The Ultimate and Complete NSG 554 Primary Care Exam 3 Study Guide 2026–2027,
Covering Advanced Primary Care Assessment, Clinical Decision-Making, Differential
Diagnosis, Cardiovascular Disorders, Hypertension, Dyslipidemia, Coronary Artery
Disease, Heart Failure, Peripheral Vascular Disease, Aortic Disorders, Respiratory
Conditions, Asthma, COPD, Pneumonia, Gastrointestinal Disorders, GERD, Peptic Ulcer
Disease, Inflammatory Bowel Disease, Genitourinary Disorders, Urinary Tract
Infections, Pyelonephritis, Nephrolithiasis, Male Reproductive Conditions, Women's
Health, Contraception, Infertility, Sexually Transmitted Infections, Osteoporosis,
Musculoskeletal Disorders, Travel-Related Illnesses, Diagnostic Testing,
Pharmacologic Management, Evidence-Based Guidelines, Health Promotion, Patient
Education, Clinical Case Scenarios, Practice Questions With Detailed Rationales, and
Comprehensive Preparation for the NSG 554 Primary Care Exam 3
Question 1: A 72-year-old male with a 45-pack-year smoking history presents with a new
onset of hoarseness that has persisted for six weeks. He denies sore throat or upper
respiratory infection symptoms. Flexible laryngoscopy reveals a unilateral vocal cord paresis.
Which of the following is the most appropriate next step in management?
A. Voice rest and speech therapy referral
B. Prescribe a course of oral corticosteroids
C. Obtain a CT scan of the neck and chest
D. Reassurance and follow-up in 3 months
CORRECT ANSWER: C. Obtain a CT scan of the neck and chest
Rationale: Unilateral vocal cord paresis in a patient with a significant smoking history is a "red
flag" symptom until proven otherwise. The most common cause of unilateral vocal cord
paralysis is malignancy, particularly lung cancer, which can affect the recurrent laryngeal nerve.
A CT scan of the neck and chest is the appropriate initial imaging study to evaluate for a mass
lesion along the course of the vagus or recurrent laryngeal nerves.
Question 2: A 45-year-old female with a history of rheumatoid arthritis presents with
complaints of dry eyes and a persistent gritty sensation. Schirmer's test is positive. She also
reports difficulty swallowing dry foods. Which of the following is the most likely underlying
diagnosis?
A. Sjögren's syndrome
B. Medication side effect
C. Vitamin A deficiency
D. Allergic conjunctivitis
CORRECT ANSWER: A. Sjögren's syndrome
Rationale: This patient presents with classic symptoms of keratoconjunctivitis sicca (dry eyes)
and xerostomia (dry mouth), which is further supported by a positive Schirmer's test. In the
,context of a pre-existing autoimmune disease like rheumatoid arthritis, this is highly suggestive
of secondary Sjögren's syndrome.
Question 3: A 28-year-old male presents with severe, sharp left-sided chest pain that worsens
with inspiration and is relieved when he leans forward. He reports a low-grade fever and
malaise. On auscultation, a pericardial friction rub is heard. An ECG shows diffuse ST-segment
elevation. Which of the following is the most appropriate initial treatment?
A. Aspirin and colchicine
B. Alteplase (tPA)
C. High-dose corticosteroids
D. Percutaneous coronary intervention
CORRECT ANSWER: A. Aspirin and colchicine
Rationale: The presentation of pleuritic chest pain, pericardial friction rub, and diffuse ST-
segment elevation is classic for acute pericarditis. The mainstay of initial treatment is a
nonsteroidal anti-inflammatory drug (NSAID) like aspirin, often in combination with colchicine
for its anti-inflammatory effect and to reduce the risk of recurrence.
Question 4: A 65-year-old male with a history of hypertension and type 2 diabetes presents
with a sudden onset of severe, "worst headache of my life." He is nauseated and has a stiff
neck. On examination, he is hypertensive and has photophobia. What is the most critical
initial step in management?
A. Administer IV narcotic analgesia
B. Stat non-contrast CT scan of the head
C. Lumbar puncture
D. Administer IV antibiotics
CORRECT ANSWER: B. Stat non-contrast CT scan of the head
Rationale: This patient's presentation is a classic "thunderclap headache" with meningismus,
raising immediate concern for a subarachnoid hemorrhage (SAH). A non-contrast CT scan of the
head is the most sensitive initial imaging modality for detecting acute SAH and should be
performed emergently before any invasive procedures like a lumbar puncture.
Question 5: A 32-year-old female presents with fatigue, cold intolerance, and weight gain
over the past 6 months. Her skin is dry, and her deep tendon reflexes show a delayed
relaxation phase. Which of the following laboratory findings would be most consistent with
her condition?
A. Elevated free T4 and low TSH
B. Low free T4 and elevated TSH
C. Elevated TSH and elevated free T4
D. Low TSH and low free T4
,CORRECT ANSWER: B. Low free T4 and elevated TSH
Rationale: The patient's symptoms of fatigue, cold intolerance, weight gain, and delayed reflex
relaxation are classic for hypothyroidism. This is a primary thyroid disorder, so the laboratory
finding would be a low free T4 (due to decreased thyroid hormone production) and an elevated
TSH (due to loss of negative feedback on the anterior pituitary).
Question 6: A 55-year-old male with a history of alcohol use disorder presents with a 4-week
history of progressive proximal muscle weakness in his hips and shoulders. He has difficulty
rising from a chair and raising his arms above his head. He also notes a non-pruritic rash on
his knuckles. Which of the following laboratory findings would be most specific for his
diagnosis?
A. Positive anti-Jo-1 antibodies
B. Elevated creatine kinase (CK)
C. Positive anti-nuclear antibody (ANA)
D. Elevated erythrocyte sedimentation rate (ESR)
CORRECT ANSWER: A. Positive anti-Jo-1 antibodies
Rationale: The patient presents with classic signs of dermatomyositis: proximal muscle
weakness and a characteristic rash (Gottron's papules). Anti-Jo-1 antibodies are highly specific
for the anti-synthetase syndrome, which overlaps with dermatomyositis and polymyositis,
making it the most specific marker among the options listed for this diagnosis.
Question 7: A 42-year-old female presents with a chief complaint of a non-healing ulcer on
her right lower leg for 3 months. She has a history of venous insufficiency. The ulcer is located
over the medial malleolus, is shallow, and has irregular borders. The surrounding skin is
hyperpigmented and indurated. What is the most important aspect of initial treatment?
A. Surgical debridement
B. Topical antibiotic ointment
C. Compression therapy
D. Oral antibiotics
CORRECT ANSWER: C. Compression therapy
Rationale: This is a classic venous stasis ulcer, characterized by location over the medial
malleolus and surrounding skin changes. The cornerstone of treatment for venous ulcers is
compression therapy (e.g., with compression stockings or multi-layer wraps) to improve venous
return and reduce edema, which allows the ulcer to heal.
Question 8: A 38-year-old male presents with a sudden onset of unilateral vision loss in his
right eye that occurred 2 hours ago. He describes it as a "curtain coming down" over his
vision. He has a history of hypertension and hyperlipidemia. What is the most likely
diagnosis?
, A. Retinal detachment
B. Central retinal artery occlusion (CRAO)
C. Optic neuritis
D. Migraine with aura
CORRECT ANSWER: B. Central retinal artery occlusion (CRAO)
Rationale: The acute, painless, unilateral loss of vision described as a "curtain coming down" in
a patient with vascular risk factors is classic for a Central Retinal Artery Occlusion (CRAO). This is
an ocular emergency requiring immediate evaluation to minimize permanent visual loss.
Question 9: A 68-year-old female with a history of osteoarthritis presents with acute onset of
a red, painful, and swollen left great toe. She reports that the pain started suddenly last night
and is so severe that she cannot bear the weight of a bedsheet on it. Which of the following is
the most appropriate initial pharmacologic treatment?
A. Allopurinol
B. Probenecid
C. Colchicine
D. Acetaminophen
CORRECT ANSWER: C. Colchicine
Rationale: This is a classic presentation of acute gouty arthritis. The first-line treatment options
for an acute flare are NSAIDs, colchicine, or corticosteroids. Colchicine is a specific and effective
treatment for acute gout flares when started early.
Question 10: A 55-year-old male with a past medical history significant only for GERD
presents with a painless, firm, enlarged lymph node in his left supraclavicular region that has
been present for two months. He has also noted a 15-pound unintentional weight loss and
night sweats. What is the most appropriate next step?
A. A 2-week course of oral antibiotics
B. Excisional biopsy of the lymph node
C. Fine-needle aspiration of the lymph node
D. Chest X-ray and abdominal ultrasound
CORRECT ANSWER: B. Excisional biopsy of the lymph node
Rationale: A painless, firm, enlarged supraclavicular lymph node (Virchow's node) in an older
patient with constitutional symptoms like weight loss and night sweats is a "red flag" for
malignancy until proven otherwise. An excisional biopsy is the diagnostic procedure of choice to
obtain adequate tissue for pathological analysis to rule out lymphoma or metastatic cancer.
Question 11: A 72-year-old male presents with progressive memory loss and difficulty finding
words. His wife reports that he has become apathetic and has poor judgment. His neurologic
Covering Advanced Primary Care Assessment, Clinical Decision-Making, Differential
Diagnosis, Cardiovascular Disorders, Hypertension, Dyslipidemia, Coronary Artery
Disease, Heart Failure, Peripheral Vascular Disease, Aortic Disorders, Respiratory
Conditions, Asthma, COPD, Pneumonia, Gastrointestinal Disorders, GERD, Peptic Ulcer
Disease, Inflammatory Bowel Disease, Genitourinary Disorders, Urinary Tract
Infections, Pyelonephritis, Nephrolithiasis, Male Reproductive Conditions, Women's
Health, Contraception, Infertility, Sexually Transmitted Infections, Osteoporosis,
Musculoskeletal Disorders, Travel-Related Illnesses, Diagnostic Testing,
Pharmacologic Management, Evidence-Based Guidelines, Health Promotion, Patient
Education, Clinical Case Scenarios, Practice Questions With Detailed Rationales, and
Comprehensive Preparation for the NSG 554 Primary Care Exam 3
Question 1: A 72-year-old male with a 45-pack-year smoking history presents with a new
onset of hoarseness that has persisted for six weeks. He denies sore throat or upper
respiratory infection symptoms. Flexible laryngoscopy reveals a unilateral vocal cord paresis.
Which of the following is the most appropriate next step in management?
A. Voice rest and speech therapy referral
B. Prescribe a course of oral corticosteroids
C. Obtain a CT scan of the neck and chest
D. Reassurance and follow-up in 3 months
CORRECT ANSWER: C. Obtain a CT scan of the neck and chest
Rationale: Unilateral vocal cord paresis in a patient with a significant smoking history is a "red
flag" symptom until proven otherwise. The most common cause of unilateral vocal cord
paralysis is malignancy, particularly lung cancer, which can affect the recurrent laryngeal nerve.
A CT scan of the neck and chest is the appropriate initial imaging study to evaluate for a mass
lesion along the course of the vagus or recurrent laryngeal nerves.
Question 2: A 45-year-old female with a history of rheumatoid arthritis presents with
complaints of dry eyes and a persistent gritty sensation. Schirmer's test is positive. She also
reports difficulty swallowing dry foods. Which of the following is the most likely underlying
diagnosis?
A. Sjögren's syndrome
B. Medication side effect
C. Vitamin A deficiency
D. Allergic conjunctivitis
CORRECT ANSWER: A. Sjögren's syndrome
Rationale: This patient presents with classic symptoms of keratoconjunctivitis sicca (dry eyes)
and xerostomia (dry mouth), which is further supported by a positive Schirmer's test. In the
,context of a pre-existing autoimmune disease like rheumatoid arthritis, this is highly suggestive
of secondary Sjögren's syndrome.
Question 3: A 28-year-old male presents with severe, sharp left-sided chest pain that worsens
with inspiration and is relieved when he leans forward. He reports a low-grade fever and
malaise. On auscultation, a pericardial friction rub is heard. An ECG shows diffuse ST-segment
elevation. Which of the following is the most appropriate initial treatment?
A. Aspirin and colchicine
B. Alteplase (tPA)
C. High-dose corticosteroids
D. Percutaneous coronary intervention
CORRECT ANSWER: A. Aspirin and colchicine
Rationale: The presentation of pleuritic chest pain, pericardial friction rub, and diffuse ST-
segment elevation is classic for acute pericarditis. The mainstay of initial treatment is a
nonsteroidal anti-inflammatory drug (NSAID) like aspirin, often in combination with colchicine
for its anti-inflammatory effect and to reduce the risk of recurrence.
Question 4: A 65-year-old male with a history of hypertension and type 2 diabetes presents
with a sudden onset of severe, "worst headache of my life." He is nauseated and has a stiff
neck. On examination, he is hypertensive and has photophobia. What is the most critical
initial step in management?
A. Administer IV narcotic analgesia
B. Stat non-contrast CT scan of the head
C. Lumbar puncture
D. Administer IV antibiotics
CORRECT ANSWER: B. Stat non-contrast CT scan of the head
Rationale: This patient's presentation is a classic "thunderclap headache" with meningismus,
raising immediate concern for a subarachnoid hemorrhage (SAH). A non-contrast CT scan of the
head is the most sensitive initial imaging modality for detecting acute SAH and should be
performed emergently before any invasive procedures like a lumbar puncture.
Question 5: A 32-year-old female presents with fatigue, cold intolerance, and weight gain
over the past 6 months. Her skin is dry, and her deep tendon reflexes show a delayed
relaxation phase. Which of the following laboratory findings would be most consistent with
her condition?
A. Elevated free T4 and low TSH
B. Low free T4 and elevated TSH
C. Elevated TSH and elevated free T4
D. Low TSH and low free T4
,CORRECT ANSWER: B. Low free T4 and elevated TSH
Rationale: The patient's symptoms of fatigue, cold intolerance, weight gain, and delayed reflex
relaxation are classic for hypothyroidism. This is a primary thyroid disorder, so the laboratory
finding would be a low free T4 (due to decreased thyroid hormone production) and an elevated
TSH (due to loss of negative feedback on the anterior pituitary).
Question 6: A 55-year-old male with a history of alcohol use disorder presents with a 4-week
history of progressive proximal muscle weakness in his hips and shoulders. He has difficulty
rising from a chair and raising his arms above his head. He also notes a non-pruritic rash on
his knuckles. Which of the following laboratory findings would be most specific for his
diagnosis?
A. Positive anti-Jo-1 antibodies
B. Elevated creatine kinase (CK)
C. Positive anti-nuclear antibody (ANA)
D. Elevated erythrocyte sedimentation rate (ESR)
CORRECT ANSWER: A. Positive anti-Jo-1 antibodies
Rationale: The patient presents with classic signs of dermatomyositis: proximal muscle
weakness and a characteristic rash (Gottron's papules). Anti-Jo-1 antibodies are highly specific
for the anti-synthetase syndrome, which overlaps with dermatomyositis and polymyositis,
making it the most specific marker among the options listed for this diagnosis.
Question 7: A 42-year-old female presents with a chief complaint of a non-healing ulcer on
her right lower leg for 3 months. She has a history of venous insufficiency. The ulcer is located
over the medial malleolus, is shallow, and has irregular borders. The surrounding skin is
hyperpigmented and indurated. What is the most important aspect of initial treatment?
A. Surgical debridement
B. Topical antibiotic ointment
C. Compression therapy
D. Oral antibiotics
CORRECT ANSWER: C. Compression therapy
Rationale: This is a classic venous stasis ulcer, characterized by location over the medial
malleolus and surrounding skin changes. The cornerstone of treatment for venous ulcers is
compression therapy (e.g., with compression stockings or multi-layer wraps) to improve venous
return and reduce edema, which allows the ulcer to heal.
Question 8: A 38-year-old male presents with a sudden onset of unilateral vision loss in his
right eye that occurred 2 hours ago. He describes it as a "curtain coming down" over his
vision. He has a history of hypertension and hyperlipidemia. What is the most likely
diagnosis?
, A. Retinal detachment
B. Central retinal artery occlusion (CRAO)
C. Optic neuritis
D. Migraine with aura
CORRECT ANSWER: B. Central retinal artery occlusion (CRAO)
Rationale: The acute, painless, unilateral loss of vision described as a "curtain coming down" in
a patient with vascular risk factors is classic for a Central Retinal Artery Occlusion (CRAO). This is
an ocular emergency requiring immediate evaluation to minimize permanent visual loss.
Question 9: A 68-year-old female with a history of osteoarthritis presents with acute onset of
a red, painful, and swollen left great toe. She reports that the pain started suddenly last night
and is so severe that she cannot bear the weight of a bedsheet on it. Which of the following is
the most appropriate initial pharmacologic treatment?
A. Allopurinol
B. Probenecid
C. Colchicine
D. Acetaminophen
CORRECT ANSWER: C. Colchicine
Rationale: This is a classic presentation of acute gouty arthritis. The first-line treatment options
for an acute flare are NSAIDs, colchicine, or corticosteroids. Colchicine is a specific and effective
treatment for acute gout flares when started early.
Question 10: A 55-year-old male with a past medical history significant only for GERD
presents with a painless, firm, enlarged lymph node in his left supraclavicular region that has
been present for two months. He has also noted a 15-pound unintentional weight loss and
night sweats. What is the most appropriate next step?
A. A 2-week course of oral antibiotics
B. Excisional biopsy of the lymph node
C. Fine-needle aspiration of the lymph node
D. Chest X-ray and abdominal ultrasound
CORRECT ANSWER: B. Excisional biopsy of the lymph node
Rationale: A painless, firm, enlarged supraclavicular lymph node (Virchow's node) in an older
patient with constitutional symptoms like weight loss and night sweats is a "red flag" for
malignancy until proven otherwise. An excisional biopsy is the diagnostic procedure of choice to
obtain adequate tissue for pathological analysis to rule out lymphoma or metastatic cancer.
Question 11: A 72-year-old male presents with progressive memory loss and difficulty finding
words. His wife reports that he has become apathetic and has poor judgment. His neurologic
