Free AANP FNP Practice Test

Answer: B. Confirm with home or ambulatory blood pressure monitoring before diagnosing hypertension

Two readings at one visit aren't enough to label someone with hypertension. The USPSTF recommends confirming an elevated office reading with measurements taken outside the clinic before treatment starts. It treats ambulatory monitoring as the reference standard, with home monitoring as an alternative. Out-of-office readings also catch white-coat hypertension, which office readings can't separate from sustained high blood pressure.

Why not A: It skips confirmation. And even once stage 1 is confirmed, the 2025 AHA/ACC guideline starts adults with PREVENT 10-year risk under 7.5% and no cardiovascular disease, previous stroke, diabetes, or CKD on 3 to 6 months of lifestyle change, adding medicine if blood pressure stays at or above 130/80 mm Hg.

Why not C: An echocardiogram looks at the heart. It can't tell you whether his blood pressure is persistently high outside the office, which is the question in front of you.

Why not D: Under the ACC/AHA categories, 130–139/80–89 mm Hg is stage 1 hypertension, not normal. These readings need confirmation and follow-up.

Rule to remember: For routine elevated office readings like these, confirm outside the office before diagnosing or treating hypertension.

Sources: USPSTF: Hypertension in Adults: Screening (2021) — April 27, 2021; Clinician Summary; Screening Tests; AHA: Top Things to Know, 2025 High Blood Pressure Guideline — 2025 guideline summary; Blood pressure categories; medication thresholds; lower-risk lifestyle trial.

Answer: D. Delirium

The Confusion Assessment Method identifies delirium when there is an acute onset or fluctuating course and inattention, plus either disorganized thinking or an altered level of consciousness. She meets that pattern: a fluctuating 2-day change, inattention (she can't do months backward), and disorganized conversation. A possible trigger is in the history. Oxybutynin is a strongly anticholinergic drug, and the AGS Beers Criteria warn that anticholinergic exposure raises the risk of delirium in older adults. Assess promptly for other causes as well, including infection or metabolic illness.

Why not A: Dementia develops over months to years, and attention is usually preserved early on. A change over 2 days in someone who managed her finances last week points away from it.

Why not B: Depression can slow thinking, but it doesn't cause an abrupt, fluctuating loss of attention over 2 days.

Why not C: Normal aging doesn't cause a sudden drop in function or attention that comes and goes.

Rule to remember: Acute, fluctuating confusion with inattention: suspect delirium and look promptly for causes, including new medicines.

Sources: Confusion Assessment Method: HIGN clinical instrument — CAM author-copyright 2003; hosted clinical-instrument copy; PDF page 2: CAM diagnostic algorithm; American Geriatrics Society 2023 updated Beers Criteria — May 4, 2023; First-generation antihistamines; delirium/anticholinergics; strong-anticholinergic table.

Answer: A. Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days

This is acute uncomplicated cystitis in a healthy, nonpregnant, premenopausal woman. CDC lists nitrofurantoin, TMP-SMX (where local resistance is under 20%), and fosfomycin as appropriate first-line agents. A 5-day course of nitrofurantoin is the standard IDSA regimen, and it's a sound choice when you don't know local TMP-SMX resistance.

Why not B: It works, but CDC says fluoroquinolones should be reserved for situations where other agents aren't appropriate. A first-line agent is available here.

Why not C: Amoxicillin isn't among CDC's first-line agents for uncomplicated cystitis.

Why not D: That combination targets sexually transmitted infection rather than routine uncomplicated cystitis. The case does not establish an indication for it; absence of vaginal discharge by itself does not exclude an STI.

Rule to remember: Uncomplicated cystitis: choose a first-line agent and save fluoroquinolones.

Sources: CDC: Outpatient Clinical Care for Adults — April 16, 2024; Acute uncomplicated cystitis; IDSA/ESCMID acute uncomplicated cystitis guideline — 2010 guideline; published 2011; Recommendations for acute uncomplicated cystitis, recommendation 1.

Answer: C. Moderate bulging of the right tympanic membrane

CDC's pediatric summary, drawn from the AAP guideline, says a definitive diagnosis requires moderate or severe bulging of the tympanic membrane or new otorrhea not caused by otitis externa. Mild bulging counts only with ear pain that began within 48 hours or intense erythema. Bulging is the finding that separates acute infection from fluid alone.

Why not A: A crying child's eardrum often looks red. Redness without bulging or effusion doesn't establish AOM.

Why not B: Fluid without bulging fits otitis media with effusion, which isn't treated with antibiotics.

Why not D: Reduced mobility shows fluid behind the drum, but effusion alone isn't AOM.

Rule to remember: AOM needs the bulging/otorrhea criteria and middle-ear effusion; fluid alone is not AOM.

Sources: CDC: Outpatient Clinical Care for Pediatric Populations — April 22, 2024; Acute otitis media: diagnosis and management.

Answer: A. Reduce apixaban to 2.5 mg twice daily

The apixaban label calls for 2.5 mg twice daily in atrial fibrillation when a patient has at least 2 of 3 features: age 80 or older, body weight 60 kg or less, or serum creatinine 1.5 mg/dL or higher. She now meets two of them (age 82 and weight 57 kg), even though her creatinine is normal. She still needs stroke protection, so the change is a lower dose, not stopping.

Why not B: Creatinine is only one of the three criteria. Any two of them trigger the lower dose.

Why not C: Age alone isn't a reason to stop. It's one of the dose-reduction criteria.

Why not D: Aspirin isn't a recommended substitute for oral anticoagulation to prevent stroke in atrial fibrillation.

Rule to remember: Apixaban for AF: any 2 of age 80 or older, weight 60 kg or less, creatinine 1.5 mg/dL or higher means 2.5 mg twice daily.

Sources: Eliquis (apixaban) U.S. prescribing information — DailyMed label; Section 2.1: Recommended Dose in Adult Patients; 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline — 2023 guideline; Recommendations for antithrombotic therapy: aspirin is not an alternative to anticoagulation.

Answer: B. Annual low-dose chest CT

The USPSTF recommends annual low-dose CT for adults aged 50 to 80 with at least a 20 pack-year history who currently smoke or quit within the past 15 years. He's 58, has 30 pack-years, and quit 10 years ago, so he qualifies. Screening stops once someone has gone 15 years without smoking or develops a health problem that limits life expectancy or the ability or willingness to undergo curative lung surgery.

Why not A: Chest radiography isn't the recommended screening test. The USPSTF recommendation is for low-dose CT.

Why not C: The window is 15 years since quitting, not 5. He's at year 10.

Why not D: Sputum cytology isn't a recommended lung cancer screening test.

Rule to remember: USPSTF: ages 50–80, 20 or more pack-years, and smoking now or quit within 15 years support annual low-dose CT when screening remains appropriate.

Sources: USPSTF: Lung Cancer: Screening (2021) — March 9, 2021; Recommendation Summary; eligibility and discontinuation.

Answer: D. A topical retinoid combined with benzoyl peroxide

The 2024 AAD guideline supports combining treatments that work on different causes of acne. A topical retinoid clears and prevents comedones, and benzoyl peroxide kills acne bacteria without creating antibiotic resistance. A fixed-dose adapalene–benzoyl peroxide product is one way to do this.

Why not A: The AAD recommends isotretinoin for severe acne or acne that has failed standard treatment. This untreated presentation supports starting with topical combination therapy.

Why not B: Using a topical antibiotic by itself encourages resistance. The AAD advises pairing antibiotics with benzoyl peroxide.

Why not C: Oral antibiotics should be time-limited and combined with topical therapy, not used alone for a year.

Rule to remember: Combine mechanisms, and pair an acne antibiotic with benzoyl peroxide rather than using antibiotic monotherapy.

Sources: AAD: Acne clinical guideline — 2024 guideline; Guideline highlights; good clinical practices; AAD: Updated guidelines for the management of acne — January 31, 2024; Strong recommendations and good-practice statements, including isotretinoin.

Answer: C. Likely viral pharyngitis; give supportive care without strep testing or antibiotics

Clinical features alone can't reliably distinguish strep from viral pharyngitis when viral features are absent. Here, though, cough, runny nose, and hoarseness clearly point to a virus. CDC recommends no group A strep testing for patients with clear viral symptoms and no antibiotics for viral pharyngitis.

Why not A: Clear viral symptoms make routine group A strep testing unnecessary in this case. Testing is not the next step merely because the throat hurts.

Why not B: Strep can't be diagnosed from the exam, and her features make it unlikely. Antibiotics would add side effects without benefit.

Why not D: Neither culture nor empiric penicillin is indicated for this clear viral presentation. A throat culture can diagnose group A strep in appropriate cases; adulthood alone does not make it an invalid test.

Rule to remember: Clear viral pharyngitis features: no routine strep test and no antibiotics.

Sources: CDC: Clinical Guidance for Group A Streptococcal Pharyngitis — November 18, 2025; Clear viral symptoms; diagnosis; treatment.

Answer: A. One-time abdominal ultrasonography

The USPSTF recommends one-time ultrasound screening for abdominal aortic aneurysm in men aged 65 to 75 who have ever smoked. "Ever smoked" includes former smokers, no matter how long ago they quit.

Why not B: Ultrasonography is the standard screening test. CT angiography isn't the recommended screen for an asymptomatic man.

Why not C: The recommendation is one-time screening, not yearly.

Why not D: Former smokers count. The criterion is having ever smoked.

Rule to remember: Men 65–75 who have ever smoked: one-time abdominal ultrasound.

Sources: USPSTF: Abdominal Aortic Aneurysm: Screening (2019) — December 10, 2019; Recommendation Summary; Clinician Summary.

Answer: C. Breath or stool antigen test at least 4 weeks after treatment, off PPIs for at least 2 weeks

The 2024 ACG guideline supports testing everyone for cure after treatment, using a test that detects active infection. Testing should wait until at least 4 weeks after antibiotics are finished, and ACG's own summary says patients should be off proton pump inhibitors for at least 2 weeks first. Otherwise, lingering drug effects can cause false-negative results.

Why not A: Antibodies can stay positive long after cure, so serology can't tell you whether the infection is gone.

Why not B: Feeling better doesn't prove eradication. ACG supports a test of cure for every treated patient.

Why not D: Biopsy-based testing is one option, but a noninvasive breath or stool test works without an endoscopy.

Rule to remember: Prove cure with a test of active infection at least 4 weeks after antibiotics and after at least 2 weeks off PPIs.

Sources: ACG: H. pylori guideline summary (2024) — September 2024; Key Concepts: proof of eradication after treatment.

Answer: B. Measure a total serum or transcutaneous bilirubin now

The 2022 AAP guideline says bilirubin should be measured as soon as possible in any infant noted to be jaundiced in the first 24 hours after birth. Early jaundice isn't assumed to be physiologic, and measured levels, not appearance, drive the next decision.

Why not A: Jaundice in the first 24 hours needs a measured bilirubin, not reassurance.

Why not C: Visual estimates of jaundice are unreliable, and the AAP calls for measuring now.

Why not D: The AAP recommends against water or dextrose water to prevent or treat high bilirubin.

Rule to remember: Jaundice in the first 24 hours: measure bilirubin now.

Sources: AAP: Management of Hyperbilirubinemia in Newborn Infants (2022) — 2022; infants at least 35 weeks gestation; Key Action Statements 2 and 4.

Answer: D. Start high-dose glucocorticoids immediately and arrange emergency specialist assessment and biopsy

This is suspected giant cell arteritis with a visual warning sign, and vision loss can become permanent. Treatment shouldn't wait for confirmation. Arrange emergency ophthalmic/specialist assessment while starting treatment. The 2021 ACR/Vasculitis Foundation guideline conditionally favors IV pulse glucocorticoids for threatened vision loss and a temporal artery biopsy within 2 weeks of starting glucocorticoids. Biopsy can still provide useful information later; treatment must not wait for it.

Why not A: That delays treatment while her vision is at risk. Biopsy is ideally obtained within 2 weeks after glucocorticoids start, but can remain informative beyond that.

Why not B: An NSAID doesn't treat vasculitis, and waiting 2 weeks risks blindness.

Why not C: A routine outpatient brain MRI delays emergency treatment and isn't the appropriate response to threatened vision. ACR conditionally prefers temporal artery biopsy over cranial-artery MRI for establishing GCA in its stated U.S. setting.

Rule to remember: Suspected GCA with visual symptoms: treat immediately, arrange emergency assessment, and confirm afterward.

Sources: ACR/Vasculitis Foundation: Giant Cell Arteritis Guideline (2021) — 2021; Printed pp. 1074 and 1076; diagnostic testing and initial treatment (PDF pages 5 and 7).

Answer: A. Whether she has ever had migraine aura

Aura means focal, reversible neurologic symptoms, such as spreading zigzag lines or one-sided numbness; it can occur before, during, or without a headache. Under the U.S. Medical Eligibility Criteria, migraine with aura is category 4 (unacceptable health risk) for combined hormonal contraception because estrogen adds to the stroke risk. Migraine without aura is category 2. If she has aura, choose a non-estrogen option using the eligibility criteria for that method.

Why not B: Family history doesn't change her eligibility for estrogen. Her own aura status does.

Why not C: Menstrual history belongs in contraceptive care, but it does not answer the immediate migraine-with-aura safety question.

Why not D: Caffeine response doesn't distinguish migraine with aura from migraine without aura.

Rule to remember: Aura changes everything for estrogen.

Sources: CDC: U.S. MEC, Combined Hormonal Contraceptives (2024) — U.S. MEC 2024; Headaches/migraine; drug interactions: St. John’s wort.

Answer: B. Diabetes is confirmed; no additional test is needed to confirm diabetes

An A1C of 6.5% or higher meets the ADA threshold for diabetes. When there's no unequivocal hyperglycemia, the diagnosis needs two abnormal results: two different diagnostic tests from the same sample, or repeat testing at a different time. He has two abnormal A1C results from separate samples, so the diagnosis is confirmed.

Why not A: Prediabetes by A1C is 5.7% to 6.4%. Both of his results are above that range.

Why not C: No third test is required. Two abnormal results already confirm the diagnosis.

Why not D: Diabetes thresholds don't shift with age.

Rule to remember: Without unequivocal hyperglycemia, confirm with two different abnormal diagnostic tests or an abnormal test repeated at another time.

Sources: ADA Standards of Care in Diabetes—2026, Section 2 — January 2026; Table 2.1 and confirming diagnosis, printed S28 onward (full-supplement PDF page 34).

Answer: C. Parent training in behavior management

For children from age 4 to the 6th birthday, the 2019 AAP guideline says behavioral treatment comes first: evidence-based parent training in behavior management, with behavioral classroom interventions if available. Methylphenidate may be considered if these don't bring significant improvement and moderate-to-severe problems continue.

Why not A: At this age, medication is a second step after behavioral treatment, used when that isn't enough or isn't available.

Why not B: The AAP's first line for preschoolers is behavioral treatment, and the medication it names as a later option is methylphenidate.

Why not D: The AAP recommends treating ADHD from age 4. Waiting leaves a moderately impaired child without help.

Rule to remember: Age 4 to the 6th birthday: behavior therapy first.

Sources: AAP: ADHD Key Action Statement 5a — 2019 guideline, official AAP KAS page; KAS 5a: preschool treatment.

Answer: D. Persistent airflow obstruction consistent with COPD

GOLD requires spirometry to diagnose COPD, using a post-bronchodilator FEV1/FVC ratio below 0.70 to identify airflow obstruction. His ratio of 0.62 after bronchodilator, together with heavy smoking and chronic productive cough, is consistent with COPD. Because a single ratio between 0.60 and 0.80 can vary, repeat spirometry on a separate occasion to confirm persistent obstruction. The pattern is not specific to COPD by itself.

Why not A: A low FVC with a preserved or high ratio can suggest restriction, but total lung capacity is needed to confirm it. His reduced ratio shows obstruction.

Why not B: A post-bronchodilator ratio below 0.70 meets the GOLD threshold for obstruction.

Why not C: Asthma can also cause persistent obstruction. This result alone cannot prove asthma; the smoking history and chronic symptoms make COPD the better fit, with repeat confirmation needed.

Rule to remember: Post-bronchodilator FEV1/FVC below 0.70 supports obstruction; use clinical context, and repeat a single ratio of 0.60–0.80.

Sources: GOLD Executive Summary: spirometry and diagnosis — 2023 executive summary; Diagnosis: Forced Spirometry.

Answer: B. Stop lisinopril and start labetalol or extended-release nifedipine

The 2025 AHA/ACC guideline names labetalol and extended-release nifedipine as the preferred agents in pregnancy. It says ACE inhibitors, ARBs, atenolol, direct renin inhibitors, and mineralocorticoid receptor antagonists shouldn't be used, to avoid fetal harm. It also recommends treating chronic hypertension in pregnancy to below 140/90 mm Hg and counseling about low-dose aspirin.

Why not A: ACE inhibitors shouldn't be used once someone is pregnant.

Why not C: ARBs carry the same fetal risk and are on the same do-not-use list.

Why not D: The guideline recommends treating chronic hypertension in pregnancy, and 3 months without monitoring isn't safe.

Rule to remember: No ACE inhibitor or ARB in pregnancy. Switch to labetalol or extended-release nifedipine.

Sources: 2025 AHA/ACC High Blood Pressure Guideline — October 2025; published guideline; Section 5.5, recommendations 1–5 and supportive text; printed e269–e271.

Answer: A. Retest about 3 months after treatment

CDC doesn't advise a test of cure for nonpregnant patients treated with a recommended regimen unless adherence is in question, symptoms persist, or reinfection is suspected. Reinfection is common, though, so CDC recommends retesting about 3 months after treatment, whether or not partners were treated. If that isn't possible, retest at the next visit within 12 months.

Why not B: Testing that early can pick up genetic material from dead organisms, and a test of cure isn't advised for her anyway.

Why not C: The 3-month retest applies regardless of whether partners were treated.

Why not D: The target is about 3 months. The next-visit rule is a fallback when that isn't possible.

Rule to remember: After recommended chlamydia treatment, retest at about 3 months; a test of cure is reserved for pregnancy or specific concerns such as adherence, persistent symptoms, or reinfection.

Sources: CDC: Chlamydial Infections — STI Treatment Guidelines 2021; Follow-Up; pregnancy exceptions.

Answer: C. About 27%

That's the positive predictive value, and you can work it out with counts. At 2% prevalence, 20 of the 1,000 people have the condition, and the test catches 90% of them: 18 true positives. The other 980 don't have it, and 5% of them test positive anyway: 49 false positives. So 18 of the 67 positives are real. 18 ÷ 67 = 26.9%, or about 27%.

Why not A: That's the sensitivity: the share of people with the condition who test positive.

Why not B: That's the specificity: the share of people without the condition who test negative.

Why not D: That's the negative predictive value: 931 true negatives out of 933 negatives.

Rule to remember: Low prevalence drags the positive predictive value down, even with a good test.

Source: Worked calculation from the hypothetical inputs in this question: 20 people have the condition, 18 test positive; 980 do not have it, and 49 test positive. Positive predictive value = 18 ÷ (18 + 49) = 26.9%.

Answer: D. Use a qualified medical interpreter by phone or video

Under 45 CFR 92.201, a covered health program must offer a qualified interpreter when interpretation is needed. It cannot rely on a minor child except temporarily during an emergency involving an imminent threat when a qualified interpreter is not immediately available. A new diagnosis and medication plan is exactly where interpretation errors do harm. Offer the available qualified phone or video service; the rule does not force a patient to accept it.

Why not A: The narrow temporary exception for a minor requires an imminent-threat emergency and no immediately available qualified interpreter. The patient's agreement does not create that exception here.

Why not B: Conversational skill isn't the same as being a qualified interpreter or qualified bilingual staff, and errors here are costly.

Why not C: That doesn't give him meaningful access to the information during the visit.

Rule to remember: Offer qualified interpretation when needed; a minor is not a substitute in a routine visit.

Sources: 45 CFR 92.201: meaningful access for individuals with limited English proficiency — 2025 CFR edition; underlying 2024 rule; Paragraphs (a)–(c), (e)(3), and (h); printed pp. 424–425.

Answer: A. Infectious mononucleosis caused by Epstein-Barr virus

Posterior cervical lymphadenopathy, a palpable spleen, and marked fatigue with exudative pharyngitis point to mononucleosis. A rash after amoxicillin is a well-known feature of EBV infection. A negative heterophile test doesn't rule it out, and even a positive result does not confirm EBV; EBV-specific antibodies can clarify the diagnosis when needed. While his spleen is enlarged, he should avoid contact sports.

Why not B: Strep doesn't explain an enlarged spleen, and a rash on amoxicillin during mono isn't reliable evidence of a penicillin allergy.

Why not C: You'd expect one-sided tonsil swelling, a deviated uvula, trismus, and a muffled voice.

Why not D: DRESS can occur earlier with beta-lactam antibiotics, so two days does not exclude it. Here, the characteristic mononucleosis illness began before amoxicillin, and no new organ injury or eosinophilia is supplied. That makes EBV the best answer; new systemic deterioration would require urgent reassessment.

Rule to remember: Posterior nodes, spleen, fatigue, and a rash on amoxicillin: think EBV.

Sources: CDC: About Infectious Mononucleosis — CDC page; Symptoms; treatment: amoxicillin/ampicillin and contact sports; CDC: Laboratory Testing for Epstein-Barr Virus — April 10, 2024; Monospot; interpretation of primary infection; DermNet: Drug hypersensitivity syndrome — Updated January 2016; Who gets it; clinical features; systemic involvement.

Answer: C. Urine, blood, and CSF testing, admission, and parenteral antibiotics

UCSF's consensus febrile-infant guideline recommends blood, urine, and CSF testing, hospital admission, and empiric IV antibiotics for well-appearing febrile infants younger than 21 days. A catheterized specimen is used for urine testing. Looking well doesn't exclude serious bacterial infection at this age.

Why not A: At 16 days, urine testing alone does not replace the full evaluation and admission, even when the infant looks well.

Why not B: A well appearance isn't enough to rule out bacteremia or meningitis in a febrile infant this young.

Why not D: Inflammatory markers do not remove the need for blood, urine, and CSF evaluation and admission in this age group.

Rule to remember: A febrile 16-day-old needs full evaluation, parenteral antibiotics, and admission even when well appearing.

Sources: UCSF: Consensus Guidelines for Febrile Infants 0–90 Days — 2023 institutional consensus guideline; Executive summary; suggested laboratory evaluation for 0–21 days; admission.

Answer: B. An SGLT2 inhibitor with proven kidney benefit

The ADA's 2026 Standards recommend an SGLT2 inhibitor with demonstrated benefit for people with type 2 diabetes and CKD, starting at an eGFR of 20 mL/min/1.73 m² or higher, to reduce CKD progression and cardiovascular events. His eGFR of 48 and albuminuria make this a clear fit. Albumin of at least 200 mg/g is not a requirement in that recommendation. An eGFR below 60 alone is not a reason to stop metformin; kidney function and individual safety factors guide continued use and dosing.

Why not A: Glipizide lowers glucose but is not the recommended kidney-protective addition here, and it adds hypoglycemia risk.

Why not C: An eGFR of 48 does not by itself require stopping metformin. Continued use and dose depend on kidney function and other risks, not a cutoff of 60.

Why not D: It isn't a recommended choice for slowing CKD progression.

Rule to remember: Type 2 diabetes plus CKD with albuminuria: add an SGLT2 inhibitor if eGFR is 20 or higher.

Sources: ADA Standards of Care in Diabetes—2026, Section 11 — January 2026; Recommendation 11.7a, printed S252 (full-supplement PDF page 258); ADA Standards of Care in Diabetes—2026, Section 9 — January 2026; Metformin section, printed S197 (full-supplement PDF page 203).

Answer: D. Stop diphenhydramine and use non-drug sleep strategies

The AGS Beers Criteria say older adults should avoid first-generation antihistamines like diphenhydramine. They're highly anticholinergic and cause confusion, constipation, and other anticholinergic effects. When new symptoms follow a new drug, suspect the drug before adding another one. Assess the new confusion as well; a suspected medication effect does not exclude other causes.

Why not A: Treating a drug's side effect with another drug is a prescribing cascade. Remove the cause instead.

Why not B: Doxylamine is also a first-generation antihistamine on the Beers avoid list.

Why not C: Confusion that began with a new anticholinergic drug calls for stopping that drug, not starting a dementia medicine.

Rule to remember: New symptoms after a new drug: suspect the drug first.

Sources: American Geriatrics Society 2023 updated Beers Criteria — May 4, 2023; First-generation antihistamines; delirium/anticholinergics; strong-anticholinergic table.

Answer: C. Hypertrophic cardiomyopathy

In hypertrophic cardiomyopathy, the outflow obstruction worsens when the ventricle is less full, so the murmur gets louder with Valsalva strain and standing and softer with squatting. Syncope during exertion and a family history of sudden death raise the stakes. He needs an echocardiogram and cardiology evaluation, and he should hold off on strenuous exercise until he's evaluated.

Why not A: Innocent murmurs are soft, often diminish with standing and Valsalva, and don't come with exertional syncope.

Why not B: The murmur of aortic stenosis gets softer with Valsalva strain and standing, the opposite of this murmur.

Why not D: Exertional syncope with this murmur and family history cannot be dismissed as vasovagal. It needs a cardiac evaluation.

Rule to remember: A systolic murmur louder with Valsalva and standing, plus exertional syncope: think hypertrophic cardiomyopathy.

Sources: MSD Manual Professional: Hypertrophic Cardiomyopathy — Reviewed/updated September 2026; Symptoms and Signs; Diagnosis.

Answer: A. New urinary retention with numbness in the saddle area

Urinary retention with saddle numbness suggests cauda equina syndrome, a surgical emergency. AANS identifies these as red flags requiring immediate medical evaluation; MRI evaluates the nerve compression. Without red flags, acute nonradicular low back pain can be managed with measures like superficial heat and NSAIDs, as described in ACP guidance.

Why not B: Buttock radiation is common in nonspecific low back pain and isn't a red flag on its own.

Why not C: Positional worsening is typical of mechanical back pain.

Why not D: Muscle spasm is an expected finding after a lifting strain.

Rule to remember: Urinary retention plus saddle numbness: think cauda equina and image urgently.

Sources: AANS: Cauda Equina Syndrome — April 5, 2024; Symptoms; Testing and Diagnosis; ACP: Guideline for treating nonradicular low back pain — February 14, 2017; Acute/subacute low-back-pain recommendations.

Answer: B. Levothyroxine 25 mcg daily, increased gradually every 6 to 8 weeks as needed

A high TSH with a low free T4 is overt primary hypothyroidism, which needs treatment. The levothyroxine label says to start older patients and those with heart disease at 12.5 to 25 mcg a day and increase every 6 to 8 weeks until TSH normalizes. Starting low avoids provoking angina or arrhythmia.

Why not A: The label reserves full starting doses for otherwise healthy, non-elderly patients. With her age and heart disease, start low.

Why not C: Her free T4 is low. That's overt hypothyroidism, not a mild age-related TSH rise.

Why not D: The dose is right, but the label adjusts every 6 to 8 weeks for patients like her. A TSH at 1 week won't reflect the change.

Rule to remember: Older adult or heart disease: start levothyroxine low and go slow.

Sources: Levoxyl (levothyroxine): U.S. prescribing information — U.S. label; Sections 2.1, 2.3 and adult monitoring.

Answer: D. Fix her technique and adherence before changing medicines

GINA advises checking inhaler technique, adherence, and modifiable risk factors before stepping up treatment. The observed technique and gaps in controller supply can explain poor control. Correct the technique, address barriers to regular use, and reassess the response.

Why not A: A stronger inhaler won't help much if she can't use it well or doesn't take it. Fix those first.

Why not B: Adding a drug doesn't solve poor technique or missed doses of the one she already has.

Why not C: She isn't having an exacerbation. This is poor ongoing control.

Rule to remember: Before you step up, check technique and adherence.

Sources: GINA 2026 Summary Guide — 2026 edition; Printed pp. 21–22: initial treatment and checks before stepping up.

Answer: B. Osteoporosis

ISCD applies T-score criteria to postmenopausal women and men aged 50 or older: a valid T-score of −2.5 or lower at the femoral neck, total hip, or lumbar spine supports osteoporosis. Her femoral neck is −2.6, so the higher spine score does not change that classification.

Why not A: Low bone mass is below −1.0 but above −2.5. Her femoral-neck result is already in the osteoporosis range.

Why not C: That's a Z-score comparison with people her own age. T-scores compare her with healthy young adults.

Why not D: For a postmenopausal woman, T-score criteria can classify bone density. A Z-score is not required to interpret the valid hip and spine T-scores supplied here.

Rule to remember: In postmenopausal women and men 50 or older, a valid hip or spine T-score at or below −2.5 supports osteoporosis.

Sources: ISCD: 2023 Official Adult Positions — 2023 positions; Central DXA for diagnosis; T-score population and sites; NIAMS: Bone Mineral Density Tests—What the Numbers Mean — Reviewed February 2025; T-score and Z-score sections.

Answer: C. Autism screen now, plus hearing and early intervention referrals

Saying at least two words together is a 2-year milestone, and he's well behind. Rarely pointing to share interest is a social-communication warning sign. The AAP recommends autism-specific screening at 18 and 24 months, and any child with a speech delay needs a hearing evaluation. Referral shouldn't wait for more time to pass.

Why not A: Waiting a year delays evaluation and early intervention for a child who's already behind.

Why not B: He already has concerning signs. Screening and referral are due now.

Why not D: Changing the home language doesn't evaluate a child who is missing milestones and not pointing. He needs screening and referral.

Rule to remember: No two-word phrases at 24 months and little pointing: screen and refer now, and check hearing.

Sources: CDC: Milestones by 2 Years — CDC milestone page; Language/communication; act early if concerned; CDC: Clinical Screening for Autism Spectrum Disorder — CDC clinical page; Screening recommendations; developmental surveillance; AAP: Language Delays in Toddlers — Updated April 30, 2021; What your child’s doctor might do; early intervention.

Answer: A. Low-dose aspirin 81 mg daily, starting now

The USPSTF recommends low-dose aspirin, 81 mg a day, after 12 weeks of gestation for people at high risk of preeclampsia. Chronic hypertension is one of the high-risk factors. The 2025 AHA/ACC guideline also recommends counseling pregnant people with hypertension about low-dose aspirin.

Why not B: The recommended dose is low-dose aspirin, 81 mg a day.

Why not C: She's already eligible at 13 weeks. There is no reason in this case to postpone the recommended preventive treatment to 28 weeks.

Why not D: Chronic hypertension makes her high risk whether or not it's controlled.

Rule to remember: High risk for preeclampsia: aspirin 81 mg daily after 12 weeks.

Sources: USPSTF: Aspirin Use to Prevent Preeclampsia (2021) — September 28, 2021; Recommendation Summary; high-risk factors; 2025 AHA/ACC High Blood Pressure Guideline — October 2025; published guideline; Section 5.5, recommendations 1–5 and supportive text; printed e269–e271.

Answer: D. Asymptomatic bacteriuria; don't treat with antibiotics

Bacteria in the urine without urinary symptoms or signs of infection is asymptomatic bacteriuria. The IDSA recommends against screening for or treating it in older people who live in long-term care facilities. Treatment exposes her to side effects and resistance without benefit. The main exceptions are pregnancy and endoscopic urologic procedures associated with mucosal trauma.

Why not A: Cystitis needs urinary symptoms. She has none.

Why not B: She has no fever, flank pain, or other sign of kidney infection.

Why not C: A positive culture alone doesn't establish symptomatic UTI. There is no supplied symptom or systemic sign requiring a kidney-infection workup.

Rule to remember: In an asymptomatic older long-term-care resident, a positive culture alone does not justify antibiotics.

Sources: IDSA: Asymptomatic Bacteriuria (2019) — 2019 guideline; Recommendations for long-term-care residents; endourologic procedures.

Answer: C. At 24–28 weeks of gestation

The USPSTF recommends screening asymptomatic pregnant people for gestational diabetes at 24 weeks or later, typically before 28 weeks. For this patient already receiving prenatal care, plan routine screening at 24–28 weeks. Its insufficient-evidence finding before 24 weeks is not a ban on earlier testing when a different indication is present.

Why not A: Routine screening at 24–28 weeks is appropriate for this asymptomatic patient without additional risk factors. The USPSTF found insufficient evidence for routine screening before 24 weeks.

Why not B: Screening is recommended for all asymptomatic pregnant people at 24 weeks or later, not only when a finding appears.

Why not D: The recommendation is for screening during pregnancy, at 24 weeks or later.

Rule to remember: Routine gestational diabetes screening is usually at 24–28 weeks; assess separate indications for earlier testing.

Sources: USPSTF: Gestational Diabetes: Screening (2021) — August 10, 2021; Clinician Summary: implementation.

Answer: B. Continue it, treat the flare, then titrate to urate below 6 mg/dL

The 2020 ACR guideline strongly recommends a treat-to-target strategy: adjust the urate-lowering dose until serum urate is below 6 mg/dL. His urate is 7.2, so review adherence and titrate the tolerated regimen toward target. ACR even conditionally recommends starting urate-lowering therapy during a flare when it's indicated, so there's no reason to interrupt therapy he's already on. Treat the flare itself with colchicine, an NSAID, or a glucocorticoid. Assess for septic arthritis; absence of fever does not exclude it, and suspected infection requires joint aspiration.

Why not A: Stopping it doesn't treat the flare and sets back urate control. ACR supports urate-lowering therapy even during a flare.

Why not C: He's still having flares and isn't at target. He needs more urate lowering, not less.

Why not D: ACR prefers allopurinol as the first-line urate-lowering drug. Review adherence and titrate it as tolerated before assuming it has failed.

Rule to remember: Don't stop urate-lowering therapy for a flare. Titrate to a urate below 6 mg/dL.

Sources: ACR: Management of Gout (2020) — 2020 guideline; Printed pp. 749–750 and 752: treat-to-target, ULT continuation and flare treatment.

Answer: A. St. John's wort speeding up her pill's metabolism

CDC's U.S. Medical Eligibility Criteria describes evidence that St. John's wort can increase contraceptive hormone metabolism, with breakthrough bleeding and ovulation. The UK drug regulator advises women using hormonal contraception not to take it. Next steps: a pregnancy test, backup contraception or a method that doesn't interact, and a different plan for her mood.

Why not B: Bleeding that starts right after a new enzyme-inducing supplement, in a young woman on a stable pill, points to the interaction first.

Why not C: Thyroid disease can change bleeding patterns, but nothing here suggests it, and the timing fits the supplement.

Why not D: A polyp is possible, but the timing fits the supplement. If bleeding continues after stopping it, examine her.

Rule to remember: St. John's wort can make hormonal contraception fail.

Sources: CDC: U.S. MEC, Combined Hormonal Contraceptives (2024) — U.S. MEC 2024; Headaches/migraine; drug interactions: St. John’s wort; MHRA: St John’s wort and hormonal contraceptives — March 2014 article; web publication December 11, 2014; Advice for healthcare professionals.

Answer: D. Whether he has decision-making capacity for this choice

Decision-making capacity is specific to the decision at hand, and it rests on four abilities: understanding the information, appreciating how it applies to him, reasoning about the options, and communicating a choice. Capacity isn't about whether he makes the choice you would. If he has it, respect the refusal, document the discussion, and offer other options, such as a stool-based test.

Why not A: Family agreement doesn't determine a capable adult's right to decide.

Why not B: Screening scores don't determine capacity for a specific decision, especially in the middle range.

Why not C: A capable patient can make a choice the clinician wouldn't make.

Rule to remember: Capacity is decision-specific: understand, appreciate, reason, and choose.

Sources: AAFP: Evaluating Medical Decision-Making Capacity in Practice — July 1, 2018; Four abilities; decision-specific capacity; directed interview; AMA Code of Medical Ethics: Informed Consent — Undated opinion; Opinion 2.1.1; USPSTF: Colorectal Cancer: Screening (2021) — May 18, 2021; Recommendation Summary; Clinician Summary; screening intervals.

Answer: C. Apply fluoride varnish to her tooth today

The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of infants and children younger than 5, starting when the first tooth erupts. She has a tooth, so varnish is due today, whether or not she has seen a dentist.

Why not A: Varnish is preventive care for children younger than 5 once teeth erupt; a cavity is not required. The USPSTF's insufficient-evidence finding for routine caries screening by primary care clinicians is not a recommendation against examining the mouth.

Why not B: The recommendation is for primary care clinicians to apply varnish, starting at tooth eruption.

Why not D: That contradicts the recommendation to start varnish when the first tooth erupts.

Rule to remember: First tooth, first fluoride varnish.

Sources: USPSTF: Prevention of Dental Caries in Children Younger Than 5 — December 7, 2021; Recommendation Summary; Clinician Summary.

Answer: A. Carpal tunnel syndrome

Numbness in the median nerve distribution (thumb, index, and middle fingers), worse at night and relieved by shaking the hand, with a positive Phalen's test, is the classic picture of carpal tunnel syndrome. A normal little finger makes ulnar and C8 problems less likely; no single finding excludes them.

Why not B: Ulnar nerve compression at the elbow affects the ring and little fingers.

Why not C: A C8 root problem affects the little finger and inner hand and often comes with neck pain.

Why not D: It causes pain at the thumb side of the wrist with thumb movement, not finger numbness.

Rule to remember: Median nerve fingers, night symptoms, and a positive Phalen's test: carpal tunnel.

Sources: AAOS OrthoInfo: Carpal Tunnel Syndrome — AAOS clinical reference; Anatomy; Symptoms; Physical Examination.

Answer: B. Timed Up and Go test with gait and balance observation

CDC's STEADI approach assesses gait, strength, and balance in older adults who screen positive for fall risk. On the Timed Up and Go test, an older adult who takes 12 seconds or longer is at risk for falling. Watching how she walks also shows which deficits to target.

Why not A: Bone density affects fracture risk, but it doesn't explain why she's falling.

Why not C: She had no head injury and didn't lose consciousness.

Why not D: A device chosen without assessing her gait and balance may not fit her problem.

Rule to remember: Fall plus unsteadiness: assess gait, strength, and balance. A TUG of 12 seconds or more means risk.

Sources: CDC STEADI: Timed Up and Go — 2017 instrument; Single-page instructions and observation checklist.

Answer: D. Start an inhaled corticosteroid–containing regimen

GINA says adults and adolescents with asthma shouldn't be treated with a short-acting bronchodilator alone. To lower the risk of severe exacerbations, their treatment should contain an inhaled corticosteroid. Starting an ICS-containing regimen addresses the ongoing symptoms and the risk left by albuterol-only treatment.

Why not A: Short-acting bronchodilator–only treatment leaves airway inflammation untreated and raises the risk of severe exacerbations.

Why not B: A long-acting bronchodilator without an inhaled corticosteroid still leaves inflammation untreated. GINA's adult and adolescent asthma regimens include an ICS.

Why not C: She isn't having an exacerbation. She needs ongoing controller treatment.

Rule to remember: For adults and adolescents with asthma, include an inhaled corticosteroid rather than relying on bronchodilator-only treatment.

Sources: GINA 2026 Summary Guide — 2026 edition; Printed pp. 21–22: initial treatment and checks before stepping up.

Answer: C. Take it fasting, 4 hours apart from calcium; recheck TSH in about 6 weeks

The levothyroxine label says to take it on an empty stomach, half an hour to an hour before breakfast, and at least 4 hours apart from drugs that interfere with its absorption, which include calcium carbonate. The timing change is a plausible explanation for her higher TSH. Fix the timing first, then recheck once a new steady state is reached.

Why not A: That treats an absorption problem with more drug. Once she takes it correctly again, the higher dose could overtreat her.

Why not B: Changing products doesn't fix the absorption problem.

Why not D: Keeping the routine leaves the absorption problem in place, and TSH won't reflect any change within a week.

Rule to remember: Rising TSH on a stable dose: first check how and when the pill is taken.

Sources: Levoxyl (levothyroxine): U.S. prescribing information — U.S. label; Sections 2.1, 2.3 and adult monitoring.

Answer: A. Polymyalgia rheumatica

The 2012 EULAR/ACR classification criteria for polymyalgia rheumatica center on this picture: age 50 or older, bilateral shoulder aching, raised ESR or CRP, morning stiffness longer than 45 minutes, hip involvement, and negative rheumatoid factor and anti-CCP. Those are classification criteria for research, not a stand-alone diagnostic test; clinical assessment must exclude mimics. Because PMR and giant cell arteritis often overlap, ask about headache, jaw pain, and vision changes at every visit.

Why not B: Negative serologies and no hand synovitis make RA less likely than PMR in this pattern.

Why not C: Osteoarthritis causes brief stiffness in specific joints, not prolonged girdle stiffness with high inflammatory markers.

Why not D: Fibromyalgia itself does not explain the elevated ESR or CRP; another inflammatory cause would still need consideration.

Rule to remember: Older adult with shoulder and hip girdle stiffness and high inflammatory markers: consider PMR, exclude mimics, and ask about GCA symptoms.

Sources: EULAR/ACR: 2012 provisional PMR classification criteria — March 2012; Abstract; classification algorithm and intended use; ACR/Vasculitis Foundation: Giant Cell Arteritis Guideline (2021) — 2021; Printed pp. 1074 and 1076; diagnostic testing and initial treatment (PDF pages 5 and 7).

Answer: B. Ask her privately and directly about current suicidal thoughts and a plan

This response needs a suicide safety assessment right away; it isn't enough to wait for a routine depression follow-up. NIMH's youth outpatient guide provides the approach: ask directly, in private if possible, about current thoughts of suicide, a plan, and access to means. Thoughts of killing herself right now require urgent mental health evaluation, and she must not be left alone. The depression questionnaire in this case is not itself the ASQ screening tool.

Why not A: Suicide screening is built on asking directly. Avoiding the question leaves her risk unknown.

Why not C: A positive screen needs a safety assessment today, not in a month.

Why not D: Treatment may come later, but her immediate safety has to be assessed first.

Rule to remember: Positive suicide screen: ask directly about current thoughts and a plan, today.

Sources: NIMH: Youth Outpatient Brief Suicide Safety Assessment Guide — Undated NIMH guide; Assess the patient: frequency of suicidal thoughts, plan and disposition.

Answer: D. Activate EMS for emergency transport and get a 12-lead ECG while you wait, without delaying transport

The 2021 AHA/ACC chest pain guideline says office patients with evidence of acute coronary syndrome should be transported urgently to the emergency department, ideally by EMS. It also calls for an ECG within 10 minutes of arrival in any setting. Do not delay transfer to obtain the ECG or other office testing.

Why not A: The guideline favors EMS, which can treat and monitor him on the way.

Why not B: Ongoing chest pain with these features is a possible acute coronary syndrome, not a stable outpatient problem.

Why not C: Assuming reflux risks missing a heart attack.

Rule to remember: Possible ACS in the office: EMS, not a private car; get an ECG if it won't delay transfer.

Sources: AHA/ACC Chest Pain Guideline: official slide set (2021) — October 28, 2021; Slides 32–33: Setting Considerations.

Answer: A. Bacterial vaginosis

CDC's clinical criteria for bacterial vaginosis require at least three of four findings: a thin, homogeneous discharge, clue cells on microscopy, vaginal pH above 4.5, and a fishy odor with potassium hydroxide (a positive whiff test). She has all four.

Why not B: Yeast infection usually comes with itching and redness, a normal pH, and yeast on microscopy, not clue cells.

Why not C: Trichomoniasis can raise vaginal pH, but diagnosis depends on detecting Trichomonas. Clue cells point to BV.

Why not D: Normal discharge doesn't have a pH above 4.5, clue cells, and a positive whiff test.

Rule to remember: Three of four (thin discharge, clue cells, pH above 4.5, positive whiff): bacterial vaginosis.

Sources: CDC: Bacterial Vaginosis — STI Treatment Guidelines 2021; Diagnostic Considerations: Amsel criteria; CDC: Vulvovaginal Candidiasis — STI Treatment Guidelines 2021; Diagnostic Considerations; CDC: Trichomoniasis — STI Treatment Guidelines 2021; Diagnostic Considerations.

Answer: C. Reconcile his discharge list against the bottles he brought

Taking two loop diuretics at once can cause volume depletion and contribute to dizziness on standing. Medication reconciliation at a transition of care means comparing what he was prescribed with what he's actually taking, resolving discrepancies like this duplicate, and updating one accurate list. Assess his blood pressure, volume status, kidney function, and electrolytes promptly while clarifying the intended regimen with the discharging team.

Why not A: He's likely already getting too much diuretic. More would make it worse.

Why not B: An echocardiogram doesn't address the medication error in front of you.

Why not D: Continuing both leaves the duplicate in place, and it's a problem now, not in 3 months.

Rule to remember: After discharge, reconcile the bottles against the list and promptly assess symptoms of a medication error.

Sources: AHRQ PSNet: Medication Reconciliation — AHRQ patient-safety primer; Definition; transitions of care and discrepancies.

Answer: B. Screen her vision today with a chart or instrument-based screener

The USPSTF recommends vision screening at least once in all children aged 3 to 5 to detect amblyopia or its risk factors. Parents often can't tell when one eye sees poorly, so a lack of concern doesn't replace screening.

Why not A: The recommended window is ages 3 to 5, while amblyopia treatment works best.

Why not C: The recommendation covers all children aged 3 to 5, not just those with concerns.

Why not D: The recommendation is for screening in primary care, not routine referral for everyone.

Rule to remember: Screen vision at least once between ages 3 and 5.

Sources: USPSTF: Vision Screening in Children — September 5, 2017; Recommendation Summary.

Answer: D. Under the NP's own NPI, with an allowed amount capped at 85% of the physician fee schedule

Incident-to billing requires the physician to have personally started the course of treatment and to stay actively involved. That has not happened for this new patient's new problem, so the NP bills the otherwise covered professional service under their own National Provider Identifier (NPI). Under 42 CFR 414.56(c), the NP allowed amount is capped at 85% of the physician fee-schedule amount. The allowed amount is not the same thing as Medicare's payment after applicable deductible and coinsurance rules.

Why not A: Being in the building is not enough. The physician has not personally initiated the course of treatment required for this incident-to claim.

Why not B: NPs bill Medicare under their own NPI.

Why not C: For this NP-billed professional service, the allowed amount is capped at 85%, not 100%, of the physician fee-schedule amount.

Rule to remember: For this new office patient, use the NP's own NPI; the allowed amount is capped at 85%. Physician presence alone does not establish incident-to eligibility.

Sources: 42 CFR 414.56: Nurse practitioner services — Current eCFR display up to date September 17, 2026; Paragraph (c): Allowed amounts; CMS Medicare Benefit Policy Manual, Chapter 15 — CMS manual; Section 60.2; PDF page 66: physician initial service and continued active participation.

Answer: C. Ankle radiographs

Under the Ottawa ankle rules, ankle x-rays are needed if there's pain in the malleolar zone and either bone tenderness at the posterior edge or tip of either malleolus (the distal 6 cm) or inability to bear weight for 4 steps both immediately after injury and at assessment. His malleolar bone tenderness meets the rule even though he can walk.

Why not A: Bearing weight doesn't cancel malleolar bone tenderness. Either one triggers ankle films.

Why not B: MRI isn't the first test for a possible acute ankle fracture.

Why not D: Foot films use a separate rule: midfoot pain plus navicular/base-of-fifth tenderness, or inability to take four steps immediately after injury and at assessment. He has no midfoot pain or those findings.

Rule to remember: With malleolar-zone pain after injury, posterior-edge or tip tenderness over the distal 6 cm of either malleolus supports ankle films even when walking is possible.

Sources: NSW Agency for Clinical Innovation: Ottawa ankle rules (adult) — governmental clinical pathway; Ankle and foot radiograph criteria.

Answer: B. Start screening now, such as annual FIT or colonoscopy every 10 years

The USPSTF recommends colorectal cancer screening for average-risk adults starting at 45 (a B recommendation for ages 45 to 49 and an A for 50 to 75). Acceptable strategies include an annual fecal immunochemical test (FIT) or colonoscopy every 10 years, among others.

Why not A: The starting age dropped to 45 in 2021.

Why not C: CEA isn't one of the recommended screening strategies.

Why not D: Those symptoms call for diagnostic evaluation. Screening is for people without symptoms.

Rule to remember: Average risk: start colorectal screening at 45.

Sources: USPSTF: Colorectal Cancer: Screening (2021) — May 18, 2021; Recommendation Summary; Clinician Summary; screening intervals.