy?

A. An 84‑year‑old woman who is a resident of a long‑term care facility with dementia, no new urinary symptoms, her urine is positive for nitrites, leukocytes, and culture reveals 100,000 colony forming units per ml of E. coli.

B. A 70‑year‑old man with an indwelling Foley catheter, no new urinary symptoms. His urine appears cloudy and foul‑smelling. His culture is 100,000 CFU of mixed flora.

C. A 30‑year‑old woman who is 10 weeks pregnant, no urinary symptoms, culture reveals 100,000 CFU per ml of E. coli.

D. A 72‑year‑old man scheduled for a transurethral prostate resection, a TURP, next week, no urinary symptoms. His culture reveals 100,000 CFU per ml of E. coli.

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A healthy seven‑month‑old boy presents with his parents for a well‑child visit. He was born at 39.5 weeks gestation via spontaneous vaginal delivery. After a pregnancy without complication, he and his mother went home after 24 hours. He is primarily breastfed with a small amount of solids and continues to be at the 50th percentile weight and 40th percentile length. The parents voice no concerns. 

Which of the following is the most appropriate developmental milestone for this child's age?

A. sits briefly with support

B. is able to pull to stand

C. rolls front to back

D. uses pincher grasp to pick up a small object

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A 28‑year‑old male non‑smoker with no chronic health problems presents with a 10‑day history of persistent cough that's worse at night, stating, "I started with a head cold about two weeks ago. The cold moved into my chest." He reports mild chest discomfort with deep cough, rare production of small amounts of clear to white sputum, and feels tired because, "the cough keeps waking me up." He denies sore throat, fever, ear pain, shortness of breath, or GI symptoms. Objective temp 97.6, heart rate 72, respiratory rate 18, BP 112 over 68, SpO2 is 99%, no acute distress, mild pharyngeal redness, no lymphadenopathy, chest without crackles, occasional dry cough, abdominal exam is within normal limits. 

Which of the following is the most appropriate next step?

A. Prescribe one week of oral amoxicillin.

B. Order a chest x-ray

C. Prescribe a five-day course of azithromycin

D. Provide advice about symptomatic care

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A 36 year old woman presents with a three month history of unintended weight loss, sensation of increased anxiety, heat intolerance, and reports, "I feel like my heart is going to beat right out of my chest." In addition, she reports a two-month history of increased frequency and looseness of stools. Physical exam reveals 3-4 plus Achilles and patella reflex response, mild exophthalmosis, bilateral fine tremor, and a diffusely enlarged non-tender thyroid. Heart rate 115 beats per minute at rest without murmur or other cardiac abnormalities. 

Considering thyroid disorder as her working diagnosis, which of the following would be her anticipated lab results?

A. Elevated TSH with normal limit free T4

B. Low TSH with elevated free T4

C. Elevated TSH with a low free T4

D. Normal limit TSH

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A 62 year old man with a 60 pack year cigarette smoking history presents with a chief complaint of progressive dyspnea on exertion and a chronic productive cough over the past eight years. Significant contributing history include two episodes of being seen in urgent care in the past year for "bronchitis" and being told he should follow up with primary care. 

When considering the diagnosis of COPD, which of the following is the most important diagnostic parameter? 

A. patient report of progressive dyspnea and chronic productive cough

B. 60-pack year cigarette smoking history

C. FEV1 to FEC ratio of less than 0.7 post bronchodilator

D. FEV1 of less than 50 % of predicted

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A 72-year-old with a prosthetic aortic valve presents stating, "I was told I have to take a medicine before I have a deep dental cleaning." Concurrent health issues include hypertension, type 2 diabetes, and dyslipidemia, currently at treatment goals. Medications include metformin, hydrochlorothiazide, telmisartan, and rosuvastatin. She has no drug allergies. Which of the following is the most appropriate next step in her care?

A. amoxicillin 2 grams PO 30 to 60 minutes prior to the procedure

B. amoxicillin 2 grams PO 1 to 2 hours after the procedure

C. cephalexin 2 grams PO 30 to 60 minutes prior to the procedure

D. inform the patient that no antimicrobial prophylaxis is needed during dental care. 

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A patient presents stating, "I've been told I need to take a medicine before I have a deep dental cleaning." Which of the following patients requires antimicrobial prophylaxis prior to this dental visit?

A. A 28-year-old female taking combined oral contraceptives with a history of the murmur of mitral valve prolapse

B. An 18 year old with a physiologic murmur and a history of ACL repair

C. A 64 year old male with hypertension, type 2 diabetes, dyslipidemia, and an A1c of 9.5%

D. A 72-year-old woman with a prosthetic aortic valve

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A 68-year-old man with a 15-year history of hypertension and dyslipidemia, as well as a 45 pack-year history of cigarette smoking, currently smoking one pack per day, was recently diagnosed with COPD. His FEV1 to FEC ratio is less than 0.7, and his FEV1 is 48% of predicted. He reports two COPD exacerbations in the past year, both treated as an outpatient, and also mentions "I need to pace myself or I get short of breath even if I walk up just a flight of stairs. I can't do any work in the yard anymore." Per current treatment recommendations, which of the following is advised for his COPD maintenance therapy?

A. SABA as needed for shortness of breath

B. Daily use of an ICS LABA

C. As needed use of a LABA for symptoms

D. Scheduled use of an inhaled LABA/LAMA

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A 45 year old woman who works as a professional baker, with a specialty in birthday and wedding cakes, is diagnosed today with carpal tunnel syndrome. Her history of present illness include a four month history of numbness and tingling of the thumb, index and middle finger of her dominant hand. Physical exam reveals normal grip strength and decreased sensation along the median nerve distribution. Thenar atrophy is absent. 

Which of the following is the most appropriate next step?

A. referral for carpal tunnel surgical decompression

B. arranging for carpal tunnel corticosteroid injection

C. advice on the use of neutral position wrist splinting

D. obtain a TSH and an A1C

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A 45-year-old woman who works as a professional baker with a specialty in birthday and wedding cakes presents with a six-month history of progressive numbness and tingling in the thumb, index, and middle fingers of her right hand. She noticed that her symptoms are worse at night and are accompanied by hand weakness and reports being right hand dominant. She denies any injury to the area and states "This is getting in the way of my work. I'm having a much harder time holding the tools that I need to use to decorate a cake." Her concurrent health history includes a five-year history of type 2 diabetes, hypertension, and dyslipidemia, obesity with a BMI of 38. Her current meds include Metformin and an SGLT2I, and ARB with a thiazide diuretic and a statin. 

When considering the diagnosis of carpal tunnel syndrome, which of the following would be one of the earliest physical exam findings?

A. Pain reproduced with forced wrist flexion held for 60 seconds

B. Diminished radial pulse

C. thenar atrophy

D. tingling of the fingers when tapping on the median nerve

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A 28-year-old woman who is breastfeeding her healthy six-week-old term infant presents with a four-day history of generalized body aches, intermittent fever to 101.2 degrees Fahrenheit, and localized pain on the upper aspect of her left breast. She states that she's been attempting to nurse her infant as tolerated and pumps the affected breast when unable to nurse. Physical exam is consistent with lactation-associated mastitis. 

Which of the following is the most appropriate next steps? 

A. advise continued expressing of milk on the affected breast through pumping or nursing as tolerated

B. initiate antimicrobial therapy with oral cephalexin for five to seven days.

C. advise discontinuing breastfeeding on the left breast and apply ice packs to the affected area.

D. initiate antimicrobial therapy with oral ciprofloxacin for 10 days. 

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A 35-year-old woman presents for a periodic physical exam with Pap and HPV testing. She states she's feeling well without complaint and has excellent exercise tolerance, running about 30 miles per week. Her current medications include an levonagestrel IUD for contraception. Physical exam includes vital signs within normal limits, a BMI of 23, and no unusual findings, save for a mid-systolic click followed by a grade two, mid to late systolic murmur with a honking quality. The murmur moves forward into systole with position change from supine to standing and does not radiate beyond the precordium. These findings most likely represent:

A. A physiologic murmur

B. The murmur of aortic stenosis

C. The murmur of mitral valve prolapse

D. The murmur related to tricuspid valve incompetency

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A 35-year-old man presents with a one-week history of new onset fatigue, nausea, as well as reporting his urine looks like, quote, ice tea. He also reports, feel like someone kicked me right underneath my ribs on the right. He denies recent travel, contact with individuals with similar signs and symptoms, and reports a new sex partner for the past six months, stating, quote, we sometimes use condoms. 

In considering the diagnosis of acute hepatitis B, which of the following laboratory profiles would be noted?

A. Hep B surface antigen positive, anti-HBs negative, or Hep B surface antibody. ALT markedly elevated at 1390. AST similarly elevated at 1100. Total bilirubin markedly elevated at 4.8

B. Hep B surface antigen positive, anti-HBs, HBS- or Hep B surface antibody ALT modestly elevated at 68 as is AST total bilirubin .9 within normal limits

C. Hep B surface antigen negative, anti-HBS- or Hep B surface antibody, ALT 24, AST 22 and a total bilirubin of 0.6

D. Hep B surface antigen negative, anti-HPS negative, ALT 150, AST 140, total bilirubin 0.7 within normal limits

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A 73-year-old female with a 20-year history of hypertension, type 2 diabetes, dyslipidemia, and stage 3B CKD, typically at treatment goals with oral medications, is being seen. She was discharged yesterday after being hospitalized for three days with community-acquired pneumonia and is here for a follow-up visit.

She states she's feeling much better with less shortness of breath, diminished cough, and sputum production, and is without fever. She mentions that while she was in the hospital that, quote, they changed my diabetes medicine and gave me insulin four times a day to keep my sugar controlled, close quote. A review of her discharge note reveals that rapid acting insulin was given according to blood glucose levels without scheduled basal insulin and this was used from admission to discharge. 

Random glucose today is at 220. The patient asks, should I start back up on those insulin shots? I've never used them before. The NP considers with which of the following.

A. given her random blood glucose is elevated, the use of a sliding scale insulin should be continued for the next week

B. the use of a sliding scale insulin potentially results in wide glucose excursions

C. sliding scale insulin is helpful as it mimics physiologic insulin secretion

D. the sliding scale insulin regimen should now be replaced with a basal insulin

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A 60-year-old male with documented ASCVD, obesity with BMI of 34, and type 2 diabetes presents for care. The patient reports he's currently feeling well without episodes of hypoglycemia. Current laboratory assessment includes the following. A1C is 8.6 % and his estimated GFR is at 62. Current medications include metformin at optimized dose and a sulfonyl urea.

Which of the following represents the nurse practitioner's next best action?

A. continue on current therapy and arrange for a three month follow up

B. discontinue the metformin and add a DPP4 inhibitor

C. add a GLP-1 inhibitor and discontinue the sulfonyl urea

D. add basal insulin and titrate to fasting glycemic goals

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A 17 yo male presents for follow up on a “fainting” episode that occurred during football practice at the end of a running exercise. He states, “I do not know what happened. We finished a set of running sprints and next thing I knew, I was on the ground.” He denies injury from the event and history of prior episodes. His physical examination reveals a crescendo-decrescendo systolic murmur heart best at the apex, increasing in intensity with position change from supine to standing position.  

This most likely represents: 

A. Mitral regurgitation 

B. Physiologic murmur 

C. Hypertrophic cardiomyopathy

D. Aortic stenosis 

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A 40 year-old accountant presents for advice on measles prevention. He reports disembarking from an airplane approximately 40 hours ago, and now being notified that one of the passengers on the plane has been diagnosed with measles today. He denies any chronic health problems, states he received “all the shots I should have” when he was a child. However, he is unable to produce documentation of childhood vaccinations. 

Which of the following represents the most appropriate action? 

A. This is an example of a low risk rubeola exposure without need for specific prophylactic action.  

B. Obtain rubeola IgG titers and provide appropriate prophylaxis based on results.  

C. Administer a single dose of MMR vaccine now with advice to contact the practice if there are concerning signs and symptoms.  

D. Order a dose of immunoglobulin and arrange for MMR vaccination update.

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A nurse practitioner receives a message from a neighbor, a 35-year-old woman who is asking for a prescription to treat a “urine infection”. The neighbor states she's had this condition occur in the past and does quite well if she gets on an antimicrobial quickly. The neighbor also mentions that she's going out of town on a business trip the next day and is unable to contact her personal healthcare provider nor get to urgent care. 

The NP considers the following in prescribing a medication to her neighbor.  

A. Given this is a request for a prescription that is not a controlled substance, the NP can provide the prescription as long as the patient can advise on what antimicrobials she has taken in the past. 

B. Providing this prescription would be a violation of federal law. 

C. In suspected UTI, an antimicrobial prescription should not be initiated until urine culture results are available.  

D. Since the NP does not have a patient provider relationship established with her neighbor, the request for an antimicrobial should be declined. 

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Which of the following best describes a disease that should be reported to the local or regional public health department?  

A. Diseases where public health intervention is needed to help prevent spread to the region or community.  

B. Diseases with significant rates of mortality and morbidity.  

C. Diseases that are most often noted among individuals with significant immunocompromise. 

D. Diseases where intervention in early life helps lead to improved health in adulthood.  

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A 6-year-old presents with his parents, with a chief complaint of a 3 day history of sore throat, intermittent frontal headache and fever with a 1 day history of a non pruritic fine, raised rash, without N, V, D or C. He is able to take fluids without difficulty but has diminished appetite. The parents report that other children in their son’s kindergarten class have been sick with similar signs and symptoms. A rapid strep screen is positive. Clinical evaluation is consistent with scarlet fever. The child has no drug allergies. 

Which of the following is the most appropriate intervention?

A. IM penicillin

B. Oralamoxicillin

C. Topical triamcinolone

D. No specific therapy is needed.

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A 50 yo woman presents with a 6-month history of intermittent RUQ abdominal pain, bloating and nausea, particularly after eating fatty food, describing the discomfort as sharp, occasionally radiating to the right shoulder, usually lasting around 45 mins,  and accompanied by eructation.  She is currently without distress, stating that, “I cut back on food that I know bothers my stomach.  Physical exam reveals, BMI=35, no jaundice, mild RUQ abdominal tenderness and negative Murphy’s sign.  

Which of the following is the next step in her care?  

A. Provide a 1-month trial of proton pump inhibitor (PPI) therapy.

B. Refer to surgery for further evaluation.  

C. Order a RUQ ab for abdominal ultrasound and hepatic enzymes.

D. Obtain serum H. pylori testing.  

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An 18-month-old toddler presents for a sick visit with a chief complaint of recent onset of fever and skin lesions.  Which of the following is most consistent with the presentation of measles (rubeola)? 

A. A 3-day history of anterior cervical lymphadenopathy, significant sore throat, fever with a 1-day history of a fine erythematous skin eruption.  

B. A 3-day history of fever, mild nasal congestion, 

and crankiness followed by resolution of elevated temperature and eruption of a fine pink rash 

C. A 3-day history of cough, conjunctivitis with clear eye discharge, mild sore throat without exudate, diffuse lymphadenopathy and fever, followed by a new onset diffuse maculopapular rash 

D. A 2-day history of fever, mild sore throat, posterior cervical lymphadenopathy, and maculopapular skin lesions.  

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A 28 year old assigned male at birth presents with the chief complaint of a "new problem in my private parts” He states he feels well otherwise. Which of the following would be most consistent with the clinical presentation of primary syphilis?

A. A three day history of purulent penile discharge with dysuria.

B. A one week history of a painless genital ulcer on the penile shaft.

C. A 5 day history of painful vesicular lesions over the penile glands, with some lesions now crusting over.

D. A one week history of N void dysuria without penile discharge.

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A 52-year-old man presents for an initial primary care visit at the nurse practitioners practice period he has not seen any health care providers since age 38, stating that he has been in good health. Social history, drinking approximately 2 beers per night over the weekend, two nights per week, has a 5 pack year cigarette smoking history, having taken up smoking when he was in college, and quit at age 22. He reports feeling well and without chief complaint or chronic health problems.  He asks about what kind of cancer screening he should have. The NP advisors which of the following?

A. Colonoscopy 

B. Prostate specific antigen (PSA) 

C. Low dose chest CT

D. Given his history, no routine cancer screening is advised. 

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A 10-year-old of Middle Eastern ancestry , assigned female at birth, is seen for routine well child care. 

She is generally healthy and plays soccer, reporting excellent exercise tolerance, stating, “I’m the fastest midfield on the team.” Physical examination is within normal limits with Tanner stage 2. Height and weight are at 40% tile, consistent with previous measures. Laboratory evaluation reveals a mild microcytic hypochromic anemia with a NL RDW. This likely represents which of the following?

A. Vitamin B 12 deficiency

B. G6PD deficiency

C. Iron deficiency

D. Beta thalassemia minor

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A 70 year old man with a 35 year history of hypertension, dyslipidemia, and a 20 year history of type 2 diabetes presents. He was recently diagnosed with systolic heart failure, presenting with dyspnea on exertion and orthopnea. Prior clinical assessment revealed the murmur of mitral regurgitation. Which of the following would the NP anticipate finding on today’s physical exam?  

A. A mid to late systolic murmur that follows a mid systolic click. 

B. In early to mid systolic murmur harsh in quality, that radiates to the neck. 

C. A holosystolic murmur that radiates to the axilla.

D. A localized mid to late diastolic murmur.

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Which of the two following findings would be anticipated in the normal funduscopic exam of a healthy 40-year-old woman who is normotensive, generally in good health and without ocular complaint?  

A. Arteriovenous nicking

B. Optic cup to disc ratio < .0.5

C. Retinal arteries are brighter and narrower than veins  

D. Slight bulging of the optic disk

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Which of the following is most consistent with the clinical presentation of a person with folate-deficiency anemia? 

A. A 45-year-old woman with uterine fibroids, menorrhagia and a microcytic, hypochromic anemia with elevated RDW 

B. A 35-year-old woman with newly diagnosed systemic lupus and a normocytic, normochromic anemia with NL RDW 

C. A 40-year-old woman with alcohol use disorder who drinks 5-6 glasses of wine per day and a macrocytic normocytic anemia with an elevated RDW 

D. A 65 yo woman with a 20 year-history of hypothyroidism presenting with a 6-month history of stocking-glove neuropathy and a macrocytic, normochromic anemia with an elevated RDW.  

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A 70 year old man with a history of BPH, HTN and dyslipidemia presents with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. He denies GI upset and is taking fluids without difficulty. He denies sexual activity with others for the past three years. He is alert, oriented and appears slightly uncomfortable while seated. Abdominal and scrotal exam are WNL, there is no penile discharge and digital rectal exam reveals a tender, enlarged prostate. UA reveals positive leukocyte esterase and > 10 WBCs per HPF. With a working diagnosis of acute bacterial prostatitis, which of the following is the most appropriate antimicrobial option in this clinical scenario?  

A. Ciprofloxacin PO x 10 days 

B. IM Ceftriaxone as a one-time dose with doxycycline PO BID X 10 days 

C. IV piperacillin with tazobactam for 5 days 

D. Nitrofurantoin PO BID x 5 days.  

---

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Which of the following clinical scenarios is most consistent with an older adult presenting with acute bacterial prostatitis?  

A. A 65  year old male who presents with a 6 month history of urinary frequency, occasional difficulty initiating urine stream, without dysuria or fever. GU exam within normal limits with the exception of prostate enlargement.  

B. A 50-year-old male with a 4 day history of increased urinary frequency, end-void dysuria, and intermittent fever. GU exam reveals suprapubic tenderness,  without  prostatic enlargement or scrotal abnormalities.  

C. A 70 year old man with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. Scrotal exam WNL and digital rectal exam reveals a tender, enlarged prostate.  

D. A 78 year old man with a 3 month history of intermittent gross hematuria and urinary frequency without dysuria. GU exam is WNL with the exam of a nontender enlarged prostate with multiple nodular lesions.  

---

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The NP sees a 74-year-old woman with a BMI=30 kg/m2 who has a 30-year history of type 2 diabetes, HTN, and dyslipidemia. Pertinent social history includes the following: a retired elementary school teacher who lives in a 1-story home with her spouse and adult child, nonsmoker, drinks approximately 2, 5 oz glasses of wine per month, and walks approximately 2 miles per day. Her current medications include telmisartan, HCTZ, rosuvastatin, metformin, semaglutide and canagliflozin at optimized doses, and current A1c=9.2%. Her current A1c= 9.2% and is at HTN and lipid goal. Prior mediations have included sitagliptin, with patient stating, “That medication did not help my sugar at all.” She states she is adherent to her medications and dietary advice. Her eGFR is within acceptable parameters and she is feeling well. Physical exams are unremarkable. 

Which of the following is the most appropriate next step? 

A. Advise that her A1c is at an age-acceptable level.  

B. Add post-meal sliding scale rapid acting insulin 

C. Prescribe basal and pre meal insulin. 

D. Add oral glipizide.  

---

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Mrs. Mahem is a 68-year-old patient with a 25-year history of type 2 diabetes mellitus. In the past year, her A1c remains at around 8.5% with the use of the following medications: metformin, sitagliptin, and canagliflozin, at optimized doses and with adherence.  She states, “ I haven’t changed the way I eat and I walk about ½ h a day, just like I have for years”. Additional health issues include HTN and dyslipidemia, treated with medications and at therapeutic goal, and obesity with a BMI= 33. Her eGFR is 65. 

Which of the following is the most appropriate next step in the pharmacologic management of her diabetes?  

A. Add glyburide to enhance glycemic control.

B. Consider discontinuing metformin due to age and renal function.

C. Advise that her glycemic control is adequate for an older adult. 

D. Prescribe semaglutide to help her achieve A1c goal.  

---

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A patient presents with a chief complaint of a gradual onset vision change, present for the past 6 months, while denying eye pain, redness or trauma. The funduscopic exam, extraocular movements and pupillary reactions are within normal limits. When considering a diagnosis of presbyopia, which of the following best describes patient presentation? 

A. A 50-year-old who states, "I need to hold what I'm reading really far away in order to see it clearly". 

B. A 75-year-old who states,"When I look at a bright light, I see a colored halo around it".

C. An 80-year-old who states, "I have a blurry spot in the middle of my eyesight". 

D. A 17-year-old who states, "I went to get my driver’s license, but failed the distance vision exam".

---

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A 27-year-old woman presents as a new patient to your practice.  She is without chief complaint. She asks to, “get a refill on my birth control pills” , having used combined oral contraceptives for the past 12 years without adverse effects.  Social history reveals she is a nonsmoker, without recreational drug use, drinks approximately 1-2 mixed drinks per week, and runs 2-3 miles 5 days a week with reported excellent activity tolerance. Her health history is generally unremarkable, but with patient report of a “mild heart murmur that was picked up when I was a teenager during a physical I needed so I could run track. I was told not to worry about it.” Physical exam is unremarkable with the exception of a mid-systolic click followed by a grade II mid to late systolic murmur without radiation. The remainder of the cardiac exam is within normal limits. 

These findings most likely represent which type of murmur?

A. Physiologic

B. Aortic stenosis

C. Mitral regurgitation

D. Mitral valve prolapse
---
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A 29-year-old who is 8 weeks pregnant presents with a chief complaint of nausea and vomiting. She states, “I’ve been like this for three weeks. I don’t know why this is called morning sickness since I feel sick to my stomach almost all the time”, reporting that she vomits 2-3 times nearly every day, stating, “I was worse 2-3 weeks ago, when I was throwing up 4-5 times a day. I figured out what food really bothers my stomach and cut those out.” A 24-h dietary recall reveals frequent low-fat meals and consistent sipping of liquids. She denies thirst or infrequent urination, and reports, “I’m just tired of feeling this way. I’ve missed so much work and can hardly keep up with my 3-year-old.”  Physical exam reveals the following; Alert, appears fatigued, with moist mucous membranes,  a 1 lb. weight loss since last visit 4 weeks ago, and minimal epigastric tenderness without rebound.  

 The NP considers advising on the following:

A.  Initiate therapy with an oral  5HT-3 antagonist such as ondansetron (Zofran®).

B.  Referral to high-risk for advise on further management. 

C.  Advise on the use of daily dose of oral  vitamin B6  with doxylamine. 

D. Increase fluid and fiber intake.
---
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The NP sees  a 44-year-old male of African ancestry with a BMI=34 kg/m2 and recently diagnosed  type 2 diabetes mellitus. He works on a rotating shift in healthcare and reports eating irregularly. He was started on metformin therapy 4 months ago, is at maximum recommended dose, and states he is tolerating the medication well. His initial A1c was 9.8%, with today’s A1c=8.7%. eGFR is within acceptable parameters and he is feeling well, stating, 

“I was so thirsty and needed to urinate all the time before I started that pill”. Physical exam reveals extensive acanthosis nigricans.  He mentions that his health insurance. “Does not pay for all that much. I’m OK with paying for the pill I am taking now, but really cannot afford expensive medicines. “ Which of the following is the most appropriate next step?

A. Prescribe weekly injectable semaglutide. 

B. Adding post-meal sliding scale rapid acting insulin.

C. Add a daily dose of pioglitazone.

D. Add glipizide on days when his eating schedule is predictable. 
---
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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

In evaluating a 66-year-old man with dilated cardiomyopathy and heart failure, the NP notes a grade 3/6 medium-pitched blowing systolic murmur that radiates to the axillae. What do these findings most likely represent?

A.Innocent murmur

B. Mitral stenosis

C. Aortic regurgitation

D. Mitral regurgitation
---
YouTube: https://www.youtube.com/watch?v=jhrYmC-kq6Y&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=102

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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

A 72-year-old woman with severe COPD, who uses an inhaled LAMA/ LAMA daily on a set schedule and SABA via MDI as needed for symptom relief, presents with a 4-day history of URI symptoms, starting with sore throat and clear nasal discharge, without fever. She denies N, V, or other GI upset. She now reports a 2-day history of increasing shortness of breath and production of clear to white sputum. SaO2= 97% and she is no acute distress. In considering the diagnosis of COPD exacerbation, which of the following best describes the role of imaging in the evaluation of COPD exacerbation?

A. A chest x-ray should be ordered in COPD exacerbation in the patient with fever and/or low SaO2 to help rule out concomitant pneumonia.

B.  A chest x-ray should be ordered routinely in the evaluation of a person with COPD exacerbation.

C. Given the frequency of COPD exacerbations that typically occur in a person with COPD, chest x-ray use should be limited due to radiation exposure risk.

D. A thoracic ultrasound is the preferred imaging study to order in a COPD exacerbation.
---
YouTube: https://www.youtube.com/watch?v=B3LrB-m6Q7g&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=101

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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

A  45-year-old woman with no chronic health problems presents a 6-month history increasing fatigue despite adequate opportunity for rest , worsening dry skin and increased menstrual flow volume. In analyzing the laboratory data below, which is most consistent with the diagnosis of hypothyroidism?

A. TSH <0.15 mIU/L (0.4–4.0 mIU/L), free T4=79 pmol/L (10–27 pmol/L)

B. TSH=8.9 mIU/L (0.4–4.0 mIU/L), free T4=15 pmol/L (10–27 pmol/L)

C. TSH=1.9 mIU/L (0.4–4.0 mIU/L), free T4=22 pmol/L (10–27 pmol/L)

D. TSH=64 mIU/L (0.4–4.0 mIU/L), free T4=3 pmol/L (10–27 pmol/L)
---
YouTube: https://www.youtube.com/watch?v=vPaY65eXMwU&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=100

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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

Saundra is a 72-year-old with hypertension who is on an appropriate dose of an ACE inhibitor with adherence. Today’s BP= 152/96 and is without HTN-related complaint.  Physical exam is unremarkable.She has a history of well-controlled asthma and is using ICS/LABA therapy.  Due to osteoarthritis, she reports, “I get up slowly. Sometimes I do not get the bathroom on time and I lose my urine control.” Which of the following represents the next best step in Saundra’s HTN therapy?

A.Advise that her BP is in an acceptable range

B. Thiazide diuretic therapy should be initiated

C. Add a CCB to her current therapy

D. A beta blocker represents the optimal additional therapy
---
YouTube: https://www.youtube.com/watch?v=JRjErXhuqpY&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=99

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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

Josh is a well 16-year-old male who presents with a reporting a 4-day history of moderate left-sided otalgia with intermittent fever.  Clinical assessment is consistent with acute otitis media (AOM).  No drug allergy or recent (within the past month) antimicrobial use is reported.  Which of the following represents the most appropriate first-line antimicrobial therapy?

A. Oral moxifloxacin

B. Oral amoxicillin

C. Oral trimethoprim-sulfamethoxazole

D. Oral azithromycin
---
YouTube: https://www.youtube.com/watch?v=8qSpIir5ht4&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=98

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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

A 35-year-old w presents complaining of a 15+ year history of recurrent cramping abdominal pain that is often relieved with defecation that occurs intermittently. Symptom onset is often accompanied by bloating and a change in stool frequency and form, particularly when “I eat certain foods.” She denies bloody or tarry stools, nausea, vomiting or fever. The NP notes the patient’s weight is stable, and there is no evidence of anemia. The most likely diagnosis is?

A. Irritable bowel syndrome

B. Paralytic ileus

C. Peptic ulcer disease

D. Ulcerative colitis
---
YouTube: https://www.youtube.com/watch?v=2exovTbGVvI&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=97

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As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

The NP sees a 34-year-old woman with a chief complaint of 6-month history of increasing fatigue despite adequate opportunity to sleep and rest. Laboratory results reveal a microcytic, hypochromic anemia with elevated RDW. You expect to find which of the following upon review of the patient’s health history?

A. Report that she has been eaten a plant-based diet since age 18

B. History of prolonged menses with the need for =8 pads per day

C. Report of drinking 5 or more 5 oz glasses of wine daily

D. A prior diagnosis of rheumatoid arthritis
---
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Which of the following is most accurate about nurse practitioner’s scope of practice?

A. The organization that grants NP certification dictates a profession scope of practice.

B. The employer is able to require the NP to provide services that are beyond what regulatory bodies outline.

C. The law of the state where the NP practices provides regulatory guidance on scope of practice.

D. Federal law advises on NP scope of practice.
---
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A four-week-old infant born at 39 weeks’ gestation, exclusively breast fed and has been healthy was brought in for an evaluation following a 2 day history of projectile vomiting that occurs after each feeding without with increased fussiness. The child's father mentioned that the baby appears to be without distress after vomiting and wants to feed immediately afterwards. Parents deny the infant has had fever, diarrhea or skin lesion; in addition, has not had exposure to individuals with similar symptoms. His last BM was about 18 hours ago, described as small and firm. Physical exam reveals an alert, active infant with a small palpable mask that is appreciated in the right upper quadrant of the abdomen. The most likely diagnosis is:

A. Viral gastroenteritis

B. Pyloric stenosis

C. Intussusception

D. Gastroesophageal reflux
---
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A 25-year-old woman gravida 2, para 1 is 24 weeks pregnant and is being seen for an urgent care visit. She reports a constant headache over the past two days along with ankle swelling. Her BP today is 162/86 in, which is a significant elevation from her pre pregnancy blood pressure of 122/68.Laboratory results indicate 2 plus proteinuria as well as elevated ALT and AST. Platelets and LDH are within normal limits, as is fundoscopic and neurological exams. The most likely diagnosis is:

A. Health syndrome

B. Gestational hypertension

C. Preeclampsia

D. Hypertensive emergency
---
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A 77-year-old man is in for a routine follow up visit. He has its twenty-year history of type 2 diabetes and hypertension as well as a 5-year history of stage 3B chronic kidney disease, or CKB. At this visit, his A1C is 8.4% and his estimated GFR is 42 mL per minute. His BP is 128/76. He states he's feeling well and denies headache, visual changes, dizziness and hypoglycemic episodes. His medications include metformin, amlodipine, lisinopril and rosuvastatin. In reviewing his current medication, the NP considers which of the following options?

A. Prescribe glipizide

B. Add pioglitazone

C. Continue on his current medication without adjustment

D. Initiate therapy with Canagliflozin
---
YouTube: https://www.youtube.com/watch?v=rOuR7ATNdMQ&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=92

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A 72-year-old woman with a 20-year history of hypertension and dyslipidemia-- both at EBP goals with appropriate drug therapy, as well as a remote history of peptic ulcer disease-- presents for follow up. She is a nonsmoker, drinks about 1- 2 glasses of wine per week and denies the use of other substances. Her daily routine includes a 2- 3 mile walk and she denies history of acute coronary syndrome or other ASCVD related conditions. She mentions that one of her friends takes an aspirin a day to “prevent a heart attack or a stroke”, and further states, “I live alone, and I need to maintain my independence.” According to the latest recommendations from US Preventative Services Task Force, which of the following is the most appropriate advice regarding low dose aspirin use in this patient?

A. Start low dose aspirin therapy 81 mg daily as the vascular benefits outweigh the risk.

B. Best evidence for primary prevention of ASCBT event is with higher dose aspirin at 325 mg a day.

C. The risks associated with aspirin therapy in this patient outweigh the potential benefits.

D. Start aspirin therapy only if the patient has a family history of heart disease and 1st degree relatives.
---
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A 57-year-old man presents for a routine physical exam during history taking. He reports that he drinks approximately 7-to-8 12-ounce beers nightly and denies other substance use, including tobacco. His physical examination is unremarkable except for mild pharyngeal erythema without exudate. In consideration of his health history, which of the following lab results would be anticipated?

A. Elevated platelets

B. Macrocytosis

C. Lymphocytosis

D. Elevated sed rate
---
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Which of the following are the most common features of skin changes noted in areas of the feet affected by tinea pedis?

A. Widely distributed with consistently raised with areas of hyperpigmentation.

B. Localized to the dorsal aspect with central clearing and a raised border

C. Involving plantar crusting and interdigital fissures

D. Remains stable in size over time with lateral lichenification.
---
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Mrs. Martinez is a 64-year-old woman with 10 year-history of type 2 diabetes mellitus, HTN, and dyslipidemia. Her current medications include metformin, an SGLT-2 inhibitor, statin, ARB and thiazide diuretic. She is at EBP-advised goals including recent A1c=6.9%. Today, she reports she is feeling well. Her history and physical examination are unremarkable. She mentions that, for the past year, in addition to her prescribed medications, she drinks a special tea blend that her sister makes, taking this each day to help “draw out the sugar” in her blood. She states, “I feel much better when I take it.” Your most appropriate response is:

A. “I don’t believe the tea is helpful in controlling your blood sugar.”

B. "Please stop using the tea until I can look into its contents."

C. "Homemade teas might interact with your medicines”

D. “Tell me more about how the tea draws out the sugar.”
---
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A 76-year-old woman with presbycusis presents for a follow-up visit on HTN and dyslipidemia, treated with an ARB, thiazide diuretic and a statin, and at treatment goal. Which of the following is she likely to report?

A. Occasional difficulty with speech discrimination

B. Need to use her prescription eyeglasses to read

C. Altered sense of smell

D. Diminished sense of touch
---
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A 24-year-old adult, assigned female at birth, presents to your practice chief complaint of bilateral lower abdominal pain for the past three days, worsening over this time frame. She describes the pain as a heavy pressure like feeling, accompanied by intermittent fever , mild dysuria, yellow vaginal discharge, as well as nausea without vomiting nausea without vomiting. She is tolerating fluids well and has a markedly decreased appetite. Additional history of present illness includes recent LMP, ending about three days ago with normal timing and normal flow, she is sexually active with two male partners, and describes that the last episode of coitus six days ago was painful for deep pelvic discomfort. The physical exam reveals a temp of 100.4 Fahrenheit, rest of vital signs within normal limits, mild lower abdominal discomfort to light and deep palpation without rebound, yellow vaginal discharge and cervical motion tenderness without palpable pelvic mass. This clinical presentation is most consistent with:

A. Acute Appendicitis

B. Pelvic Inflammatory Disease

C. Ovarian Cyst

D. Ectopic Pregnancy
---
YouTube: https://www.youtube.com/watch?v=hS0zWLA9b_A&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=86

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A 14 yo presents with a 4 h history of sudden onset LLQ abdominal and scrotal pain, described as a pulling, burning sensation. He denies vomiting, diarrhea or constipation, and reports mild nausea and is taking fluids without difficulty. HPI is negative for recent trauma to the region, dysuria, penile discharge, genital lesions or fever. He reports milder, similar episodes during the past 3 months, “that just went away.” Physical exam reveals loss of the cremasteric reflex, negative Blumberg sign and a high riding left testicle.

A. Testicular Neoplasia

B. Acute Epididymitis

C. Incarcerated Inguinal Hernia

D. Testicular Torsion
---
YouTube: https://www.youtube.com/watch?v=cGczKmYTdVU&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=85

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A 24-year-old woman presents to your practice with a diagnosis of pelvic inflammatory disease, suitable for outpatient treatment. Which of the following is recommended? Chose two that apply.

A. A single dose of IM ceftriaxone

B. A two-week course of oral doxycycline and oral metronidazole

C. A five-day course of oral azithromycin with a one-week course of oral ciprofloxacin

D. A single dose of IM penicillin
---
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A 72-year-old man presents to primary care for a sick visit, with the chief complaint of a one-day history of fever, projective cough with yellow sputum and increasing shortness of breath. He denies GI distress but states his appetite is not what it usually is. He has a history of hypertension, type 2 diabetes, and dyslipidemia at guideline-based goals. He is a former smoker, quitting about 10 years ago with approximately a 35-pack-year history and was diagnosed 5 years ago with COPD.  Clinical assessment confirms the diagnosis of community-acquired pneumonia, suitable for outpatient treatment.  Which of the following represents the most appropriate antimicrobial option?

A. Oral levofloxacin

B. Injectable ceftriaxone

C. Oral azithromycin

D. Oral amoxicillin
---
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A 9-year-old female presents for well child care with her parent. She is in the 4th grade, doing well academically, plays soccer on a local team, and reports, “I have 3 best friends”. Health history per parent and child reveals no concerns. On physical exam the clinician's notes the child is at about 40th percentile height and weight for age, and has breast budding and downy, straight, slightly pigmented pubic hair long the labia majora.

These physical findings are consistent with:

A. Precocious puberty

B. Early onset normative puberty

C. Age-appropriate pubertal findings

D. Concern for a GNrH producing lesion
---
YouTube: https://www.youtube.com/watch?v=mD3dYdIPWmg&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=82

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A 40-year-old computer programmer presents for a sick visit with the chief complaint of a two-day history of low back pain. He reports the pain started after many hour stretch of doing yard work. The pain is described as a dull constant ache, worse with activity, better with rest, across the lower back, without radiation to the legs. He denies leg weakness, tingling, or numbness, and states he had similar pain in the past after doing extensive lifting. In considering the diagnosis of lumbar sacral strain, which of the following would most likely be noted on clinical assessment in this patient?

A. Diminished to absent lower extremity DTRs

B. Patient report of new-onset difficulty with voiding.

C. Paraspinal muscle tenderness

D. Positive straight leg raise test
---
YouTube: https://www.youtube.com/watch?v=DNBqP0V2m2A&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=81

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A 22-year-old woman who is 20-weeks pregnant was treated for C. trachomatis 4 weeks ago with an appropriate antimicrobial. She presents today for a follow-up visit and reports she is currently without symptoms, that her partner was also treated,  “And we both took the medicine just as we were advised.” Which of the following represents next steps in this patient’s care?

Choose two that apply. 

A. Testing for C. trachomatis should be obtained at today’s visit.

B. A repeat of C. trachomatis testing should be conducted at 1 month postpartum.

C. Given she is without symptoms and her partner was also treated, no further C. trachomatis testing is advised. 

D. In the absence of new clinical findings, follow-up test is advised at around 28-32 weeks gestation. 

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A 55-year-old man with a BMI of 40%, with the chief complaint of low back pain for the past two weeks. He describes the pain as originating in the lumbar sacral region, with radiation across the left buttock associated with numbness and tingling sensation in his left leg. The pain is worse with sitting and somewhat better with standing. He denies lower extremity weakness or a change in bowel or bladder function. He states, “I've tried ice, heat and ibuprofen and these just take the edge off. I've had back pain like this in the past. Usually just lasts a couple of days and it's not that bad. I'm going to try that again and it's not this bad.” This history of present illness is most consistent with:

A. Lumbar Radiculopathy

B. Spinal Stenosis

C. Vertebral Fracture

D. Lumbar Sacral Strain
---
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A 45-year-old adult presents for a sick visit, with the chief complaint of three-day history of low back pain. Clinical assessment is consistent with lumbar sacral strain. Which of the following represents the most appropriate next step in this person's care?

A. Advised three days of bed rest on a firm surface.

B. Apply ice or heat to the affected area based on clinical response.

C. Refer to neurology for further advice.

D. Order a lumbar sacral x ray to help confirm the diagnosis.
---
YouTube: https://www.youtube.com/watch?v=bNQp-Vq4jds&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=78

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You see a 44-year-old woman with a 6-month history of increasing fatigue despite adequate opportunity for sleep and rest.  Laboratory results reveal a microcytic, hypochromic anemia with elevated RDW as well as TSH within normal limits. You expect to find which of the following upon review of the patient’s health history?

A. Report that she has been consuming a plant-based diet since age 18

B. Report of menorrhagia

C. A history of alcohol use disorder

D. A diagnosis of rheumatoid arthritis
---
YouTube: https://www.youtube.com/watch?v=fSmpWW2doHE&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=77

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A 48-year-old woman presents for follow up on T2DM and HTN. As part of today’s visit, routine labs are ordered. Which of the following is an appropriate form of electronic communication for sharing these  results  with the patient?

A. Private message through Facebook® or similar social media website with patient permission

B. Electronic fax or scan uploaded to the patient’s personal account for a third-party file sharing service (e.g., DropBox®)

C. Using encrypted email  or other messaging service that is part of the patient’s electronic medical record (EMR) system 

D. Text message using the patient’s personal mobile phone number
---
YouTube: https://www.youtube.com/watch?v=MH2-1Wi0NWQ&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=76

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A 72-year-old man presents to primary care for a sick visit, with the chief complaint of a one day history of fever, productive cough with yellow sputum and increasing shortness of breath. His vital signs are as follows, temp 99.8 °F (37.6 °C) , BP 140/85, heart rate 98 beats per minute, and respiratory rate 22 at rest period O2 saturation is 94% on room air. He has a history hypertension and type 2 diabetes, at guideline-based goals. He is a former smoker, quitting about 35 years ago with approximately a 25-pack year history. On physical exam, he has crackles in his right lower lung fields, no wheezing, and can speak in complete sentences. He answers questions appropriately, has moist mucous membranes, and reports voiding approximately 1 hour ago. He denies GI distress but states his appetite’s not what it usually is. He lives in a single-story home with his spouse and adult child, both of whom are with him for today's visit. His laboratory results include a mild leukocytosis and renal function is within normal limits. There is no evidence of anemia, and chest X-ray confirms a right lower lobe infiltrate consisted with pneumonia. Which of the following is the most appropriate treatment location for this patient? 

A. Intensive care unit

B. At home with careful follow up

C. Inpatient medical ward

D. Long-term care facility
---
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A 49-year-old woman with type 2 diabetes mellitus was started on a standard dose of an ARB daily 6 weeks ago for the management of hypertension. Today her blood pressure is 128/78 mm Hg, stating she is taking the medication without difficulty and is feeling well. The appropriate action at this time would be to:

A. Order a white blood cell count to assess for neutropenia.

B. Continue her current medication regimen. 

C. Add HCTZ to enhance HTN control.

D. Obtain a 12-lead ECG
---
YouTube: https://www.youtube.com/watch?v=7Qai4U4zO5o&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=74

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Esteban is an 18-month-old child who presents with his father for a sick visit. The child, who is typically healthy and UTD with immunizations and has no drug allergies, has had URI-like symptoms for the past 6 days with congested cough and clear to yellow nasal discharge. Per parental report, Esteban is drinking fluids without difficulty and has a slightly reduced appetite and had a single episode of post tussive vomiting 3 days ago.  For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6 °F (39.2 °C), with father stating, “This is how he acted a few months ago when he had an ear infection.” Physical exam confirms the diagnosis of bilateral AOM. When prescribing an antimicrobial for this child, which of the following represents the first-line treatment option?

A. Oral azithromycin

B. Oral cefpodoxime

C. IM ceftriaxone

D. Oral amoxicillin
---
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An 18-month-old toddler, Estaban, presents with his father for a sick visit. The child, who is typically healthy and UTD with immunizations, has had URI-like symptoms for the past 6 days with congested cough and clear to yellow nasal discharge. Per parental report, Esteban is drinking fluids without difficulty and has a slightly reduced appetite and had a single episode of post tussive vomiting 3 days ago.  For the past 36 hours, his father reports increased crankiness and intermittent fever to 102.6°F   (39.2°C), with the father stating, “This is how he acted a few months ago when he had an ear infection.”  Which of the two following findings are most suggestive in the diagnosis of acute otitis media in a toddler?

A. Bulging tympanic membrane

B. Cough

C. Evidence of ear discomfort

D. Bilateral cervical lymphadenopathy
---
YouTube: https://www.youtube.com/watch?v=IrdfBpjYODQ&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=72

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A 60 year old man presents with a chief complaint of a 6 month history of increasing fatigue despite adequate rest and sleep. He denies chest pain or difficulty breathing, and reports he is a non smoker. Concurrent history includes a 25 year history of alcohol used disorder, with daily intake of 5-7, occasionally more, 1.5 oz shots of whiskey, and chronic poor nutrition, reporting, “I eat chips and crackers a lot, I do not have the time to make a meal and I cannot afford to eat out. He is currently employed as a warehouse working, and states, “I get to work every day. The booze is really not  problem.”  On physical exam, mild pharyngeal redness without exudate, conjunctival pallor, and epigastric tenderness are present. The following lab results are noted.

Hgb = 9 g/dL (normal 14 to 16 g/dL)

Hct = 28.5% (normal 42% to 48%)

RBC = 3.4 million mm3 (normal 4.7 to 6.1 million mm3)

MCV = 108 fL (normal 81 to 96 fL)

MCHC = 33.2 g/dL (normal 31 to 37 g/dL)

RDW = 18.4% (normal 11-15%)

 These findings are most likely caused by:

A. iron deficiency anemia

B. Vitamin B12 deficiency anemia

C. Folic acid deficiency anemia

D. Anemia of chronic disease.
---
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A 45 year old woman with a 10 year history of hypothyroidism presents for follow up care. She's been taking levothyroxine 100 micrograms per day with excellent adherence. Stating "I take the medicine every morning on an empty stomach with a big glass of water.” She states she's generally feeling well, but notices increased fatigue over the past four months, which she attributes to the stress of starting her graduate studies while working full time. The results of today's laboratory testing include the following:

TSH is 2.3, the norm being .4 to 4, pre T4 15 with norm being 10 to 27.

The next step in her care is to:

A. continue on the same levothyroxine dose and obtain a repeat TSH in one year.

B. increase the levothyroxine dose by 25 micrograms per day and repeated TSH in one month.

C. increase the levothyroxine dose by 25 micrograms per day and repeated TSH in two months.

D. Repeat the TSH and free T4 today and provide counseling about taking the medication with breakfast.
---
YouTube: https://www.youtube.com/watch?v=NOXdT0E5oFM&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=70

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A 28-year-old woman presents with new onset worsening fatigue, present for approximately the last month. She is 28 weeks pregnant with her second child, has a 1.5-year-old healthy child at home, says she remembers being tired towards the end of her pregnancy with her first child, but states, “This is worse than with my last pregnancy”. She denies vaginal bleeding or discharge, abdominal pain, or other concerning issues, is sleeping about 7 hours per night, and has adequate access to nutritious food. She is not taking a prenatal vitamin, reporting, “I kept throwing up every time I took one.” During early pregnancy. PHQ-9 screening tool results are without concern.

Labs results are as follows.

Hemoglobin 9.2g per dl (NL=12-14)

Hct=27% (NL=36-42%)

Total RBC= 2.9 million (3.9 to 5.2 million cells per microliter (million/µL)

MCV 75 FL (NL=80-98)

MCH 22 PG (NL=27-33)

RDW 18% (NL=11.5-15%)

These results are most consistent with:

A. Pregnancy related hemodilution.
B. Folic acid deficiency anemia
C. Iron deficiency anemia.
D. Beta thalassemia minor.
---
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A 35 year old presents with chief complaint of “my sinus infection is not getting better”, with continued nasal and sinus congestion, yellow to white nasal discharge, and a feeling of sinus pressure particularly when he bends over. He denies sore throat headache, and GI symptoms, and previously reported fever prior to treatment is now resolved. The EMR documentation notes a prescription for dose-appropriate amoxicillin with clavulanate written 2 1/2 days ago when seen for a sick visit. Patient states he has taken the antibiotic as advised, staring the medicine on the day of his sick visit, and has not missed any doses. Physical exam reveals a no acute distress, mild tenderness to sinus palpation, and no fever. The next most appropriate step in this patient's treatment plan is to:

A. Advise the patient to continue his current course of therapy.
B. Switch his antimicrobial to moxifloxacin.
C. Order a CT of the sinuses.
D. Perform a posterior pharyngeal culture and sensitivity.
---
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Joseph is a 14 year-old, generally well and up-to-date with health maintenance, who presents for a sick visit, stating, “My stomach has not been right for about 4  days. The illness began with a 36 h hx of gradual onset nausea, vomiting and loose stools, reporting “I’m not sure how many times I threw up or had diarrhea.” He last vomited about 24 h ago, last stool was around 4 h ago, reported as yellow-brown in color, small volume and without blood.  He has been tolerating  clear liquids for the past 24  h and voided a small amount around 2 h ago.  He feels “a little bit hungry but I am afraid to eat or I might throw up again. I still feel a little bit sick to my stomach.”  Joesph reports that he is on the wresting team at his high school and that, “For the past week, one guy after another got this same thing.” VS are within normal limits  and denies dizziness with position change from supine to sit or stand. His mucous membranes are slightly dry, with intact skin turgor, and  mild diffuse abdominal tenderness without rebound.  With a working diagnosis of viral gastroenteritis, which of the two following clinical actions should be taken?

A. Obtain stool for culture and sensitivity.
B. Order a chem panel.
C. Provide information about a slowly progressive diet as tolerated.
D. Prescribe an antiemetic.
---
YouTube: https://www.youtube.com/watch?v=_P1Ff1fWzJI&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=67

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Joseph is a 14 year-old, generally well and up-to-date with health maintenance, who presents for a sick with a 36 h hx of gradual onset nausea, vomiting and loose stools, reporting “I’m not sure how many times I threw up or had diarrhea.” He last vomited about 4 h ago, last stool was around 2 h ago, reported as yellow brown in color, small volume and without blood.  He has been tolerating a sips of clear liquids for the past 3 h and voided a small amount around 2 h ago. Joesph reports that he is on the wresting team at his high school and that, “For the past week, one guy after another got this same thing.” VS are within normal limits and his mucous membranes are slightly dry. The most likely cause of Joseph’s clinical condition is:

A. Staphylococcal food poisoning
B. Clostridium difficile (C. diff) enteritis
C. Viral gastroenteritis
D. Gastric ulcer
---
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Sonia is a 15 year old teen who plays varsity basketball and is generally well and up-to-date with health maintenance.  She presents for an urgent care visit with a 6-h history of sudden onset nausea, with multiple episodes of vomiting, abdominal cramping and 2 episodes of diarrhea with stool described as light to dark brown without visible blood. Her VS are within normal limits and mucous membranes are slightly dry. She has slightly hyperactive bowel sounds and mild exceptional tenderness without rebound.  When considering a diagnosis of staphylococcal food poisoning, which would most likely be reported by Sonia?

A. "One after another, the people on my basketball team have been getting sick like this during the past week."

B. "My basketball team stopped at a restaurant today to get something to eat on our way home from a game. Practically all of us who got turkey sandwiches are sick like this.”

C. "I had an ear infection a couple of weeks ago, and I took about 5 days of an antibiotic."

D. "I have really bad cramps during my period, and I take a lot of ibuprofen to help out."
---
YouTube: https://www.youtube.com/watch?v=_UylkKk9VkY&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=66

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The nurse practitioner sees a six week old with her parents for an urgent care visit. The family is of southeast Asian ancestry.  They voiced concern about “dark spots” over her lower back and buttocks that have developed over the past three weeks. The child was born after a full term pregnancy, went home with parents in 24 hours, has had an appropriate weight gain, and is meeting developmental milestones. On physical exam, the infant appears in no acute distress, and has blue to blue gray spots over the back, and the buttocks. The areas are flat with irregular shape and unclear edges and are noted in the areas that the parents report.  The areas of discoloration are 8 to 20 centimeters in diameter. Palpating the areas does not appear to elicit any discomfort in the child and the color does not blanch with pressure. The skin texture is within normal limits, and The physical exam is otherwise within normal limits. These findings are most consistent with:

A. cafe au lait spots
B. Congenital dermal melanocytosis
C. Port wine stain
D. Capillary Hemangioma
---
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A three year old otherwise well child for a sick visit. Her caregivers report that the child has been well, with the exception of a number of small, new skin lesions on the chin and arms, present for about 3 days. The child will occasionally rub the lesions, but does not complain about pain, has no fever, no other symptoms. Exam is consistent with non bullous impetigo, with approximately 6 lesions, all less than two to three centimeters in diameter, scattered over the chin and both arms. The child is in no acute distress, and age appropriately resist the exam. Which of the following is the preferred treatment option?

A. Topical bacitracin, polymyxin and neomycin cream
B. Mupirocin ointment
C. Oral trimethoprim sulfamethoxazole
D. Triamcinolone cream
---
YouTube: https://www.youtube.com/watch?v=1Pepu_wBoLk&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=63

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A 5 year-old otherwise well child presents with a 4-day history of “a skin problem”. . She is without fever and in no acute distress. Her parent advises that other children in the child’s playgroup have developed  similar skin lesions. Considering the diagnosis of non bullous impetigo, the NP expects to find which of the following?

A : A four-centimeter, round, honey-crusted lesion surrounded by about a 0.5 centimeter area of erythema, localized to the chin. 

B: Multiple papular skin lesions about 0.25 centimeters in diameter, with burrow marks in a linear fashion on both arms. 

C : A generalized vesicular rash over the trunk and extremities.  

D. : Areas of lichenification in the antecubital fossa. 
---
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A 33 year-old who is pregnant with her 2d child presents for prenatal care. She does not have record of her immunizations, but states she has not had any vaccines in more than 1 year. She is without complaint, and exam is consistent with gestational age, with FHT= 140 BPM and visible fetal activity. Today which two vaccines are recommended?

A: Measles, mumps, rubella. 
B: Varicella. 
C: COVID 19. 
D: Tdap or tetanus-diphtheria-acellular pertussis. 
---
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Which of the following is consistent with the clinical presentation of placental abruption? 

a. A 38 year-old with primary HTN, who is now 28 weeks pregnant with her 6th child, presents with a 1-h history of sudden onset abdominal pain as well as dark red vaginal bleeding,dizziness,  tachycardia and BP= 88/ 55

b. A 32 year old who's pregnant with her eighth child, now 32 weeks pregnant presenting with A2 hour history of bright red vaginal bleeding stating she does not have abdominal pain.

c. 28 year old who states she had a positive home pregnancy test three days ago with last menstrual period six weeks ago. Normal timing and flow with an 8 hour history of intermittent bright red vaginal spot spotting with mild cramping.

d. A 26 year old with a past medical history of pelvic inflammatory disease who's now 8 weeks pregnant by LMP with A2 hour History of sudden onset. Severe left sided abdominal pain radiating to the shoulder, Small amount of bright red bleeding per vagina. Feeling lightheaded. Vital signs reveal tachycardia in ABP of 80 / 45.

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The nurse practitioner sees a six week old with her parents for an urgent care visit. The family is of southeast Asian ancestry.  They voiced concern about “dark spots” over her lower back and buttocks that have developed over the past three weeks. The child was born after a full term pregnancy, went home with parents in 24 hours, has had an appropriate weight gain, and is meeting developmental milestones. On physical exam, the infant appears in no acute distress, and has blue to blue gray spots over the back, and the buttocks. The areas are flat with irregular shape and unclear edges and are noted in the areas that the parents report.  The areas of discoloration are 8 to 20 centimeters in diameter. Palpating the areas does not appear to elicit any discomfort in the child and the color does not blanch with pressure. The skin texture is within normal limits, and The physical exam is otherwise within normal limits. These findings are most consistent with:

A.  Cafe au lait spots
B.  Congenital dermal melanocytosis
C.  Port wine stain
D.  Capillary Hemangioma

---
YouTube: https://www.youtube.com/watch?v=CJnbvuB_iO0&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=59

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A 56-year-old man with a 10-year history of hypertension (HTN) presents for a primary care visit, stating he has not taken his HTN medications, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the past 3 months due to “running out of the medication and not getting to the pharmacy.” Today, his blood pressure (BP) is 192/120, and he is without complaint, denying shortness of  breath, chest pain or visual changes.  He states, “ I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a ½ hour.”  His physical examination shows no acute distress, grade 1 HTN retinopathy, and S4 heart sound, neck veins WNL, chest is clear, no peripheral edema with resting HR= 73, RR=16. 12-lead ECG is WNL. BMI= 33. Which of the following is the next best step in this patient’s care?

A.  Administer in-office oral clonidine and reassess blood pressure in 1 hour.
B.  Activate EMS with prompt transfer to emergency department
C.  Restart prior blood pressure medications with follow-up within the next month
D.  Advise restricting dietary sodium and weight loss to help with BP control.

---
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A 56-year-old man with a 10-year history of hypertension (HTN) presents for a primary care visit, stating he has not taken his HTN medications, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the past 3 months due to “running out of the medication and not getting to the pharmacy.” Today, his blood pressure (BP) is 192/120, and he is without complaint, denying shortness of  breath, chest pain or visual changes.  He states, “ I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a ½ hour.”  His physical examination is normal with the exception of which of the following?

A. S4 heart sound
B. Grade 3 HTN retinopathy
C. Neck vein distension
D. Murmur of aortic regurgitation

---
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A 12-month-old is seen for well child care. He has been walking solo since age 11 months, and now waves “bye-bye”, searches for an item under a blanket as well as using “mama” and “dada” specifically. His physical examination is within normal limits. Laboratory evaluation reveals a mild microcytic hypochromic anemia with an elevated RDW.  The NP considers which of the following two are the most likely contributing causes of this anemia. 

A. Vitamin B 12 deficiency

B. Plumbism

C. Iron deficiency

D. Beta thalassemia minor

---
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Ariel is a 7 month old infant, born at 40 weeks gestation, with Apgar scores of 9 and 10. The baby is up-to-date for well child care and immunizations and has had 2 minor episodic illnesses at aged 4 and 6 months with full recovery.  Ariel rolled tummy to back, started to purposely bring hands together, and babble at around age 4 months, and has had a social smile since age 2 months. Ariel is the youngest of three children, and today, parents mention that they are concerned that, “She’s not sitting up by herself yet. Our older kids were all sitting by now. She tries but then falls over.” Physical exam reveals a highly interactive healthy appearing infant with excellent muscle tone, who age appropriately resists exam. The NP considers which of the following? 

A.  Refer the infant to an early intervention program for additional evaluation. 

B.  Discuss a referral for genetic counseling with the child’s parents. 

C.  Advise that the child’s clinical presentation is consistent with normal parameters for an infant of this age. 

D.  Order testing for plumbism and iron-deficiency anemia. 

---
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A 22-year-old woman presents with a chief complaint of a 4-day history of mild dysuria, described as, “It burns a bit when I urinate.” She denies fever, GI upset, urinary urgency and frequency. About 1 month ago, she entered a relationship with a male partner who is currently without symptoms. Clinical assessment reveals a friable cervix covered by a thick yellow discharge. Suprapubic, CVA and cervical motion tenderness are absent.  UA is positive for leukocytes and negative for nitrites, and microscopic examination of vaginal discharge reveals a large number of white blood cells (WBCs).  She is in no acute distress. Thie presentation is most consistent with:

A.  Pelvic inflammatory disease

B.  Lower urinary tract infection

C.  Genital herpes

D. Chlamydia trachomatis cervicitis. 

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Which of the following applies when considering issues in clinical testing in a target disease? 

A.  A false negative result identifies a person with the target disease 

B.  A true positive result identifies a person with the target disease.  

C.  A true negative result allows for the patient and clinician to discuss treatment 
options for the target disease. 

D.  A false positive result supports a patient and clinician to discussion on  the impact of the target disease on the patient’s overall health. 

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A 68-year-old woman presents for follow-up at her primary care provider with a chief complaint of “another urine infection”, stating she was seen 4 days ago at urgent care with new onset dysuria and urinary frequency. A review of her clinical record reveals that she has had 3 symptomatic, culture-confirmed UTIs in the past 8 months.  She is currently on day 4 of 5 of the antimicrobial prescribed and is without symptoms. Her concomitant health issues include HTN and dyslipidemia, both at treatment goals with lifestyle modification and medication.  When discussing with the patient efforts to prevent future UTIs, the NP considers which of the following will be appropriate?

A. Adding cranberry juice supplements to her diet daily.

B. Avoiding tub baths.

C. Initiating long-term antimicrobial prophylaxis

D. Regular use of a vaginal estrogen.

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A 28 year-old woman presents with a 2-day history of urinary frequency, urgency and dysuria, stating, “This feels like when I had a urine infection 4 years ago.” She denies fever or GI upset and otherwise feels well.  In consideration of the diagnosis of lower UTI/cystitis, a urinalysis is ordered.  Which of the following is the most sensitive and specific finding for UTI caused by  a Gram-negative organism?

A. Positive leukocyte esterase

B. Presence of bacteriuria

C. Proteinuria

D. Positive nitrite

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YouTube: https://www.youtube.com/watch?v=LxjF5uUuSHg&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=51

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Which of the following examples represents a potential medical malpractice scenario?

A. A 25-year-old who is being treated for acute otitis media, reports penicillin allergy to the healthcare provider. An amoxicillin prescription is advised. The patient takes prescribed amoxicillin without adverse reaction.
B. A 40-year-old patient with acute bacterial sinusitis reports to his healthcare provider that his symptoms have not improved after 2 days of a dose-appropriate prescription for amox with clavulanate.
C. Before taking a medication, a 28-year-old patient realizes the wrong drug was dispensed at the pharmacy. She returned the prescription and the correct medication was dispensed.
D. A 50-year-old patient has an abnormal mammogram and was not advised by her healthcare providers about appropriate follow-up. A  mammogram  1 year later confirmed the prior findings, the HCP shared the findings and the patient was referred for further evaluation and breast biopsy.

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A 67-year-old man with a five-year history of heart failure with reduced ejection fraction presented to the ER approximately 7 days ago with worsening shortness of breath, and new onset orthopnea. He was hospitalized for two days, with medications adjusted, and states at that time his symptoms were significantly improved. The nurse practitioner now sees him in follow up. The patient states today that, “For the past day, I feel just like I did the day I was admitted to the hospital. I might even feel worse.”  The patient reports a 5 lb weight gain since arriving home from the hospital. He denies dietary indiscretion with high sodium foods and states he is taking all medications prescribed at hospital discharge as advised   On physical exam, he is sitting upright, slightly labored breathing,  BP=165/92, his resting heart rate=110 with S3 heart sound present, respiratory rate 26, neck veins to 8 cm, and bilateral crackles through the lung fields. The most appropriate next step in his care is to:

A. Perform medication reconciliation.
B. Obtain a detailed 48-hour dietary and fluid intake history.
C. Advise on the need for evaluation and treatment in the emergency department.
D. Ensure he has a cardiology follow-up within the next week.

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A 14-month-old is brought into the clinic for a well-child visit. Born at 39.5 weeks gestation, he has been healthy and is up-to-date with immunizations. The child started to walk at age 12 months and the parents note that “his feet look a little crooked when he stands and sometimes he will trip when he is trying to run because they curve in.”  The NP notes a mild inward curvature of the front half of the foot bilaterally,  with an intoeing positioning when he stands. The feet are flexible and the child walks with ease without evidence of discomfort during ambulation or on exam. There is no joint redness, heat, or swelling. This most likely represents: 

1. Pes planus. 
2. Club foot. 
3. Metatarsus adductus. 
4. Idiopathic juvenile arthritis. 

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A 68-year-old with atrial fibrillation is taking warfarin as part of therapy for the prevention of thromboembolic event.  His goal INR is 2-3, which is checked monthly and has been within acceptable range for the past 6 months. Today he presents with an INR=3.8. He denies bleeding events and reports, “I am taking my medicine just like I was told.” The NP considers that:

A. The INR should be repeated today.
B. A single dose of injectable vitamin K should be ordered.
C. His health history should be reviewed carefully, with a focus on interacting with medications and/or foods.
D.   His weekly warfarin dose should be increased by 15%.

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A 35-year-old woman presents for a well-woman exam. She is without complaint, with BMI=22, and reports that she runs about 28 miles per week, 4-5 miles with each run, and has excellent exercise tolerance. She states, “I am in great health.”  On physical examination, the NP notes a faint mid-systolic click followed by a grade 2/6  mid- to late-systolic murmur, best heard at the apex. No other abnormalities are noted.  These findings are most suggestive of

A. aortic stenosis
B. mitral stenosis
C. mitral regurgitation
D. mitral valve prolapse

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A 28-year-old woman who is breastfeeding her healthy 3-month-old term infant presents with a 48-hour history of generalized body aches, intermittent fever to 101.2 F, and localized pain on the upper aspect of her left breast. Nursing her child worsens the breast pain, while putting a cool compress on the area helps with pain control. She denies cough, GI symptoms or other skin alterations and does not have allergies to any medication. Physical exam is consistent with the diagnosis of lactation mastitis.  Which of the following represents the two best treatment options?

A. Discontinue breastfeeding on the affected side.
B. Prescribe an appropriate course of antimicrobial therapy.
C. Ensure that milk flow through the breast is encouraged via nursing as is tolerated or pumping.
D. Discard the milk from the affected breast.

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A nurse practitioner is newly licensed to practice. Which of the following best describes the NP’s ability to prescribe controlled substances?

A. Any NP who meets state-level requirements for a license to practice is able to prescribe controlled substances.
B. NPs are significantly restricted nationally from prescribing controlled substances.
C. NPs are able to prescribe controlled substances with significant physician oversight.
D. Controlled substance prescribing authority for NPs is regulated at the state and national level.

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The NP is seeing a 60-year-old woman with a 10 year history of T2DM. Her current medications include oral metformin and an oral SGLT2-I, and states she is feeling well, without report of blurred vision, excessive thirst or polyuria.  She has not had any laboratory tests done in the past 6 months.  Which of the following represents the best choice of test to determine her overall glucose control?

A. Fasting plasma glucose
B. Serum creatinine/ e GFR (estimated glomerular filtration rate)
C. Hemoglobin A1c
D. Random blood glucose

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A 21 year-old woman with a 15 year history of asthma. presents with acute bacterial rhinosinusitis; she is without fever and in no acute distress.  Her current medications include an ICS/LABA inhaler for reliever and prevention asthma therapy, and a LNG-IUD for contraception. She also reports being told by her parents that she has penicillin allergy, and states, “I had a pink rash on my face and body for a few days when I took penicillin at around 3 or 4 years-old.” In considering ABRS antimicrobial therapy for this patient, the preferred treatment option would be: 

A. Cefpodoxime
B. Azithromycin
C. Amoxicillin
D. Trimethoprim-sulfamethoxazole

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A 76 year-old man with a 20-year history of HTN presents for a sick visit in the primary care clinic, stating, “I do not think that new medicine agrees with me.”  Until recently, his BP was at goal with an ARB, but about 1 week ago, due to continued elevated readings, a second BP med, a thiazide diuretic, was added.  Which of the following is most likely to be reported by this patient?

A. “Since I started on the medicine, I passed out and woke up on the floor 4 times.”
B. “About 2 days after I started the new medicine, I started feeling lightheaded when I stand up quickly.”
C.” After starting the new medication, I feel like the room is spinning around me.”
D. “I’ve had chest pain and sweating off and on since I started the new medication.”

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A 60 year-old man who has a 10 year history of Parkinson disease presents with a chief complaint of “flaking skin that just does not go away, sometimes worse, sometimes better”, stating this problem has been present for > 6 years. Concurrent health issues include HTN, dyslipidemia and generalized anxiety disorder. The affected areas are occasionally itchy and will ache when particularly severe. He has used OTC hydrocortisone cream and skin moisturizers without seeing improvement. Physical exam reveals inflamed patches on the scalp, accompanied by greasy yellow scales. Similar lesions are noted in the nasolabial folds and behind the ears and into the ear canals. Which of the following is the most likely diagnosis?

A. Dandruff
B. Seborrheic dermatitis
C. Psoriasis
D. Atopic dermatitis

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A 35-year-old man who is generally well was diagnosed with scabies 3 days ago presents with a chief complaint. “I do not think that skin medicine I was given worked. I am still really itchy and the rash looks the same”.  He reports using topical permethrin as advised. Physical exam reveals excoriated papules on the interdigital area and scattered similar areas in the axillary and groin regions.  Microscopic examination of skin scrapings supports the scabies diagnosis.  He is otherwise without new findings. The NP considers the following:

A. Another course of permethrin is advised, to be used as soon as possible.
B. A skin biopsy should be performed today.
C. Low dose topical corticosteroids and oral antihistamines should be prescribed.
D. A topical antibacterial is advised.

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A 28-year-old woman with a longstanding history of injection drug use presents with a 10-day history of malaise, nausea, and fatigue, and a two day “yellow eyes”.  Physical exam reveals scleral icterus and mild hepatomegaly with right upper quadrant tenderness. Considering the possibility of acute hepatitis B in the differential, the NP anticipates laboratory results will include. 

A. The presence of hepatitis B surface antibody (HBsAb)
B. Thrombocytosis. 
C. Leukocytosis. 
D. The presence hepatitis B surface antigen (HBsAg). 

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A 22-year-old woman presents for follow-up after a recent clinic, requested STI screening. Testing for Chlamydia trachomatis was positive. She states, “I am really surprised, I feel fine.”  Her current medications include combined oral contraceptive and her LMP was about 10 days ago, with appropriate timing and a  3 day light flow. The NP considers which of the following is the best option?
A. Given she is asymptomatic, no further intervention is needed
B. Oral azithromycin as a single dose should be offered
C. Testing for C. trachomatis should be repeated today
D. A 7-day course of oral doxycycline is advised

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A 62-year-old woman with T2DM presents 2 days after noticing a “bug bite” on her left lower leg, stating, “I am not sure what bit me.” During this time, the area has increased in size and she reports discomfort in the region.  Examination reveals a tender warm, red, erythematous area with poorly demarcated borders, approximately 15 cm at its widest diameter on the anterior lower leg.  Calf circumference is equal bilaterally.  The patient is with no fever or additional complaints with no additional contributory history.  This most likely represents:
A. Deep vein thrombus
B. Erythema migrans
C. Cellulitis
D. Contact dermatitis 

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The NP sees a well, 18-month-old with a two-day history of clear nasal discharge, dry cough, intermittent fever to 101.4 or 38.5C, and mild crankiness. She's up to date with all recommended vaccination. Parents report everyone at home has this cold. Testing for RSV, COVID-19, influenza are all negative. She is alert, age appropriately resists the exam, which is consistent with viral URI.  Her father states, “We got her fever under control by giving her two different medicines around the clock.” He presents two medication bottles, one with liquid acetaminophen and one with liquid ibuprofen. The NP considers that alternating between ibuprofen and acetaminophen for a child with fever will:

 A. Result in additive effect in fever reduction.
B. Is encouraged in order to prevent febrile seizures.
C. Is only recommended in higher fever, such as when the fever is 100 degrees F or 38.8 degrees C or greater.
D. Is not recommended due to higher potential for adverse effects.

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The NP is seeing a 35 year-old well woman for a health promotion and physical exam woman. She has not complaints, is a nonsmoker, a light social drinker with 1-2 glasses of wine per month, and exercises about 30 mins 5 days a week. Her BMI is 22 and vital signs are unremarkable with BP= 110/70. Which of the following is an anticipated finding on her funduscopic exam?

A. Retinal arteries wider than veins
B. Arteriovenous nicking
C. Physiologic cup-to-optic disc ratio of less than 0.5 
D. Blurred optic disc margins

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A healthy 1 year old, accompanied by his mother, is in for a well child visit. He is due to receive routine immunizations for a child his age. His mother mentions that she is about 6 weeks pregnant and read that, “I know he should get the chickenpox and German measles vaccines today. Since I am pregnant, is this safe?” The NP considers the following:

A. Neither vaccine contain live virus and both can be given today.

B. Both vaccines contain live virus that the child will not shed, and he can receive these immunizations today.

C. The vaccines contain live virus and should be delayed until the mom is out of the first trimester of pregnancy.

D. Due to the mother’s pregnancy, these vaccines should be delayed until after she gives birth.

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A 78 year-old woman with well-controlled hypertension and dyslipidemia presents with a chief complaint of a many month history of pain, described as achiness, and stiffness in the joints both hands, particularly towards the end of the day. A part-time seamstress, she reports this discomfort is worse on work days.  She denies redness or heat in the affected regions and has no systemic complaints. Physical exam reveals Heberden and Bouchard nodes bilaterally. These findings are most consistent with a diagnosis of:

A. Rheumatoid arthritis
B. Systemic lupus erythematosus 
C. Osteoporosis
D. Osteoarthritis

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A 67-year-old man who is diagnosed with acute bacterial prostatitis presents with a chief complaint of a one-week history of constant perineal pain, arthralgia, irritative voiding symptoms, and intermittent fever. Which of the following is most consistent with anticipated findings on prostatic digital rectal exam (DRE) with this condition?

A. An enlarged prostate with obliterated median sulcus
B. A prostatic exam that reveals multiple firm, non tender nodular lesions
C. A tender, boggy prostate
D. A firm, non tender prostate

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Which of the following is most likely to be reported as part of the HPI in a woman presenting with bacterial vaginosis?

A. A 19-year-old woman with a 3-day history of vaginal and perineal itch, clumping white vaginal discharge that has a slight “musty” odor.

B. A 24-year-old woman with a 1-week history of mild perineal irritation, thin, grey-green vaginal discharge with a strong “fishy” odor.

C. A 68 year-old with chief complaint of vaginal irritation, discomfort on vaginal sexual activity, and denies unusual vaginal discharge or odor.

D. A 28 year-old woman with 10-day history of copious purulent yellow vaginal discharge without unusual odor, perineal irritation and mild dysuria.

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A 67-year-old man has been recently diagnosed with HTN, dyslipidemia and T2DM. As part of his medication treatment plan, he agrees to start statin therapy. The NP appreciates that which of the following laboratory tests should be conducted about 4-12 weeks after starting statin therapy?

A. AST and ALT
B. CK and potassium
C. Lipid profile
D. CBC with WBC differential and platelet count

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A 65-year-old woman has hypertension, dyslipidemia, type 2 diabetes, a 50 pack-year history of cigarette smoking, currently smoking ½ PPD,  and stage 3B chronic kidney disease (CKD)  (GFR = 37 mL/min/1.73 m2). She is not currently taking any dyslipidemia therapy and her LDL= 140 mg/dL. Which of the following represents the most appropriate pharmacologic intervention for treatment of dyslipidemia?

A. Owing to her age and comorbidity, no further intervention is required.

B. Moderate-intensity statin therapy is the preferred treatment option.

C. Niacin should be prescribed.

D. The use of ezetimibe (Zetia®) will likely be sufficient to achieve dyslipidemia control.

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Leonardo is a healthy 4- month-old who was born at 40-weeks gestation is in the office for a well child visit. His parents voice no concerns and state, “He is a very happy baby who loves to eat and is a good sleeper.” Which of the following is an anticipated normative developmental finding on an infant of this age?

A. Sitting without support  
B. Minimal to no Moro reflex noted
C. Rolling over tummy to back
D. Smiles when smiled to

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A 28-year-old woman G2P1LC1AB0, currently 22-weeks pregnant, presents with a 3-day history of urinary frequency and dysuria.  She is in no acute distress, without fever or vaginal discharge, reports “The baby is really moving around a lot” and denies GI symptoms. Fundal height is consistent with gestational age and FHT= 140 BPM and regular. UA dip in office is positive for leukocyte esterase and nitrites, yielding a working diagnosis of lower UTI.   Which of the following antimicrobials is preferred for the treatment of a UTI during pregnancy?

A. Doxycycline

B. Levofloxacin

C. Cephalexin

D. Azithromycin

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Robert has recently graduated from a NP program. During a job interview for an organization that has clinical sites in multiple states, he is asked questions about NP practice issues. Which of the following is accurate?

A.   Once I am nationally certified, I am also licensed to practice as an NP.

B. Once I am a certified NP and licensed to practice in one state, I will be able to practice in every state.

C. From state to state, NP practice acts are largely standardized.

D. NPs must obtain state-level prescriptive authority as well as a federal Drug Enforcement Agency (DEA) registration number in order to prescribe controlled substance.

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A 45-year-old woman presents for a sick visit with a chief complaint of 2–3-day sudden onset right elbow swelling with pain, stating, “I’ve never had pain like this. It looks like I have a swollen ball hanging from my elbow”.  She denies recent or remote injury to the area, fever, pain in other joints or skin lesions, and does report recently spending an extensive period of time on her computer due to a major work project. Physical exam reveals an area of painful sac-like swelling behind the right elbow, slightly warm, without redness or evidence of trauma. Joint range of motion (ROM) elicits discomfort but is largely intact. This clinical presentation is most consistent with: 

A. Rheumatoid arthritis 

B. Tendonitis 

C. Olecranon bursitis

D. Septic arthritis

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A 37-year-old adult was diagnosed with dyspepsia with documented H. pylori infection. An appropriate course of antimicrobial and proton pump inhibitor (PPI) therapy was prescribed and completed approximately 4 weeks ago. The patient states that the presenting symptoms have resolved and, “My stomach feels much better.” Which of the following is the most appropriate next step in care?

A.  Serologic test for H. pylori antibodies should be checked today.

B. The patient should be referred to gastroenterology for biopsy via endoscopy.

C. No further testing is needed as the patient’s symptoms have resolved.

D. Urea breath test should be conducted to confirm H. pylori eradication.

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Sarah is a 75 year-old woman with a 40 year history of HTN and a 30 year history of T2DM and dyslipidemia who was recently diagnosed with stage 4 chronic kidney disease (CKD). Given this history, which of the following hemograms would be expected? 

A. Hb = 9.7 g/dL (12 to 14 g/dL); MCV = 69 fL (80 to 96 fL); RDW=18% (11.5-15%)

B. Hb = 7.2 g/dL (12 to 14 g/dL); MCV = 122 fL (80 to 96 fL); RDW= 18.1% (11.5-15%)

C. Hb = 9.4 g/dL (12 to 14 g/dL); MCV = 83 fL (80 to 96 fL);  RDW= 13% (11.5-15%)

D. Hb = 10.4 g/dL (12 to 14 g/dL); MCV = 82 fL (80 to 96 fL); RDW= 18% (11.5-15%)

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Which of the following is a MEC Category 4 (use represents unacceptable health risk) to the use of a CHC (combined hormonal contraception method such as combined oral contraception [COC])?

A.  Mother with a history of breast cancer.

B. Personal history of hepatitis A at age 10 years.

C. Presence of factor V Leiden mutation.

D. Cigarette smoking one pack per day in a 22-year-old.

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You see a  17-year-old  woman with a long-standing history  of eczema and allergic rhinitis. Today she presents with worsening symptoms of skin lesions with itch for the past 2 months, now affecting the antecubital fossa of both arms, stating, “I get like this every winter but I am much better during warm weather. “  She is otherwise healthy. The most important aspects of skin care for this scenario is:

A.Daily use of medium to higher potency topical corticosteroids.

B. Twice-daily application of an antifungal cream.

C. Use of a topical antibiotic until skin lesions are clear.

D. Maintaining skin lubrication.

E. The use of low to medium potency topical corticosteroids to treat layers. 

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A 72-year-old woman with severe COPD, who uses an inhaled LAMA/ LAMA daily on a set schedule and SABA via MDI as needed for symptom relief, presents with a 4-day history of URI symptoms, starting with sore throat and clear nasal discharge, without fever. She denies N, V, or other GI upset. She now reports a 2-day history of increasing shortness of breath and production of clear to white sputum. SaO2= 97% and she is no acute distress. In considering the diagnosis of COPD exacerbation, which of the following best describes the role of imaging in the evaluation of COPD exacerbation?

A. A chest x-ray should be ordered in COPD exacerbation in the patient with fever and/or low SaO2 to help rule out concomitant pneumonia.

B.  A chest x-ray should be ordered routinely in the evaluation of a person with COPD exacerbation.

C. Given the frequency of COPD exacerbations that typically occur in a person with COPD, chest x-ray use should be limited due to radiation exposure risk.

D. A thoracic ultrasound is the preferred imaging study to order in a COPD exacerbation.

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The NP is seeing a 65-year-old woman who is a former smoker, having quit at age 40, with a 20 pack-year cigarette smoking history, and has been diagnosed with community-acquired pneumonia (CAP). Which of the following is most often noted CAP finding in an adult who is deemed to be appropriate for outpatient treatment? 

A. Pleuritic chest pain

B. Dyspnea

C. Purulent sputum production

D. Cough

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A 27-year-old, otherwise well, woman complains of recurrent headache that occurs every 1‒2 weeks and lasts up to 24 hours. During headache, she reports sudden onset of unilateral pulsating pain, nearly always on the left side that is accompanied by photophobia, phonophobia and mild nausea without vomiting. Her first headache occurred when she was approximately 12-years-old.  Her neurological exam is within normal limits. What is this clinical scenario most consistent with?

A. Cluster headache 
B. Tension-type headache 
C. Intracranial lesion 
D. Migraine without aura

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When advising a patient on the use of emergency contraception (EC) with levonorgestrel (LNG), which of the following is correct?

A. If pregnancy does occur post LNG EC use, a teratogenic pattern in the offspring has been noted

B. EC LNG must be used within 12 hours after unprotected heterosexual vaginal intercourse to provide EC benefit. 

C. LNG EC’s use is limited due to a number of common contraindications. 

D. LNG EC use does not result in the interruption of an established pregnancy.

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The NP is caring for a 68 year-old man with a 20 year-history of  type 2 DM, HTN, dyslipidaemia, obesity (BMI=32 kg/m2) stage 3a CKD who is currently taking all of the following medications at optimized doses and with adherence, ACEI, thiazide diuretic, statin, and metformin. His current A1c= 8.2%. (NL= <5-6%)  and states he is feeling well. Which of the following should be considered as next step therapy?

A. A sulfonylurea

B. Basal insulin

C. A SGLT2- inhibitor 

D. No additional therapy as he is feeling well.

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In which of the following situations is parental consent usually needed prior to treatment? 

A. A 16-year-old requesting information about contraception. 

B. A 17-year-old who wants help with smoking cessation. 

C.A 16-year-old requesting treatment for acne vulgaris. 

D. An 18-year-old who requests treatment for a sexually transmitted infection.

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The legal authority of a nurse practitioner’s scope of practice is defined by:

A. The organization that grants NP certification. 

B. The NP’s employer. 

C. The law of the state where the NP practices.    

D. Federal law.

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The nurse practitioner is seeing a 24-year-old man in follow-up visit.  Three weeks ago, he was diagnosed with allergic rhinitis,  reporting that, “ for years, every spring when the pollen count is high, I get a runny, stuffy nose, and itchy throat”.  He started on a regimen of daily use of an intranasal corticosteroid as a controller medication with PRN use of an oral second-generation antihistamine for more severe symptoms. Which statement indicates that the patient understands his medication instructions from the initial visit?

A.“I take my antihistamine every day and am saving the nasal spray for really bad pollen days.”

B. “I use my antihistamine every day and my prescribed nasal spray only when I have a really bad runny or stuffy nose.”

C. "I use my prescribed nasal spray as advised every day, but I notice I haven’t had to use the antihistamine for a week.”  

D."I can use either the antihistamine pills or the nasal spray since both work the same way.” 

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A 34-year-old woman presents with uncomplicated UTI. Her last menstrual period ended approximately 5 days ago and has a history of bilateral tubal ligation approximately 5 years ago. She is otherwise healthy, has not received a systemic antimicrobial in the past year, denies drug allergies, and is not taking any medications. Per local antibiogram,  E. coli resistance rate to TMP/SMX is about 25%. Which of the following is the best choice for her therapy? 

A. Prescribe a course of 3-day oral trimethoprim-sulfamethoxazole
B. Order a single dose of IM ceftriaxone
C. Prescribe a 5-day course of oral nitrofurantoin
D. Advise that a 1-week course of oral ciprofloxacin therapy is needed

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In evaluating a 66-year-old man with dilated cardiomyopathy and heart failure, the NP notes a grade 3/6 medium-pitched blowing systolic murmur that radiates to the axillae. What do these findings most likely represent?

A.Innocent murmur

B. Mitral stenosis

C. Aortic regurgitation

D. Mitral regurgitation

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In treating a 26-year-old man with panic disorder who is otherwise healthy, you consider prescribing:

A. Bupropion.

B. Alprazolam.

C. Citalopram

D. Risperidone

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Which of the following is a most often noted in a 65-year-old woman with osteoarthritis?

A. Anemia of chronic disease is often noted. 

B. Usually presents as a systemic polyarthritis.

C. Constitutional signs and symptoms, including fatigue and unintended weight loss are reported 

D. Typically impacts weight-bearing joints, particularly in early disease

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A 55-year-old woman with recently diagnosed hypertension was started on a standard dose of or a thiazide diuretic daily 6 weeks ago. Today her blood pressure is 128/78 mm Hg and the patient is feeling well, and clinical exam fails to reveal abnormal heart sounds or hypertensive retinopathy.  The appropriate action at this time would be to?

A. Consider switching her HTN medication to a calcium channel blocker

B. Continue on her current medication regimen 

C. Add an ACEI to enhance HTN control

D. Advise patient she needs to take her HBP for at least 1 more month prior to evaluating its effectiveness

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A  45-year-old woman with no chronic health problems presents a 6-month history increasing fatigue despite adequate opportunity for rest , worsening dry skin and increased menstrual flow volume. In analyzing the laboratory data below, which is most consistent with the diagnosis of hypothyroidism? 

A. TSH <0.15 mIU/L (0.4–4.0 mIU/L), free T4=79 pmol/L (10–27 pmol/L)

B. TSH=8.9 mIU/L (0.4–4.0 mIU/L), free T4=15 pmol/L (10–27 pmol/L)

C. TSH=1.9 mIU/L (0.4–4.0 mIU/L), free T4=22 pmol/L (10–27 pmol/L)

D. TSH=64 mIU/L (0.4–4.0 mIU/L), free T4=3 pmol/L (10–27 pmol/L)

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Saundra is a 72-year-old with hypertension who is on an appropriate dose of an ACE inhibitor with adherence. Today’s BP= 152/96 and is without HTN-related complaint.  Physical exam is unremarkable.She has a history of well-controlled asthma and is using ICS/LABA therapy.  Due to osteoarthritis, she reports, “I get up slowly. Sometimes I do not get the bathroom on time and I lose my urine control.” Which of the following represents the next best step in Saundra’s HTN therapy? 

A.Advise that her BP is in an acceptable range

B. Thiazide diuretic therapy should be initiated

C. Add a CCB to her current therapy

D. A beta blocker represents the optimal additional therapy

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Josh is a well 16-year-old male who presents with a reporting a 4-day history of moderate left-sided otalgia with intermittent fever.  Clinical assessment is consistent with acute otitis media (AOM).  No drug allergy or recent (within the past month) antimicrobial use is reported.  Which of the following represents the most appropriate first-line antimicrobial therapy?

A. Oral moxifloxacin

B. Oral amoxicillin 

C. Oral trimethoprim-sulfamethoxazole

D. Oral azithromycin

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A 35-year-old w presents complaining of a 15+ year history of recurrent cramping abdominal pain that is often relieved with defecation that occurs intermittently. Symptom onset is often accompanied by bloating and a change in stool frequency and form, particularly when “I eat certain foods.” She denies bloody or tarry stools, nausea, vomiting or fever. The NP notes the patient’s weight is stable, and there is no evidence of anemia. The most likely diagnosis is?

A. Irritable bowel syndrome

B. Paralytic ileus

C. Peptic ulcer disease

D. Ulcerative colitis

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The NP sees a 34-year-old woman with a chief complaint of 6-month history of increasing fatigue despite adequate opportunity to sleep and rest. Laboratory results reveal a microcytic, hypochromic anemia with elevated RDW. You expect to find which of the following upon review of the patient’s health history?

A. Report that she has been eaten a plant-based diet since age 18

B. History of prolonged menses with the need for =8 pads per day

C. Report of drinking 5 or more 5 oz glasses of wine daily

D. A prior diagnosis of rheumatoid arthritis

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