NR 601 Final Exam Practice Questions Primary Care
of the Maturing and Aged Family – 2026 Edition
Questions with Answers & Rationales
SECTION 1: COMPLEX GERIATRIC SYNDROMES (Questions 1–15)
1. An 82-year-old female is brought to the clinic by her daughter for a 3-
month history of progressive memory loss, difficulty with household tasks,
and getting lost in familiar places. The daughter reports the patient has
become withdrawn and irritable. Which of the following is the most
appropriate initial screening tool for cognitive impairment in this patient?
A) Montreal Cognitive Assessment (MoCA)
B) Mini-Mental State Examination (MMSE)
C) Mini-Cog
D) Clock Drawing Test alone
Answer: C) Mini-Cog
Rationale: The Mini-Cog is a brief, validated screening tool that combines a three-
item recall test with a clock-drawing test. It takes only 3–5 minutes to administer
and is less affected by education and language than the MMSE or MoCA, making
it practical for primary care settings. It has good sensitivity and specificity for
detecting cognitive impairment. The MoCA and MMSE are more comprehensive
but take longer to administer.
2. A 78-year-old patient with a history of hypertension and type 2 diabetes is
noted to have a blood pressure of 162/88 mmHg. The patient is currently on
lisinopril 20 mg daily and amlodipine 5 mg daily. What is the most
appropriate next step in management?
A) Increase lisinopril to 40 mg daily
B) Add hydrochlorothiazide 12.5 mg daily
C) Increase amlodipine to 10 mg daily
D) Add a beta-blocker
Answer: B) Add hydrochlorothiazide 12.5 mg daily
,Rationale: For patients with uncontrolled hypertension on two agents, the addition
of a third agent from a different class is recommended. A thiazide diuretic
(hydrochlorothiazide) is an appropriate add-on to an ACE inhibitor and calcium
channel blocker. This combination is often effective and well-tolerated. Increasing
lisinopril to 40 mg is an option but may increase the risk of hyperkalemia and renal
dysfunction, especially in older adults.
3. A 76-year-old patient presents with a 2-week history of progressive
confusion, lethargy, and urinary incontinence. The patient's daughter reports
that the patient has been "not acting like herself" and has been sleeping more
than usual. Which of the following is the most likely diagnosis?
A) Alzheimer's disease
B) Delirium due to urinary tract infection
C) Vascular dementia
D) Depression with psychotic features
Answer: B) Delirium due to urinary tract infection
Rationale: Delirium is an acute, fluctuating disturbance in attention and cognition
that is often triggered by an underlying medical condition. In older adults, urinary
tract infection is a common cause. The acute onset, lethargy, and new-onset
incontinence are characteristic of delirium. Dementia has a gradual onset.
Depression may present with lethargy but typically does not cause acute confusion.
4. An 80-year-old patient with a history of osteoarthritis reports taking
ibuprofen 600 mg three times daily for knee pain. The patient has a history of
chronic kidney disease stage 3 (eGFR 45 mL/min/1.73 m²). Which of the
following is the most appropriate recommendation?
A) Continue ibuprofen and add a PPI
B) Switch to celecoxib
C) Discontinue ibuprofen and consider acetaminophen or topical NSAIDs
D) Add misoprostol
Answer: C) Discontinue ibuprofen and consider acetaminophen or topical
NSAIDs
,Rationale: NSAIDs should be avoided in patients with chronic kidney disease due
to the risk of further renal impairment. Acetaminophen is the preferred analgesic
for osteoarthritis in patients with renal impairment. Topical NSAIDs may be
considered as they have minimal systemic absorption. If an NSAID is necessary, a
COX-2 inhibitor (celecoxib) may be used with caution and at the lowest effective
dose, but it still carries renal risks.
5. A 72-year-old patient with a history of heart failure with preserved ejection
fraction (HFpEF) presents with worsening dyspnea and lower extremity
edema. Which of the following is the most appropriate initial management?
A) Increase loop diuretic dose
B) Start an ACE inhibitor
C) Start a beta-blocker
D) Start a mineralocorticoid receptor antagonist
Answer: A) Increase loop diuretic dose
Rationale: In HFpEF, diuretics are the mainstay of treatment for managing
volume overload and relieving symptoms. Increasing the loop diuretic dose is the
most appropriate initial step for this patient with worsening dyspnea and edema.
While ACE inhibitors, beta-blockers, and MRAs have mortality benefit in HFrEF,
their benefit in HFpEF is less established, though they may be used for
comorbidities.
6. A 74-year-old patient with a history of type 2 diabetes is noted to have a
hemoglobin A1c of 8.5% on metformin 1,000 mg twice daily and glipizide 10
mg twice daily. The patient reports adherence to the medication regimen.
What is the most appropriate next step?
A) Increase glipizide to 20 mg twice daily
B) Add an SGLT-2 inhibitor (empagliflozin)
C) Add insulin glargine
D) Add a DPP-4 inhibitor (sitagliptin)
Answer: B) Add an SGLT-2 inhibitor (empagliflozin)
, Rationale: For patients with type 2 diabetes who are not at goal on metformin and
a sulfonylurea, the addition of an SGLT-2 inhibitor is a recommended option,
particularly in patients with cardiovascular disease or risk factors. Empagliflozin
has demonstrated cardiovascular and renal benefits. Insulin may be considered if
glycemic targets remain unmet, but an SGLT-2 inhibitor is a reasonable next step
before insulin. DPP-4 inhibitors are less potent than SGLT-2 inhibitors and may be
preferred in patients who cannot tolerate SGLT-2 inhibitors.
7. A 69-year-old patient presents with a 6-month history of bilateral hand pain
and stiffness, worse in the mornings and lasting more than 60 minutes. The
patient also reports fatigue and weight loss. Rheumatoid factor is positive.
What is the most likely diagnosis?
A) Osteoarthritis
B) Rheumatoid arthritis
C) Polymyalgia rheumatica
D) Gout
Answer: B) Rheumatoid arthritis
Rationale: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune
disease that presents with symmetric polyarthritis, morning stiffness lasting >60
minutes, and systemic symptoms (fatigue, weight loss). Positive rheumatoid factor
and anti-CCP antibodies support the diagnosis. Osteoarthritis has morning stiffness
<30 minutes and no systemic symptoms. Polymyalgia rheumatica affects the
shoulders and hips, not the hands.
8. An 82-year-old patient with a history of dementia is brought to the clinic by
her caregiver. The caregiver reports that the patient has been increasingly
agitated and has had episodes of wandering at night. Which of the following is
the most appropriate initial management?
A) Start haloperidol
B) Start lorazepam
C) Non-pharmacologic interventions (e.g., structured routine, environmental
modifications)
D) Start donepezil
of the Maturing and Aged Family – 2026 Edition
Questions with Answers & Rationales
SECTION 1: COMPLEX GERIATRIC SYNDROMES (Questions 1–15)
1. An 82-year-old female is brought to the clinic by her daughter for a 3-
month history of progressive memory loss, difficulty with household tasks,
and getting lost in familiar places. The daughter reports the patient has
become withdrawn and irritable. Which of the following is the most
appropriate initial screening tool for cognitive impairment in this patient?
A) Montreal Cognitive Assessment (MoCA)
B) Mini-Mental State Examination (MMSE)
C) Mini-Cog
D) Clock Drawing Test alone
Answer: C) Mini-Cog
Rationale: The Mini-Cog is a brief, validated screening tool that combines a three-
item recall test with a clock-drawing test. It takes only 3–5 minutes to administer
and is less affected by education and language than the MMSE or MoCA, making
it practical for primary care settings. It has good sensitivity and specificity for
detecting cognitive impairment. The MoCA and MMSE are more comprehensive
but take longer to administer.
2. A 78-year-old patient with a history of hypertension and type 2 diabetes is
noted to have a blood pressure of 162/88 mmHg. The patient is currently on
lisinopril 20 mg daily and amlodipine 5 mg daily. What is the most
appropriate next step in management?
A) Increase lisinopril to 40 mg daily
B) Add hydrochlorothiazide 12.5 mg daily
C) Increase amlodipine to 10 mg daily
D) Add a beta-blocker
Answer: B) Add hydrochlorothiazide 12.5 mg daily
,Rationale: For patients with uncontrolled hypertension on two agents, the addition
of a third agent from a different class is recommended. A thiazide diuretic
(hydrochlorothiazide) is an appropriate add-on to an ACE inhibitor and calcium
channel blocker. This combination is often effective and well-tolerated. Increasing
lisinopril to 40 mg is an option but may increase the risk of hyperkalemia and renal
dysfunction, especially in older adults.
3. A 76-year-old patient presents with a 2-week history of progressive
confusion, lethargy, and urinary incontinence. The patient's daughter reports
that the patient has been "not acting like herself" and has been sleeping more
than usual. Which of the following is the most likely diagnosis?
A) Alzheimer's disease
B) Delirium due to urinary tract infection
C) Vascular dementia
D) Depression with psychotic features
Answer: B) Delirium due to urinary tract infection
Rationale: Delirium is an acute, fluctuating disturbance in attention and cognition
that is often triggered by an underlying medical condition. In older adults, urinary
tract infection is a common cause. The acute onset, lethargy, and new-onset
incontinence are characteristic of delirium. Dementia has a gradual onset.
Depression may present with lethargy but typically does not cause acute confusion.
4. An 80-year-old patient with a history of osteoarthritis reports taking
ibuprofen 600 mg three times daily for knee pain. The patient has a history of
chronic kidney disease stage 3 (eGFR 45 mL/min/1.73 m²). Which of the
following is the most appropriate recommendation?
A) Continue ibuprofen and add a PPI
B) Switch to celecoxib
C) Discontinue ibuprofen and consider acetaminophen or topical NSAIDs
D) Add misoprostol
Answer: C) Discontinue ibuprofen and consider acetaminophen or topical
NSAIDs
,Rationale: NSAIDs should be avoided in patients with chronic kidney disease due
to the risk of further renal impairment. Acetaminophen is the preferred analgesic
for osteoarthritis in patients with renal impairment. Topical NSAIDs may be
considered as they have minimal systemic absorption. If an NSAID is necessary, a
COX-2 inhibitor (celecoxib) may be used with caution and at the lowest effective
dose, but it still carries renal risks.
5. A 72-year-old patient with a history of heart failure with preserved ejection
fraction (HFpEF) presents with worsening dyspnea and lower extremity
edema. Which of the following is the most appropriate initial management?
A) Increase loop diuretic dose
B) Start an ACE inhibitor
C) Start a beta-blocker
D) Start a mineralocorticoid receptor antagonist
Answer: A) Increase loop diuretic dose
Rationale: In HFpEF, diuretics are the mainstay of treatment for managing
volume overload and relieving symptoms. Increasing the loop diuretic dose is the
most appropriate initial step for this patient with worsening dyspnea and edema.
While ACE inhibitors, beta-blockers, and MRAs have mortality benefit in HFrEF,
their benefit in HFpEF is less established, though they may be used for
comorbidities.
6. A 74-year-old patient with a history of type 2 diabetes is noted to have a
hemoglobin A1c of 8.5% on metformin 1,000 mg twice daily and glipizide 10
mg twice daily. The patient reports adherence to the medication regimen.
What is the most appropriate next step?
A) Increase glipizide to 20 mg twice daily
B) Add an SGLT-2 inhibitor (empagliflozin)
C) Add insulin glargine
D) Add a DPP-4 inhibitor (sitagliptin)
Answer: B) Add an SGLT-2 inhibitor (empagliflozin)
, Rationale: For patients with type 2 diabetes who are not at goal on metformin and
a sulfonylurea, the addition of an SGLT-2 inhibitor is a recommended option,
particularly in patients with cardiovascular disease or risk factors. Empagliflozin
has demonstrated cardiovascular and renal benefits. Insulin may be considered if
glycemic targets remain unmet, but an SGLT-2 inhibitor is a reasonable next step
before insulin. DPP-4 inhibitors are less potent than SGLT-2 inhibitors and may be
preferred in patients who cannot tolerate SGLT-2 inhibitors.
7. A 69-year-old patient presents with a 6-month history of bilateral hand pain
and stiffness, worse in the mornings and lasting more than 60 minutes. The
patient also reports fatigue and weight loss. Rheumatoid factor is positive.
What is the most likely diagnosis?
A) Osteoarthritis
B) Rheumatoid arthritis
C) Polymyalgia rheumatica
D) Gout
Answer: B) Rheumatoid arthritis
Rationale: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune
disease that presents with symmetric polyarthritis, morning stiffness lasting >60
minutes, and systemic symptoms (fatigue, weight loss). Positive rheumatoid factor
and anti-CCP antibodies support the diagnosis. Osteoarthritis has morning stiffness
<30 minutes and no systemic symptoms. Polymyalgia rheumatica affects the
shoulders and hips, not the hands.
8. An 82-year-old patient with a history of dementia is brought to the clinic by
her caregiver. The caregiver reports that the patient has been increasingly
agitated and has had episodes of wandering at night. Which of the following is
the most appropriate initial management?
A) Start haloperidol
B) Start lorazepam
C) Non-pharmacologic interventions (e.g., structured routine, environmental
modifications)
D) Start donepezil
