Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 2 — Questions and Answers
Question 1: An 82-year-old woman with hypertension and diabetes presents with acute confusion, fever of 101.8°F, and suprapubic discomfort. Urinalysis shows pyuria and bacteriuria. Which is the most appropriate next step?
- Treat empirically with oral trimethoprim-sulfamethoxazole for 3 days
- Obtain urine culture and initiate empiric antibiotics appropriate for her age and comorbidities (Correct answer)
- Obtain urine culture and defer antibiotics until culture results return
- Refer immediately to the ED for IV antibiotics
Correct answer: Obtain urine culture and initiate empiric antibiotics appropriate for her age and comorbidities
In an elderly patient with systemic signs of infection (fever, altered mental status), urine culture should be obtained but empiric antibiotics should be started immediately without waiting for results.
Question 2: A 74-year-old man on warfarin for atrial fibrillation presents with an INR of 5.8 but no active bleeding. What is the most appropriate management?
- Hold warfarin and administer 10 mg IV vitamin K
- Hold 1-2 doses of warfarin and recheck INR in 1-2 days (Correct answer)
- Continue warfarin at reduced dose and recheck INR in 1 week
- Administer fresh frozen plasma and admit to hospital
Correct answer: Hold 1-2 doses of warfarin and recheck INR in 1-2 days
For an elevated INR without bleeding, holding 1-2 doses and rechecking INR is appropriate management unless the patient has high bleeding risk factors.
Question 3: A 68-year-old woman with osteoporosis has been on alendronate for 5 years. She reports new jaw pain and her dentist found an exposed area of bone. Which complication should the NP consider?
- Osteogenesis imperfecta
- Osteonecrosis of the jaw (Correct answer)
- Trigeminal neuralgia
- Temporomandibular joint disorder
Correct answer: Osteonecrosis of the jaw
Osteonecrosis of the jaw (ONJ) is a rare but recognized complication of bisphosphonate therapy, especially following dental procedures.
Question 4: A 79-year-old man is brought in by his daughter who reports he has been confused at home for the past 3 days. He is on multiple medications including anticholinergics. His MMSE score today is 18. Which tool best identifies whether this is delirium superimposed on dementia?
- Geriatric Depression Scale
- Confusion Assessment Method (CAM) (Correct answer)
- Montreal Cognitive Assessment (MoCA)
- Clock Drawing Test
Correct answer: Confusion Assessment Method (CAM)
The Confusion Assessment Method (CAM) is the validated tool for detecting delirium, including when superimposed on underlying dementia.
Question 5: A 71-year-old woman with type 2 diabetes and CKD stage 3b (eGFR 32) presents for medication review. Which diabetes medication should be avoided given her renal function?
- Sitagliptin
- Metformin (Correct answer)
- Insulin glargine
- Dulaglutide
Correct answer: Metformin
Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² and should be used with caution and dose reduction at eGFR 30-45, making it inappropriate at eGFR of 32.
Question 6: A 77-year-old man presents with a 6-month history of urinary frequency, hesitancy, and nocturia three times per night. PSA is 2.1 ng/mL, DRE reveals a smooth, enlarged prostate. His AUA symptom score is 18. What is the first-line treatment?
- Finasteride alone
- Watchful waiting only
- Alpha-1 blocker (tamsulosin) (Correct answer)
- Immediate referral for TURP
Correct answer: Alpha-1 blocker (tamsulosin)
Alpha-1 blockers such as tamsulosin are first-line pharmacological treatment for moderate to severe BPH symptoms.
Question 7: A 65-year-old woman presents with a 2-week history of fatigue, weight loss of 8 lbs, night sweats, and a firm, non-tender left supraclavicular lymph node. The NP's primary concern should be:
- Reactive lymphadenopathy from a recent upper respiratory infection
- Malignancy requiring urgent evaluation (Correct answer)
- Thyroid disease causing lymph node enlargement
- Infectious mononucleosis
Correct answer: Malignancy requiring urgent evaluation
A firm, non-tender supraclavicular lymph node with constitutional symptoms (weight loss, night sweats, fatigue) is highly concerning for malignancy and requires urgent workup.
Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 2
An 82-year-old woman with hypertension and diabetes presents with acute confusion, fever of 101.8°F, and suprapubic discomfort.
Urinalysis shows pyuria and bacteriuria.
Which is the most appropriate next step?