FNP NR511: Differential Diagnosis Midterm Exam at
Chamberlain College QUALIFIED Questions &
EXPLAINED ANSWERS Answers ALREADY
GRADED A+..
1. A patient presents with acute onset of severe unilateral knee pain and swelling without preceding
trauma. Examination reveals a warm, erythematous joint with limited range of motion. Synovial
fluid analysis shows needle-shaped negatively birefringent crystals under polarized light
microscopy. Which of the following is the most appropriate next step in management?
A. Initiate allopurinol and colchicine prophylaxis
B. Administer intra-articular corticosteroids after aspirating fluid
C. Start oral prednisone 40 mg daily for 5 days
D. Prescribe naproxen 500 mg twice daily for 7 days
Answer: B
Rationale: The findings are classic for acute gouty arthritis. Intra-articular corticosteroids are highly
effective and appropriate after confirming no infection. Allopurinol is contraindicated during an acute
flare. Oral prednisone is an alternative but intra-articular is more targeted. Naproxen is first-line but
less effective than intra-articular steroids in severe monoarthritis.
2. A patient with a history of hypertension and type 2 diabetes presents with substernal chest
pressure radiating to the left arm, associated with diaphoresis and nausea. ECG shows ST-segment
depression in leads V3-V5. High-sensitivity troponin I is elevated. Which of the following is the
most appropriate immediate diagnostic test to guide revascularization?
A. Exercise stress echocardiography
B. Coronary computed tomography angiography (CCTA)
C. Coronary angiography
D. Myocardial perfusion imaging (MPI) with adenosine
Answer: C
Rationale: The patient has high-risk features (ST depression, elevated troponin, typical symptoms)
consistent with non-ST-elevation myocardial infarction (NSTEMI). Urgent coronary angiography is
indicated for revascularization. CCTA is for low-risk patients. Stress testing (exercise echo or MPI) is
contraindicated in acute MI.
3. A patient presents with a 3-week history of progressive dyspnea on exertion, nonproductive
cough, and low-grade fever. Chest X-ray shows bilateral interstitial infiltrates with hilar
lymphadenopathy. Serum angiotensin-converting enzyme (ACE) level is elevated. Which of the
following is the most likely diagnosis?
Page 1
,A. Hypersensitivity pneumonitis
B. Tuberculosis
C. Sarcoidosis
D. Lymphangitic carcinomatosis
Answer: C
Rationale: The combination of bilateral interstitial infiltrates, hilar lymphadenopathy, and elevated ACE
level is classic for sarcoidosis. Hypersensitivity pneumonitis typically has a history of antigen exposure
and no hilar adenopathy. Tuberculosis often has apical infiltrates and cavitations. Lymphangitic
carcinomatosis would not have hilar adenopathy and ACE is not elevated.
4. A patient presents with epigastric pain that awakens them at night, relieved by antacids and
worsened by fasting. Upper endoscopy reveals a 2-cm duodenal ulcer with a clean base. Biopsy is
negative for Helicobacter pylori. Which of the following is the most appropriate next step in
management?
A. Start triple therapy with amoxicillin, clarithromycin, and omeprazole
B. Prescribe a proton pump inhibitor (PPI) for 8 weeks and reassess
C. Order a serum gastrin level to rule out Zollinger-Ellison syndrome
D. Refer for surgical vagotomy and antrectomy
Answer: B
Rationale: A clean-based duodenal ulcer with negative H. pylori is likely due to NSAID use or idiopathic.
PPI therapy for 8 weeks is standard. Triple therapy is not indicated without H. pylori. Serum gastrin is
only if recurrent or multiple ulcers. Surgery is reserved for complications.
5. A patient presents with acute onset of severe headache, nuchal rigidity, and photophobia. CSF
analysis reveals elevated opening pressure, neutrophilic pleocytosis, low glucose, and elevated
protein. Gram stain shows gram-positive cocci in pairs. Which of the following is the most
appropriate empiric antibiotic regimen?
A. Ceftriaxone plus vancomycin
B. Ampicillin plus gentamicin
C. Ceftazidime plus acyclovir
D. Metronidazole plus cefepime
Answer: A
Rationale: The CSF findings are consistent with bacterial meningitis. Gram-positive diplococci suggest
Streptococcus pneumoniae. Empiric therapy for community-acquired meningitis in adults is ceftriaxone
plus vancomycin to cover resistant pneumococcus. Ampicillin/gentamicin is for Listeria in
neonates/elderly. Ceftazidime/acyclovir is for herpes encephalitis. Metronidazole/cefepime is for
nosocomial meningitis.
6. A patient presents with a pruritic, erythematous rash with well-demarcated plaques and silvery
scales on the elbows and knees. Nail pitting is noted. Which of the following is the most appropriate
first-line topical treatment?
A. Clobetasol propionate 0.05% ointment twice daily
B. Ciclopirox olamine 0.77% cream twice daily
Page 2
,C. Pimecrolimus 1% cream twice daily
D. Hydrocortisone 2.5% cream twice daily
Answer: A
Rationale: The description is classic for plaque psoriasis. High-potency topical corticosteroids like
clobetasol are first-line. Ciclopirox is antifungal, not for psoriasis. Pimecrolimus is for atopic
dermatitis. Hydrocortisone is too low potency for thick plaques.
7. A patient with a history of hypothyroidism on levothyroxine presents with palpitations, weight
loss, and heat intolerance. TSH is <0.01 mIU/L, free T4 is 3.5 ng/dL, and free T3 is 8.0 pg/mL.
Thyroid ultrasound shows a 2-cm hypoechoic nodule with increased vascularity. Which of the
following is the most appropriate next step?
A. Discontinue levothyroxine and monitor TSH in 6 weeks
B. Perform a radioactive iodine uptake scan
C. Order a fine-needle aspiration biopsy of the nodule
D. Start methimazole 10 mg daily
Answer: B
Rationale: The patient has overt hyperthyroidism with a nodule. Radioactive iodine uptake scan will
determine if the nodule is hyperfunctioning (toxic adenoma) or if there is Graves' disease. FNA is not
indicated for hyperfunctioning nodules. Discontinuing levothyroxine is appropriate for factitious
hyperthyroidism but here there is a nodule. Methimazole is treatment but the scan guides management.
8. A patient presents with dysuria, urinary frequency, and suprapubic pain. Urinalysis shows
positive nitrites and leukocyte esterase, with >50 WBCs/hpf. Urine culture grows Escherichia coli
>100,000 CFU/mL. The patient has no known drug allergies. Which of the following is the most
appropriate first-line antibiotic?
A. Ciprofloxacin 500 mg twice daily for 3 days
B. Nitrofurantoin 100 mg twice daily for 5 days
C. Trimethoprim-sulfamethoxazole DS twice daily for 3 days
D. Amoxicillin-clavulanate 875/125 mg twice daily for 7 days
Answer: B
Rationale: According to IDSA guidelines, nitrofurantoin is first-line for uncomplicated cystitis due to low
resistance rates and narrow spectrum. Fluoroquinolones (ciprofloxacin) are reserved for complicated
cases due to resistance. TMP-SMX is an alternative if local resistance <20%. Amoxicillin-clavulanate is
not first-line due to higher resistance and broader spectrum.
9. A patient presents with a 2-week history of excessive worry, restlessness, and difficulty
concentrating. They report muscle tension and sleep disturbance. Symptoms are not better
explained by a medical condition or substance use. Which of the following is the most appropriate
first-line pharmacotherapy?
A. Buspirone 10 mg twice daily
B. Diazepam 5 mg three times daily as needed
C. Sertraline 50 mg daily
D. Propranolol 20 mg twice daily
Page 3
, Answer: C
Rationale: The symptoms meet criteria for generalized anxiety disorder (GAD). SSRIs like sertraline are
first-line due to efficacy and safety. Buspirone is an alternative but less effective. Benzodiazepines
(diazepam) are not first-line due to dependence risk. Propranolol is for performance anxiety only.
10. A patient presents with acute onset of severe, colicky flank pain radiating to the groin,
associated with nausea and hematuria. CT scan reveals a 5-mm obstructing ureterovesical junction
stone. Which of the following is the most appropriate initial management?
A. Extracorporeal shock wave lithotripsy (ESWL)
B. Ureteroscopy with laser lithotripsy
C. Medical expulsive therapy with tamsulosin and hydration
D. Percutaneous nephrolithotomy
Answer: C
Rationale: Stones <10 mm in the distal ureter have a high chance of spontaneous passage. Medical
expulsive therapy with alpha-blockers (tamsulosin) and hydration is first-line. ESWL is for stones >10
mm or proximal stones. Ureteroscopy is for failed medical therapy or larger stones. Percutaneous
nephrolithotomy is for large renal stones.
11. A patient presents with acute onset of severe, unilateral, throbbing headache accompanied by
nausea, photophobia, and phonophobia. The patient reports a history of similar episodes. Which of
the following pathophysiological mechanisms is most directly implicated in the aura phase of this
condition?
A. Cortical spreading depression leading to transient neuronal dysfunction
B. Vasodilation of intracranial arteries triggering trigeminal nerve activation
C. Serotonin receptor activation causing platelet aggregation and vasoconstriction
D. Inflammation of the meninges due to immune complex deposition
Answer: A
Rationale: The aura phase of migraine is caused by cortical spreading depression (CSD), a wave of
neuronal and glial depolarization that suppresses cortical activity. This explains the transient
neurological symptoms. Vasodilation (B) is more associated with the headache phase, not aura.
Serotonin (C) is involved in migraine pathophysiology but not directly in aura. Meningeal inflammation
(D) is not characteristic of migraine.
12. A patient with a history of type 2 diabetes mellitus presents with a painful, erythematous,
swollen toe without a history of trauma. On examination, the toe is warm, and there is a small
ulcer on the plantar surface. Which of the following diagnostic tests is most appropriate to
differentiate between osteomyelitis and Charcot neuroarthropathy?
A. Plain radiography of the foot
B. Magnetic resonance imaging (MRI) with contrast
C. Three-phase bone scan
D. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
Answer: B
Page 4
Chamberlain College QUALIFIED Questions &
EXPLAINED ANSWERS Answers ALREADY
GRADED A+..
1. A patient presents with acute onset of severe unilateral knee pain and swelling without preceding
trauma. Examination reveals a warm, erythematous joint with limited range of motion. Synovial
fluid analysis shows needle-shaped negatively birefringent crystals under polarized light
microscopy. Which of the following is the most appropriate next step in management?
A. Initiate allopurinol and colchicine prophylaxis
B. Administer intra-articular corticosteroids after aspirating fluid
C. Start oral prednisone 40 mg daily for 5 days
D. Prescribe naproxen 500 mg twice daily for 7 days
Answer: B
Rationale: The findings are classic for acute gouty arthritis. Intra-articular corticosteroids are highly
effective and appropriate after confirming no infection. Allopurinol is contraindicated during an acute
flare. Oral prednisone is an alternative but intra-articular is more targeted. Naproxen is first-line but
less effective than intra-articular steroids in severe monoarthritis.
2. A patient with a history of hypertension and type 2 diabetes presents with substernal chest
pressure radiating to the left arm, associated with diaphoresis and nausea. ECG shows ST-segment
depression in leads V3-V5. High-sensitivity troponin I is elevated. Which of the following is the
most appropriate immediate diagnostic test to guide revascularization?
A. Exercise stress echocardiography
B. Coronary computed tomography angiography (CCTA)
C. Coronary angiography
D. Myocardial perfusion imaging (MPI) with adenosine
Answer: C
Rationale: The patient has high-risk features (ST depression, elevated troponin, typical symptoms)
consistent with non-ST-elevation myocardial infarction (NSTEMI). Urgent coronary angiography is
indicated for revascularization. CCTA is for low-risk patients. Stress testing (exercise echo or MPI) is
contraindicated in acute MI.
3. A patient presents with a 3-week history of progressive dyspnea on exertion, nonproductive
cough, and low-grade fever. Chest X-ray shows bilateral interstitial infiltrates with hilar
lymphadenopathy. Serum angiotensin-converting enzyme (ACE) level is elevated. Which of the
following is the most likely diagnosis?
Page 1
,A. Hypersensitivity pneumonitis
B. Tuberculosis
C. Sarcoidosis
D. Lymphangitic carcinomatosis
Answer: C
Rationale: The combination of bilateral interstitial infiltrates, hilar lymphadenopathy, and elevated ACE
level is classic for sarcoidosis. Hypersensitivity pneumonitis typically has a history of antigen exposure
and no hilar adenopathy. Tuberculosis often has apical infiltrates and cavitations. Lymphangitic
carcinomatosis would not have hilar adenopathy and ACE is not elevated.
4. A patient presents with epigastric pain that awakens them at night, relieved by antacids and
worsened by fasting. Upper endoscopy reveals a 2-cm duodenal ulcer with a clean base. Biopsy is
negative for Helicobacter pylori. Which of the following is the most appropriate next step in
management?
A. Start triple therapy with amoxicillin, clarithromycin, and omeprazole
B. Prescribe a proton pump inhibitor (PPI) for 8 weeks and reassess
C. Order a serum gastrin level to rule out Zollinger-Ellison syndrome
D. Refer for surgical vagotomy and antrectomy
Answer: B
Rationale: A clean-based duodenal ulcer with negative H. pylori is likely due to NSAID use or idiopathic.
PPI therapy for 8 weeks is standard. Triple therapy is not indicated without H. pylori. Serum gastrin is
only if recurrent or multiple ulcers. Surgery is reserved for complications.
5. A patient presents with acute onset of severe headache, nuchal rigidity, and photophobia. CSF
analysis reveals elevated opening pressure, neutrophilic pleocytosis, low glucose, and elevated
protein. Gram stain shows gram-positive cocci in pairs. Which of the following is the most
appropriate empiric antibiotic regimen?
A. Ceftriaxone plus vancomycin
B. Ampicillin plus gentamicin
C. Ceftazidime plus acyclovir
D. Metronidazole plus cefepime
Answer: A
Rationale: The CSF findings are consistent with bacterial meningitis. Gram-positive diplococci suggest
Streptococcus pneumoniae. Empiric therapy for community-acquired meningitis in adults is ceftriaxone
plus vancomycin to cover resistant pneumococcus. Ampicillin/gentamicin is for Listeria in
neonates/elderly. Ceftazidime/acyclovir is for herpes encephalitis. Metronidazole/cefepime is for
nosocomial meningitis.
6. A patient presents with a pruritic, erythematous rash with well-demarcated plaques and silvery
scales on the elbows and knees. Nail pitting is noted. Which of the following is the most appropriate
first-line topical treatment?
A. Clobetasol propionate 0.05% ointment twice daily
B. Ciclopirox olamine 0.77% cream twice daily
Page 2
,C. Pimecrolimus 1% cream twice daily
D. Hydrocortisone 2.5% cream twice daily
Answer: A
Rationale: The description is classic for plaque psoriasis. High-potency topical corticosteroids like
clobetasol are first-line. Ciclopirox is antifungal, not for psoriasis. Pimecrolimus is for atopic
dermatitis. Hydrocortisone is too low potency for thick plaques.
7. A patient with a history of hypothyroidism on levothyroxine presents with palpitations, weight
loss, and heat intolerance. TSH is <0.01 mIU/L, free T4 is 3.5 ng/dL, and free T3 is 8.0 pg/mL.
Thyroid ultrasound shows a 2-cm hypoechoic nodule with increased vascularity. Which of the
following is the most appropriate next step?
A. Discontinue levothyroxine and monitor TSH in 6 weeks
B. Perform a radioactive iodine uptake scan
C. Order a fine-needle aspiration biopsy of the nodule
D. Start methimazole 10 mg daily
Answer: B
Rationale: The patient has overt hyperthyroidism with a nodule. Radioactive iodine uptake scan will
determine if the nodule is hyperfunctioning (toxic adenoma) or if there is Graves' disease. FNA is not
indicated for hyperfunctioning nodules. Discontinuing levothyroxine is appropriate for factitious
hyperthyroidism but here there is a nodule. Methimazole is treatment but the scan guides management.
8. A patient presents with dysuria, urinary frequency, and suprapubic pain. Urinalysis shows
positive nitrites and leukocyte esterase, with >50 WBCs/hpf. Urine culture grows Escherichia coli
>100,000 CFU/mL. The patient has no known drug allergies. Which of the following is the most
appropriate first-line antibiotic?
A. Ciprofloxacin 500 mg twice daily for 3 days
B. Nitrofurantoin 100 mg twice daily for 5 days
C. Trimethoprim-sulfamethoxazole DS twice daily for 3 days
D. Amoxicillin-clavulanate 875/125 mg twice daily for 7 days
Answer: B
Rationale: According to IDSA guidelines, nitrofurantoin is first-line for uncomplicated cystitis due to low
resistance rates and narrow spectrum. Fluoroquinolones (ciprofloxacin) are reserved for complicated
cases due to resistance. TMP-SMX is an alternative if local resistance <20%. Amoxicillin-clavulanate is
not first-line due to higher resistance and broader spectrum.
9. A patient presents with a 2-week history of excessive worry, restlessness, and difficulty
concentrating. They report muscle tension and sleep disturbance. Symptoms are not better
explained by a medical condition or substance use. Which of the following is the most appropriate
first-line pharmacotherapy?
A. Buspirone 10 mg twice daily
B. Diazepam 5 mg three times daily as needed
C. Sertraline 50 mg daily
D. Propranolol 20 mg twice daily
Page 3
, Answer: C
Rationale: The symptoms meet criteria for generalized anxiety disorder (GAD). SSRIs like sertraline are
first-line due to efficacy and safety. Buspirone is an alternative but less effective. Benzodiazepines
(diazepam) are not first-line due to dependence risk. Propranolol is for performance anxiety only.
10. A patient presents with acute onset of severe, colicky flank pain radiating to the groin,
associated with nausea and hematuria. CT scan reveals a 5-mm obstructing ureterovesical junction
stone. Which of the following is the most appropriate initial management?
A. Extracorporeal shock wave lithotripsy (ESWL)
B. Ureteroscopy with laser lithotripsy
C. Medical expulsive therapy with tamsulosin and hydration
D. Percutaneous nephrolithotomy
Answer: C
Rationale: Stones <10 mm in the distal ureter have a high chance of spontaneous passage. Medical
expulsive therapy with alpha-blockers (tamsulosin) and hydration is first-line. ESWL is for stones >10
mm or proximal stones. Ureteroscopy is for failed medical therapy or larger stones. Percutaneous
nephrolithotomy is for large renal stones.
11. A patient presents with acute onset of severe, unilateral, throbbing headache accompanied by
nausea, photophobia, and phonophobia. The patient reports a history of similar episodes. Which of
the following pathophysiological mechanisms is most directly implicated in the aura phase of this
condition?
A. Cortical spreading depression leading to transient neuronal dysfunction
B. Vasodilation of intracranial arteries triggering trigeminal nerve activation
C. Serotonin receptor activation causing platelet aggregation and vasoconstriction
D. Inflammation of the meninges due to immune complex deposition
Answer: A
Rationale: The aura phase of migraine is caused by cortical spreading depression (CSD), a wave of
neuronal and glial depolarization that suppresses cortical activity. This explains the transient
neurological symptoms. Vasodilation (B) is more associated with the headache phase, not aura.
Serotonin (C) is involved in migraine pathophysiology but not directly in aura. Meningeal inflammation
(D) is not characteristic of migraine.
12. A patient with a history of type 2 diabetes mellitus presents with a painful, erythematous,
swollen toe without a history of trauma. On examination, the toe is warm, and there is a small
ulcer on the plantar surface. Which of the following diagnostic tests is most appropriate to
differentiate between osteomyelitis and Charcot neuroarthropathy?
A. Plain radiography of the foot
B. Magnetic resonance imaging (MRI) with contrast
C. Three-phase bone scan
D. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
Answer: B
Page 4
