1
NR 601 Midterm Exam – Primary Care Maturing & Aged
Family – (2026) 100 Actual Questions & Answers
(Chamberlain) 100% Guarantee Pass
Questions 1–10 (Polypharmacy, Altered Pharmacokinetics, & Medication
Management)
1. An 82-year-old woman with hypertension, osteoarthritis, and insomnia is taking
hydrochlorothiazide, amlodipine, naproxen, and diphenhydramine. She presents
with confusion and constipation. Which medication is most likely contributing to
her acute confusional state?
A. Hydrochlorothiazide
B. Amlodipine
C. Naproxen
D. Diphenhydramine
E. All of the above equally
Answer : D
Explanation: Diphenhydramine is a first-generation antihistamine with strong
anticholinergic properties. In older adults, anticholinergics can cause acute
confusion, sedation, urinary retention, and constipation. The Beers Criteria
strongly recommend avoiding diphenhydramine in persons ≥65 years.
Hydrochlorothiazide and amlodipine are not typically associated with confusion
unless causing severe electrolyte imbalance or hypotension, which is less likely in
this presentation. Naproxen can cause GI and renal effects but not acute
confusion.
2. A 78-year-old man with stage 3 chronic kidney disease (eGFR 35 mL/min) and
type 2 diabetes is on metformin 1000 mg twice daily. His HbA1c is 7.8%. What is
the most appropriate medication adjustment?
A. Continue metformin, add sitagliptin
B. Reduce metformin to 500 mg twice daily
C. Discontinue metformin, start glipizide
pg. 1
,2
D. Continue current metformin dose
E. Discontinue metformin, start canagliflozin
Answer : B
Explanation: Metformin is renally cleared. For eGFR 30–44 mL/min, the maximum
recommended dose is 1000 mg/day (or 500 mg twice daily). Continuing at 2000
mg/day increases the risk of lactic acidosis. Reducing the dose is appropriate.
Adding a DPP-4 inhibitor can be considered, but the question asks for the most
appropriate adjustment. Glipizide can cause hypoglycemia. SGLT2 inhibitors like
canagliflozin have reduced efficacy at eGFR <45 and are not first-line at this GFR
for glycemic control alone.
3. An 85-year-old woman with atrial fibrillation (not on anticoagulation) and
frequent falls is admitted with a hip fracture. Her CHA₂DS₂-VASc score is 6. She
asks if she should start a blood thinner. What is the best recommendation based
on shared decision-making?
A. Start warfarin with INR goal 2–3
B. Start apixaban 5 mg twice daily
C. Start aspirin 325 mg daily
D. No anticoagulation due to fall risk
E. Discuss risks and benefits of anticoagulation versus left atrial appendage
occlusion
Answer : E
Explanation: In very high-risk patients with recurrent falls, the decision to
anticoagulate is complex. While DOACs like apixaban have a better safety profile
than warfarin, fall risk is not an absolute contraindication. Shared decision-making
is key. Options may include DOACs at reduced dose (apixaban 2.5 mg BID if ≥2
criteria: age ≥80, weight ≤60 kg, creatinine ≥1.5), or left atrial appendage closure.
Aspirin is no longer recommended for stroke prevention in AF. Thus, discussing all
options is the best approach.
4. A 76-year-old male with heart failure, COPD, and chronic low back pain is on
furosemide, lisinopril, tiotropium, and acetaminophen. He presents with a fall and
pg. 2
,3
is found to have orthostatic hypotension. Which drug is most likely the culprit?
A. Furosemide
B. Lisinopril
C. Tiotropium
D. Acetaminophen
E. Furosemide and lisinopril
Answer : E
Explanation: Both furosemide and lisinopril can cause orthostatic hypotension,
especially in older adults. Furosemide reduces intravascular volume, and lisinopril
blunts the sympathetic response. Together they increase fall risk. Tiotropium is
inhaled and has minimal systemic anticholinergic effects; acetaminophen does
not affect BP.
5. A 90-year-old nursing home resident with advanced dementia develops
agitation. Non-pharmacological measures fail. Which medication is most
appropriate to initiate?
A. Haloperidol 2 mg IM
B. Lorazepam 1 mg PO
C. Risperidone 0.25 mg PO
D. Olanzapine 5 mg PO
E. Diphenhydramine 25 mg PO
Answer : C
Explanation: Risperidone at a low starting dose (0.25 mg BID) is FDA-approved for
agitation in dementia, though with a black box warning for increased mortality in
elderly with dementia-related psychosis. Among atypical antipsychotics,
risperidone, olanzapine, and aripiprazole have the best evidence, but low doses
are essential. Haloperidol is a typical antipsychotic with high risk of
extrapyramidal symptoms. Benzodiazepines can worsen confusion and cause
paradoxical agitation. Anticholinergics (diphenhydramine) should be avoided.
6. A 74-year-old woman with hypertension, diabetes, and GERD is on lisinopril,
metformin, and omeprazole. She is diagnosed with osteoporosis and started on
pg. 3
, 4
alendronate. Which counseling point is most critical?
A. Take alendronate with food to reduce GI upset
B. Take alendronate first thing in the morning with a full glass of water, remain
upright for 30 minutes
C. Take alendronate at bedtime
D. Stop omeprazole due to interaction
E. Alendronate has no dietary restrictions
Answer : B
Explanation: Bisphosphonates like alendronate require strict administration: take
on an empty stomach with 6–8 oz plain water, remain upright for at least 30
minutes (some guidelines 60 minutes) to prevent esophagitis and esophageal
ulceration. They should not be taken with food or other medications. PPIs can
reduce absorption but are not an absolute contraindication if separation is
maintained; however, taking them together should be avoided.
7. An 86-year-old man with benign prostatic hyperplasia and overactive bladder is
started on oxybutynin. He later develops confusion and dry mouth. What is the
mechanism?
A. Alpha-1 adrenergic blockade
B. Anticholinergic effects
C. Histamine H1 blockade
D. Dopamine antagonism
E. GABA agonism
Answer : B
Explanation: Oxybutynin is an anticholinergic/antimuscarinic agent used for OAB.
Anticholinergics block muscarinic receptors, leading to dry mouth, constipation,
blurred vision, and cognitive impairment. Older adults are especially susceptible
to central anticholinergic effects. Alternative agents like mirabegron (beta-3
agonist) or trospium (quaternary amine, less CNS penetration) might be
considered.
pg. 4
NR 601 Midterm Exam – Primary Care Maturing & Aged
Family – (2026) 100 Actual Questions & Answers
(Chamberlain) 100% Guarantee Pass
Questions 1–10 (Polypharmacy, Altered Pharmacokinetics, & Medication
Management)
1. An 82-year-old woman with hypertension, osteoarthritis, and insomnia is taking
hydrochlorothiazide, amlodipine, naproxen, and diphenhydramine. She presents
with confusion and constipation. Which medication is most likely contributing to
her acute confusional state?
A. Hydrochlorothiazide
B. Amlodipine
C. Naproxen
D. Diphenhydramine
E. All of the above equally
Answer : D
Explanation: Diphenhydramine is a first-generation antihistamine with strong
anticholinergic properties. In older adults, anticholinergics can cause acute
confusion, sedation, urinary retention, and constipation. The Beers Criteria
strongly recommend avoiding diphenhydramine in persons ≥65 years.
Hydrochlorothiazide and amlodipine are not typically associated with confusion
unless causing severe electrolyte imbalance or hypotension, which is less likely in
this presentation. Naproxen can cause GI and renal effects but not acute
confusion.
2. A 78-year-old man with stage 3 chronic kidney disease (eGFR 35 mL/min) and
type 2 diabetes is on metformin 1000 mg twice daily. His HbA1c is 7.8%. What is
the most appropriate medication adjustment?
A. Continue metformin, add sitagliptin
B. Reduce metformin to 500 mg twice daily
C. Discontinue metformin, start glipizide
pg. 1
,2
D. Continue current metformin dose
E. Discontinue metformin, start canagliflozin
Answer : B
Explanation: Metformin is renally cleared. For eGFR 30–44 mL/min, the maximum
recommended dose is 1000 mg/day (or 500 mg twice daily). Continuing at 2000
mg/day increases the risk of lactic acidosis. Reducing the dose is appropriate.
Adding a DPP-4 inhibitor can be considered, but the question asks for the most
appropriate adjustment. Glipizide can cause hypoglycemia. SGLT2 inhibitors like
canagliflozin have reduced efficacy at eGFR <45 and are not first-line at this GFR
for glycemic control alone.
3. An 85-year-old woman with atrial fibrillation (not on anticoagulation) and
frequent falls is admitted with a hip fracture. Her CHA₂DS₂-VASc score is 6. She
asks if she should start a blood thinner. What is the best recommendation based
on shared decision-making?
A. Start warfarin with INR goal 2–3
B. Start apixaban 5 mg twice daily
C. Start aspirin 325 mg daily
D. No anticoagulation due to fall risk
E. Discuss risks and benefits of anticoagulation versus left atrial appendage
occlusion
Answer : E
Explanation: In very high-risk patients with recurrent falls, the decision to
anticoagulate is complex. While DOACs like apixaban have a better safety profile
than warfarin, fall risk is not an absolute contraindication. Shared decision-making
is key. Options may include DOACs at reduced dose (apixaban 2.5 mg BID if ≥2
criteria: age ≥80, weight ≤60 kg, creatinine ≥1.5), or left atrial appendage closure.
Aspirin is no longer recommended for stroke prevention in AF. Thus, discussing all
options is the best approach.
4. A 76-year-old male with heart failure, COPD, and chronic low back pain is on
furosemide, lisinopril, tiotropium, and acetaminophen. He presents with a fall and
pg. 2
,3
is found to have orthostatic hypotension. Which drug is most likely the culprit?
A. Furosemide
B. Lisinopril
C. Tiotropium
D. Acetaminophen
E. Furosemide and lisinopril
Answer : E
Explanation: Both furosemide and lisinopril can cause orthostatic hypotension,
especially in older adults. Furosemide reduces intravascular volume, and lisinopril
blunts the sympathetic response. Together they increase fall risk. Tiotropium is
inhaled and has minimal systemic anticholinergic effects; acetaminophen does
not affect BP.
5. A 90-year-old nursing home resident with advanced dementia develops
agitation. Non-pharmacological measures fail. Which medication is most
appropriate to initiate?
A. Haloperidol 2 mg IM
B. Lorazepam 1 mg PO
C. Risperidone 0.25 mg PO
D. Olanzapine 5 mg PO
E. Diphenhydramine 25 mg PO
Answer : C
Explanation: Risperidone at a low starting dose (0.25 mg BID) is FDA-approved for
agitation in dementia, though with a black box warning for increased mortality in
elderly with dementia-related psychosis. Among atypical antipsychotics,
risperidone, olanzapine, and aripiprazole have the best evidence, but low doses
are essential. Haloperidol is a typical antipsychotic with high risk of
extrapyramidal symptoms. Benzodiazepines can worsen confusion and cause
paradoxical agitation. Anticholinergics (diphenhydramine) should be avoided.
6. A 74-year-old woman with hypertension, diabetes, and GERD is on lisinopril,
metformin, and omeprazole. She is diagnosed with osteoporosis and started on
pg. 3
, 4
alendronate. Which counseling point is most critical?
A. Take alendronate with food to reduce GI upset
B. Take alendronate first thing in the morning with a full glass of water, remain
upright for 30 minutes
C. Take alendronate at bedtime
D. Stop omeprazole due to interaction
E. Alendronate has no dietary restrictions
Answer : B
Explanation: Bisphosphonates like alendronate require strict administration: take
on an empty stomach with 6–8 oz plain water, remain upright for at least 30
minutes (some guidelines 60 minutes) to prevent esophagitis and esophageal
ulceration. They should not be taken with food or other medications. PPIs can
reduce absorption but are not an absolute contraindication if separation is
maintained; however, taking them together should be avoided.
7. An 86-year-old man with benign prostatic hyperplasia and overactive bladder is
started on oxybutynin. He later develops confusion and dry mouth. What is the
mechanism?
A. Alpha-1 adrenergic blockade
B. Anticholinergic effects
C. Histamine H1 blockade
D. Dopamine antagonism
E. GABA agonism
Answer : B
Explanation: Oxybutynin is an anticholinergic/antimuscarinic agent used for OAB.
Anticholinergics block muscarinic receptors, leading to dry mouth, constipation,
blurred vision, and cognitive impairment. Older adults are especially susceptible
to central anticholinergic effects. Alternative agents like mirabegron (beta-3
agonist) or trospium (quaternary amine, less CNS penetration) might be
considered.
pg. 4
