Advanced NP Critical Thinking Scenarios –
High-Yield Questions Answers And Rationales.
2025/2026
1. A 68-year-old man with known CAD presents with acute crushing
chest pain and ST elevation in leads V2–V4. He is allergic to aspirin
(hives). The immediate antiplatelet strategy before PCI should be:
A. Clopidogrel
B. Prasugrel
C. No antiplatelet until after PCI
D. Ticagrelor
Rationale: Prasugrel or ticagrelor are preferred P2Y12 agents in
PCI; prasugrel is contraindicated if prior stroke/TIA—if no
contraindication, it's appropriate.
2. A 45-year-old woman with new-onset atrial fibrillation and
hyperthyroidism — best initial approach to rate control:
A. Digoxin
B. Beta-blocker (propranolol or metoprolol)
C. Calcium channel blocker (verapamil)
D. Electrical cardioversion immediately
Rationale: Beta-blockers control rate and reduce peripheral
conversion of T4; propranolol also inhibits peripheral T4 to T3
conversion.
3. A patient with COPD exacerbation on chronic theophylline
presents with new-onset nausea, vomiting, and arrhythmia.
Theophylline level is 40 mcg/mL. Next step:
A. Increase bronchodilator therapy
, B. Give activated charcoal and supportive care
C. Stop theophylline and admit for monitoring; consider charcoal
and benzodiazepines for seizures
D. No change
Rationale: Toxic theophylline levels (>20–25 mcg/mL) cause GI,
CNS, and arrhythmias; stop drug and manage toxicity.
4. A 29-year-old pregnant woman at 10 weeks with hyperemesis
gravidarum and ketonuria — best initial outpatient management:
A. IV fluids and admission
B. Start oral pyridoxine (vitamin B6) ± doxylamine
C. Metoclopramide PO long-term
D. Ondansetron as first-line
Rationale: Vitamin B6 ± doxylamine is first-line for nausea in
pregnancy; escalate if ineffective.
5. A 55-year-old diabetic with neuropathic pain: first-line
pharmacologic therapy:
A. Gabapentin only after opioids fail
B. Tramadol
C. Duloxetine (SNRI) or gabapentin/pregabalin
D. Amitriptyline only
Rationale: First-line agents include duloxetine, gabapentin,
pregabalin, and tricyclics depending on comorbidities.
6. 72-year-old with acute ischemic stroke within 2 hours, no
contraindications — immediate therapy:
A. Aspirin only
B. Subacute thrombectomy later
C. IV alteplase (tPA)
D. Heparin infusion
, Rationale: IV tPA is indicated within 4.5 hours in eligible patients
to improve outcomes.
7. Young adult with suspected meningitis: lumbar puncture shows
neutrophilic pleocytosis and low glucose — initial empiric
antibiotics:
A. Vancomycin + ceftriaxone (+ ampicillin if >50 or
immunocompromised)
B. Acyclovir only
C. Cefazolin alone
D. Vancomycin alone
Rationale: Empiric coverage for bacterial meningitis includes
vancomycin and a 3rd-gen cephalosporin; add ampicillin for
Listeria coverage when indicated.
8. A patient on warfarin with INR 9.5 but no bleeding — appropriate
action:
A. Immediate vitamin K IV and hospitalize
B. Hold warfarin and give low-dose oral vitamin K
C. Give prothrombin complex concentrate without vitamin K
D. Continue warfarin and recheck
Rationale: For INR >9 and no bleeding, give oral vitamin K and
hold warfarin; reserve PCC for bleeding.
9. A 35-year-old with bipolar mania; best mood stabilizer safe in
pregnancy?
A. Valproate
B. Lithium with caution (avoid first-trimester high-risk
counseling)
C. Carbamazepine
D. Clozapine
Rationale: All mood stabilizers have risks; valproate is
, teratogenic (neural tube). Lithium may be used with counseling
and monitoring.
10. 60-year-old with newly diagnosed type 2 DM, A1c 9.0% —
initial pharmacotherapy:
A. Start insulin only
B. Metformin + immediate insulin
C. Start metformin and lifestyle modifications; consider early
insulin if symptoms or very high A1c
D. Sulfonylurea monotherapy
Rationale: Metformin is first-line unless contraindicated; insulin
considered if symptomatic or very high A1c.
11. Child with febrile seizure — no prior neurologic disease —
recommended disposition:
A. Start prophylactic phenobarbital
B. Reassure and outpatient follow-up; educate on seizure first
aid
C. Immediate EEG and MRI
D. Begin daily anticonvulsant therapy
Rationale: Simple febrile seizures are benign; no chronic
anticonvulsants or neuroimaging required unless atypical
features.
12. A 70-year-old with community-acquired pneumonia, CURB-
65 score 3 — place of care:
A. Home with oral antibiotics
B. Outpatient with IV therapy
C. Hospital admission (consider ICU depending on other factors)
D. Hospice
Rationale: CURB-65 ≥2 suggests hospital admission; 3 indicates
higher risk.
High-Yield Questions Answers And Rationales.
2025/2026
1. A 68-year-old man with known CAD presents with acute crushing
chest pain and ST elevation in leads V2–V4. He is allergic to aspirin
(hives). The immediate antiplatelet strategy before PCI should be:
A. Clopidogrel
B. Prasugrel
C. No antiplatelet until after PCI
D. Ticagrelor
Rationale: Prasugrel or ticagrelor are preferred P2Y12 agents in
PCI; prasugrel is contraindicated if prior stroke/TIA—if no
contraindication, it's appropriate.
2. A 45-year-old woman with new-onset atrial fibrillation and
hyperthyroidism — best initial approach to rate control:
A. Digoxin
B. Beta-blocker (propranolol or metoprolol)
C. Calcium channel blocker (verapamil)
D. Electrical cardioversion immediately
Rationale: Beta-blockers control rate and reduce peripheral
conversion of T4; propranolol also inhibits peripheral T4 to T3
conversion.
3. A patient with COPD exacerbation on chronic theophylline
presents with new-onset nausea, vomiting, and arrhythmia.
Theophylline level is 40 mcg/mL. Next step:
A. Increase bronchodilator therapy
, B. Give activated charcoal and supportive care
C. Stop theophylline and admit for monitoring; consider charcoal
and benzodiazepines for seizures
D. No change
Rationale: Toxic theophylline levels (>20–25 mcg/mL) cause GI,
CNS, and arrhythmias; stop drug and manage toxicity.
4. A 29-year-old pregnant woman at 10 weeks with hyperemesis
gravidarum and ketonuria — best initial outpatient management:
A. IV fluids and admission
B. Start oral pyridoxine (vitamin B6) ± doxylamine
C. Metoclopramide PO long-term
D. Ondansetron as first-line
Rationale: Vitamin B6 ± doxylamine is first-line for nausea in
pregnancy; escalate if ineffective.
5. A 55-year-old diabetic with neuropathic pain: first-line
pharmacologic therapy:
A. Gabapentin only after opioids fail
B. Tramadol
C. Duloxetine (SNRI) or gabapentin/pregabalin
D. Amitriptyline only
Rationale: First-line agents include duloxetine, gabapentin,
pregabalin, and tricyclics depending on comorbidities.
6. 72-year-old with acute ischemic stroke within 2 hours, no
contraindications — immediate therapy:
A. Aspirin only
B. Subacute thrombectomy later
C. IV alteplase (tPA)
D. Heparin infusion
, Rationale: IV tPA is indicated within 4.5 hours in eligible patients
to improve outcomes.
7. Young adult with suspected meningitis: lumbar puncture shows
neutrophilic pleocytosis and low glucose — initial empiric
antibiotics:
A. Vancomycin + ceftriaxone (+ ampicillin if >50 or
immunocompromised)
B. Acyclovir only
C. Cefazolin alone
D. Vancomycin alone
Rationale: Empiric coverage for bacterial meningitis includes
vancomycin and a 3rd-gen cephalosporin; add ampicillin for
Listeria coverage when indicated.
8. A patient on warfarin with INR 9.5 but no bleeding — appropriate
action:
A. Immediate vitamin K IV and hospitalize
B. Hold warfarin and give low-dose oral vitamin K
C. Give prothrombin complex concentrate without vitamin K
D. Continue warfarin and recheck
Rationale: For INR >9 and no bleeding, give oral vitamin K and
hold warfarin; reserve PCC for bleeding.
9. A 35-year-old with bipolar mania; best mood stabilizer safe in
pregnancy?
A. Valproate
B. Lithium with caution (avoid first-trimester high-risk
counseling)
C. Carbamazepine
D. Clozapine
Rationale: All mood stabilizers have risks; valproate is
, teratogenic (neural tube). Lithium may be used with counseling
and monitoring.
10. 60-year-old with newly diagnosed type 2 DM, A1c 9.0% —
initial pharmacotherapy:
A. Start insulin only
B. Metformin + immediate insulin
C. Start metformin and lifestyle modifications; consider early
insulin if symptoms or very high A1c
D. Sulfonylurea monotherapy
Rationale: Metformin is first-line unless contraindicated; insulin
considered if symptomatic or very high A1c.
11. Child with febrile seizure — no prior neurologic disease —
recommended disposition:
A. Start prophylactic phenobarbital
B. Reassure and outpatient follow-up; educate on seizure first
aid
C. Immediate EEG and MRI
D. Begin daily anticonvulsant therapy
Rationale: Simple febrile seizures are benign; no chronic
anticonvulsants or neuroimaging required unless atypical
features.
12. A 70-year-old with community-acquired pneumonia, CURB-
65 score 3 — place of care:
A. Home with oral antibiotics
B. Outpatient with IV therapy
C. Hospital admission (consider ICU depending on other factors)
D. Hospice
Rationale: CURB-65 ≥2 suggests hospital admission; 3 indicates
higher risk.
