Explorez tous les épisodes du podcast NP Certification Q&A

A healthy 30-year-old at 33 weeks' gestation presents for routine prenatal care in late September in the northeast USA. She's not previously received any vaccines. And about the past ten years and states, "I heard there are shots to protect the baby from RSV. My niece had this when she was a month old and got very sick". 

Which of the following is the best response?

A. Recommend a single dose of an FDA approved RSV vaccine as soon as possible. 

B. The maternal RSV vaccine is recommended with each pregnancy, preferably given in the first trimester.

C.  Given that her baby will be born outside of the typical RSV season, the use of maternal RSV vaccine is not recommended. 

D. The maternal RSV vaccine is given to provide protection to the mother but not the baby. 

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A 12-year-old male presents with his father for a routine Whelchel visit. The father asked to speak to you privately, as he's concerned that his son is, quote, showing some body changes. Close quote during the visit, the child is alert, interactive with physical exam findings consistent with Tanner's Stage three sexual maturation. He remains on his growth curve for height and weight. 

When discussing these findings with the father, which of the following is the most accurate statement? 

A. These findings are normal for his age.

B. This is an unusual finding in a 12-year-old. 

C. This signals he is likely nearly his adult height.

D. He just started puberty changes.

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A seven year old with a diagnosis of asthma since age to present with his parents for a new patient visit. He has cough, wheezing and shortness of breath 4 to 5 days per week and awakens with asthma symptoms about once weekly. His parents states when he's playing soccer, sometimes he needs to stop running because of his cough. So last visit with his prior PCP was about seven months ago when he was prescribed, according to his parents quote, "a pill to take every day to help control his cough". His last dose of this medication was about two months ago because the medication had no refills. 

He's currently using albuterol as needed. Two puffs, about 3 to 4 times a day. About. Five days per week to help control his cough and shortness of breath. The medication, per his parent quote, "works pretty well most times". The child is currently feeling well without evidence of acute asthma exacerbation. He is alert oriented, talkative, and able to demonstrate adequate inhaler technique. Peak expiratory flow rate is approximately 60% a predictor. 

 Which of the following is an appropriate preferred treatment option for this child? 

A. Continue current therapy as it is providing adequate symptom control.

B. They begin low dose ICS formoterol therapy, as maintenance and reliever therapy or marked therapy.

C. Begin daily montelukast albuterol as needed. 

D. Begin nebulizer budesonide twice daily with nebulizer albuterol as needed.

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A healthy 12 month old child is scheduled for a routine well, child's visit and age appropriate immunizations in three days. The parent message is the nurse practitioner and ask, quote, my mother told me to give her some acetaminophen Tylenol before she gets her shots. That way she won't be uncomfortable afterwards. I want to check with you first. Is this a good idea? 

A. Give acetaminophen about one hour before the appointment to relieve to prevent fever and injection site discomfort.

B. If she develops a fever or discomfort after the vaccines, you can give her an age and weight appropriate dose of acetaminophen as needed. 

C. Give ibuprofen at the time of the vaccinations and continue it every six hours for the first 24 hours. 

D. Try to avoid acetaminophen and ibuprofen for at least 48 hours after the vaccines, so that they can work as well as possible. 

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According to the latest American College of Cardiology and American Heart Association dyslipidemia guidance, in which of the following patients is it most appropriate to obtain a lipoprotein A level? 

A. A twenty-eight-year-old woman with obesity and polyendocrine metabolic ovarian syndrome, formerly known as PCOS, whose father had a myocardial infarction at age 48. 

B. A 47-year-old man with well-controlled hypertension for the past five years, without a family history of early cardiovascular disease and an LDL cholesterol of 92

C. A 35-year-old woman with episodic migraine since age 12 and an LDL of 72 who exercises regularly. 

D. A 52-year-old man with triglycerides of 320 related to uncontrolled type 2 diabetes. 

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A 55-year-old man is seen in follow up six weeks post hospitalization for acute coronary syndrome with drug eluding stent placement, has a 40-pack-year cigarette smoking history and currently smokes two packs of cigarettes per day. His medical history is also significant for stage 3-A CKD, with current estimated GFR of 52. His medications include high-intensity statin therapy and ezetimibe or Zetia, along with standard post ACS and CKD therapies. He states he's feeling well and taking all his medications as advised without adverse effects. Laboratory results today reveal an LDL cholesterol of 98, HDL of 35, triglycerides of 154. 

Which of the following is the most appropriate next step in lipid management? 

A. As he is feeling well, an LDL cholesterol is post ACS goal. Continue current therapy. 

B. Due to his GFR, discontinue Zetia and substitute with bempedoic acid. 

C. Add a PCSK9 inhibitor to current regimen. 

D. Advise that moderate intensity statin therapy is preferred in stage 3-A CKD.

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A 29-year-old patient presents with a genital lesion he first noted five days ago. The patient reports a new sex partner for the past four weeks with infrequent condom use. He denies dysuria, fever, urinary frequency, abdominal or scrotal pain, or penile discharge. Examination reveals a single well-defined ulcer on the shaft of the penis. The lesion is painless with a clear base and no purulent discharge. Mild non-tender inguinal lymphadenopathy is present. This clinical presentation is most consistent with:

A. genital herpes

B. primary syphilis

C. chancroid

D. Secondary syphilis

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 A 75-year-old woman presents to the urgent care service of her primary care provider's practice for a sick visit with a chief complaint of a two-day history of dysuria, urinary frequency, and urgency. She denies fever, flank pain, nausea, or vomiting. Her past medical history includes hypertension, stage three ACKD, and dyslipidemia. Current medications include an ARB, thiazide diuretic, statin, and an SGLT2i. Vital signs are stable. Physical exam is unremarkable except for mild suprapubic tenderness. Laboratory results include the following: Urinalysis, positive for leukocyte esterase and nitrites. Reference lab is negative for those substances. Estimated GFR is 48, Serum potassium is 4.8. 

Which of the following is the most appropriate treatment? 

A. Trimethoprim sulfamethoxazole DS

B. Nitrofurantoin

C. Ciprofloxacin

D. Amoxicillin

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A 38-year-old woman presents for a sick visit with a two-day history of, "not feeling right. I've never felt like this before." Approximately four days ago, she self-discontinued a standard dose SSRI after taking this medication for the past 18 months, stating, "I feel like my depression had gotten much better." She denies alcohol or recreational drug use. When considering the diagnosis of antidepressant discontinuation syndrome, which of the following is most likely to be reported?

A. tremor, diaphoresis, tachycardia, hypertension, agitation

B. yawning, rhinorrhea, abdominal cramping, diarrhea, piloerection

C. dizziness, nausea, body aches, sleep disturbance, irritability, brief vibrating sensations

D. restlessness, sweating, diarrhea, tremor, fever, and involuntary muscle jerking

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A 25-year-old woman presents for follow-up with a 12-year history of intermittent headache reported as unilateral throbbing pain with nausea, photophobia, phonophobia that usually lasts about 12 to 24 hours. At the onset of her headache, she takes oral high dose ibuprofen with Sumitriptan reporting, "my headache is usually gone within an hour or so." She reports no particular pattern to the headache trigger and denies headache prodrome. Family history is positive for mother and sister with similar headache. She's currently headache free and her neuro exam is within normal limits. Today she asked if she needs, "any tests to find out what causes my headache." The NP considers the following.

A. head MRI due to duration of headache

B. order a head CT with contrast due to frequency of headache

C. discuss the utility of carotid Doppler ultrasonography in confirming the diagnosis of migraine

D. advise the patient that neuroimaging is not routinely indicated in this clinical scenario

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The parents of a four day old infant born at 41.5 weeks gestation via normal spontaneous vaginal delivery after an uneventful pregnancy present with a chief complaint of a "rash" over the baby's face and body that began about 10 hours ago. They report that she is a vigorous nurser, has about six wet diapers and four yellow-green bowel movements in the past 24 hours. For the past 48 hours since she came home from the hospital with her mom, skincare has been limited to the use of a mild skin cleanser as needed. Physical exam reveals an alert child without fever and no acute distress with scattered erythematous macules and papules with occasional pinpoint pustules on the face, trunk, and proximal extremities.The rest of the clinical presentation is unremarkable. 

The most likely diagnosis is:

A. Neonatal Acne

B. Milia

C. Neonatal Herpes Simplex

D. Erythema Toxicum Neonatorum

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A 50-year-old woman presents for follow-up on recent lab tests obtained at a health maintenance visit. She reports feeling well and denies fatigue, weight changes, constipation, cold intolerance, palpitations, or changes in mood. She was recently diagnosed with subclinical hypothyroidism. 

Which of the following would be her expected lab results?

A. TSH of 8.6, elevated free T4 of 14, which is normal.

B. TSH of less than 0.15, undetectable. Free T4 of 79, markedly elevated.

C. TSH of 24, elevated. A free T4 of three, markedly reduced.

D. TSH of 1.8, which is normal and a free T4 of 14, also normal.

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A 29-year-old otherwise healthy adult presents with a five-day history of nasal congestion, clear to white rhinorrhea, sore throat, and dry cough. She also denies dyspnea, pleuritic chest pain, GI upset, or fever. The patient is in no acute distress. Vital signs are temperature 99.2 Fahrenheit or 37.3 degrees centigrade. Respiratory rate is 16. O2 sat is 98 % on room air. Physical exam reveals mild pharyngeal erythema without exudate, no lymphadenopathy and tympanic membranes within normal limits. Lung resam is unremarkable except for occasional cough. The nurse practitioner diagnoses a viral URI or a common cold. The patient states, “I have trip coming up in five days, and I'm really worried that I might have the start of a sinus infection or pneumonia or a strep throat.” 

The NP considers which of the following in addressing the patient's concerns? 

A. if you start to cough up phlegm within the next day or so, this could indicate the start of a pneumonia

B. If your nasal discharge turns to green or dark yellow, this usually indicates that an antibiotic is needed

C. your cough could persist for a couple of weeks, which is quite common in a viral respiratory tract infection

D. if your sore throat persists for two to three more days, it means that a strep infection is starting

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A six-month, two-week-old infant who was born at 40.5 weeks gestation after an uneventful pregnancy is brought in for a well child visit. His parents mentioned, “his older sister was a really different baby. I think he's not quite where she was in his development at this age.” Which of the following would not be a red flag requiring further evaluation? 

A. Inability to roll in either direction

B. Unable to transfer objects hand to hand

C. Reaches for objects with one hand

D. Ability to sit briefly without support

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Sarah, a healthy infant born at 40.5 weeks gestation after an uncomplicated pregnancy, is brought in for a four-month well child visit. Parents report the infant is feeding well, smiling frequently, and becoming more interactive with family members. 

Which of the following is most consistent with a normal developmental exam for an infant of this age?

A. Rolls back to abdomen and transfers objects hand to hand

B. brings hands together and laughs out loud

C. Lifts head briefly when prone and startles to loud sounds

D. Increase babbling and sits without support

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A 24-year-old woman presents for a well-adult visit. Her health history includes the diagnosis of mitral valve prolapse without significant mitral regurgitation. She is feeling well, has no chief complaint, and denies activity intolerance, stating she plays tennis or pickleball for about one hour three to four times a week. Her only medication is an oral combined hormonal contraceptive and reports being pleased with her contraceptive method. She states that she read online that “I know I have a heart murmur and I'm worried about whether the birth control pill is safe for me.” The nurse practitioner considers the following when advising this patient

A. she should switch to a progestin only contraceptive method

B. if no other contraindications are present, she can continue to use combined hormonal contraception

C. in this clinical scenario, barrier contraceptive method is advised

D. she should be referred to cardiology for advice on contraceptive methods

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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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