Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 4 — Questions and Answers
Question 1: An 84-year-old woman with advanced dementia is brought in by her son. She has lost 15% of body weight in 3 months and can no longer swallow safely. Her son asks about placing a feeding tube. What is the evidence-based recommendation?
- Recommend PEG tube placement to ensure adequate nutrition
- Recommend nasogastric tube as a temporary measure while awaiting recovery
- Advise that feeding tubes do not improve survival or comfort in advanced dementia and discuss hand-feeding (Correct answer)
- Refer to a gastroenterologist for tube placement decision
Correct answer: Advise that feeding tubes do not improve survival or comfort in advanced dementia and discuss hand-feeding
Evidence does not support feeding tube use in advanced dementia; hand-feeding with comfort-focused care is the recommended approach endorsed by major geriatric societies.
Question 2: A 72-year-old man presents with a serum sodium of 128 mEq/L, euvolemic exam, urine sodium of 42 mEq/L, and urine osmolality of 520 mOsm/kg. He takes an SSRI. What is the most likely diagnosis?
- Hypovolemic hyponatremia from diuretic use
- Syndrome of inappropriate antidiuretic hormone secretion (SIADH) (Correct answer)
- Hypothyroidism-induced hyponatremia
- Psychogenic polydipsia
Correct answer: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Euvolemic hyponatremia with elevated urine sodium and urine osmolality in a patient on an SSRI is consistent with SIADH, a known adverse effect of SSRIs.
Question 3: A 67-year-old woman with newly diagnosed stage I hypertension (BP 142/88) has no diabetes, CKD, or cardiovascular disease. She is African American. Which first-line antihypertensive is most appropriate per JNC/ACC guidelines?
- ACE inhibitor (lisinopril)
- Beta-blocker (metoprolol)
- Thiazide diuretic (chlorthalidone) or calcium channel blocker (amlodipine) (Correct answer)
- ARB (losartan) alone
Correct answer: Thiazide diuretic (chlorthalidone) or calcium channel blocker (amlodipine)
In Black patients without compelling indications, thiazide diuretics and calcium channel blockers are preferred as first-line agents due to better efficacy in this population.
Question 4: A 78-year-old man with chronic low back pain has been on hydrocodone/acetaminophen for 2 years. He now requests dose escalation. A urine drug screen is negative for opioids. What is the most appropriate interpretation?
- The test is a false negative; continue current management
- The patient may not be taking the medication as prescribed; this warrants a careful conversation (Correct answer)
- Order a repeat urine drug screen before making any changes
- Increase the dose since he likely has true opioid tolerance
Correct answer: The patient may not be taking the medication as prescribed; this warrants a careful conversation
A urine drug screen negative for prescribed opioids suggests the patient may be diverting or not taking the medication, requiring a direct and non-confrontational clinical conversation.
Question 5: A 65-year-old woman has a DEXA scan T-score of -2.8 at the femoral neck. She has no prior fractures. Her 10-year FRAX probability is 22% for major osteoporotic fracture. What is the recommended treatment?
- Calcium and vitamin D supplementation alone, recheck DEXA in 1 year
- Initiate bisphosphonate therapy plus calcium and vitamin D (Correct answer)
- Start raloxifene only
- Refer to endocrinology before initiating any therapy
Correct answer: Initiate bisphosphonate therapy plus calcium and vitamin D
A FRAX 10-year probability ≥20% for major osteoporotic fracture or a T-score ≤-2.5 with no other risk factors meets the threshold to initiate pharmacological therapy with bisphosphonates.
Question 6: A 71-year-old man with stable COPD presents with new exertional dyspnea and leg edema. Echo shows moderate pulmonary hypertension and right ventricular dilation. What is the most likely etiology in this clinical context?
- Left-sided heart failure causing pulmonary venous hypertension
- Cor pulmonale secondary to chronic hypoxemia from COPD (Correct answer)
- Idiopathic pulmonary arterial hypertension
- Pulmonary embolism causing acute right heart strain
Correct answer: Cor pulmonale secondary to chronic hypoxemia from COPD
In a patient with established COPD, pulmonary hypertension with right ventricular dilation is most consistent with cor pulmonale from chronic hypoxic pulmonary vasoconstriction.
Question 7: A 66-year-old woman with a 30 pack-year history is screened for lung cancer per USPSTF guidelines. She stopped smoking 4 years ago. Is she eligible for low-dose CT (LDCT) screening?
- No, she must be a current smoker to qualify for LDCT screening
- Yes, former smokers who quit within the past 15 years aged 50-80 with 20+ pack-years qualify (Correct answer)
- No, she would need a family history of lung cancer to qualify
- Yes, but only if she has respiratory symptoms
Correct answer: Yes, former smokers who quit within the past 15 years aged 50-80 with 20+ pack-years qualify
USPSTF recommends annual LDCT lung cancer screening for adults aged 50-80 with a 20 pack-year history who currently smoke or quit within the past 15 years.
Adult-Gerontology Primary Care Nurse Practitioner Exam Case Studies & Practical Application 4
An 84-year-old woman with advanced dementia is brought in by her son.
She has lost 15% of body weight in 3 months and can no longer swallow safely.
Her son asks about placing a feeding tube.
What is the evidence-based recommendation?