NP Certification Q&A

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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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.
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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.
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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."
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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
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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

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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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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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