NR 601 Midterm Exam – Primary Care of the Maturing and
Aged Family Practicum – (2026)
This comprehensive midterm examination is designed to assess your knowledge and clinical
reasoning skills in the primary care of the maturing and aged population. The exam covers a
broad spectrum of topics essential for the family nurse practitioner, including geriatric
syndromes, pharmacotherapy, chronic disease management, mental health, and palliative care.
Each question is accompanied by multiple correct answers and a detailed rationale to reinforce
key concepts and evidence-based practice guidelines.
1. An 82-year-old male with a history of hypertension and type 2 diabetes presents for a
routine physical. His blood pressure is 138/82 mmHg. His home medications include
lisinopril 20 mg daily and metformin 1000 mg BID. Which of the following are the most
appropriate next steps in managing his hypertension, according to the 2017 ACC/AHA
guidelines for older adults?
A. Recheck blood pressure in one month and initiate a thiazide diuretic if it remains
above 130/80.
B. Consider that his current blood pressure is at goal if he is functionally independent
with a life expectancy >5 years.
C. Add amlodipine 2.5 mg daily to lower his systolic blood pressure to <130 mmHg, as
this is the standard target for all adults.
D. Evaluate for orthostatic hypotension and review his current medication list for
potential contributors to his blood pressure reading.
E. Discuss with the patient the risks and benefits of intensive blood pressure control,
including the potential for falls and acute kidney injury.
Correct Answers: B, D, E
Rationale: The 2017 ACC/AHA guideline recommends a blood pressure target of <130/80
for most adults, including older adults, if they can tolerate it. However, for older adults, a
more individualized approach is recommended, considering functional status,
comorbidities, and life expectancy. Option B is correct because a target of <130/80 is
reasonable for community-ambulating older adults with a life expectancy >5 years.
Option D is correct as orthostatic hypotension must be assessed before initiating or
intensifying antihypertensive therapy, and medication review is a key step. Option E is
correct because shared decision-making is crucial, weighing the benefits of
cardiovascular risk reduction against the risks of adverse effects, particularly in this
vulnerable population. Option A is incorrect because adding a medication should be
, based on a confirmed elevated reading over time, not a single visit. Option C is incorrect
because it does not account for individualization; amlodipine might be appropriate, but
not solely based on this one reading without further assessment.
2. A 76-year-old female with a history of osteoporosis and chronic kidney disease stage 3
presents for a follow-up. Her DEXA scan T-score is -3.0 at the femoral neck. She is
concerned about fractures. Which of the following pharmacologic agents are considered
appropriate first-line therapies for her osteoporosis, and what are key monitoring
parameters?
A. Alendronate 70 mg weekly, with monitoring for renal function and serum calcium.
B. Denosumab 60 mg subcutaneously every 6 months, with monitoring for
hypocalcemia, especially in patients with CKD.
C. Raloxifene 60 mg daily, with monitoring for venous thromboembolism and hot
flashes.
D. Teriparatide 20 mcg daily, with monitoring for hypercalcemia and osteosarcoma risk.
E. Zoledronic acid 5 mg IV annually, with monitoring for renal function and acute phase
reactions.
Correct Answers: B, C, D
Rationale: For patients with osteoporosis and CKD, the choice of therapy depends on
bone turnover markers and renal function. Bisphosphonates (A and E) are generally not
recommended when eGFR is <30-35 mL/min due to the risk of accumulation and
nephrotoxicity. Denosumab (B) is not cleared by the kidneys and can be used in CKD, but
monitoring for hypocalcemia is critical. Raloxifene (C) is an appropriate choice for
postmenopausal women, especially if they have an increased risk of breast cancer, but
requires monitoring for thromboembolic events. Teriparatide (D) is an anabolic agent
indicated for patients with severe osteoporosis or those who have failed other therapies,
and its use is not contraindicated in CKD, though monitoring for hypercalcemia is
essential.
3. A 68-year-old male with a 40-pack-year smoking history presents with a new onset of a
cough and exertional dyspnea. He has noted a 10-pound unintentional weight loss over
the past 3 months. His physical exam is unremarkable. Which of the following are the
most appropriate initial diagnostic steps and considerations in his evaluation?
A. Obtain a chest X-ray and complete blood count.
B. Consider a trial of antibiotics for community-acquired pneumonia before further
work-up.
C. Perform pulmonary function tests to evaluate for COPD.
D. Order a CT scan of the chest to evaluate for a pulmonary nodule or mass.
E. Evaluate for extrapulmonary manifestations of cancer, such as digital clubbing or
hypertrophic osteoarthropathy.
, F. Initiate smoking cessation counseling.
Correct Answers: A, D, E, F
Rationale: This patient's presentation (new cough, dyspnea, weight loss, heavy smoking
history) is concerning for lung cancer. The initial evaluation should include a chest X-ray
(A) to look for a mass or effusion. Given the high clinical suspicion, a CT scan of the chest
(D) is a more sensitive initial test than X-ray alone and is appropriate in this setting.
Digital clubbing and hypertrophic osteoarthropathy (E) are classic extrapulmonary signs
of lung cancer. Smoking cessation counseling (F) is always indicated. A trial of antibiotics
(B) is not appropriate without clear signs of infection and would delay diagnosis of a
potentially serious condition. Pulmonary function tests (C) are more helpful for
diagnosing COPD in a stable setting, but this patient's symptoms and weight loss are
more concerning for malignancy.
4. A 72-year-old female with a history of atrial fibrillation on warfarin presents with a 3-day
history of dark, tarry stools and dizziness. Her INR is 5.2. She is hemodynamically stable.
Which of the following are the most appropriate immediate management steps?
A. Administer vitamin K 5 mg orally.
B. Administer prothrombin complex concentrate (PCC) intravenously.
C. Hold warfarin therapy.
D. Monitor INR daily until it is in the therapeutic range.
E. Administer fresh frozen plasma (FFP) immediately.
F. Assess for the cause of elevated INR, including dietary changes, new medications, or
missed doses.
Correct Answers: C, D, F
Rationale: This patient has a supratherapeutic INR with bleeding (melena). For an
elevated INR with bleeding, the general recommendation is to hold warfarin and
consider vitamin K. However, in a hemodynamically stable patient with a bleed, vitamin
K 5-10 mg IV can be given. Oral vitamin K (A) is less reliable and slower. PCC (B) and FFP
(E) are reserved for life-threatening bleeds or when rapid reversal is needed. The
cornerstone of management is to hold warfarin (C), monitor the INR (D), and identify the
cause of the elevated INR (F), such as drug interactions, dietary changes, or acute illness.
5. A 79-year-old male presents with a 6-month history of worsening memory, difficulty
managing his finances, and getting lost in familiar places. His family reports he has
become more withdrawn. His MMSE score is 22/30. Which of the following are the most
appropriate initial steps in his evaluation and management, according to the Alzheimer's
Association?
A. Order a comprehensive metabolic panel, complete blood count, thyroid stimulating
hormone, and vitamin B12 level.
B. Initiate treatment with donepezil 5 mg daily.
, C. Order a CT or MRI of the head without contrast.
D. Refer to a neurologist for a lumbar puncture to assess for biomarkers.
E. Evaluate for depression using a screening tool such as the PHQ-9.
F. Assess for medication side effects that may be contributing to cognitive decline.
Correct Answers: A, C, E, F
Rationale: The evaluation of cognitive impairment should include a thorough history,
physical exam, and laboratory tests to rule out reversible causes of dementia (A).
Neuroimaging (C) is recommended to rule out structural lesions, such as stroke or tumor.
Evaluation for depression (E) is essential as it can mimic dementia (pseudodementia). A
medication review (F) is crucial as many drugs can cause cognitive impairment. While
donepezil (B) is an appropriate treatment for Alzheimer's disease, it should not be
initiated before a comprehensive diagnostic evaluation is complete. A lumbar puncture
for biomarkers (D) is typically reserved for research settings or atypical cases and is not a
standard initial diagnostic step.
6. A 65-year-old female with no significant past medical history presents for a wellness
visit. She is up to date on her screening mammograms and colonoscopies. She has a 15-
year history of type 2 diabetes well-controlled on metformin. She is a current smoker
with a 25-pack-year history. Which of the following screening tests are recommended for
her, according to the USPSTF guidelines?
A. One-time screening for abdominal aortic aneurysm (AAA) with ultrasound.
B. Screening for lung cancer with low-dose computed tomography (LDCT) annually.
C. Screening for colorectal cancer with high-sensitivity fecal immunochemical test (FIT)
every year or colonoscopy every 10 years.
D. Screening for osteoporosis with DEXA scan.
E. Screening for diabetes for prediabetes and type 2 diabetes.
F. Screening for hepatitis C virus (HCV) infection.
Correct Answers: B, C, E, F
Rationale: The USPSTF recommends annual screening for lung cancer with LDCT (B) for
adults aged 50-80 years with a 20 pack-year history who currently smoke or quit within
the past 15 years. Colorectal cancer screening (C) is recommended for adults aged 50-75
years. Screening for diabetes (E) is recommended for adults aged 35-70 who are
overweight or obese. A one-time screening for hepatitis C (F) is recommended for all
adults aged 18-79. Abdominal aortic aneurysm screening (A) is recommended for men
aged 65-75 who have ever smoked; this patient is female, so it is not recommended.
Osteoporosis screening (D) with DEXA is recommended for women aged 65 and older, so
this is appropriate for this patient and should be included.
7. An 80-year-old male with a history of heart failure with preserved ejection fraction
(HFpEF) and hypertension presents for a follow-up. He reports increasing shortness of
Aged Family Practicum – (2026)
This comprehensive midterm examination is designed to assess your knowledge and clinical
reasoning skills in the primary care of the maturing and aged population. The exam covers a
broad spectrum of topics essential for the family nurse practitioner, including geriatric
syndromes, pharmacotherapy, chronic disease management, mental health, and palliative care.
Each question is accompanied by multiple correct answers and a detailed rationale to reinforce
key concepts and evidence-based practice guidelines.
1. An 82-year-old male with a history of hypertension and type 2 diabetes presents for a
routine physical. His blood pressure is 138/82 mmHg. His home medications include
lisinopril 20 mg daily and metformin 1000 mg BID. Which of the following are the most
appropriate next steps in managing his hypertension, according to the 2017 ACC/AHA
guidelines for older adults?
A. Recheck blood pressure in one month and initiate a thiazide diuretic if it remains
above 130/80.
B. Consider that his current blood pressure is at goal if he is functionally independent
with a life expectancy >5 years.
C. Add amlodipine 2.5 mg daily to lower his systolic blood pressure to <130 mmHg, as
this is the standard target for all adults.
D. Evaluate for orthostatic hypotension and review his current medication list for
potential contributors to his blood pressure reading.
E. Discuss with the patient the risks and benefits of intensive blood pressure control,
including the potential for falls and acute kidney injury.
Correct Answers: B, D, E
Rationale: The 2017 ACC/AHA guideline recommends a blood pressure target of <130/80
for most adults, including older adults, if they can tolerate it. However, for older adults, a
more individualized approach is recommended, considering functional status,
comorbidities, and life expectancy. Option B is correct because a target of <130/80 is
reasonable for community-ambulating older adults with a life expectancy >5 years.
Option D is correct as orthostatic hypotension must be assessed before initiating or
intensifying antihypertensive therapy, and medication review is a key step. Option E is
correct because shared decision-making is crucial, weighing the benefits of
cardiovascular risk reduction against the risks of adverse effects, particularly in this
vulnerable population. Option A is incorrect because adding a medication should be
, based on a confirmed elevated reading over time, not a single visit. Option C is incorrect
because it does not account for individualization; amlodipine might be appropriate, but
not solely based on this one reading without further assessment.
2. A 76-year-old female with a history of osteoporosis and chronic kidney disease stage 3
presents for a follow-up. Her DEXA scan T-score is -3.0 at the femoral neck. She is
concerned about fractures. Which of the following pharmacologic agents are considered
appropriate first-line therapies for her osteoporosis, and what are key monitoring
parameters?
A. Alendronate 70 mg weekly, with monitoring for renal function and serum calcium.
B. Denosumab 60 mg subcutaneously every 6 months, with monitoring for
hypocalcemia, especially in patients with CKD.
C. Raloxifene 60 mg daily, with monitoring for venous thromboembolism and hot
flashes.
D. Teriparatide 20 mcg daily, with monitoring for hypercalcemia and osteosarcoma risk.
E. Zoledronic acid 5 mg IV annually, with monitoring for renal function and acute phase
reactions.
Correct Answers: B, C, D
Rationale: For patients with osteoporosis and CKD, the choice of therapy depends on
bone turnover markers and renal function. Bisphosphonates (A and E) are generally not
recommended when eGFR is <30-35 mL/min due to the risk of accumulation and
nephrotoxicity. Denosumab (B) is not cleared by the kidneys and can be used in CKD, but
monitoring for hypocalcemia is critical. Raloxifene (C) is an appropriate choice for
postmenopausal women, especially if they have an increased risk of breast cancer, but
requires monitoring for thromboembolic events. Teriparatide (D) is an anabolic agent
indicated for patients with severe osteoporosis or those who have failed other therapies,
and its use is not contraindicated in CKD, though monitoring for hypercalcemia is
essential.
3. A 68-year-old male with a 40-pack-year smoking history presents with a new onset of a
cough and exertional dyspnea. He has noted a 10-pound unintentional weight loss over
the past 3 months. His physical exam is unremarkable. Which of the following are the
most appropriate initial diagnostic steps and considerations in his evaluation?
A. Obtain a chest X-ray and complete blood count.
B. Consider a trial of antibiotics for community-acquired pneumonia before further
work-up.
C. Perform pulmonary function tests to evaluate for COPD.
D. Order a CT scan of the chest to evaluate for a pulmonary nodule or mass.
E. Evaluate for extrapulmonary manifestations of cancer, such as digital clubbing or
hypertrophic osteoarthropathy.
, F. Initiate smoking cessation counseling.
Correct Answers: A, D, E, F
Rationale: This patient's presentation (new cough, dyspnea, weight loss, heavy smoking
history) is concerning for lung cancer. The initial evaluation should include a chest X-ray
(A) to look for a mass or effusion. Given the high clinical suspicion, a CT scan of the chest
(D) is a more sensitive initial test than X-ray alone and is appropriate in this setting.
Digital clubbing and hypertrophic osteoarthropathy (E) are classic extrapulmonary signs
of lung cancer. Smoking cessation counseling (F) is always indicated. A trial of antibiotics
(B) is not appropriate without clear signs of infection and would delay diagnosis of a
potentially serious condition. Pulmonary function tests (C) are more helpful for
diagnosing COPD in a stable setting, but this patient's symptoms and weight loss are
more concerning for malignancy.
4. A 72-year-old female with a history of atrial fibrillation on warfarin presents with a 3-day
history of dark, tarry stools and dizziness. Her INR is 5.2. She is hemodynamically stable.
Which of the following are the most appropriate immediate management steps?
A. Administer vitamin K 5 mg orally.
B. Administer prothrombin complex concentrate (PCC) intravenously.
C. Hold warfarin therapy.
D. Monitor INR daily until it is in the therapeutic range.
E. Administer fresh frozen plasma (FFP) immediately.
F. Assess for the cause of elevated INR, including dietary changes, new medications, or
missed doses.
Correct Answers: C, D, F
Rationale: This patient has a supratherapeutic INR with bleeding (melena). For an
elevated INR with bleeding, the general recommendation is to hold warfarin and
consider vitamin K. However, in a hemodynamically stable patient with a bleed, vitamin
K 5-10 mg IV can be given. Oral vitamin K (A) is less reliable and slower. PCC (B) and FFP
(E) are reserved for life-threatening bleeds or when rapid reversal is needed. The
cornerstone of management is to hold warfarin (C), monitor the INR (D), and identify the
cause of the elevated INR (F), such as drug interactions, dietary changes, or acute illness.
5. A 79-year-old male presents with a 6-month history of worsening memory, difficulty
managing his finances, and getting lost in familiar places. His family reports he has
become more withdrawn. His MMSE score is 22/30. Which of the following are the most
appropriate initial steps in his evaluation and management, according to the Alzheimer's
Association?
A. Order a comprehensive metabolic panel, complete blood count, thyroid stimulating
hormone, and vitamin B12 level.
B. Initiate treatment with donepezil 5 mg daily.
, C. Order a CT or MRI of the head without contrast.
D. Refer to a neurologist for a lumbar puncture to assess for biomarkers.
E. Evaluate for depression using a screening tool such as the PHQ-9.
F. Assess for medication side effects that may be contributing to cognitive decline.
Correct Answers: A, C, E, F
Rationale: The evaluation of cognitive impairment should include a thorough history,
physical exam, and laboratory tests to rule out reversible causes of dementia (A).
Neuroimaging (C) is recommended to rule out structural lesions, such as stroke or tumor.
Evaluation for depression (E) is essential as it can mimic dementia (pseudodementia). A
medication review (F) is crucial as many drugs can cause cognitive impairment. While
donepezil (B) is an appropriate treatment for Alzheimer's disease, it should not be
initiated before a comprehensive diagnostic evaluation is complete. A lumbar puncture
for biomarkers (D) is typically reserved for research settings or atypical cases and is not a
standard initial diagnostic step.
6. A 65-year-old female with no significant past medical history presents for a wellness
visit. She is up to date on her screening mammograms and colonoscopies. She has a 15-
year history of type 2 diabetes well-controlled on metformin. She is a current smoker
with a 25-pack-year history. Which of the following screening tests are recommended for
her, according to the USPSTF guidelines?
A. One-time screening for abdominal aortic aneurysm (AAA) with ultrasound.
B. Screening for lung cancer with low-dose computed tomography (LDCT) annually.
C. Screening for colorectal cancer with high-sensitivity fecal immunochemical test (FIT)
every year or colonoscopy every 10 years.
D. Screening for osteoporosis with DEXA scan.
E. Screening for diabetes for prediabetes and type 2 diabetes.
F. Screening for hepatitis C virus (HCV) infection.
Correct Answers: B, C, E, F
Rationale: The USPSTF recommends annual screening for lung cancer with LDCT (B) for
adults aged 50-80 years with a 20 pack-year history who currently smoke or quit within
the past 15 years. Colorectal cancer screening (C) is recommended for adults aged 50-75
years. Screening for diabetes (E) is recommended for adults aged 35-70 who are
overweight or obese. A one-time screening for hepatitis C (F) is recommended for all
adults aged 18-79. Abdominal aortic aneurysm screening (A) is recommended for men
aged 65-75 who have ever smoked; this patient is female, so it is not recommended.
Osteoporosis screening (D) with DEXA is recommended for women aged 65 and older, so
this is appropriate for this patient and should be included.
7. An 80-year-old male with a history of heart failure with preserved ejection fraction
(HFpEF) and hypertension presents for a follow-up. He reports increasing shortness of
