NR511 WEEK 4 MIDTERM EXAM/ ACTUAL EXAM
NR 511: DIFFERENTIAL DIAGNOSIS & PRIMARY CARE
QUESTIONS AND 100% VERIFIED ANSWERS WITH
RATIONALES GRADED A+ LATEST
Question 1
A 46-year-old woman presents with a 3-month history of intermittent fatigue,
constipation, cold intolerance, and an 8-lb weight gain. She reports increasingly
dry skin and heavier menstrual periods. Examination reveals a mildly enlarged,
nontender thyroid. Which laboratory finding would most strongly support the
suspected diagnosis?
A. Decreased TSH and increased free T4
B. Increased TSH and decreased free T4
C. Decreased TSH and decreased free T4
D. Increased TSH and increased free T4
Answer: B
Rationale: Primary hypothyroidism, commonly caused by Hashimoto thyroiditis,
produces decreased thyroid hormone production with compensatory elevation of
TSH. The combination of elevated TSH and low free T4 is diagnostic of overt
primary hypothyroidism.
Question 2
A 58-year-old man reports substernal burning that occurs after large meals and
when lying down at night. He has experienced symptoms twice weekly for 4
months and obtains partial relief with over-the-counter antacids. He denies
dysphagia, odynophagia, gastrointestinal bleeding, or unintentional weight loss.
Which initial management approach is most appropriate?
A. Immediate upper endoscopy
B. Trial of once-daily proton pump inhibitor therapy
,C. Barium swallow followed by esophageal manometry
D. Long-term metoclopramide therapy
Answer: B
Rationale: Typical gastroesophageal reflux symptoms without alarm features can
generally be managed initially with an empiric proton pump inhibitor trial along
with lifestyle measures. Endoscopy is indicated when alarm symptoms such as
dysphagia, bleeding, anemia, or weight loss are present or when symptoms fail to
respond appropriately to empiric therapy.
Question 3
A 67-year-old patient with hypertension reports dizziness when standing and
several recent near-falls. Current medications include lisinopril,
hydrochlorothiazide, and amlodipine. Blood pressure is 138/76 mm Hg while
seated and 112/62 mm Hg after standing for 3 minutes. Heart rate increases from
68 to 78 beats/minute. Which diagnosis best explains these findings?
A. White-coat hypertension
B. Orthostatic hypotension
C. Vasovagal syncope
D. Hypertensive urgency
Answer: B
Rationale: Orthostatic hypotension is characterized by a significant reduction in
blood pressure after standing and commonly causes dizziness, weakness, and falls
in older adults. Antihypertensive and diuretic medications can contribute to the
condition.
,Question 4
A 32-year-old woman presents with dysuria, urinary frequency, and suprapubic
discomfort for 2 days. She denies vaginal discharge, flank pain, fever, or
pregnancy. Urinalysis demonstrates positive leukocyte esterase and nitrites. Which
diagnosis is most likely?
A. Acute uncomplicated cystitis
B. Acute pyelonephritis
C. Vulvovaginal candidiasis
D. Nephrolithiasis
Answer: A
Rationale: Dysuria and frequency accompanied by positive leukocyte esterase and
nitrites strongly support a lower urinary tract infection. The absence of fever, flank
pain, and systemic illness makes pyelonephritis less likely.
Question 5
A 41-year-old man presents with episodic unilateral headaches associated with
tearing and nasal congestion on the same side. Each episode lasts approximately 60
minutes and occurs almost nightly for the past 2 weeks. He becomes restless
during attacks and reports pacing rather than lying down. Which diagnosis is most
consistent with this presentation?
A. Migraine without aura
B. Tension-type headache
C. Cluster headache
D. Medication-overuse headache
Answer: C
Rationale: Cluster headaches cause severe unilateral orbital or temporal pain with
ipsilateral autonomic symptoms such as lacrimation and nasal congestion. Attacks
typically last 15–180 minutes and may occur repeatedly during a cluster period.
Restlessness is also characteristic.
, Question 6
A 55-year-old woman presents with progressive pain and stiffness in both hands.
Symptoms are worst in the morning and last approximately 90 minutes before
improving with activity. Examination reveals symmetric swelling and tenderness
of the MCP and PIP joints. Which diagnosis should be highest on the differential?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Carpal tunnel syndrome
D. Gout
Answer: B
Rationale: Rheumatoid arthritis typically produces symmetric inflammatory
polyarthritis involving the MCP and PIP joints with prolonged morning stiffness
that improves with movement. Osteoarthritis more commonly affects DIP and PIP
joints and produces shorter periods of morning stiffness.
Question 7
A 73-year-old woman reports new-onset unilateral temporal headache
accompanied by scalp tenderness and pain when chewing. She has no previous
history of similar headaches. Which additional finding would most strongly
support the suspected diagnosis?
A. Elevated erythrocyte sedimentation rate
B. Positive Romberg test
C. Decreased serum lipase
D. Positive nitrite test
Answer: A
Rationale: New headache in an older adult accompanied by scalp tenderness and
jaw claudication raises concern for giant cell arteritis. Elevated inflammatory
markers, particularly ESR and CRP, commonly support the diagnosis. Prompt
recognition is critical because untreated disease can result in permanent visual loss.
NR 511: DIFFERENTIAL DIAGNOSIS & PRIMARY CARE
QUESTIONS AND 100% VERIFIED ANSWERS WITH
RATIONALES GRADED A+ LATEST
Question 1
A 46-year-old woman presents with a 3-month history of intermittent fatigue,
constipation, cold intolerance, and an 8-lb weight gain. She reports increasingly
dry skin and heavier menstrual periods. Examination reveals a mildly enlarged,
nontender thyroid. Which laboratory finding would most strongly support the
suspected diagnosis?
A. Decreased TSH and increased free T4
B. Increased TSH and decreased free T4
C. Decreased TSH and decreased free T4
D. Increased TSH and increased free T4
Answer: B
Rationale: Primary hypothyroidism, commonly caused by Hashimoto thyroiditis,
produces decreased thyroid hormone production with compensatory elevation of
TSH. The combination of elevated TSH and low free T4 is diagnostic of overt
primary hypothyroidism.
Question 2
A 58-year-old man reports substernal burning that occurs after large meals and
when lying down at night. He has experienced symptoms twice weekly for 4
months and obtains partial relief with over-the-counter antacids. He denies
dysphagia, odynophagia, gastrointestinal bleeding, or unintentional weight loss.
Which initial management approach is most appropriate?
A. Immediate upper endoscopy
B. Trial of once-daily proton pump inhibitor therapy
,C. Barium swallow followed by esophageal manometry
D. Long-term metoclopramide therapy
Answer: B
Rationale: Typical gastroesophageal reflux symptoms without alarm features can
generally be managed initially with an empiric proton pump inhibitor trial along
with lifestyle measures. Endoscopy is indicated when alarm symptoms such as
dysphagia, bleeding, anemia, or weight loss are present or when symptoms fail to
respond appropriately to empiric therapy.
Question 3
A 67-year-old patient with hypertension reports dizziness when standing and
several recent near-falls. Current medications include lisinopril,
hydrochlorothiazide, and amlodipine. Blood pressure is 138/76 mm Hg while
seated and 112/62 mm Hg after standing for 3 minutes. Heart rate increases from
68 to 78 beats/minute. Which diagnosis best explains these findings?
A. White-coat hypertension
B. Orthostatic hypotension
C. Vasovagal syncope
D. Hypertensive urgency
Answer: B
Rationale: Orthostatic hypotension is characterized by a significant reduction in
blood pressure after standing and commonly causes dizziness, weakness, and falls
in older adults. Antihypertensive and diuretic medications can contribute to the
condition.
,Question 4
A 32-year-old woman presents with dysuria, urinary frequency, and suprapubic
discomfort for 2 days. She denies vaginal discharge, flank pain, fever, or
pregnancy. Urinalysis demonstrates positive leukocyte esterase and nitrites. Which
diagnosis is most likely?
A. Acute uncomplicated cystitis
B. Acute pyelonephritis
C. Vulvovaginal candidiasis
D. Nephrolithiasis
Answer: A
Rationale: Dysuria and frequency accompanied by positive leukocyte esterase and
nitrites strongly support a lower urinary tract infection. The absence of fever, flank
pain, and systemic illness makes pyelonephritis less likely.
Question 5
A 41-year-old man presents with episodic unilateral headaches associated with
tearing and nasal congestion on the same side. Each episode lasts approximately 60
minutes and occurs almost nightly for the past 2 weeks. He becomes restless
during attacks and reports pacing rather than lying down. Which diagnosis is most
consistent with this presentation?
A. Migraine without aura
B. Tension-type headache
C. Cluster headache
D. Medication-overuse headache
Answer: C
Rationale: Cluster headaches cause severe unilateral orbital or temporal pain with
ipsilateral autonomic symptoms such as lacrimation and nasal congestion. Attacks
typically last 15–180 minutes and may occur repeatedly during a cluster period.
Restlessness is also characteristic.
, Question 6
A 55-year-old woman presents with progressive pain and stiffness in both hands.
Symptoms are worst in the morning and last approximately 90 minutes before
improving with activity. Examination reveals symmetric swelling and tenderness
of the MCP and PIP joints. Which diagnosis should be highest on the differential?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Carpal tunnel syndrome
D. Gout
Answer: B
Rationale: Rheumatoid arthritis typically produces symmetric inflammatory
polyarthritis involving the MCP and PIP joints with prolonged morning stiffness
that improves with movement. Osteoarthritis more commonly affects DIP and PIP
joints and produces shorter periods of morning stiffness.
Question 7
A 73-year-old woman reports new-onset unilateral temporal headache
accompanied by scalp tenderness and pain when chewing. She has no previous
history of similar headaches. Which additional finding would most strongly
support the suspected diagnosis?
A. Elevated erythrocyte sedimentation rate
B. Positive Romberg test
C. Decreased serum lipase
D. Positive nitrite test
Answer: A
Rationale: New headache in an older adult accompanied by scalp tenderness and
jaw claudication raises concern for giant cell arteritis. Elevated inflammatory
markers, particularly ESR and CRP, commonly support the diagnosis. Prompt
recognition is critical because untreated disease can result in permanent visual loss.
