NRNP 6568 Synthesis in Advanced Nursing
Practice of Patients in Family Care Settings
(Walden University)
Final Exam Guide 280 Questions, Answers & Rationales
1. A patient presents with polyuria, polydipsia, and unintentional weight loss. What is the priority
initial diagnostic test?
Correct Answer: Fasting plasma glucose or HbA1c to screen for diabetes mellitus
Rationale: This classic symptom triad reflects the osmotic diuresis and catabolic state associated
with significant hyperglycemia, and prompt screening confirms or excludes this diagnosis, guiding
immediate management decisions.
2. What is the diagnostic criteria for diabetes mellitus based on HbA1c testing?
Correct Answer: HbA1c of 6.5% or greater on two separate occasions (or once with
classic symptoms and a confirmatory elevated glucose)
Rationale: HbA1c provides an assessment of average glycemic control over approximately 3
months and is a convenient, widely used diagnostic criterion that does not require fasting, though
confirmation is generally recommended unless the patient has unequivocal hyperglycemia with
classic symptoms.
3. A patient is newly diagnosed with type 2 diabetes with an HbA1c of 7.8%. What is the
recommended first-line pharmacologic therapy, per current guidelines?
Correct Answer: Metformin, combined with lifestyle modification, unless
contraindicated
Rationale: Metformin remains first-line therapy for most patients with type 2 diabetes given its
efficacy, safety profile, weight-neutral effect, and low cost, with additional agents added based on
individual patient factors, comorbidities, and glycemic response.
4. What is the priority consideration for metformin use in a patient with significantly reduced renal
function?
Correct Answer: Metformin should be dose-adjusted or avoided based on eGFR, given
the risk of lactic acidosis with accumulation in significant renal impairment
1
, Rationale: Current guidelines provide specific eGFR-based dosing recommendations for
metformin, moving away from a strict creatinine cutoff, and the FNP must apply current
recommendations to determine appropriate use in patients with varying degrees of renal
impairment.
5. A patient with type 2 diabetes and established atherosclerotic cardiovascular disease requires
additional glucose-lowering therapy beyond metformin. What medication class should be
prioritized given demonstrated cardiovascular benefit?
Correct Answer: An SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated
cardiovascular benefit
Rationale: Current guidelines recommend prioritizing these medication classes in patients with
established cardiovascular disease, independent of their glucose-lowering effect, given their
demonstrated reduction in major adverse cardiovascular events in clinical trials.
6. What is the priority patient education regarding sick day management for a patient with type 2
diabetes taking an SGLT2 inhibitor?
Correct Answer: Hold the SGLT2 inhibitor during acute illness, particularly with reduced
oral intake or dehydration, given the risk of euglycemic diabetic ketoacidosis
Rationale: SGLT2 inhibitors carry a risk of euglycemic DKA, a form of ketoacidosis that can occur
with relatively normal or only mildly elevated glucose levels, making this less recognizable and
potentially dangerous; sick day protocols specifically addressing this medication are an important
safety education point.
7. A patient with type 2 diabetes on metformin monotherapy has an HbA1c of 9.2% at follow-up
despite reported adherence. What is the appropriate next step?
Correct Answer: Intensify therapy by adding a second glucose-lowering agent, selected
based on patient-specific factors including comorbidities, weight considerations, and
hypoglycemia risk
Rationale: An HbA1c significantly above target despite adherence to initial monotherapy
indicates the need for treatment intensification, and agent selection should be individualized
based on the patient's overall clinical profile and treatment goals, per current stepwise treatment
algorithms.
8. What is the recommended HbA1c target for most non-pregnant adults with diabetes, per general
guidelines?
Correct Answer: Less than 7%, though individualized based on patient factors such as
age, comorbidities, hypoglycemia risk, and life expectancy
2
, Rationale: While less than 7% is a commonly cited general target, guidelines emphasize
individualization, with less stringent targets appropriate for older adults or those with significant
comorbidities where the risks of tight control (particularly hypoglycemia) may outweigh the
benefits.
9. What is the appropriate HbA1c target consideration for a frail older adult with multiple
comorbidities and limited life expectancy?
Correct Answer: A less stringent target, often around 8-8.5%, is appropriate to balance
glycemic control against hypoglycemia risk in this population
Rationale: In frail older adults, the risks of hypoglycemia (falls, cognitive impairment,
cardiovascular events) often outweigh the long-term microvascular benefits of tight glycemic
control, supporting individualized, relaxed targets that prioritize safety and quality of life.
10. A patient with type 1 diabetes presents with nausea, vomiting, abdominal pain, and is found to
have significant hyperglycemia with ketones in the urine. What is the priority action?
Correct Answer: Immediate referral to the emergency department for evaluation and
treatment of diabetic ketoacidosis
Rationale: DKA is a life-threatening emergency requiring hospitalization for IV fluid
resuscitation, insulin therapy, and electrolyte management; this presentation cannot be safely
managed in the outpatient primary care setting and requires urgent emergency referral.
11. What is the recommended screening frequency for diabetic retinopathy in a patient with type 2
diabetes?
Correct Answer: Annual dilated eye examination, beginning at the time of diabetes
diagnosis
Rationale: Unlike type 1 diabetes, where screening typically begins 5 years after diagnosis, type 2
diabetes often has a preceding period of undiagnosed hyperglycemia, so retinopathy screening
begins immediately at diagnosis given the possibility that retinopathy may already be present.
12. A patient with diabetes presents for a routine foot exam. What is the priority assessment
technique to evaluate for loss of protective sensation?
Correct Answer: Monofilament testing (10-gram Semmes-Weinstein monofilament) at
standardized foot locations
Rationale: Monofilament testing is a simple, validated office-based screening tool for identifying
peripheral neuropathy and loss of protective sensation, which significantly increases risk for
unrecognized foot injury and subsequent ulceration, guiding appropriate patient education and
referral.
3
, 13. What is the priority patient education for a patient with diabetic peripheral neuropathy
regarding foot care?
Correct Answer: Daily foot self-inspection, properly fitted footwear, avoiding walking
barefoot, and prompt reporting of any wounds or changes
Rationale: Because reduced sensation impairs the patient's ability to feel minor injuries,
proactive daily inspection becomes essential to identify problems early, before they progress to
more serious complications such as infection or ulceration requiring more intensive treatment.
14. A patient presents with fatigue, weight gain, cold intolerance, and constipation. What is the
priority initial diagnostic test?
Correct Answer: TSH (thyroid-stimulating hormone)
Rationale: This classic symptom pattern suggests hypothyroidism, and TSH is the most sensitive
initial screening test for primary thyroid dysfunction, with an elevated level supporting further
evaluation with free T4.
15. What is the appropriate initial levothyroxine starting dose for a healthy, young adult with newly
diagnosed overt hypothyroidism, compared to an older adult with cardiac disease?
Correct Answer: A full replacement dose (weight-based) is generally appropriate for a
healthy young adult; a lower starting dose with gradual titration is recommended for an
older adult or one with cardiac disease, to avoid precipitating cardiac ischemia or
arrhythmia
Rationale: This age- and comorbidity-based dosing approach reflects the increased cardiac
sensitivity to rapid metabolic changes in older or cardiac patients, where too-rapid correction of
hypothyroidism can increase myocardial oxygen demand and precipitate cardiac events.
16. What is the recommended follow-up interval for TSH monitoring after initiating or adjusting
levothyroxine dosing?
Correct Answer: Approximately 6-8 weeks after initiation or dose change
Rationale: This interval allows adequate time for TSH levels to reach a new steady state
reflecting the current dose, given the relatively long half-life of levothyroxine, before further dose
adjustments are made based on the follow-up result.
17. A patient presents with unintentional weight loss, heat intolerance, palpitations, and tremor.
What is the priority initial diagnostic test?
Correct Answer: TSH, with reflex free T4 and/or free T3 if TSH is suppressed
4
Practice of Patients in Family Care Settings
(Walden University)
Final Exam Guide 280 Questions, Answers & Rationales
1. A patient presents with polyuria, polydipsia, and unintentional weight loss. What is the priority
initial diagnostic test?
Correct Answer: Fasting plasma glucose or HbA1c to screen for diabetes mellitus
Rationale: This classic symptom triad reflects the osmotic diuresis and catabolic state associated
with significant hyperglycemia, and prompt screening confirms or excludes this diagnosis, guiding
immediate management decisions.
2. What is the diagnostic criteria for diabetes mellitus based on HbA1c testing?
Correct Answer: HbA1c of 6.5% or greater on two separate occasions (or once with
classic symptoms and a confirmatory elevated glucose)
Rationale: HbA1c provides an assessment of average glycemic control over approximately 3
months and is a convenient, widely used diagnostic criterion that does not require fasting, though
confirmation is generally recommended unless the patient has unequivocal hyperglycemia with
classic symptoms.
3. A patient is newly diagnosed with type 2 diabetes with an HbA1c of 7.8%. What is the
recommended first-line pharmacologic therapy, per current guidelines?
Correct Answer: Metformin, combined with lifestyle modification, unless
contraindicated
Rationale: Metformin remains first-line therapy for most patients with type 2 diabetes given its
efficacy, safety profile, weight-neutral effect, and low cost, with additional agents added based on
individual patient factors, comorbidities, and glycemic response.
4. What is the priority consideration for metformin use in a patient with significantly reduced renal
function?
Correct Answer: Metformin should be dose-adjusted or avoided based on eGFR, given
the risk of lactic acidosis with accumulation in significant renal impairment
1
, Rationale: Current guidelines provide specific eGFR-based dosing recommendations for
metformin, moving away from a strict creatinine cutoff, and the FNP must apply current
recommendations to determine appropriate use in patients with varying degrees of renal
impairment.
5. A patient with type 2 diabetes and established atherosclerotic cardiovascular disease requires
additional glucose-lowering therapy beyond metformin. What medication class should be
prioritized given demonstrated cardiovascular benefit?
Correct Answer: An SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated
cardiovascular benefit
Rationale: Current guidelines recommend prioritizing these medication classes in patients with
established cardiovascular disease, independent of their glucose-lowering effect, given their
demonstrated reduction in major adverse cardiovascular events in clinical trials.
6. What is the priority patient education regarding sick day management for a patient with type 2
diabetes taking an SGLT2 inhibitor?
Correct Answer: Hold the SGLT2 inhibitor during acute illness, particularly with reduced
oral intake or dehydration, given the risk of euglycemic diabetic ketoacidosis
Rationale: SGLT2 inhibitors carry a risk of euglycemic DKA, a form of ketoacidosis that can occur
with relatively normal or only mildly elevated glucose levels, making this less recognizable and
potentially dangerous; sick day protocols specifically addressing this medication are an important
safety education point.
7. A patient with type 2 diabetes on metformin monotherapy has an HbA1c of 9.2% at follow-up
despite reported adherence. What is the appropriate next step?
Correct Answer: Intensify therapy by adding a second glucose-lowering agent, selected
based on patient-specific factors including comorbidities, weight considerations, and
hypoglycemia risk
Rationale: An HbA1c significantly above target despite adherence to initial monotherapy
indicates the need for treatment intensification, and agent selection should be individualized
based on the patient's overall clinical profile and treatment goals, per current stepwise treatment
algorithms.
8. What is the recommended HbA1c target for most non-pregnant adults with diabetes, per general
guidelines?
Correct Answer: Less than 7%, though individualized based on patient factors such as
age, comorbidities, hypoglycemia risk, and life expectancy
2
, Rationale: While less than 7% is a commonly cited general target, guidelines emphasize
individualization, with less stringent targets appropriate for older adults or those with significant
comorbidities where the risks of tight control (particularly hypoglycemia) may outweigh the
benefits.
9. What is the appropriate HbA1c target consideration for a frail older adult with multiple
comorbidities and limited life expectancy?
Correct Answer: A less stringent target, often around 8-8.5%, is appropriate to balance
glycemic control against hypoglycemia risk in this population
Rationale: In frail older adults, the risks of hypoglycemia (falls, cognitive impairment,
cardiovascular events) often outweigh the long-term microvascular benefits of tight glycemic
control, supporting individualized, relaxed targets that prioritize safety and quality of life.
10. A patient with type 1 diabetes presents with nausea, vomiting, abdominal pain, and is found to
have significant hyperglycemia with ketones in the urine. What is the priority action?
Correct Answer: Immediate referral to the emergency department for evaluation and
treatment of diabetic ketoacidosis
Rationale: DKA is a life-threatening emergency requiring hospitalization for IV fluid
resuscitation, insulin therapy, and electrolyte management; this presentation cannot be safely
managed in the outpatient primary care setting and requires urgent emergency referral.
11. What is the recommended screening frequency for diabetic retinopathy in a patient with type 2
diabetes?
Correct Answer: Annual dilated eye examination, beginning at the time of diabetes
diagnosis
Rationale: Unlike type 1 diabetes, where screening typically begins 5 years after diagnosis, type 2
diabetes often has a preceding period of undiagnosed hyperglycemia, so retinopathy screening
begins immediately at diagnosis given the possibility that retinopathy may already be present.
12. A patient with diabetes presents for a routine foot exam. What is the priority assessment
technique to evaluate for loss of protective sensation?
Correct Answer: Monofilament testing (10-gram Semmes-Weinstein monofilament) at
standardized foot locations
Rationale: Monofilament testing is a simple, validated office-based screening tool for identifying
peripheral neuropathy and loss of protective sensation, which significantly increases risk for
unrecognized foot injury and subsequent ulceration, guiding appropriate patient education and
referral.
3
, 13. What is the priority patient education for a patient with diabetic peripheral neuropathy
regarding foot care?
Correct Answer: Daily foot self-inspection, properly fitted footwear, avoiding walking
barefoot, and prompt reporting of any wounds or changes
Rationale: Because reduced sensation impairs the patient's ability to feel minor injuries,
proactive daily inspection becomes essential to identify problems early, before they progress to
more serious complications such as infection or ulceration requiring more intensive treatment.
14. A patient presents with fatigue, weight gain, cold intolerance, and constipation. What is the
priority initial diagnostic test?
Correct Answer: TSH (thyroid-stimulating hormone)
Rationale: This classic symptom pattern suggests hypothyroidism, and TSH is the most sensitive
initial screening test for primary thyroid dysfunction, with an elevated level supporting further
evaluation with free T4.
15. What is the appropriate initial levothyroxine starting dose for a healthy, young adult with newly
diagnosed overt hypothyroidism, compared to an older adult with cardiac disease?
Correct Answer: A full replacement dose (weight-based) is generally appropriate for a
healthy young adult; a lower starting dose with gradual titration is recommended for an
older adult or one with cardiac disease, to avoid precipitating cardiac ischemia or
arrhythmia
Rationale: This age- and comorbidity-based dosing approach reflects the increased cardiac
sensitivity to rapid metabolic changes in older or cardiac patients, where too-rapid correction of
hypothyroidism can increase myocardial oxygen demand and precipitate cardiac events.
16. What is the recommended follow-up interval for TSH monitoring after initiating or adjusting
levothyroxine dosing?
Correct Answer: Approximately 6-8 weeks after initiation or dose change
Rationale: This interval allows adequate time for TSH levels to reach a new steady state
reflecting the current dose, given the relatively long half-life of levothyroxine, before further dose
adjustments are made based on the follow-up result.
17. A patient presents with unintentional weight loss, heat intolerance, palpitations, and tremor.
What is the priority initial diagnostic test?
Correct Answer: TSH, with reflex free T4 and/or free T3 if TSH is suppressed
4
