Free AGPCNP Practice Test: 100 Questions With Rationales

Answer: B. One-time ultrasound screening for abdominal aortic aneurysm (AAA)

The USPSTF recommends one-time ultrasound screening for AAA in men 65 to 75 who have ever smoked (grade B). “Ever smoked” means at least 100 cigarettes in a lifetime, so quitting decades ago doesn't remove the indication. He is a 68-year-old former smoker, so he qualifies.

Why not the others:

• A. USPSTF low-dose CT lung screening is for adults 50 to 80 with at least 20 pack-years who still smoke or quit within the past 15 years. He quit 27 years ago, so he doesn't meet that rule.
• C. The USPSTF names ultrasound as the screening test; abdominal palpation isn't accurate enough to find or rule out an aneurysm.
• D. The 15-year limit belongs to lung cancer screening. AAA screening applies to any man 65 to 75 who has ever smoked.

Key point: USPSTF AAA screening uses “ever smoked” (men 65 to 75). Lung CT uses pack-years plus years since quitting.

Source: USPSTF: Abdominal Aortic Aneurysm: Screening, Recommendation summary; screening tests; definition of ever smoking (December 10, 2019). USPSTF: Lung Cancer: Screening, Recommendation summary and practice considerations (March 9, 2021). Source check: September 22, 2026.

Topic: AAA screening · ANCC: Professional Practice · NPCB: Assess · NPCB age tag: Older adult

Answer: C. Diabetes is confirmed by these two results

Without unequivocal hyperglycemia, the ADA requires two abnormal results. They can be two different tests from the same sample, such as A1C and fasting glucose, or the same test on two different days. Both of his values are in the diabetes range: A1C of 6.5% or higher and fasting glucose of 126 mg/dL or higher.

Why not the others:

• A. Both values are above the prediabetes ranges (A1C 5.7% to 6.4%, fasting glucose 100 to 125 mg/dL).
• B. A repeat test is needed when only one result is abnormal. Here two different tests already agree.
• D. An oral glucose tolerance test is one way to diagnose diabetes, not a requirement when other criteria are met.

Key point: Two abnormal results confirm diabetes, and they can come from one blood draw if they are two different tests.

Source: ADA Standards of Care 2026: Diagnosis and Classification, Diagnostic tests; confirming the diagnosis; Tables 2.1 and 2.2 (Standards of Care 2026). Source check: September 22, 2026.

Topic: Diagnosing diabetes · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Adult

Answer: A. Right conductive hearing loss

In conductive loss, the Weber sound is louder in the affected ear, and the Rinne test is abnormal on that side, with bone conduction beating air conduction. Both findings point to the right ear.

Why not the others:

• B. With right sensorineural loss, the Weber would lateralize to the left (the better ear), and the right Rinne would stay normal.
• C. Left sensorineural loss can make the Weber lateralize right, but it wouldn't make the right-ear Rinne abnormal.
• D. The left ear's Rinne is normal, and the Weber lateralizes away from it.

Key point: The Weber lateralizes toward a conductive loss and away from a sensorineural loss. Interpret Rinne and Weber together, then confirm the cause with the appropriate hearing evaluation.

Source: MSD Manual Professional: Hearing Loss, Evaluation: tuning-fork tests (Live professional reference). Source check: September 22, 2026.

Topic: Hearing loss: Weber and Rinne · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Adult

Answer: D. Order HLA-B*58:01 testing

The 2020 ACR gout guideline conditionally recommends HLA-B*58:01 testing before allopurinol in patients of Southeast Asian descent (such as Han Chinese, Korean, or Thai) and in African American patients. Carrying this allele sharply raises the risk of a severe allopurinol hypersensitivity reaction. A positive result points you to a different urate-lowering drug.

Why not the others:

• A. A full starting dose skips the screening this patient needs, and ACR favors starting low and titrating to a urate target.
• B. A urine uric acid collection doesn't address the hypersensitivity risk that matters here.
• C. Timing isn't the gap. Genetic screening is, and waiting doesn't replace it.

Key point: ACR conditionally recommends HLA-B*58:01 testing before allopurinol in higher-risk groups, including Korean, Han Chinese, Thai, and African American patients.

Source: ACR 2020 Guideline for the Management of Gout, Allopurinol/HLA-B*5801; urate targets; initiation and prophylaxis recommendations (2020 guideline). Source check: September 22, 2026.

Topic: Allopurinol safety · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Adult

Answer: B. Persistent airflow obstruction consistent with COPD

COPD is confirmed by spirometry showing a post-bronchodilator FEV1/FVC below 0.70 in someone with compatible symptoms and exposures. Her ratio is 0.64 after bronchodilator, with a long smoking history and chronic symptoms. That confirms persistent airflow obstruction; her FEV1 percent predicted then sets the severity grade.

Why not the others:

• A. Giving a bronchodilator is part of the standard test. The post-bronchodilator ratio confirms obstruction here, but the degree of bronchodilator response alone does not reliably distinguish asthma from COPD.
• C. Restrictive disease typically keeps the FEV1/FVC ratio normal or high. A low ratio signals obstruction.
• D. Spirometry, not CT, is what confirms COPD.

Key point: COPD means compatible symptoms, a risk exposure, and a post-bronchodilator FEV1/FVC below 0.70.

Source: GOLD Science Committee: Spirometry for COPD Diagnosis, Post-bronchodilator confirmation and repeat testing around the diagnostic threshold (2025). Source check: September 22, 2026.

Topic: Confirming COPD · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Brief cognitive screen, such as the Mini-Cog, and a functional assessment

Gradual memory change that disrupts managing money deserves a structured look. The Mini-Cog, which combines three-word recall with clock drawing, is a brief cognitive screen. Pair it with a functional assessment, since paying bills is an instrumental activity of daily living. A positive screen calls for fuller evaluation, not an immediate diagnosis.

Why not the others:

• B. Changes that disrupt everyday tasks like paying bills shouldn't be dismissed as normal aging.
• C. Imaging may be part of a later workup, but it doesn't replace bedside cognitive and functional assessment.
• D. A screening concern isn't a diagnosis. The cause and severity still need evaluation.

Key point: A memory complaint plus a change in daily function calls for a brief validated cognitive screen and an IADL assessment.

Source: Mini-Cog: Scoring and Interpretation, Recall score; clock score; interpreting the score (Live developer guidance). Hartford Institute: Lawton Instrumental Activities of Daily Living Scale, Best tool; target population; domains (Try This clinical tool). Source check: September 22, 2026.

Topic: Memory concerns · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Elderly

Answer: B. Arrange a qualified medical interpreter

Under 45 CFR 92.201, covered health programs must provide meaningful language access, including a qualified interpreter when interpretation is required. An unqualified accompanying adult is not the default: the regulation allows tightly limited emergency assistance or a patient-requested arrangement subject to safeguards. Neither exception applies, and a new diagnosis needs accurate communication.

Why not the others:

• A. His family relationship does not establish interpreter qualifications or satisfy the rule’s safeguards.
• C. Being bilingual doesn't make someone a qualified medical interpreter.
• D. A handout can't replace a real conversation about a new diagnosis.

Key point: Use a qualified interpreter when needed for meaningful communication; an unqualified relative is not the default substitute.

Source: 45 CFR 92.201: Meaningful Access for Individuals With Limited English Proficiency, Subsections (a)–(e), especially interpreter qualifications and restrictions (eCFR current text, September 2026). Source check: September 22, 2026.

Topic: Language access · ANCC: Professional Practice · NPCB: Plan · NPCB age tag: Older adult

Answer: C. Trimethoprim-sulfamethoxazole

The warfarin label lists cotrimoxazole (trimethoprim-sulfamethoxazole) as a CYP2C9 inhibitor. CYP2C9 clears the more potent S-enantiomer of warfarin, so inhibiting it raises warfarin exposure and the INR. The label advises closer INR monitoring whenever an interacting drug is started or stopped.

Why not the others:

• A. This laxative isn't among the CYP2C9, 1A2, or 3A4 inhibitors listed in the warfarin label.
• B. Hydrochlorothiazide isn't among the CYP inhibitors listed in the warfarin label.
• D. Docusate isn't among the CYP inhibitors listed in the warfarin label.

Key point: A rising INR after a new antibiotic should make you think of CYP2C9 inhibitors such as TMP-SMX, metronidazole, and fluconazole.

Source: Warfarin Sodium: U.S. Prescribing Information, Section 7.2 and Table 2, CYP450 interactions (DailyMed update June 10, 2025). Source check: September 22, 2026.

Topic: Warfarin interactions · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: C. Giant cell arteritis

A new headache after age 50, jaw claudication, scalp tenderness, and a high ESR make giant cell arteritis most likely. Jaw claudication is linked to a higher risk of blindness. When GCA is suspected, corticosteroids shouldn't wait for the temporal artery biopsy, which should be arranged promptly even when treatment has already started.

Why not the others:

• A. A brand-new headache pattern after 50 with a very high ESR isn't typical of migraine.
• B. A jaw joint problem doesn't explain the scalp tenderness or the high inflammatory markers.
• D. Trigeminal neuralgia causes brief, electric facial pain, not a steady headache with pain on chewing.

Key point: Age over 50, new headache, jaw claudication, and a high ESR mean treat for GCA now without waiting for the biopsy.

Source: Merck Manual Professional: Giant Cell Arteritis, Symptoms/signs; diagnosis; urgent treatment (Live professional reference). Source check: September 22, 2026.

Topic: New headache after 50 · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Phalen test (holding the wrists fully flexed)

Her numbness follows the median nerve, which suggests carpal tunnel syndrome. The Phalen test flexes the wrists to compress the carpal tunnel and bring on the symptoms. Tinel's sign, tapping over the median nerve at the wrist, is the other classic maneuver.

Why not the others:

• B. Eichhoff stresses the thumb tendons to look for de Quervain tenosynovitis.
• C. Spurling compresses the cervical spine to reproduce radiating nerve-root pain.
• D. Lachman tests the knee's anterior cruciate ligament.

Key point: Median-nerve numbness calls for the Phalen and Tinel tests for carpal tunnel syndrome.

Source: Stanford Medicine: Musculoskeletal Examination Benchmarks, Pages 1–2: hand/wrist, neck, knee examination (August 2018). Source check: September 22, 2026.

Topic: Hand numbness · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Adult

Answer: D. Cognitive behavioral therapy for insomnia (CBT-I)

The American College of Physicians strongly recommends CBT-I as the initial treatment for chronic insomnia disorder in all adults. It combines sleep restriction, stimulus control, cognitive work, and sleep education, and it can start in primary care. For an older adult, it also avoids sedatives the Beers Criteria flag as potentially inappropriate.

Why not the others:

• A. First-generation antihistamines like diphenhydramine are strongly anticholinergic and on the Beers list to avoid in older adults.
• B. The 2023 Beers Criteria advise avoiding Z-drug hypnotics such as zolpidem because of falls, fractures, and delirium.
• C. Benzodiazepines carry the same risks for older adults and are also on the Beers list to avoid.

Key point: Treat chronic insomnia with CBT-I first. In older adults, avoid antihistamines, benzodiazepines, and Z-drugs.

Source: ACP: Cognitive Behavioral Therapy as Initial Treatment for Chronic Insomnia, First-line CBT-I recommendation and shared decision-making after inadequate response (May 3, 2016). AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Topic: Chronic insomnia · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Older adult

Answer: C. Treat as viral pharyngitis, without strep testing or antibiotics

CDC's adult guidance uses the Centor criteria: fever, tonsillar exudate, tender anterior neck nodes, and no cough. She meets none. Adults who meet fewer than two criteria shouldn't be tested or treated for group A strep; symptom care is enough.

Why not the others:

• A. Rapid testing is for adults who meet two or more Centor criteria.
• B. Antibiotics aren't recommended without a positive strep test.
• D. Throat cultures aren't routinely recommended for adults.

Key point: In an adult with a sore throat and fewer than two Centor criteria, don't test for strep or give an antibiotic.

Source: CDC: Adult Outpatient Antibiotic Treatment Recommendations, Acute bronchitis; pharyngitis; uncomplicated cystitis (April 16, 2024). Source check: September 22, 2026.

Topic: Adult sore throat · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Young adult

Answer: A. Offer routine private time, explaining confidentiality and its limits

Bright Futures recommends routine one-on-one time with adolescents, presented as standard for every teen, along with a clear explanation of what stays confidential and its limits, such as a risk of serious harm. Framing it as routine protects the teen's privacy without implying anything about the parent.

Why not the others:

• B. With his mother in the room for the whole visit, he's unlikely to share risk behaviors.
• C. The history should come from the adolescent, not a proxy.
• D. Sharing his answers with his mother would undercut the confidentiality that makes screening work.

Key point: Teens get routine private time plus a clear explanation of confidentiality and its limits.

Source: AAP Bright Futures: Adolescent Confidentiality and Privacy, Private interview and explaining confidentiality limits (Bright Futures clinical guidance). Source check: September 22, 2026.

Topic: Adolescent interview · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Adolescent

Answer: D. Deintensify insulin and/or glipizide and individualize a less stringent A1C goal

ADA guidance for older adults supports less strict glycemic goals, such as an A1C below 8.0%, for people with complex health that includes mild cognitive or functional impairment. It calls for deintensifying therapy when hypoglycemia risk is high. Both insulin and sulfonylureas can cause hypoglycemia; the regimen and glucose pattern determine which doses to reduce or stop. An A1C of 6.4% with recurrent lows means he's overtreated.

Why not the others:

• A. A low A1C with repeated hypoglycemia is overtreatment, not good control.
• B. Adding another drug to push the A1C lower adds burden without benefit for someone in his health status.
• C. Increasing a hypoglycemia-causing drug would worsen the problem rather than reduce treatment burden.

Key point: For an older adult with cognitive impairment and recurrent lows, simplify hypoglycemia-causing treatment and individualize the glycemic goal.

Source: ADA Standards of Care 2026: Older Adults, Recommendations 13.7–13.9; Tables 13.2 and 13.3; deintensification (Standards of Care 2026). AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Topic: Overtreated diabetes · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Elderly

Answer: B. Increased risk of eye involvement from zoster; arrange same-day eye evaluation

Blisters on the tip of the nose (Hutchinson sign) mean the nasociliary branch of the ophthalmic nerve is involved. That branch also supplies the eye, so complications such as keratitis and uveitis are more likely. She needs urgent ophthalmology care along with antiviral treatment.

Why not the others:

• A. A painful, one-sided rash of grouped blisters in a nerve distribution points to zoster, not contact dermatitis.
• C. Impetigo doesn't follow the path of a single facial nerve branch.
• D. Rosacea doesn't cause painful blisters in a nerve distribution.

Key point: Zoster on the tip of the nose (Hutchinson sign) signals increased ocular risk and calls for urgent eye evaluation.

Source: MSD Manual Professional: Herpes Zoster Ophthalmicus, Ophthalmic distribution; diagnosis; treatment (Live professional reference). Source check: September 22, 2026.

Topic: Zoster near the eye · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: B. A 7 mm mole that has changed in shape and color over 3 months

The ABCDE criteria flag asymmetry, border irregularity, color variation, a diameter over 6 mm, and evolution. This lesion is over 6 mm and changing, and evolution is the feature added to the criteria because changing lesions carry special weight.

Why not the others:

• A. A small, uniform mole that hasn't changed lacks warning features.
• C. A waxy, stuck-on look is typical of a seborrheic keratosis.
• D. Skin tags are benign and aren't pigmented lesions of concern.

Key point: A changing mole larger than 6 mm needs a biopsy.

Source: Abbasi et al.: Early Diagnosis of Cutaneous Melanoma—Revisiting the ABCD Criteria, Abstract: evidence synthesis and conclusions (JAMA, 2004). Source check: September 22, 2026.

Topic: Which mole to worry about · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Adult

Answer: C. An ACE inhibitor or ARB, titrated to the maximum tolerated dose

The ADA–KDIGO consensus recommends an ACE inhibitor or ARB, titrated to the maximum tolerated dose, for people with diabetes and hypertension who have severely increased albuminuria (UACR 300 mg/g or higher) or an eGFR below 60. These drugs slow kidney disease progression and reduce cardiovascular events. Her UACR of 350 mg/g meets that threshold.

Why not the others:

• A. Amlodipine lowers blood pressure but doesn't give the kidney protection her albuminuria calls for.
• B. A thiazide can be added later, but it isn't the preferred first agent here.
• D. Her albuminuria makes medication indicated now, not after a 6-month delay.

Key point: For diabetes, hypertension, and a UACR of 300 mg/g or more, start an ACE inhibitor or ARB and titrate to the maximum tolerated dose.

Source: ADA–KDIGO Consensus Report: Diabetes Management in Chronic Kidney Disease, Consensus statements; RAS inhibition; lipid management; metformin and SGLT2 sections (2022). Source check: September 22, 2026.

Topic: Diabetes, hypertension, and albuminuria · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Adult

Answer: B. Generalized anxiety disorder

Generalized anxiety disorder involves excessive, hard-to-control worry about several areas of life on most days for at least 6 months. It comes with symptoms such as restlessness, fatigue, poor concentration, irritability, muscle tension, or disturbed sleep. He meets the duration, the worry across many topics, and the associated symptoms, with real impairment.

Why not the others:

• A. Panic disorder centers on recurrent, unexpected panic attacks, which he doesn't have.
• C. Adjustment disorder follows a specific stressor, and his worry spans many topics without one trigger.
• D. Social anxiety is fear of being judged in social situations, not broad everyday worry.

Key point: Worry about many things, most days, for 6 months or more, with physical symptoms, fits GAD.

Source: NIMH: Generalized Anxiety Disorder, Signs and symptoms; how GAD is diagnosed (Live NIMH guidance). Source check: September 22, 2026.

Topic: Persistent worry · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Young adult

Answer: A. Continue 25 mcg; recheck TSH 6 to 8 weeks after starting

Levothyroxine labeling advises starting at 12.5 to 25 mcg daily in older patients or those with heart disease and increasing the dose only every 6 to 8 weeks as needed. TSH should be checked 6 to 8 weeks after any change, since it takes that long to reach a new steady state. Feeling unchanged at 10 days is expected.

Why not the others:

• B. A large early increase risks angina or arrhythmia in someone with coronary disease.
• C. A TSH at 10 days hasn't reached steady state and would mislead the dose decision.
• D. Stopping leaves her hypothyroidism untreated; slow improvement is expected.

Key point: In older or cardiac patients, start low and wait 6 to 8 weeks before rechecking TSH or changing the dose.

Source: Levoxyl: U.S. Prescribing Information, Section 2, elderly/cardiac dosing; secondary/tertiary hypothyroidism; monitoring (Label revision December 2018). Pfizer Medical: Levoxyl Dosage and Administration, Monitoring TSH and/or T4; adult primary hypothyroidism (Live manufacturer labeling page). Source check: September 22, 2026.

Topic: Starting levothyroxine · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: A. A brief validated tool such as the AUDIT-C

The USPSTF recommends screening all adults for unhealthy alcohol use (grade B) and found 1- to 3-item tools, including the AUDIT-C and the single alcohol screening question, to be the most accurate. The AUDIT-C asks how often, how much, and how often heavy drinking happens. A positive screen needs further assessment; risky drinking may call for brief counseling, while an alcohol use disorder may require more extensive treatment.

Why not the others:

• B. A vague social-drinking question isn't a validated screen.
• C. Screening is done by asking questions, not with lab tests.
• D. The recommendation applies to all adults, not only those with liver disease.

Key point: Screen every adult for unhealthy alcohol use with a brief validated tool like the AUDIT-C.

Source: USPSTF: Unhealthy Alcohol Use—Screening and Counseling, Screening tools and response to a positive screen (November 13, 2018). Source check: September 22, 2026.

Topic: Alcohol screening · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Adult

Answer: D. Recombinant zoster vaccine, 2 doses given 2 to 6 months apart

CDC recommends 2 doses of recombinant zoster vaccine (Shingrix), 2 to 6 months apart, for immunocompetent adults 50 and older. There's no need to screen for prior chickenpox. Her age alone qualifies her.

Why not the others:

• A. Past chickenpox is exactly why shingles can happen, because the virus stays dormant.
• B. CDC says there's no need to screen, by history or blood test, for prior varicella.
• C. The live zoster vaccine (Zostavax) is no longer available in the United States.

Key point: Adults 50 and older get two doses of recombinant zoster vaccine, 2 to 6 months apart, with no varicella screening.

Source: CDC: Shingles Vaccine Recommendations, Routine recommendations, prior herpes zoster, dosing interval (October 22, 2024). Source check: September 22, 2026.

Topic: Shingles vaccine · ANCC: Professional Practice · NPCB: Plan · NPCB age tag: Adult

Answer: D. Anemia of chronic disease

Anemia of chronic disease occurs with chronic inflammatory conditions such as rheumatoid arthritis. Serum iron and transferrin (reflected in the TIBC) are typically low, while ferritin is normal or high. The anemia is usually normocytic or microcytic, which matches his results.

Why not the others:

• A. Iron deficiency would show a low ferritin, usually with a high TIBC.
• B. B12 deficiency causes a macrocytic anemia, and his MCV is normal.
• C. Thalassemia trait usually shows a low MCV with normal iron studies.

Key point: Low iron, low TIBC, and a normal or high ferritin in someone with chronic inflammation point to anemia of chronic disease.

Source: Merck Manual Professional: Anemia of Chronic Disease, Diagnosis: iron, transferrin/TIBC, ferritin, inflammatory confounding (Reviewed March 2025). Source check: September 22, 2026.

Topic: Anemia with inflammation · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: C. No antibiotic; symptom care and return precautions

He has acute uncomplicated bronchitis, which is usually viral. CDC-based guidance says routine antibiotics aren't recommended, however long the cough has lasted. Pneumonia is unlikely in a healthy adult with normal vital signs and a normal lung exam, and a bronchitis cough can last 3 weeks or longer.

Why not the others:

• A. Colored sputum doesn't indicate a bacterial infection.
• B. The cough's length alone doesn't justify antibiotics; bronchitis coughs often last weeks.
• D. With normal vital signs and a clear chest, a radiograph usually isn't needed.

Key point: For uncomplicated acute bronchitis, don't give antibiotics, even with colored sputum or a long cough.

Source: CDC: Adult Outpatient Antibiotic Treatment Recommendations, Acute bronchitis; pharyngitis; uncomplicated cystitis (April 16, 2024). Source check: September 22, 2026.

Topic: Cough after a cold · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Young adult

Answer: A. Check inhaler technique and adherence first

Poor inhaler technique and missed doses are common reasons asthma stays uncontrolled. Guidance advises confirming the symptoms are asthma and checking technique and adherence before stepping up. Correct identifiable technique or adherence problems, then reassess whether treatment needs to be stepped up.

Why not the others:

• B. Stepping up without checking technique may add a drug she also can't use well.
• C. An oral steroid burst is for exacerbations, not gradual loss of control.
• D. Changing the albuterol device doesn't address whether she takes her controller correctly.

Key point: Before stepping up asthma therapy, check technique, adherence, and the diagnosis.

Source: GINA 2026 Summary Guide for Asthma Management and Prevention, Printed pages 14 and 21–25: uncontrolled asthma; treatment tracks; Step 2 (July 2026). Source check: September 22, 2026.

Topic: Asthma not controlled · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Young adult

Answer: D. 25

Absolute risk reduction (ARR) is 10% minus 6%, which is 4%, or 0.04. NNT is 1 divided by the ARR: 1 ÷ 0.04 = 25. On average, those trial rates correspond to one fewer event per 25 people treated over 5 years, not a guarantee for any particular group of 25.

Why not the others:

• A. 4 is the absolute risk reduction in percentage points, not the NNT.
• B. 40 is the relative risk reduction (4 ÷ 10 = 40%), not the NNT.
• C. 60 comes from the relative risk (6 ÷ 10 = 0.6), which isn't the NNT.

Key point: NNT equals 1 divided by the absolute risk reduction.

Source: Worked calculation: number needed to treat: 1 / (0.10 − 0.06) = 25 over five years. Derived from the values in this question. Source check: September 22, 2026.

Topic: Number needed to treat · ANCC: Professional Practice · NPCB: Evaluate · NPCB age tag: Adult

Answer: D. Atrial fibrillation

Atrial fibrillation replaces organized P waves with chaotic fibrillatory activity, so the ventricular rhythm is irregularly irregular. Absent P waves with irregular, narrow QRS complexes is the classic pattern.

Why not the others:

• A. Atrial flutter shows organized sawtooth flutter waves rather than no atrial activity.
• B. Multifocal atrial tachycardia still has distinct P waves of varying shapes before each QRS.
• C. Sinus arrhythmia has a normal P wave before every QRS, with rate varying with breathing.

Key point: No P waves plus an irregularly irregular rhythm is atrial fibrillation.

Source: MSD Manual Professional: Atrial Fibrillation, Diagnosis: ECG findings (Live professional reference). Source check: September 22, 2026.

Topic: Palpitations · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Adult

Answer: C. Mitral regurgitation

In mitral regurgitation, blood leaks back into the left atrium during systole, producing a holosystolic, blowing murmur at the apex that radiates to the axilla. Timing, location, and radiation together identify it.

Why not the others:

• A. Aortic stenosis is a harsh systolic murmur at the right upper sternal border that radiates to the carotids.
• B. Mitral stenosis is a low-pitched diastolic rumble at the apex, often with an opening snap.
• D. Aortic regurgitation is a high-pitched diastolic murmur along the left sternal border.

Key point: A holosystolic murmur at the apex radiating to the axilla is mitral regurgitation.

Source: MSD Manual Professional: Mitral Regurgitation, Symptoms and signs; auscultation (Live professional reference). Source check: September 22, 2026.

Topic: Murmur at the apex · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Older adult

Answer: D. A daily low-dose inhaled corticosteroid

His symptoms are persistent, so he needs an inhaled corticosteroid-containing regimen, not albuterol-only therapy. GINA 2026 prefers as-needed low-dose ICS-formoterol for many adults with mild asthma. When that option is unavailable, daily low-dose ICS with an appropriate reliever is a Step 2 alternative, provided he can adhere to the daily treatment.

Why not the others:

• A. A long-acting beta-agonist shouldn't be used without an inhaled corticosteroid in asthma.
• B. Albuterol alone treats symptoms but not the airway inflammation driving them.
• C. A nebulizer changes the delivery device, not the missing controller therapy.

Key point: Persistent asthma needs an anti-inflammatory controller; reliever-only therapy isn't enough.

Source: GINA 2026 Summary Guide for Asthma Management and Prevention, Printed pages 14 and 21–25: uncontrolled asthma; treatment tracks; Step 2 (July 2026). Source check: September 22, 2026.

Topic: Mild persistent asthma · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Young adult

Answer: C. Start now, with any recommended test

The USPSTF recommends colorectal cancer screening for average-risk adults 45 to 49 (grade B) and 50 to 75 (grade A). Several stool-based and direct visualization tests are acceptable; the best test is one he'll actually complete.

Why not the others:

• A. The starting age dropped from 50 to 45 in the 2021 recommendation.
• B. Stool-based tests such as annual FIT are recommended options too.
• D. The recommendation covers average-risk adults; a family history can mean starting earlier, not being the only reason to screen.

Key point: Average-risk colorectal screening starts at 45, with several acceptable test choices.

Source: USPSTF: Colorectal Cancer Screening, Recommendation summary; positive stool-test follow-up (May 18, 2021). Source check: September 22, 2026.

Topic: When to start colorectal screening · ANCC: Professional Practice · NPCB: Assess · NPCB age tag: Adult

Answer: C. Hold sertraline and arrange immediate emergency evaluation for symptomatic hyponatremia

Sertraline can cause hyponatremia, and older adults are at greater risk. Its U.S. label directs discontinuation and appropriate medical intervention when hyponatremia is symptomatic. New confusion and unsteadiness with sodium 125 mEq/L require immediate assessment in a setting that can monitor and treat the sodium abnormality; other causes also need evaluation.

Why not the others:

• A. Raising the dose would likely worsen the sodium problem.
• B. New confusion 3 weeks after starting a drug that causes hyponatremia isn't a reason to start a dementia drug.
• D. Extra fluid can worsen hyponatremia caused by SIADH.

Key point: New neurologic symptoms with significant hyponatremia need acute medical evaluation; hold a suspected causative drug rather than simply scheduling follow-up.

Source: Sertraline Tablets: U.S. Prescribing Information, Sections 2.1 and 5.8: dosage; hyponatremia (DailyMed update May 10, 2021). Source check: September 22, 2026.

Topic: New confusion on an SSRI · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Elderly

Answer: D. Managing her own medications

The Lawton IADL scale measures the more complex tasks needed to live independently in the community: using the phone, shopping, preparing food, housekeeping, laundry, transportation, handling medications, and managing finances. Basic activities such as bathing and dressing are measured by the Katz ADL index.

Why not the others:

• A. Bathing is a basic activity of daily living.
• B. Dressing is a basic activity of daily living.
• C. Toileting is a basic activity of daily living.

Key point: IADLs are the complex tasks of independent living, such as medications, money, shopping, and transportation.

Source: Hartford Institute: Lawton Instrumental Activities of Daily Living Scale, Best tool; target population; domains (Try This clinical tool). Source check: September 22, 2026.

Topic: Functional status · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Elderly

Answer: D. Acute angle-closure glaucoma

Acute angle-closure glaucoma causes severe eye pain and redness, decreased vision, colored halos, headache, nausea, and vomiting. Exam shows a hazy cornea and a fixed mid-dilated pupil, with very high eye pressure. The whole-body symptoms can be mistaken for a neurologic or stomach problem. It needs immediate treatment to prevent permanent vision loss.

Why not the others:

• A. Conjunctivitis doesn't cause severe pain, halos, vision loss, or a fixed pupil.
• B. Migraine doesn't cause a red eye, a hazy cornea, or a fixed pupil.
• C. A subconjunctival hemorrhage is painless and doesn't affect vision or the pupil.

Key point: Red, painful eye plus halos, vomiting, and a fixed mid-dilated pupil is angle-closure glaucoma until proven otherwise.

Source: MSD Manual Professional: Angle-Closure Glaucoma, Acute symptoms/signs and immediate treatment (Live professional reference). Source check: September 22, 2026.

Topic: Painful red eye · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Explore his own reasons using the 5 R's, and revisit at every visit

For patients not ready to make a quit attempt, AHRQ recommends the 5 R's: relevance, risks, rewards, roadblocks, and repetition. The patient names why quitting matters to him, what he'd gain, and what's in the way. The conversation is repeated at every visit, because most people need several attempts before they succeed.

Why not the others:

• B. Setting a date he hasn't agreed to ignores where he is right now.
• C. A lecture tells him the risks instead of helping him identify them himself.
• D. Repetition at every visit is part of the approach, so dropping it misses the chance.

Key point: Not ready to quit? Use the 5 R's, and repeat the conversation every visit.

Source: AHRQ: Patients Not Ready to Make a Quit Attempt—The 5 R’s, Relevance, Risks, Rewards, Roadblocks, Repetition (December 2012 page). USPSTF: Tobacco Smoking Cessation in Adults, Recommendation summary and clinical considerations (January 19, 2021). Source check: September 22, 2026.

Topic: Not ready to quit · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Adult

Answer: B. Abnormal orthostatic response that raises his fall risk

CDC's STEADI protocol measures blood pressure after 5 minutes lying down and again after 1 and 3 minutes standing. A systolic drop of 20 mm Hg or more, a diastolic drop of 10 mm Hg or more, or lightheadedness on standing is abnormal. His systolic fell 24 mm Hg and he felt dizzy, so the result is abnormal and counts as a fall risk factor.

Why not the others:

• A. A drop this size with symptoms isn't a normal part of aging.
• C. The criterion is the size of the drop and symptoms, not whether the pressure stays above a fixed number.
• D. STEADI uses 1- and 3-minute standing readings; a 10-minute reading isn't required.

Key point: A drop of 20 systolic or 10 diastolic, or symptoms on standing, is abnormal and adds to fall risk.

Source: CDC STEADI: Measuring Orthostatic Blood Pressure, Page 1: method and abnormal results (2017). Source check: September 22, 2026.

Topic: Lightheaded on standing · ANCC: Patient Assessment Process · NPCB: Diagnose · NPCB age tag: Older adult

Answer: C. Add a thiazide-type diuretic or calcium channel blocker

The 2025 AHA/ACC guideline sets a treatment goal below 130/80 mm Hg for most adults. He's well above it despite good adherence, so therapy should be intensified. Adding a drug from a different first-line class works through a second mechanism.

Why not the others:

• A. Waiting 6 months leaves his blood pressure uncontrolled.
• B. Combining an ACE inhibitor with an ARB blocks the same pathway twice and adds risk, such as high potassium and kidney injury, without a second mechanism.
• D. He's tolerating his ACE inhibitor; switching to a beta-blocker isn't the logical step without a specific reason.

Key point: Not at goal on one drug and taking it reliably? Add a second first-line class rather than waiting.

Source: ACC: 2025 ACC/AHA High Blood Pressure Guideline—Clinical Guidance, Pharmacotherapy selection and combination treatment (October 1, 2025). ADA–KDIGO Consensus Report: Diabetes Management in Chronic Kidney Disease, Consensus statements; RAS inhibition; lipid management; metformin and SGLT2 sections (2022). Source check: September 22, 2026.

Topic: Blood pressure not at goal · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Adult

Answer: B. Gout

Needle-shaped, negatively birefringent monosodium urate crystals in joint fluid confirm gout. The first metatarsophalangeal joint is the most commonly involved. Crystals don't rule out a coexisting infection, so if infection is suspected, Gram stain and culture are still needed.

Why not the others:

• A. Pseudogout crystals are rhomboid and positively birefringent.
• C. Septic arthritis is diagnosed by infection findings, not urate crystals, though the two can coexist.
• D. Rheumatoid arthritis doesn't produce urate crystals in joint fluid.

Key point: Needle-shaped, negatively birefringent crystals mean gout; rhomboid, positively birefringent crystals mean pseudogout.

Source: MSD Manual Professional: Gout, Diagnosis: synovial fluid and crystal microscopy (Reviewed July 2025; modified April 2026). Source check: September 22, 2026.

Topic: Hot, swollen big toe · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Adult

Answer: B. McMurray test

Twisting, joint-line pain, and catching or locking point toward a meniscal injury. McMurray's test moves the knee through flexion, rotation, and extension to look for a painful click or reproduction of joint-line symptoms. The examination guides further evaluation; a single maneuver does not establish or exclude every meniscal tear.

Why not the others:

• A. Lachman tests the anterior cruciate ligament.
• C. Valgus stress tests the medial collateral ligament.
• D. Posterior drawer tests the posterior cruciate ligament.

Key point: Locking or catching with joint-line pain points to the menisci, so do a McMurray test.

Source: Grover: Evaluating Acutely Injured Patients for Internal Derangement of the Knee, Ottawa Knee Rule; meniscal injury; McMurray test (American Family Physician, February 1, 2012). Stanford Medicine: Musculoskeletal Examination Benchmarks, Pages 1–2: hand/wrist, neck, knee examination (August 2018). Source check: September 22, 2026.

Topic: Twisting knee injury · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Young adult

Answer: B. Respect his refusal, document it, and revisit later

The ANA Code of Ethics recognizes the patient's moral and legal right to decide what is done to their own person, including the right to refuse treatment without coercion, after receiving accurate, understandable information. He has capacity and understands the choice. Documenting the discussion and offering to revisit it keeps the door open.

Why not the others:

• A. A family member can't override a capable patient's decision.
• C. Prescribing against his stated wishes ignores his refusal.
• D. Threatening to end care is coercion, which undermines self-determination.

Key point: A patient with capacity can refuse recommended treatment. Document the discussion and revisit it.

Source: ANA Code of Ethics, Provision 1.4: Right to Self-Determination, Informed decisions, refusal, freedom from coercion (2025 Code). Source check: September 22, 2026.

Topic: Declining anticoagulation · ANCC: Professional Practice · NPCB: Plan · NPCB age tag: Elderly

Answer: A. Nitrofurantoin

The 2023 AGS Beers Criteria recommend avoiding nitrofurantoin in older adults with creatinine clearance below 30 mL/min. Her clearance of 24 is below that threshold. Culture results, infection site, allergies, and renal dosing still matter when choosing an alternative.

Why not the others:

• B. Fosfomycin is not the drug identified by the Beers nitrofurantoin cutoff; its suitability and dose still require assessment of the infection and kidney function.
• C. Cephalexin is not the drug identified by the Beers nitrofurantoin cutoff; its suitability and dose still require assessment of the infection and kidney function.
• D. Amoxicillin-clavulanate is not the drug identified by the Beers nitrofurantoin cutoff; its suitability and dose still require assessment of the infection and kidney function.

Key point: Avoid nitrofurantoin when kidney function is significantly reduced.

Source: AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Topic: Cystitis with low kidney function · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Elderly

Answer: B. Free T4

Levothyroxine labeling states that TSH isn't a reliable measure of dose adequacy in secondary or tertiary hypothyroidism and shouldn't be used to monitor therapy. Because her pituitary can't make a normal TSH, the free T4 level is used instead.

Why not the others:

• A. Her pituitary can't produce a reliable TSH, so TSH can't guide her dose.
• C. Antibodies help identify autoimmune thyroid disease; they don't guide replacement dosing.
• D. Thyroglobulin is used in thyroid cancer follow-up, not to dose levothyroxine.

Key point: In central hypothyroidism, dose levothyroxine by free T4, not TSH.

Source: Levoxyl: U.S. Prescribing Information, Section 2, elderly/cardiac dosing; secondary/tertiary hypothyroidism; monitoring (Label revision December 2018). Pfizer Medical: Levoxyl Dosage and Administration, Monitoring TSH and/or T4; adult primary hypothyroidism (Live manufacturer labeling page). Source check: September 22, 2026.

Topic: Monitoring central hypothyroidism · ANCC: Plan of Care (diagnosis) · NPCB: Assess · NPCB age tag: Adult

Answer: D. Add an inhaled corticosteroid (LABA + LAMA + ICS)

GOLD-based guidance advises considering triple therapy (LABA + LAMA + ICS) for patients hospitalized for an exacerbation when the blood eosinophil count is at least 100 cells/µL. His technique and adherence have already been checked, so the gap is in his regimen. Discuss ICS adverse effects, including pneumonia risk, rather than treating an eosinophil count as the only treatment consideration.

Why not the others:

• A. Removing a bronchodilator after a hospitalization moves in the wrong direction.
• B. A short-acting bronchodilator alone is less treatment than he's on now.
• C. Long-term oral steroids aren't a maintenance strategy for COPD.

Key point: After a COPD hospitalization on LABA + LAMA, an eosinophil count at least 100 supports adding an ICS.

Source: COPD Checklist: GOLD 2026 Follow-up Algorithm, Hosted by Ohio AFP, Page 3: hospitalization/eosinophils and reproduced GOLD Figure 3.9; page 4 references (April 2026 checklist; cites GOLD 2026). Source check: September 22, 2026.

Topic: COPD after a hospitalization · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: C. Immune from hepatitis B vaccination

In CDC's interpretation chart, a negative HBsAg, negative anti-HBc, and positive anti-HBs means immunity from vaccination. The vaccine produces only surface antibody, so the core antibody stays negative.

Why not the others:

• A. Immunity from natural infection shows a positive anti-HBc along with positive anti-HBs.
• B. Chronic infection shows a positive HBsAg.
• D. A susceptible person has all three markers negative.

Key point: Anti-HBs alone is vaccine immunity. Anti-HBs plus anti-HBc is immunity from infection.

Source: CDC: Clinical Testing and Diagnosis for Hepatitis B, Interpretation of screening tests and recommended actions (Live CDC guidance). Source check: September 22, 2026.

Topic: Hepatitis B serologies (I) · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Young adult

Answer: D. “What dusts, fumes, or chemicals are you exposed to at work?”

COPD can occur in people who have never smoked. Occupational and environmental exposure to dusts, chemicals, and fumes is an important risk factor, so an exposure history belongs in the workup.

Why not the others:

• A. Seasonal nasal symptoms point toward allergy, not COPD exposure.
• B. Cough after meals points toward reflux.
• C. Needing more pillows at night points toward heart failure.

Key point: Not smoking doesn't rule out COPD, so ask about workplace dusts, chemicals, and fumes.

Source: GOLD Science Committee: Spirometry for COPD Diagnosis, Post-bronchodilator confirmation and repeat testing around the diagnostic threshold (2025). COPD Checklist: GOLD 2026 Follow-up Algorithm, Hosted by Ohio AFP, Page 3: hospitalization/eosinophils and reproduced GOLD Figure 3.9; page 4 references (April 2026 checklist; cites GOLD 2026). Source check: September 22, 2026.

Topic: Cough in a never-smoker · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Adult

Answer: A. Sildenafil can be started at 25 mg, since he's stable on the alpha-blocker

Sildenafil labeling says that when it's given with an alpha-blocker, the patient should be stable on the alpha-blocker first and sildenafil should start at 25 mg. That lowers the risk of symptomatic low blood pressure. Nitrates, not alpha-blockers, are the contraindication.

Why not the others:

• B. The contraindication is nitrates. Alpha-blockers call for caution and a low starting dose.
• C. The label calls for starting at 25 mg with an alpha-blocker, not 100 mg.
• D. Stopping his BPH treatment isn't necessary; he just needs to be stable on it.

Key point: With an alpha-blocker, be stable first and start sildenafil at 25 mg. With nitrates, don't use it at all.

Source: Viagra: U.S. Prescribing Information, Sections 2.3, 4.1 and 5.5: alpha-blockers and nitrates (Label revision December 2017). Source check: September 22, 2026.

Topic: Erectile dysfunction on tamsulosin · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Older adult

Answer: A. Use a low-hypoglycemia regimen and connect her with food resources

Sulfonylureas can cause hypoglycemia, and missed meals increase that risk. Changing to a lower-risk regimen and addressing the food barrier treats the actual problem. The medication plan must fit her access to food, not assume that advice alone can make regular meals affordable.

Why not the others:

• B. More sulfonylurea means more hypoglycemia when she skips meals.
• C. Advice to eat regularly doesn't address why she can't.
• D. Insulin also causes hypoglycemia and doesn't fix the food barrier.

Key point: When lows follow missed meals, address the food barrier and use lower-hypoglycemia medications.

Source: Glucotrol XL (glipizide): U.S. Prescribing Information, Section 5.1: hypoglycemia and deficient caloric intake (Full prescribing information revised August 2023). Source check: September 22, 2026.

Topic: Food insecurity and diabetes · ANCC: Professional Practice · NPCB: Evaluate · NPCB age tag: Adult

Answer: C. Asymptomatic bacteriuria; don't treat it

IDSA strongly recommends against screening for or treating asymptomatic bacteriuria in older residents of long-term care facilities. Bacteriuria is common in this group, and treating it brings harm without benefit. Without symptoms, a positive culture isn't an infection that needs antibiotics.

Why not the others:

• A. Antibiotics aren't indicated for bacteriuria without symptoms.
• B. Antibiotics aren't indicated, and fluoroquinolones add their own harms.
• D. A repeat positive culture still isn't an indication to treat without symptoms.

Key point: Bacteria in the urine without symptoms isn't an infection. Don't screen for it, and don't treat it.

Source: IDSA 2019 Guideline: Asymptomatic Bacteriuria, Recommendations for older adults, long-term care and nonlocalizing symptoms (2019). Source check: September 22, 2026.

Topic: Positive urine culture without symptoms · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Elderly

Answer: D. An exercise program for gait, strength, and balance

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 and older at increased fall risk (grade B). CDC's STEADI algorithm pairs poor gait, strength, or balance with physical therapy or an evidence-based exercise program such as tai chi.

Why not the others:

• A. Restricting activity weakens him further and doesn't lower fall risk.
• B. Bed rest leads to deconditioning.
• C. Sedative hypnotics like zolpidem increase fall risk and are on the Beers list to avoid.

Key point: For an older adult at increased fall risk, exercise for gait, strength, and balance is the core intervention.

Source: CDC STEADI: Algorithm for Fall Risk Screening, Assessment, and Intervention, Pages 1–2: assess and intervene (2019). Source check: September 22, 2026.

Topic: Preventing falls · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Older adult

Answer: B. A validated malnutrition screen, such as the MNA-SF

The MNA-SF is a six-item tool developed for older adults. It was developed as a malnutrition-risk screen and is designed as the first step of a two-step process: people found at risk get a fuller assessment to confirm the diagnosis and plan care.

Why not the others:

• A. BMI alone can miss someone losing weight from a normal or high starting point.
• C. A single day's intake doesn't capture his weight loss or other risk factors.
• D. He has already lost significant weight, and waiting delays care.

Key point: Unintentional weight loss in an older adult calls for a validated screen such as the MNA-SF, then a fuller assessment if positive.

Source: Rubenstein et al.: Screening for Undernutrition in Geriatric Practice—MNA-SF, Abstract: six-item screen, older-adult sample and further assessment (2001). Source check: September 22, 2026.

Topic: Unintentional weight loss · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Elderly

Answer: B. Raise allopurinol toward urate below 6; keep prophylaxis

ACR's 2020 guideline recommends a treat-to-target strategy: titrate urate-lowering therapy until serum urate is below 6 mg/dL. Flare prophylaxis continues for 3 to 6 months, and longer if flares continue. He isn't at target and is still flaring, so the allopurinol dose goes up and prophylaxis stays.

Why not the others:

• A. He isn't at the urate target, so the current dose is too low.
• C. Prophylaxis continues while flares persist.
• D. Allopurinol is a daily long-term medication, not a symptom treatment.

Key point: In gout, titrate allopurinol to a serum urate below 6 mg/dL and keep prophylaxis while flares continue.

Source: ACR 2020 Guideline for the Management of Gout, Allopurinol/HLA-B*5801; urate targets; initiation and prophylaxis recommendations (2020 guideline). Source check: September 22, 2026.

Topic: Gout still flaring · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Adult

Answer: D. A 6-month prognosis must be certified, and she can later stop hospice

Medicare covers hospice when the hospice doctor and her regular doctor, if she has one, certify she is terminally ill, with a life expectancy of 6 months or less if the illness runs its normal course. She accepts comfort care instead of care to cure her illness, but she can change her mind and stop hospice. Care can continue past 6 months with recertification.

Why not the others:

• A. Hospice isn't limited to cancer; heart failure qualifies.
• B. She keeps the right to stop hospice and return to other treatment.
• C. Hospice care is usually provided at home or where she lives.

Key point: Medicare hospice requires a certified prognosis of 6 months or less, focuses on comfort, and can be stopped by the patient.

Source: Medicare: Hospice Care Coverage, Eligibility, provider requirements, setting, comfort versus curative treatment (Live Medicare guidance). 42 CFR 418.28: Revoking the Election of Hospice Care, Subsections (a)–(c) (eCFR current text, September 2026). Source check: September 22, 2026.

Topic: Choosing hospice · ANCC: Professional Practice · NPCB: Evaluate · NPCB age tag: Elderly

Answer: D. Chronic hepatitis B infection

In CDC's interpretation chart, a positive HBsAg with a positive total core antibody, a negative IgM core antibody, and a negative surface antibody means chronic infection. The persistent positive HBsAg means he is still infected and can transmit the virus.

Why not the others:

• A. Acute infection shows a positive IgM anti-HBc.
• B. Immunity after infection shows a negative HBsAg and a positive anti-HBs.
• C. Vaccine immunity shows a negative HBsAg and anti-HBc, with a positive anti-HBs.

Key point: HBsAg positive with IgM anti-HBc negative, persisting over time, is chronic hepatitis B.

Source: CDC: Clinical Testing and Diagnosis for Hepatitis B, Interpretation of screening tests and recommended actions (Live CDC guidance). Source check: September 22, 2026.

Topic: Hepatitis B serologies (II) · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Increased fall risk needing further assessment

CDC's STEADI tools flag a Timed Up and Go time of 12 seconds or more as a gait, strength, and balance risk factor for falls. Her 15 seconds means she's at increased risk, which calls for assessing modifiable risk factors and intervening on them.

Why not the others:

• B. Twelve seconds or more is flagged as a risk factor, not a normal variation.
• C. The TUG measures mobility, not cognition.
• D. The result points to fall-prevention interventions, not a wheelchair.

Key point: A Timed Up and Go of 12 seconds or more means increased fall risk.

Source: CDC STEADI: Fall Risk Factors Checklist, Page 1: TUG, tandem stance, vision and medication factors (2017). Source check: September 22, 2026.

Topic: Timed Up and Go · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Older adult

Answer: C. Initiate statin therapy after discussing benefits, risks, and appropriate intensity

The ADA–KDIGO consensus recommends statin therapy for people with diabetes and chronic kidney disease. Moderate-intensity therapy is recommended for primary prevention, with higher intensity appropriate for some people with additional risk factors. A previous cardiovascular event is not required before addressing lipid-related risk.

Why not the others:

• A. An over-the-counter supplement is not a substitute for the recommended statin strategy.
• B. Niacin alone does not follow the recommended statin-based approach.
• D. Diabetes with CKD supports primary prevention before a first cardiovascular event.

Key point: Diabetes with CKD is a reason to address cardiovascular risk with statin therapy, not to wait for a first event.

Source: ADA–KDIGO Consensus Report: Diabetes Management in Chronic Kidney Disease, Consensus statements; RAS inhibition; lipid management; metformin and SGLT2 sections (2022). Source check: September 22, 2026.

Topic: Lipid management in diabetes with CKD · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Adult

Answer: B. Screen now with bone measurement testing, such as a DXA scan

The USPSTF recommends osteoporosis screening for all women 65 and older (grade B) to prevent fractures. Screening can use DXA bone mineral density testing, with or without a fracture risk assessment tool.

Why not the others:

• A. Screening starts at 65 for women, not 70.
• C. A plain radiograph isn't a bone density screening test.
• D. A vitamin D level doesn't measure bone density or fracture risk.

Key point: All women 65 and older should be screened for osteoporosis with bone measurement testing.

Source: USPSTF: Osteoporosis to Prevent Fractures—Screening, Recommendation summary and population (January 14, 2025). Source check: September 22, 2026.

Topic: Osteoporosis screening · ANCC: Professional Practice · NPCB: Assess · NPCB age tag: Older adult

Answer: C. Ask directly about suicidal thoughts, plan, intent, and means

A positive answer about self-harm needs a same-visit safety assessment. NIMH's assessment guide, developed for positive ASQ screens, illustrates the relevant safety questions and guides clinicians to ask how often the thoughts occur, whether they're present right now, whether there is a plan and intent, and about access to means. Thoughts of suicide at this moment signal imminent risk that needs urgent mental health evaluation.

Why not the others:

• A. Starting a medication with a 4-week follow-up skips the safety assessment today.
• B. A waitlist doesn't address his safety today.
• D. Deferring the assessment ignores a positive answer now.

Key point: Any positive self-harm answer calls for a direct suicide safety assessment in the same visit.

Source: NIMH: Adult Outpatient Brief Suicide Safety Assessment Guide, Pages 1–2: current thoughts, plan, access to means and disposition (December 8, 2025). Source check: September 22, 2026.

Topic: Positive suicide item · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Young adult

Answer: B. Hold potassium-raising drugs and arrange immediate acute assessment with ECG and repeat potassium

Spironolactone can cause hyperkalemia, especially with impaired kidney function and an ACE inhibitor such as lisinopril. Potassium of 6.1 mEq/L needs immediate clinical assessment, including ECG, urgent confirmation of potassium and kidney function, and treatment guided by the results. Hold potassium-raising drugs while arranging that care; do not wait for a routine follow-up visit.

Why not the others:

• A. A potassium of 6.1 needs prompt action, not a month's wait.
• C. More ACE inhibitor would raise potassium further.
• D. The label advises against potassium supplements with spironolactone.

Key point: Hyperkalemia at 6.1 mEq/L in CKD calls for immediate assessment and management, not merely stopping one medicine and waiting.

Source: Aldactone: U.S. Prescribing Information, Section 5.1: hyperkalemia; section 7 drug interactions (Label revision November 2025). MSD Manual Professional: Hyperkalemia, Diagnosis, ECG assessment and moderate-to-severe hyperkalemia treatment (Live professional reference). Source check: September 22, 2026.

Topic: High potassium on spironolactone · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: C. Bell palsy (peripheral facial nerve palsy)

Weakness of the whole side of the face, including the forehead, points to a peripheral (lower motor neuron) facial nerve lesion, and Bell palsy is the most common cause. A supranuclear lesion typically spares the forehead because the forehead gets input from both sides of the brain; a brainstem lesion can produce a peripheral pattern. Bell palsy remains a diagnosis of exclusion.

Why not the others:

• A. The isolated whole-face pattern is more consistent with a peripheral facial palsy, but new neurologic deficits or an atypical course require evaluation for other causes, including stroke.
• B. Ramsay Hunt syndrome typically comes with a vesicular rash in or around the ear.
• D. Myasthenia gravis causes fatigable weakness, often with drooping eyelids, not a sudden one-sided facial palsy.

Key point: Weakness of the upper and lower face supports a peripheral facial-nerve pattern; the full neurologic examination and course still matter.

Source: MSD Manual Professional: Facial Nerve Palsy, Symptoms/signs and differential diagnosis (Live professional reference). Source check: September 22, 2026.

Topic: Facial droop · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Adult

Answer: B. Complete advance care planning and name a health care proxy now

Early in dementia, cognition may be intact enough for the person to discuss goals and make decisions. As the disease progresses, decision-making gets harder. Advance care discussions are appropriate in these early stages, with the patient and family, so his own wishes guide later care.

Why not the others:

• A. Waiting until he loses capacity removes his voice from the decisions.
• C. His family can be involved, but the plan should reflect his own wishes while he can express them.
• D. Waiting for a hospitalization risks a rushed decision without him.

Key point: Plan early in dementia, while the person can still take part in decisions.

Source: Alzheimer’s Association: Legal Documents and Planning, Legal capacity; advance directives; health-care decisions (Live organization guidance). Source check: September 22, 2026.

Topic: Planning ahead with dementia · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Elderly

Answer: C. The 30-Second Chair Stand

STEADI's 30-Second Chair Stand counts how many times the patient can rise to a full stand from a chair in 30 seconds, with arms crossed. Its stated purpose is to test leg strength and endurance. A below-average score for age and sex indicates fall risk.

Why not the others:

• A. The Timed Up and Go measures overall mobility.
• B. The 4-Stage Balance Test measures static balance.
• D. The Mini-Cog is a cognitive screen.

Key point: Leg strength and endurance in STEADI means the 30-Second Chair Stand.

Source: CDC STEADI: 30-Second Chair Stand, Page 1: purpose and instructions (2017). Source check: September 22, 2026.

Topic: Leg strength test · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Elderly

Answer: B. Behavioral cessation counseling combined with cessation medication

The USPSTF recommends behavioral interventions and FDA-approved pharmacotherapy for tobacco cessation in nonpregnant adults who use tobacco. Combining counseling with cessation medication addresses both behavioral and physical dependence. The medication should be chosen with the patient after reviewing contraindications and preferences.

Why not the others:

• A. The USPSTF finds insufficient evidence to recommend e-cigarettes for cessation and directs clinicians toward interventions with established effectiveness and safety.
• C. The recommended approach combines counseling with medication.
• D. Unassisted cutting down leaves out the counseling and medication he's ready for.

Key point: For someone ready to quit, combine counseling with cessation medication.

Source: USPSTF: Tobacco Smoking Cessation in Adults, Recommendation summary and clinical considerations (January 19, 2021). Source check: September 22, 2026.

Topic: Ready to quit smoking · ANCC: Professional Practice · NPCB: Plan · NPCB age tag: Adult

Answer: B. Prediabetes

ADA defines prediabetes as an A1C of 5.7% to 6.4%, a fasting glucose of 100 to 125 mg/dL, or a 2-hour glucose of 140 to 199 mg/dL on an oral glucose tolerance test. Both of her values fall in the prediabetes ranges.

Why not the others:

• A. Both values are above the normal range.
• C. Neither value reaches the diabetes thresholds (A1C 6.5% or higher, fasting glucose 126 mg/dL or higher).
• D. A1C and fasting glucose are each valid for classification; an OGTT isn't required.

Key point: A1C 5.7% to 6.4% or fasting glucose 100 to 125 mg/dL means prediabetes.

Source: ADA Standards of Care 2026: Diagnosis and Classification, Diagnostic tests; confirming the diagnosis; Tables 2.1 and 2.2 (Standards of Care 2026). Source check: September 22, 2026.

Topic: Prediabetes · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Adult

Answer: A. Consider ubrogepant after checking contraindications, interactions, and cardiovascular precautions

Sumatriptan is contraindicated in ischemic coronary artery disease, including a history of myocardial infarction. Ubrogepant is an approved acute migraine treatment without that coronary-disease contraindication. It is not risk-free: its label includes hypertension and Raynaud phenomenon warnings, and medication interactions must be checked.

Why not the others:

• B. Sumatriptan labeling contraindicates use with ischemic coronary artery disease or a prior myocardial infarction.
• C. Ergotamine is also a vasoconstrictor and a poor choice after a heart attack.
• D. Daily preventive treatment does not answer the question about treating an acute migraine attack.

Key point: Migraine plus coronary disease: avoid triptans and consider a gepant.

Source: Ubrelvy: U.S. Prescribing Information, Sections 1, 4 and 5: indication, contraindications, hypertension and Raynaud warnings (Current label served; warnings revised in 2025). Imitrex: U.S. Prescribing Information, Reproduced Label, Contraindications and warnings: coronary artery disease/vasospasm (U.S. prescribing information, revised December 2025). Source check: September 22, 2026.

Topic: Migraine after a heart attack · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Adult

Answer: D. Review every bottle he takes, including OTCs and supplements

CDC's STEADI fall-risk checklist covers all medications: prescriptions, over-the-counter products, and supplements. Identifying fall-risk medications, such as those on the Beers list, is a core part of the assessment. Reviewing the actual bottles catches drugs that single-source lists miss.

Why not the others:

• A. A pharmacy list misses OTC products, supplements, and prescriptions filled elsewhere.
• B. An EHR list often misses outside prescriptions and nonprescription products.
• C. Recall alone can omit doses, nonprescription products, and recently changed prescriptions; compare the patient’s account with the products and available records.

Key point: Fall-risk medication review includes every bottle: prescriptions, OTC products, and supplements.

Source: CDC STEADI: Algorithm for Fall Risk Screening, Assessment, and Intervention, Pages 1–2: assess and intervene (2019). Source check: September 22, 2026.

Topic: Complete medication history · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Elderly

Answer: A. Reduce his medications toward a relaxed goal, such as below 140/90

The 2026 ADA Standards set a relaxed blood pressure goal, such as below 140/90 mm Hg, for older adults with poor health, limited life expectancy, or a high risk of adverse effects. CDC's STEADI algorithm pairs orthostatic hypotension with stopping, switching, or reducing medications that raise fall risk. He has symptoms and a significant drop, so his regimen should be reduced.

Why not the others:

• B. His symptoms and orthostatic drop outweigh the seated reading.
• C. A stricter goal would worsen his dizziness and fall risk.
• D. Stopping everything at once isn't necessary; a stepwise reduction is safer.

Key point: For frail older adults, a relaxed blood pressure goal and fewer drugs can be the safer choice.

Source: ADA Standards of Care 2026: Older Adults, Recommendations 13.7–13.9; Tables 13.2 and 13.3; deintensification (Standards of Care 2026). CDC STEADI: Algorithm for Fall Risk Screening, Assessment, and Intervention, Pages 1–2: assess and intervene (2019). CDC STEADI: Measuring Orthostatic Blood Pressure, Page 1: method and abnormal results (2017). Source check: September 22, 2026.

Topic: Blood pressure too low for him · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Elderly

Answer: D. Call 911 for emergency stroke evaluation and note the time symptoms started

Sudden one-sided weakness and trouble speaking are stroke warning signs. CDC advises calling 911 right away and noting when symptoms began, because the most effective stroke treatments depend on timing. People having a stroke shouldn't be driven to the hospital; an ambulance lets treatment begin on the way.

Why not the others:

• A. An outpatient scan later wastes time that matters for treatment.
• B. CDC advises against driving; EMS can start treatment en route.
• C. Waiting delays time-sensitive treatment.

Key point: Stroke signs mean call 911 now and note the time symptoms started.

Source: CDC: Signs and Symptoms of Stroke, FAST and emergency response (May 19, 2026). Source check: September 22, 2026.

Topic: Sudden weakness in clinic · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: B. Penicillin V 500 mg by mouth twice daily for 10 days

For confirmed group A strep pharyngitis in an adult without penicillin allergy, CDC's adult recommendations list penicillin V 500 mg twice daily or amoxicillin 500 mg twice daily as first-line, for 10 days. Penicillin V is the option offered here.

Why not the others:

• A. Azithromycin is an alternative for some patients with penicillin allergy, not the preferred choice here; resistance varies geographically and over time.
• C. A fluoroquinolone isn't a recommended treatment for strep throat.
• D. His test is positive, so treatment is indicated.

Key point: Confirmed strep with no penicillin allergy: penicillin V or amoxicillin for 10 days.

Source: CDC: Clinical Guidance for Group A Streptococcal Pharyngitis, Recommended antibiotics and alternative regimens (Live CDC guidance). Source check: September 22, 2026.

Topic: Confirmed strep throat · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Adult

Answer: B. Unable to hold a full tandem stance for 10 seconds

CDC's STEADI checklist flags an inability to hold a full tandem stance (one foot directly in front of the other) for 10 seconds on the 4-Stage Balance Test as a gait, strength, and balance risk factor.

Why not the others:

• A. Using the arms to stand relates to the 30-Second Chair Stand, not the balance test.
• C. A TUG of 10 seconds is under the 12-second threshold for concern.
• D. Standing with feet side by side is the easiest stage, and completing it doesn't signal risk.

Key point: On the 4-Stage Balance Test, a tandem stance held less than 10 seconds signals fall risk.

Source: CDC STEADI: Fall Risk Factors Checklist, Page 1: TUG, tandem stance, vision and medication factors (2017). Source check: September 22, 2026.

Topic: Balance testing · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Older adult

Answer: C. Taper or step down to on-demand use

The Beers Criteria advise avoiding scheduled PPI use beyond 8 weeks in older adults unless there's a high-risk reason, such as Barrett esophagus, erosive esophagitis, or chronic NSAID or steroid use. Long-term use carries risks including C. difficile infection and bone loss with fractures. She has none of those indications and has not failed a withdrawal trial, so reassessing the need and stepping down is appropriate.

Why not the others:

• A. She has no ongoing indication, so indefinite use adds risk without benefit.
• B. Her symptoms have resolved, so more acid suppression isn't needed.
• D. A higher dose adds risk without an indication.

Key point: Without a high-risk indication, try to deprescribe PPIs used longer than 8 weeks.

Source: AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Topic: Long-term PPI · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: C. NSAID-related acute kidney injury; stop the ibuprofen

The timing and medication combination make NSAID-associated acute kidney injury the leading concern. Ibuprofen can impair renal perfusion, particularly in someone with CKD taking an ACE inhibitor and a diuretic. Stop the ibuprofen and promptly assess kidney function, potassium, volume status, and other possible causes rather than assuming the drug is the only explanation.

Why not the others:

• A. The abrupt rise over four days calls for evaluation of acute injury rather than attribution to expected CKD progression.
• B. Obstruction is possible but doesn't fit the timing with the new drug.
• D. A rise from 1.3 to 2.0 is far beyond normal variation.

Key point: A new NSAID plus an ACE inhibitor and diuretic in CKD is a setup for acute kidney injury.

Source: AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). KDIGO 2024 Clinical Practice Guideline for CKD, Printed S137, Tables 1–3; recommendation 3.7.1; medication stewardship (2024). Source check: September 22, 2026.

Topic: Rising creatinine · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Explain that the child needs a clinician with the appropriate pediatric or family population preparation

Under the APRN Consensus Model, nurse practitioners are educated, certified, and licensed in a role and at least one population focus. Education, certification, and licensure must be congruent in role and population, and certification doesn't expand scope beyond them. A young child falls outside the adult-gerontology focus. The Consensus Model is a scope framework, not a substitute for the law governing practice in a particular state.

Why not the others:

• B. Full practice authority changes independence from physician oversight, not the population focus.
• C. A consent form doesn't change the NP's scope of practice.
• D. A brief exam is still practice outside the population focus.

Key point: An NP's scope follows the population focus of their education, certification, and licensure.

Source: NCSBN: Advanced Practice Registered Nurses and the Consensus Model, Roles and population foci (Live NCSBN guidance). Source check: September 22, 2026.

Topic: Scope of practice · ANCC: Professional Practice · NPCB: Plan · NPCB age tag: Young adult

Answer: B. Narrow-margin excisional biopsy of the whole lesion

Any suspicious pigmented lesion should be biopsied. Whatever method is used, the specimen has to be deep enough to measure how far the lesion has penetrated (Breslow depth), which guides staging and treatment. Excising the whole lesion with narrow margins does that.

Why not the others:

• A. Cryotherapy destroys the tissue, leaving nothing to examine.
• C. A superficial shave can cut through the lesion and make its depth impossible to measure.
• D. A changing lesion with ABCDE features shouldn't be watched for a year.

Key point: Suspected melanoma needs a biopsy deep enough to measure its thickness.

Source: Shenenberger: Cutaneous Malignant Melanoma—A Primary Care Perspective, Biopsy of a suspicious lesion; complete excision and depth (American Family Physician, January 15, 2012). Source check: September 22, 2026.

Topic: Suspicious pigmented lesion · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Adult

Answer: D. “What is the gender or genders of your partners?”

CDC's 5 P's guide covers partners, practices, protection from STIs, past history of STIs, and pregnancy intention. It reminds clinicians never to assume a patient's sexual orientation or the gender identity of the patient or partners, and it uses open questions such as asking the gender of partners.

Why not the others:

• A. Marital status doesn't tell you about partners or risk.
• B. A leading question discourages an honest answer about protection.
• C. This assumes orientation, which CDC's guide specifically warns against.

Key point: Use open, nonjudgmental questions and don't assume orientation or partners' gender.

Source: CDC: Guide to Taking a Sexual History, The five Ps (Live CDC guidance). Source check: September 22, 2026.

Topic: Sexual history · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Young adult

Answer: A. An SGLT2 inhibitor

KDIGO recommends an SGLT2 inhibitor for people with type 2 diabetes, CKD, and an eGFR of at least 20 mL/min/1.73 m². Her eGFR of 42 and albuminuria fit this kidney-protective strategy in addition to tolerated ARB therapy. Review contraindications, volume status, and sick-day precautions when initiating treatment.

Why not the others:

• B. Combining an ACE inhibitor with an ARB increases the risk of hyperkalemia and acute kidney injury without improving long-term outcomes enough to justify the combination.
• C. Her ARB should stay; it's part of her kidney protection.
• D. Glyburide adds hypoglycemia risk and doesn't protect the kidneys; the Beers Criteria advise avoiding sulfonylureas in older adults.

Key point: Type 2 diabetes and CKD on an ACE inhibitor or ARB: add an SGLT2 inhibitor.

Source: KDIGO 2024 Clinical Practice Guideline for CKD, Printed S137, Tables 1–3; recommendation 3.7.1; medication stewardship (2024). ADA–KDIGO Consensus Report: Diabetes Management in Chronic Kidney Disease, Consensus statements; RAS inhibition; lipid management; metformin and SGLT2 sections (2022). Source check: September 22, 2026.

Topic: Diabetic kidney disease · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: D. Evaluate for other causes of delirium; don't treat the bacteriuria

IDSA recommends that when an older adult with cognitive impairment has bacteriuria and delirium but no genitourinary symptoms or systemic signs of infection, clinicians assess for other causes and observe carefully rather than treat. Bacteriuria is common in nursing home residents and often isn't the cause of the confusion.

Why not the others:

• A. Treating the culture result can miss the real cause of her delirium.
• B. Antibiotics aren't indicated without urinary symptoms or systemic signs of infection.
• C. A repeat positive culture doesn't change the recommendation.

Key point: Confusion plus a positive urine culture isn't automatically a UTI. Look for other causes first.

Source: IDSA 2019 Guideline: Asymptomatic Bacteriuria, Recommendations for older adults, long-term care and nonlocalizing symptoms (2019). Source check: September 22, 2026.

Topic: Delirium with bacteriuria · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Re-explain it a different way, then have her teach it back again

AHRQ's teach-back method asks patients to explain in their own words what they need to know or do. If a patient can't teach it back correctly, re-teach using different wording or a different approach and check again until she can. Her answer shows a dosing misunderstanding that matters for an anticoagulant.

Why not the others:

• B. The same words, louder, don't fix a misunderstanding.
• C. A pamphlet without rechecking leaves the error in place.
• D. “Do you understand?” invites a yes without confirming understanding.

Key point: If teach-back fails, re-teach differently and check again.

Source: AHRQ: Use the Teach-Back Method, Tool 5, Action steps: explain in the patient’s words, clarify and check again (Health Literacy Universal Precautions Toolkit, 3rd edition, 2024). Source check: September 22, 2026.

Topic: When teach-back fails · ANCC: Professional Practice · NPCB: Evaluate · NPCB age tag: Older adult

Answer: A. Parkinson disease

A one-sided resting tremor that lessens with movement, plus slowness (bradykinesia) and rigidity, is the classic picture of Parkinson disease. Essential tremor, by contrast, is typically an action or postural tremor, usually on both sides, and often improves with alcohol.

Why not the others:

• B. Essential tremor appears with action or holding a posture, not mainly at rest.
• C. Cerebellar tremor worsens as the hand approaches a target and comes with incoordination.
• D. Physiologic tremor is a fine, two-sided tremor made worse by caffeine or anxiety, without rigidity or slowness.

Key point: Resting tremor with bradykinesia and rigidity points to Parkinson disease; action tremor points to essential tremor.

Source: Merck Manual Professional: Parkinson Disease, Symptoms/signs; resting tremor, rigidity, bradykinesia (Live professional reference). Source check: September 22, 2026.

Topic: Tremor · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. Zarit Burden Interview

The Zarit Burden Interview measures the burden felt by caregivers of cognitively impaired older adults. Shorter 12-item and 4-item screening versions were developed for use across diagnostic groups, which makes it practical in primary care.

Why not the others:

• B. A cognitive screen for her doesn't measure caregiving strain.
• C. The Katz index measures basic self-care, not caregiver burden.
• D. The Morse Fall Scale estimates fall risk in hospitalized patients.

Key point: Caregiver strain calls for the Zarit Burden Interview.

Source: Bédard et al.: The Zarit Burden Interview—A New Short Version and Screening Version, Research abstract: caregiver-burden instrument and shortened versions (2001). Source check: September 22, 2026.

Topic: Caregiver strain · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Older adult

Answer: C. Sildenafil is contraindicated with nitrates

Sildenafil labeling contraindicates its use in anyone taking nitrates in any form, regularly or intermittently, because it potentiates the blood-pressure-lowering effect of nitrates. The label also notes it's unknown when nitrates could safely be given after a dose.

Why not the others:

• A. The contraindication doesn't depend on dose.
• B. Other PDE5 inhibitors carry the same nitrate interaction.
• D. Spacing doses doesn't make the combination safe.

Key point: Do not combine a PDE5 inhibitor with ongoing nitrate therapy; a patient should not invent a spacing interval to bypass the contraindication.

Source: Viagra: U.S. Prescribing Information, Sections 2.3, 4.1 and 5.5: alpha-blockers and nitrates (Label revision December 2017). Source check: September 22, 2026.

Topic: Erectile dysfunction with nitrates · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Older adult

Answer: D. Screen for chlamydia and gonorrhea now

The USPSTF recommends screening for chlamydia and gonorrhea in all sexually active women 24 or younger (grade B), when they are asymptomatic. Most of these infections cause no symptoms, which is why screening matters.

Why not the others:

• A. Screening is recommended precisely because infections are often silent.
• B. A Pap test screens for cervical cancer, not chlamydia or gonorrhea.
• C. Herpes serology isn't part of routine STI screening for someone without symptoms.

Key point: Sexually active women 24 and under should be screened for chlamydia and gonorrhea.

Source: USPSTF: Chlamydia and Gonorrhea Screening, Recommendation summary; population (September 14, 2021). Source check: September 22, 2026.

Topic: STI screening in a teen · ANCC: Professional Practice · NPCB: Assess · NPCB age tag: Adolescent

Answer: B. Stop oxybutynin and reassess her

Oxybutynin labeling warns of anticholinergic central nervous system effects, including confusion, agitation, and hallucinations, and advises considering stopping or reducing it if they develop. Older adults are especially sensitive, and the Beers Criteria flag strongly anticholinergic drugs as potentially inappropriate. Acute confusion still needs assessment for other causes; the medication timing does not establish the diagnosis by itself.

Why not the others:

• A. Adding a drug to treat a side effect (a prescribing cascade) leaves the cause in place.
• C. A higher dose would worsen anticholinergic effects.
• D. An antipsychotic adds risk and doesn't address the cause.

Key point: New confusion after starting an anticholinergic in an older adult: suspect the drug and stop it.

Source: Oxybutynin Chloride: U.S. Prescribing Information, Section 5.2: central nervous system effects (DailyMed label as served September 22, 2026). AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Topic: New confusion on a bladder drug · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Elderly

Answer: A. It's a new kind of headache that began after age 50

A new headache pattern after age 50 is a red flag. It raises concern for giant cell arteritis and other secondary causes. Merck advises considering immediate corticosteroid treatment when a patient over 50 has a new headache with jaw claudication, visual changes, or temporal artery tenderness.

Why not the others:

• B. Throbbing quality is common in benign headaches.
• C. A family history of migraine doesn't explain a new pattern at 68.
• D. Relief with acetaminophen doesn't rule out a serious cause.

Key point: A new headache pattern after 50 needs evaluation for secondary causes, including GCA.

Source: Merck Manual Professional: Giant Cell Arteritis, Symptoms/signs; diagnosis; urgent treatment (Live professional reference). Source check: September 22, 2026.

Topic: Headache red flag · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Older adult

Answer: D. Vitamin B12 deficiency

Metformin labeling warns that it can lower vitamin B12 levels and that deficiency can cause anemia or neuropathy. The cited label advises annual blood counts and notes that periodic B12 testing may be useful in people predisposed to low B12; her anemia and neuropathy call for evaluation now. A macrocytic anemia with new neuropathy in someone on long-term metformin fits B12 deficiency.

Why not the others:

• A. Folate deficiency can cause macrocytosis but doesn't explain the link to metformin, and B12 should be checked first.
• B. Iron deficiency causes a low MCV, not a high one.
• C. Diabetic neuropathy doesn't explain a macrocytic anemia.

Key point: Long-term metformin plus macrocytic anemia or neuropathy: check B12.

Source: Glumetza: U.S. FDA Prescribing Information, Section 5.2: vitamin B12 levels; renal restrictions (2017 archival FDA label). ADA Standards of Care 2026: Older Adults, Recommendations 13.7–13.9; Tables 13.2 and 13.3; deintensification (Standards of Care 2026). Source check: September 22, 2026.

Topic: Anemia on metformin · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: C. Refer to palliative care alongside his ongoing COPD treatment

Palliative care is medical care for people living with a serious illness, focused on relieving symptoms and supporting quality of life. It can be provided along with disease treatment and started at any stage. The stem establishes a need for symptom support, not hospice eligibility. Palliative care can be added without requiring a terminal prognosis or abandonment of his COPD regimen.

Why not the others:

• A. Palliative care does not require stopping disease-directed COPD treatment. Hospice can also include treatments used for comfort; the distinction is the care goals and benefit requirements, not whether every inhaler is discontinued.
• B. Palliative care doesn't have to wait until the end of life.
• D. His symptom burden calls for more support than specialty follow-up alone.

Key point: Palliative care can accompany ongoing treatment for serious illness; hospice has separate goals and eligibility requirements.

Source: Center to Advance Palliative Care: What Is Palliative Care?, Definition; serious illnesses including COPD; concurrent treatment (Live CAPC guidance). Medicare: Hospice Care Coverage, Eligibility, provider requirements, setting, comfort versus curative treatment (Live Medicare guidance). Source check: September 22, 2026.

Topic: Palliative care with COPD · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Older adult

Answer: B. An S3, suggesting heart failure

In an older adult with dyspnea and orthopnea, an S3 supports concern for heart failure and calls for further evaluation. An S3 reflects rapid ventricular filling; the finding alone does not establish the ejection fraction or distinguish every cause of heart failure.

Why not the others:

• A. An S3 isn't a normal finding at 72.
• C. Mitral stenosis produces a diastolic rumble with an opening snap, not an isolated S3.
• D. Pericarditis produces a friction rub.

Key point: An S3 with congestion symptoms in an older adult supports heart-failure evaluation; it is not an ejection-fraction measurement.

Source: MSD Manual Professional: Acute Heart Failure, Cardiac findings and diagnostic assessment (Live professional reference). Source check: September 22, 2026.

Topic: Extra heart sound · ANCC: Patient Assessment Process · NPCB: Diagnose · NPCB age tag: Older adult

Answer: B. Ask the patient whether she agrees to sharing the results with her daughter

HHS guidance allows relevant information to be shared with a person involved in care when a capable patient agrees, does not object, or the clinician can reasonably infer no objection in the circumstances. Ask the patient privately what she wants shared and with whom. Being her daughter does not automatically give her access to all her information.

Why not the others:

• A. Being family doesn't by itself authorize sharing her information.
• C. HIPAA permits sharing with involved family when the patient agrees or doesn't object.
• D. Verifying identity doesn't replace the patient's agreement.

Key point: When the patient has capacity, ask her before sharing information with family.

Source: HHS: Communicating With a Patient’s Family, Friends, or Others Involved in Care, Pages 1 and 5: capable patients, agreement/no objection/inference, relevant information (HHS provider guide). Source check: September 22, 2026.

Topic: Sharing results with family · ANCC: Professional Practice · NPCB: Plan · NPCB age tag: Elderly

Answer: B. Colonoscopy

The USPSTF states that positive results on stool-based screening tests require follow-up colonoscopy for the benefits of screening to be achieved. A positive FIT isn't a cancer diagnosis, but it has to be evaluated directly.

Why not the others:

• A. A negative repeat FIT doesn't cancel a positive one.
• C. Screening tests are for people without symptoms, so feeling well doesn't explain away the result.
• D. CT isn't the recommended follow-up for a positive stool test.

Key point: A positive stool-based screening test needs a colonoscopy.

Source: USPSTF: Colorectal Cancer Screening, Recommendation summary; positive stool-test follow-up (May 18, 2021). Source check: September 22, 2026.

Topic: Positive stool test · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: C. No; the Ottawa Knee Rule doesn't indicate a radiograph

The Ottawa Knee Rule recommends a radiograph only if the patient is 55 or older, has tenderness at the fibular head, has isolated patellar tenderness, can't flex to 90 degrees, or can't bear weight for four steps both right after the injury and in the exam room. He meets none of these, and the rule is highly sensitive for fractures.

Why not the others:

• A. The sport itself is not an Ottawa Knee Rule indication for a radiograph.
• B. MRI isn't a first step for an acute knee injury without red flags.
• D. Pain alone doesn't meet the rule's criteria.

Key point: With no Ottawa Knee Rule criterion present, the rule does not indicate a knee radiograph; reassess persistent or worsening symptoms.

Source: Grover: Evaluating Acutely Injured Patients for Internal Derangement of the Knee, Ottawa Knee Rule; meniscal injury; McMurray test (American Family Physician, February 1, 2012). Source check: September 22, 2026.

Topic: Knee injury imaging · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Young adult

Answer: D. Ofloxacin otic drops

Topical drops are the preferred treatment for otitis externa. When the eardrum is perforated or might be, drops with ototoxic potential, such as aminoglycoside-containing neomycin products, shouldn't be used. Ofloxacin otic solution is labeled for otitis externa and for ear infections with a perforated eardrum.

Why not the others:

• A. Aminoglycoside ear drops can reach the middle ear through a perforation and have been linked to ototoxicity.
• B. Oral antibiotics aren't first-line for uncomplicated otitis externa.
• C. Irrigation isn't appropriate with a perforated eardrum.

Key point: With a perforated eardrum, use non-ototoxic drops such as ofloxacin, not neomycin.

Source: AAO-HNSF Clinical Practice Guideline: Acute Otitis Externa, Abstract: action statements 3 and 5 (February 2014 guideline). Ofloxacin Otic Solution: U.S. Prescribing Information, Reproduced Label, Indications/usage; perforated tympanic membranes; precautions (U.S. label reproduction accessed September 22, 2026). Source check: September 22, 2026.

Topic: Ear drops with a perforated eardrum · ANCC: Plan of Care (pharmacology) · NPCB: Plan · NPCB age tag: Young adult

Answer: C. Reduce metformin to a total of 1,000 mg daily, reassess benefit and risk, and monitor kidney function

The ADA–KDIGO consensus recommends reducing metformin to a total of 1,000 mg daily at eGFR 30–44 and monitoring eGFR every 3–6 months once it is below 60. U.S. labeling advises reassessing continuation below 45, does not recommend initiation at 30–45, and contraindicates use below 30. Continuing his current 2,000 mg daily without a dose review misses the key safety issue.

Why not the others:

• A. The label doesn't require stopping at an eGFR of 38; stopping is required below 30.
• B. Glyburide raises hypoglycemia risk in older adults and with reduced kidney function.
• D. A higher dose would increase exposure as kidney function falls.

Key point: At eGFR 30–44, ADA–KDIGO recommends metformin 1,000 mg/day; reassess continuation and stop if eGFR falls below 30.

Source: ADA–KDIGO Consensus Report: Diabetes Management in Chronic Kidney Disease, Consensus statements; RAS inhibition; lipid management; metformin and SGLT2 sections (2022). Glumetza: U.S. FDA Prescribing Information, Section 5.2: vitamin B12 levels; renal restrictions (2017 archival FDA label). Source check: September 22, 2026.

Topic: Metformin with falling kidney function · ANCC: Plan of Care (pharmacology) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: C. Serum ferritin

Serum ferritin is the recommended initial laboratory test in evaluating microcytosis. A low value supports iron deficiency, but ferritin can be normal or elevated with inflammation, so a non-low value may require additional iron studies and clinical interpretation. Confirmed iron deficiency in an adult man requires investigation of the cause, including possible gastrointestinal blood loss.

Why not the others:

• A. Electrophoresis looks for hemoglobin disorders and isn't the first test for a new microcytic anemia.
• B. Bone marrow biopsy is invasive and rarely needed for this question.
• D. Vitamin B12 deficiency typically causes macrocytosis; it is not the first test directed at this microcytic pattern, although mixed deficiencies can occur.

Key point: Microcytic anemia: start with ferritin.

Source: Van Vranken: Evaluation of Microcytosis, Initial evaluation and diagnostic strategy (American Family Physician, November 1, 2010). Merck Manual Professional: Anemia of Chronic Disease, Diagnosis: iron, transferrin/TIBC, ferritin, inflammatory confounding (Reviewed March 2025). Source check: September 22, 2026.

Topic: Microcytic anemia workup · ANCC: Plan of Care (diagnosis) · NPCB: Assess · NPCB age tag: Adult

Answer: C. Exercise plus a topical NSAID such as diclofenac gel

ACR's osteoarthritis guidance strongly recommends exercise and topical NSAIDs for knee osteoarthritis, and its 2026 update keeps exercise, weight loss when appropriate, and topical NSAIDs as its strongest recommendations. Oral NSAIDs are a poor fit here because of her kidney disease and age. Topical NSAIDs still have contraindications and precautions; use is not automatically risk-free because the formulation is topical.

Why not the others:

• A. Long-term high-dose oral naproxen adds renal and gastrointestinal risks in an older adult with CKD; a plan minimizing systemic NSAID exposure is preferable here.
• B. ACR recommends against glucosamine and chondroitin for knee osteoarthritis.
• D. The ACR 2026 recommendation summary conditionally recommends against TENS for knee or hip osteoarthritis.

Key point: Knee osteoarthritis: exercise plus a topical NSAID, especially when oral NSAIDs are risky.

Source: ACR 2026 Osteoarthritis Guideline: Official Recommendation Summary, Pages 1–3: exercise, topical NSAIDs, TENS, glucosamine/chondroitin (September 14, 2026 summary). AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Topic: Knee osteoarthritis with CKD · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Older adult

Answer: A. A Snellen acuity test, flagging acuity worse than 20/40

STEADI's assessment includes checking visual acuity with a Snellen chart. Its checklist flags acuity worse than 20/40, or no eye exam in more than a year, as a fall risk factor. If visual impairment is found, the algorithm calls for referral to an eye care professional and a review of medications that affect vision.

Why not the others:

• B. An Amsler grid checks for central distortion, not the acuity STEADI assesses.
• C. The Weber test assesses hearing, not vision.
• D. Confrontation fields don't measure acuity.

Key point: In a fall-risk assessment, check visual acuity with a Snellen chart.

Source: CDC STEADI: Fall Risk Factors Checklist, Page 1: TUG, tandem stance, vision and medication factors (2017). CDC STEADI: Algorithm for Fall Risk Screening, Assessment, and Intervention, Pages 1–2: assess and intervene (2019). Source check: September 22, 2026.

Topic: Vision in a fall assessment · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Older adult

Answer: A. G3a, A2

CKD is an abnormality of kidney structure or function present for at least 3 months. Full CKD classification includes cause, GFR category (G3a is 45 to 59) and albuminuria category (A2 is 30 to 300 mg/g). His eGFR of 48 and UACR of 120 put him in G3a and A2.

Why not the others:

• B. G3b is an eGFR of 30 to 44, and A3 is a UACR above 300.
• C. G2 is an eGFR of 60 to 89, and A1 is a UACR below 30.
• D. An eGFR below 60 for at least 3 months already meets the definition of CKD.

Key point: Describe CKD by cause, GFR category, and albuminuria category; the supplied values establish G3a and A2.

Source: KDIGO 2024 Clinical Practice Guideline for CKD, Printed S137, Tables 1–3; recommendation 3.7.1; medication stewardship (2024). Source check: September 22, 2026.

Topic: Staging chronic kidney disease · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: C. Increase the sertraline dose

Sertraline labeling notes that patients who don't respond fully to 50 mg may benefit from dose increases, in 25–50 mg steps at intervals of at least a week, up to 200 mg a day. She's tolerating the drug and partly responding, so there's room to optimize the dose before switching.

Why not the others:

• A. Switching gives up a partly effective, well-tolerated drug before its dose has been optimized.
• B. A benzodiazepine doesn't treat depression and adds risks.
• D. She's partly responding, so stopping throws away the benefit.

Key point: Partial response with good tolerance makes dose optimization a reasonable next step before switching.

Source: Sertraline Tablets: U.S. Prescribing Information, Sections 2.1 and 5.8: dosage; hyponatremia (DailyMed update May 10, 2021). Source check: September 22, 2026.

Topic: Partial response to an SSRI · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Young adult

Answer: D. 80%

Sensitivity is true positives divided by everyone with the disease: 40 ÷ 50 = 80%. It tells you how well the test catches people who have the condition.

Why not the others:

• A. 90% is the specificity: 135 true negatives ÷ 150 people without disease.
• B. Approximately 73% is the positive predictive value: 40 true positives ÷ 55 total positives.
• C. 20% is the false-negative rate: 10 missed cases ÷ 50 with disease.

Key point: Sensitivity is true positives ÷ all who have the disease; specificity is true negatives ÷ all who don't.

Source: Worked calculation: diagnostic-test accuracy: Sensitivity 40/50; specificity 135/150; PPV 40/55; FNR 10/50. Derived from the values in this question. Source check: September 22, 2026.

Topic: Test accuracy · ANCC: Professional Practice · NPCB: Evaluate · NPCB age tag: Adult

Answer: D. Arrange prompt evaluation of the endometrium for the cause of postmenopausal bleeding

Postmenopausal bleeding warrants prompt evaluation because it can be a sign of endometrial cancer, even after a single episode. Endometrial tissue testing is used to diagnose that cancer; the clinician chooses the appropriate evaluation based on the presentation and risk. A Pap test does not substitute for evaluating the endometrium.

Why not the others:

• A. Atrophy is common, but cancer has to be excluded first.
• B. Treating before evaluating could delay a cancer diagnosis.
• C. A Pap test screens the cervix and doesn't evaluate the endometrium.

Key point: Any postmenopausal bleeding needs evaluation for endometrial cancer.

Source: NCI: Endometrial Cancer Treatment—Patient Version, Signs/symptoms; diagnostic evaluation and endometrial sampling (Live NCI PDQ). Source check: September 22, 2026.

Topic: Postmenopausal bleeding · ANCC: Plan of Care (diagnosis) · NPCB: Diagnose · NPCB age tag: Older adult

Answer: A. The Confusion Assessment Method (CAM)

The CAM assesses for delirium using acute onset with a fluctuating course and inattention, plus either disorganized thinking or an altered level of consciousness. Her sudden, fluctuating confusion and inattention make it an appropriate assessment tool. The stem does not supply every feature needed to call a CAM result positive; complete the assessment and evaluate the cause.

Why not the others:

• B. The MMSE measures cognition but doesn't distinguish delirium from dementia.
• C. The GDS screens for depression.
• D. The Katz index measures basic self-care.

Key point: Acute, fluctuating confusion with inattention calls for the CAM to assess for delirium.

Source: MSD Manual Professional: Confusion Assessment Method, Required features and diagnostic rule (Live table citing Inouye et al., 1990). Source check: September 22, 2026.

Topic: Sudden confusion · ANCC: Patient Assessment Process · NPCB: Assess · NPCB age tag: Elderly

Answer: D. Refer to a structured diabetes prevention program focused on sustainable lifestyle change

His A1C is in the prediabetes range. A structured diabetes prevention program helps people at increased risk work on healthy eating, physical activity, and sustainable weight management. Referral supplies organized support rather than waiting for diabetes to develop.

Why not the others:

• A. He doesn't have diabetes, and insulin isn't a prevention strategy.
• B. Prediabetes is the time to act, since progression can be delayed.
• C. Waiting 5 years misses the chance to prevent progression.

Key point: Prediabetes with overweight or obesity is a reason to offer a structured diabetes prevention program.

Source: ADA Standards of Care 2026: Diagnosis and Classification, Diagnostic tests; confirming the diagnosis; Tables 2.1 and 2.2 (Standards of Care 2026). CDC: Preventing Type 2 Diabetes With the Lifestyle Change Program, Overview; benefits; action plan (May 15, 2024). Source check: September 22, 2026.

Topic: Preventing diabetes · ANCC: Plan of Care (implementation and evaluation) · NPCB: Plan · NPCB age tag: Adult

Answer: A. Consider a drug holiday with periodic reassessment

Alendronate labeling notes that the optimal duration of use hasn't been determined and that for patients at low risk for fracture, stopping after 3 to 5 years can be considered. Her risk should be reassessed periodically in case treatment needs to resume.

Why not the others:

• B. Lifelong use isn't required for low-risk patients.
• C. Switching drugs isn't indicated when her risk is low.
• D. A drug holiday still needs follow-up, since risk can change.

Key point: After 3 to 5 years of alendronate in a low-risk patient, consider a drug holiday with reassessment.

Source: Fosamax: U.S. Prescribing Information, Section 1.6: important limitations of use and duration (Label served September 22, 2026). Source check: September 22, 2026.

Topic: Long-term alendronate · ANCC: Plan of Care (implementation and evaluation) · NPCB: Evaluate · NPCB age tag: Older adult

Answer: A. Assess her safety privately and report suspected exploitation through the applicable Adult Protective Services process

Possible financial exploitation and fear call for a private safety assessment. The Department of Justice directs community elder-abuse concerns to Adult Protective Services and immediate danger to 911. Follow the applicable state reporting requirements and procedures; proof of abuse is not a prerequisite for reporting a reasonable concern.

Why not the others:

• B. Financial exploitation is a recognized form of elder abuse, and it affects her health and safety.
• C. Confronting him in front of her could put her at greater risk.
• D. Waiting puts the burden on a patient who may be afraid to speak.

Key point: Suspected elder exploitation: assess safety privately and report to Adult Protective Services under state law.

Source: U.S. Department of Justice: Find Help or Report Elder Abuse, Emergency assistance; reporting to APS; state/territory locator (Live DOJ guidance). Source check: September 22, 2026.

Topic: Suspected financial exploitation · ANCC: Professional Practice · NPCB: Evaluate · NPCB age tag: Elderly

Answer: A, C, F.

• A. Select. First-generation antihistamines are strongly anticholinergic and on the avoid list.
• B. Leave unselected. Sertraline is not on the general avoid list solely because of his age. SSRIs warrant caution for hyponatremia and in people with a history of falls or fractures; individual risks still need review.
• C. Select. Benzodiazepines raise the risk of cognitive impairment, delirium, falls, and fractures and are on the avoid list.
• D. Leave unselected. Statins aren't on the Beers avoid list.
• E. Leave unselected. Amlodipine isn't on the Beers avoid list.
• F. Select. Z-drug hypnotics carry benzodiazepine-like risks and are on the avoid list.

Key point: First-generation anticholinergic antihistamines, benzodiazepines, and Z-drug hypnotics are generally on the Beers avoid list; specified exceptions and individual circumstances matter.

Source: AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.

Answer: B, D, E.

• A. Leave unselected. He quit more than 15 years ago, so he no longer qualifies.
• B. Select. She is 50 to 80, has at least 20 pack-years, and currently smokes.
• C. Leave unselected. Screening starts at 50.
• D. Select. He quit within the past 15 years and meets the age and pack-year criteria.
• E. Select. He is within the age range, has at least 20 pack-years, and quit less than 15 years ago.
• F. Leave unselected. She has fewer than 20 pack-years.

Key point: USPSTF lung CT screening: ages 50 to 80, at least 20 pack-years, and currently smoking or quit within 15 years, with the necessary health and treatment-willingness conditions.

Source: USPSTF: Lung Cancer: Screening, Recommendation summary and practice considerations (March 9, 2021). Source check: September 22, 2026.

Answer: A, C, E.

• A. Select. This addresses a medication that increases fall risk.
• B. Leave unselected. Restricting activity worsens strength and balance.
• C. Select. This addresses her impaired gait, strength, and balance.
• D. Leave unselected. Diphenhydramine is also a Beers-list drug to avoid and adds anticholinergic risk.
• E. Select. This addresses the home hazards.
• F. Leave unselected. Bed rest leads to deconditioning.

Key point: Match each intervention to a specific identified risk: gait and balance, medications, and home hazards.

Source: CDC STEADI: Algorithm for Fall Risk Screening, Assessment, and Intervention, Pages 1–2: assess and intervene (2019). AGS 2023 Updated Beers Criteria, Tables 2–7: anticholinergics, hypnotics, sulfonylureas, PPIs, falls, renal function (2023). Source check: September 22, 2026.