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Symptoms of systemic lupus erythematosus (SLE) that more commonly occur in children than in adults include:
Detailed Rationale
Children with SLE more frequently present with fever, lymphadenopathy, hepatosplenomegaly, and renal involvement. Dry eyes/mouth (Sjogren's) more common in adults.
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A 55-year-old male is diagnosed with hypertension. His blood pressure readings have been gradually increasing over time, with a reading today of 152/98 mm Hg. Diagnostic studies are normal. The MOST likely diagnosis for this patient is:
Detailed Rationale
Essential (primary) hypertension accounts for 90-95% of cases, with gradual onset, no identifiable cause. Resistant hypertension requires >3 medications; secondary has identifiable cause; isolated systolic has DBP <90.
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After completion of a 7-day course of doxycycline (Vibramycin) for the treatment of chlamydia, an 18-year-old patient returns to the clinic for a follow-up exam. Symptoms appear to have resolved, and the nurse practitioner explains to the patient that test-of-cure:
Detailed Rationale
CDC recommends test-of-cure for chlamydia only in pregnancy or if adherence concerns. Routine test-of-cure not indicated for non-pregnant patients if symptoms resolved and treatment completed. Rescreening at 3 months for reinfection is recommended.
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Which of the following patients should be evaluated for testicular cancer?
Detailed Rationale
Painless testicular mass or swelling is the classic presentation of testicular cancer, most common in 15-35 year olds. Gynecomastia, ED, joint pain/lymphadenopathy are not typical presentations.
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A 58-year-old male presents for a well exam. Examination reveals a full-thickness ulcer with surrounding callused skin on the plantar aspect of the first metatarsophalangeal joint of the right foot. He states that it is not painful. This condition is most likely:
Detailed Rationale
Neuropathic (diabetic) ulcers occur on plantar surface, are painless due to neuropathy, have callused borders. Pressure ulcers over bony prominences. Venous stasis ulcers have irregular borders, on lower leg. Bunion is deformity, not ulcer.
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Depressed mood and tooth erosion are present in a 22-year-old patient. Initially, the patient should be referred to a:
Detailed Rationale
Depressed mood + tooth erosion suggests bulimia nervosa (self-induced vomiting). Cognitive behavioral therapy is first-line treatment. Dentist can identify erosion but CBT addresses underlying disorder.
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The most appropriate treatment for a child with mild croup is:
Detailed Rationale
Mild croup is treated with supportive care: cool mist, hydration, reassurance. Corticosteroids (dexamethasone) may be used. Bronchodilators are for asthma; antibiotics for bacterial; decongestants not effective.
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A 55-year-old male has microscopic hematuria. He is otherwise asymptomatic. The initial test that is MOST sensitive for further evaluation of this patient is a(n):
Detailed Rationale
CT urography (abdomen/pelvis with contrast) is the most sensitive imaging for evaluating asymptomatic microscopic hematuria, detecting stones, tumors, or other causes. Cystoscopy is invasive, IVP less sensitive.
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A screening ultrasound on a 65-year-old patient shows an abdominal aortic aneurysm that is 5.5 cm in diameter. The patient is asymptomatic. The clinician should:
Detailed Rationale
AAA ≥5.5 cm in men or ≥5.0 cm in women, or symptomatic, or rapidly expanding, requires surgical referral. Surveillance not appropriate at this size. CT angiogram may be ordered by surgeon.
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Which of the following is NOT a prerenal condition that may lead to subacute kidney injury?
Detailed Rationale
Malignant hypertension causes intrinsic renal injury (hypertensive nephrosclerosis), not prerenal. Prerenal causes include volume depletion (diarrhea, decreased intake, overdiuresis) or decreased perfusion.
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A first-occurrence urinary tract infection is diagnosed in a 4-year-old female. Which of the following statements is true?
Detailed Rationale
E. coli is the most common uropathogen in children as well as adults. UTIs are not unusual at age 4; constipation may be a risk factor but not an absolute evaluation requirement; underlying anomalies are less likely with first UTI at this age.
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A recently divorced 29-year-old male reports poor appetite, low-grade fever, and malaise. His ALT is 650 U/L; AST is 250 U/L. Normal ranges: ALT 0-48, AST 0-42. This patient's lab results are most likely suggestive of:
Detailed Rationale
Markedly elevated ALT (>10-15x upper limit) with AST > ALT suggests acute viral hepatitis. Chronic hepatitis has lower elevations; acetaminophen toxicity typically has very high AST/ALT; alcoholic hepatitis has AST:ALT >2:1.
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A 55-year-old male has decided, through shared decision making with the NP, to be screened for prostate cancer. The preferred method of screening is:
Detailed Rationale
PSA alone is the preferred initial screening test per USPSTF and AUA. DRE adds little sensitivity when PSA is normal. TRUS is diagnostic, not screening.
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The NP advises a 49-year-old patient with hypothyroidism that the best exercise to decrease the risk of osteoporosis is:
Detailed Rationale
Weight-bearing exercises (walking, jogging, weight training) are most effective for bone density. Swimming and biking are non-weight-bearing; yoga improves flexibility but less impact on bone density.
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When evaluating a patient with depression and suicidal ideation, the NP knows that the patient who is most likely to successfully commit suicide is:
Detailed Rationale
Elderly white males have the highest suicide completion rate. Risk factors include male gender, older age, white race, depression, social isolation, physical illness.
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The CBC for a 48-year-old obese male with symptoms of obstructive sleep apnea shows elevated red blood cells. The best course of action is to order a sleep study and:
Detailed Rationale
Elevated RBCs in OSA suggest secondary erythrocytosis due to chronic hypoxia. Low-dose aspirin reduces thrombotic risk. Iron and B12 are for deficiency; melatonin not indicated.
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A grade school principal reports being exposed to a student with pertussis. The principal is currently asymptomatic. The best course of action is to:
Detailed Rationale
Post-exposure prophylaxis for pertussis is with a macrolide (azithromycin) within 21 days of exposure. Cephalosporins and fluoroquinolones are not effective for Bordetella pertussis.
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A patient reports he was diagnosed with hepatitis B infection 1 year ago and has not seen a healthcare provider since then. What information should this patient receive at this time?
Detailed Rationale
Chronic hepatitis B increases risk of hepatocellular carcinoma. It is not self-limiting in all; vaccine is preventive, not therapeutic; antiviral treatments exist.
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Chlamydia was diagnosed in a 23-year-old patient who is not pregnant. The recommended treatment is:
Detailed Rationale
CDC recommends doxycycline 100 mg BID x7 days for chlamydia. Azithromycin 1g single dose is alternative. Ceftriaxone is for gonorrhea co-treatment.
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Screening for type 2 diabetes in a child with BMI in the 85th percentile and at least one other T2DM risk factor should occur at minimum:
Detailed Rationale
ADA recommends screening overweight/obese children with additional risk factors starting at age 10 or at onset of puberty, then every 3 years. Starting at age 5 is incorrect; yearly is too frequent.
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A unique provider identification number is required for all healthcare providers, established by HIPAA Administrative Simplification Standard. The term for this number is:
Detailed Rationale
National Provider Identifier (NPI) is the unique 10-digit number required by HIPAA for all healthcare providers. It is standard across all payers.
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An otherwise healthy 12-year-old had elevated BP 2 weeks ago and now remains elevated, diagnosed with prehypertension. The MOST appropriate intervention is:
Detailed Rationale
For prehypertension in children, lifestyle modifications (diet, exercise, weight management) are first-line. Medications not indicated. Diagnostic workup may be considered but not first step.
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A 53-year-old male with BPH takes sildenafil for erectile dysfunction. The medication that is LEAST likely to interact with Viagra is:
Detailed Rationale
Finasteride (5-alpha reductase inhibitor) does not cause hypotension and has no significant interaction with sildenafil. Alpha-blockers (tamsulosin, alfuzosin, doxazosin) can cause additive hypotensive effects.
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A 67-year-old male has a 20 pack-year smoking history, quit 7 years ago. To screen for abdominal aortic aneurysm, the NP should order:
Detailed Rationale
USPSTF recommends one-time abdominal ultrasound screening for AAA in men aged 65-75 with smoking history. CT is more expensive with radiation; aortography is invasive.
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A 21-year-old female is suspected to have trichomoniasis. The most sensitive diagnostic test for detecting Trichomonas vaginalis in females is:
Detailed Rationale
NAAT is the most sensitive test for trichomoniasis. Wet prep sensitivity ~50-70%; culture is sensitive but slower; rapid antigen less sensitive than NAAT.
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Loud, hollow, high-pitched sounds heard anteriorly over the manubrium and posteriorly between C7 and T3 vertebrae is termed:
Detailed Rationale
Bronchial breath sounds are loud, hollow, high-pitched, heard over trachea and main bronchi (manubrium, C7-T3). Bronchovesicular are medium-pitched; vesicular are soft/low-pitched.
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A 22-year-old college student presents with cough for about 6 weeks. Which diagnosis would be in the differential list?
Detailed Rationale
Chronic cough (>4 weeks) differential includes asthma, post-nasal drip, GERD, and pertussis. Pneumonia, URI, acute bronchitis typically resolve within 3 weeks.
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A 16-year-old patient with mild inflammatory facial acne seeks treatment. The NP should prescribe:
Detailed Rationale
First-line for mild inflammatory acne: combination of topical retinoid + topical antimicrobial (benzoyl peroxide or antibiotic). Systemic antibiotics reserved for moderate-severe or refractory cases.
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A 41-year-old patient takes buspirone for anxiety but reports 3 panic attacks in the last week. The most appropriate class for short-term treatment of anxiety in this patient is:
Detailed Rationale
Benzodiazepines are indicated for short-term management of acute panic attacks/breakthrough anxiety. SSRIs/TCAs are first-line for maintenance but not acute relief. Beta-blockers for performance anxiety.
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A 50-year-old male reports several episodes of vomiting blood. Comorbid conditions that may lead to upper GI bleeding include:
Detailed Rationale
Cirrhosis (non-alcoholic or alcoholic) can cause portal hypertension, leading to esophageal varices and upper GI bleeding. GERD without esophagitis rarely causes bleeding; Crohn's affects lower GI; microcytic anemia is a consequence, not cause.
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Cigarette smoking while breastfeeding is associated with an increased risk of infant:
Detailed Rationale
Smoking during breastfeeding is associated with increased risk of infant respiratory infections, wheezing, and SIDS. Not specifically reflux, failure to thrive, galactosemia, or allergy as the primary association.
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A 30-year-old patient presents with generalized hyperpigmentation on both forearms and both knees. The patient states that she has been experiencing progressive weakness, fatigue, recent weight loss, salt craving, and intermittent episodes of dizziness. The physical exam reveals hypotension, an absence of axillary and pubic hair, and several hyperpigmented areas over the extremities. The MOST likely diagnosis is:
Detailed Rationale
Addison's disease (primary adrenal insufficiency) presents with hyperpigmentation, fatigue, weight loss, salt craving, hypotension, and loss of axillary/pubic hair. Cushing's has hypercortisolism; hypothyroidism doesn't cause hyperpigmentation.
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A 60-year-old patient with a history of rheumatic fever presents with complaints of dyspnea. While the patient is lying on their left side and holding their breath, the nurse practitioner auscultates a low-pitched diastolic murmur over the apex. This is most likely:
Detailed Rationale
Rheumatic fever history + low-pitched diastolic murmur at apex (with patient in left lateral decubitus) is classic for mitral stenosis. Pulmonary stenosis is systolic; mitral prolapse is mid-systolic click; aortic stenosis is systolic at right 2nd ICS.
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A 78-year-old female is accompanied by her adult child, who reports that her mother has become forgetful. The nurse practitioner should consider mild dementia if the patient has difficulty remembering:
Detailed Rationale
Forgetfulness interfering with daily activities (medication adherence) suggests mild cognitive impairment/dementia. Forgetting spouse's name or birthday suggests more advanced disease; forgetting how to start car indicates significant functional impairment.
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A 37-year-old female patient is pregnant for the first time. The most appropriate time for amniocentesis to be performed on a pregnant female patient is:
Detailed Rationale
Amniocentesis is typically performed between 15-20 weeks for genetic testing. Earlier (11-14 weeks) carries higher risk; later for lung maturity assessment.
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An urgent call is received from a patient's spouse, who states that their husband is having chest pain that is unrelieved by three nitroglycerin tablets. The nearest hospital is 40 minutes away. Besides having the patient reach the hospital as soon as possible, what intervention can the nurse practitioner suggest to increase the chances of a positive outcome?
Detailed Rationale
Aspirin 324 mg chewed as soon as possible in suspected MI reduces mortality. Continuing NTG beyond 3 doses without BP monitoring is unsafe; delaying care for BP check is not recommended.
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When considering a diagnosis of chronic kidney disease in a 65-year-old female, the criteria that is NOT considered diagnostic is:
Detailed Rationale
CKD is defined by GFR <60 mL/min or markers of kidney damage for ≥3 months. Identification of underlying cause is desirable but not required for diagnosis. Increased creatinine/urea alone is not specific.
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