Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 3 — Questions and Answers
Question 1: A 73-year-old woman with a history of GERD and osteoporosis is taking omeprazole daily for 4 years. At her annual visit, which monitoring concern is most relevant to her long-term PPI use?
- Liver enzyme elevation
- Hypomagnesemia and vitamin B12 deficiency (Correct answer)
- Hyperkalemia
- Elevated serum calcium
Correct answer: Hypomagnesemia and vitamin B12 deficiency
Long-term PPI use is associated with hypomagnesemia, vitamin B12 deficiency, and increased fracture risk, warranting periodic monitoring.
Question 2: An 80-year-old man with heart failure (EF 35%) is started on carvedilol. At his 2-week follow-up, he reports feeling much more fatigued and his BP is 88/54. What should the NP do?
- Discontinue carvedilol immediately and start digoxin
- Reassure him that fatigue is expected and continue current dose
- Reduce the carvedilol dose and optimize volume status before uptitration (Correct answer)
- Switch to metoprolol succinate at maximum dose
Correct answer: Reduce the carvedilol dose and optimize volume status before uptitration
Symptomatic hypotension and fatigue during beta-blocker initiation in HFrEF warrants dose reduction and volume optimization before attempting uptitration.
Question 3: A 69-year-old woman presents with 4 months of progressive dysphagia to solids, unintentional weight loss of 12 lbs, and occasional regurgitation. What is the most appropriate next diagnostic step?
- Empiric trial of PPI therapy for 8 weeks
- Barium swallow study
- Upper endoscopy (EGD) (Correct answer)
- Esophageal manometry
Correct answer: Upper endoscopy (EGD)
Progressive dysphagia with weight loss in an older adult is a red flag alarm symptom requiring urgent upper endoscopy to rule out esophageal malignancy.
Question 4: A 76-year-old man with COPD uses a long-acting beta-agonist and long-acting muscarinic antagonist. He reports 3 exacerbations last year. According to GOLD guidelines, what therapy should be added?
- Inhaled corticosteroid (ICS) (Correct answer)
- Oral theophylline
- Systemic oral prednisone daily
- Roflumilast only if eosinophils are elevated
Correct answer: Inhaled corticosteroid (ICS)
GOLD guidelines recommend adding an inhaled corticosteroid to dual bronchodilator therapy in COPD patients with frequent exacerbations (≥2/year or ≥1 hospitalization).
Question 5: A 70-year-old woman presents with sudden-onset severe headache she describes as 'the worst headache of my life,' with neck stiffness and photophobia. Vital signs show BP 162/94, temperature 98.6°F. What is the most urgent action?
- Perform a lumbar puncture in the office immediately
- Order an urgent non-contrast CT head and call 911/transfer to ED (Correct answer)
- Prescribe sumatriptan for a likely migraine and reassess in 24 hours
- Start dexamethasone and empiric antibiotics in the office
Correct answer: Order an urgent non-contrast CT head and call 911/transfer to ED
A thunderclap headache with meningeal signs is a medical emergency; immediate CT head to rule out subarachnoid hemorrhage and ED transfer are required.
Question 6: A 68-year-old man with type 2 diabetes and a BMI of 34 presents for follow-up. His A1C is 7.9%, and he has a history of ASCVD. Which medication addition would provide both glycemic control and cardiovascular benefit?
- Glipizide
- Pioglitazone
- Semaglutide (GLP-1 RA) (Correct answer)
- Sitagliptin
Correct answer: Semaglutide (GLP-1 RA)
GLP-1 receptor agonists such as semaglutide have demonstrated cardiovascular outcome benefits and are preferred in patients with T2DM and established ASCVD.
Question 7: A 75-year-old woman with moderate Alzheimer's disease and agitation is prescribed low-dose quetiapine by a consultant. She has a history of falls. What must the NP document when prescribing an atypical antipsychotic to this patient?
- Informed consent regarding increased risk of mortality in elderly dementia patients (Correct answer)
- Written approval from a geriatric psychiatrist
- Pharmacy benefits verification prior to prescribing
- Caregiver's agreement to monitor weight weekly
Correct answer: Informed consent regarding increased risk of mortality in elderly dementia patients
Atypical antipsychotics carry an FDA black box warning for increased mortality in elderly patients with dementia-related psychosis; informed consent must be documented.
Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 3
A 73-year-old woman with a history of GERD and osteoporosis is taking omeprazole daily for 4 years.
At her annual visit, which monitoring concern is most relevant to her long-term PPI use?