FAMILY NP BARKLEY PRACTICE EXAM EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Advanced Assessment, Diagnosis, and Management Across the Lifespan
2. Primary Care Pharmacotherapy and Clinical Pharmacology
3. Health Promotion, Disease Prevention, and Screening Guidelines
4. Professional Role, Ethics, and Evidence-Based Practice Standards
5. Management of Acute and Chronic Complex Conditions in Primary Care
1. A 45-year-old male presents for a routine primary care evaluation with a 3-month history of
worsening fatigue, unintentional 15-pound weight loss, and generalized bone pain. Laboratory
results reveal a serum calcium of 11.8 mg/dL, serum creatinine of 2.1 mg/dL, and normocytic
anemia. Urinalysis shows 3+ protein with negative dipstick for blood, and serum protein
electrophoresis demonstrates an M-spike. What is the most likely diagnosis?
A. Chronic kidney disease secondary to diabetic nephropathy
B. Multiple myeloma
C. Hyperparathyroidism secondary to vitamin D deficiency
D. Metastatic prostate adenocarcinoma
CORRECT ANSWER : B
Rationale: The constellation of bone pain, hypercalcemia, renal impairment, normocytic anemia,
and a monoclonal protein (M-spike) on serum protein electrophoresis is classic for multiple
myeloma. Option A explains renal impairment but fails to account for hypercalcemia and the M-
spike. Option C presents with elevated parathyroid hormone rather than monoclonal protein
elevation. Option D typically presents with osteoblastic lesions and elevated prostate-specific
antigen rather than an M-protein.
,2. A 32-year-old female presents to the clinic complaining of palpitations, heat intolerance, weight
loss, and fine tremors over the past two months. Laboratory studies reveal a TSH of < 0.01
mIU/L and free T4 of 3.2 ng/dL. Thyroid receptor antibodies are elevated, and a radioactive
iodine uptake scan demonstrates diffuse, symmetrical increased uptake throughout the gland.
What is the preferred first-line pharmacological treatment for this patient?
A. Radioactive iodine ablation ($I-131$) immediately
B. Methimazole daily with monitoring for agranulocytosis
C. Propylthiouracil (PTU) for lifelong maintenance therapy
D. Subtotal thyroidectomy after beta-blocker initiation
CORRECT ANSWER : B
Rationale: Methimazole is the first-line pharmacotherapy for Graves' disease due to its
favorable once-daily dosing and lower incidence of severe hepatotoxicity compared to
propylthiouracil. Option A is definitive therapy but often deferred or used post-medical
stabilization. Option C is reserved for the first trimester of pregnancy or thyroid storm due to
liver failure risks. Option D is surgical intervention reserved for specific indications.
3. A 68-year-old male with a history of hypertension, type 2 diabetes mellitus, and stable chronic
kidney disease stage 3 presents for a medication review. His current regimen includes lisinopril,
metformin, atorvastatin, and hydrochlorothiazide. His latest laboratory results show a serum
creatinine increase of 25% from baseline and a serum potassium of 5.4 mEq/L. Which clinical
action is most appropriate?
A. Immediately discontinue atorvastatin and initiate ezetimibe
B. Evaluate for bilateral renal artery stenosis and consider reducing or holding lisinopril
C. Increase hydrochlorothiazide dosage to lower the serum potassium level
D. Double the metformin dosage to enhance glycemic control and renal protection
CORRECT ANSWER : B
Rationale: An acute rise in serum creatinine following the initiation or continuation of an ACE
inhibitor like lisinopril, especially in older adults with vascular disease, strongly suggests
bilateral renal artery stenosis, requiring caution or cessation. Option A is incorrect as statins do
not cause this specific electrolyte and creatinine shift. Option C does not address the primary
mechanism of hyperkalemia and renal hemodynamic decline. Option D is contraindicated given
the declining renal function.
,4. A 24-year-old female presents with a 2-week history of intermittent palpitations, anxiety, and
mild tremors. She reports recent upper respiratory symptoms. Physical examination reveals a
tender, enlarged thyroid gland. Laboratory studies demonstrate suppressed TSH, elevated free
T4, and a significantly depressed radioactive iodine uptake scan at 24 hours. What is the most
appropriate initial management strategy?
A. Initiate methimazole therapy immediately
B. Symptomatic management with non-selective beta-blockers (e.g., propranolol) and non-
steroidal anti-inflammatory drugs
C. Schedule urgent subtotal thyroidectomy
D. Administer high-dose radioactive iodine therapy
CORRECT ANSWER : B
Rationale: Subacute granulomatous thyroiditis is a self-limiting inflammatory condition typically
presenting with a painful thyroid and transient thyrotoxicosis; management focuses on symptom
control with beta-blockers and NSAIDs. Option A is ineffective because the hormone elevation
stems from preformed hormone release, not hyper-synthesis. Option C and D are completely
inappropriate for a transient, self-limiting inflammatory process.
5. A 55-year-old male with a 40 pack-year smoking history presents with a 3-month history of a
persistent, hacking cough, hemoptysis, and a 20-pound weight loss. A chest radiograph reveals a
central right hilar mass. Further workup confirms small cell lung cancer with evidence of
hyponatremia (serum sodium 124 mEq/L), low serum osmolality, and inappropriately
concentrated urine. What is the underlying pathophysiology of this electrolyte disturbance?
A. Primary adrenal insufficiency causing renal salt wasting
B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to
ectopic hormone production
C. Excessive diuretic use for occult peripheral edema
D. Nephrogenic diabetes insipidus caused by paraneoplastic destruction
CORRECT ANSWER : B
Rationale: Small cell lung cancer frequently causes SIADH through ectopic production of
antidiuretic hormone, leading to euvolemic hypotonic hyponatremia. Option A involves
hyperkalemia and hypotension, unlike SIADH. Option C would present with signs of volume
depletion. Option D causes hypernatremia and polyuria, opposing hyponatremia.
, 6. A 50-year-old female presents for health maintenance. She has a history of type 2 diabetes
mellitus, hypertension, and hyperlipidemia. Her blood pressure is 138/86 mmHg, and her fasting
lipid panel shows an LDL cholesterol of 130 mg/dL. According to current American Diabetes
Association guidelines, what is the appropriate statin intensity recommendation for this patient?
A. Low-intensity statin therapy
B. Moderate-to-high-intensity statin therapy
C. No statin indicated if lifestyle modifications succeed
D. Bile acid sequestrant monotherapy
CORRECT ANSWER : B
Rationale: Patients aged 40-75 with diabetes mellitus should be managed with at least
moderate-intensity statin therapy, and high-intensity therapy is recommended if additional
cardiovascular risk factors are present. Option A is insufficient for primary prevention in
diabetic patients over 40. Option C ignores established risk reduction guidelines. Option D does
not replace statin therapy.
7. A 60-year-old male presents with severe, acute pain and swelling in his right first
metatarsophalangeal joint. Arthrocentesis confirms negatively birefringent needle-shaped
crystals under polarized light microscopy. His past medical history includes gout, chronic kidney
disease stage 3, and peptic ulcer disease. Which medication is contraindicated for treating this
acute flare?
A. Oral colchicine
B. High-dose systemic non-steroidal anti-inflammatory drugs (NSAIDs)
C. Intra-articular corticosteroid injection
D. Oral prednisone taper
CORRECT ANSWER : B
Rationale: Systemic NSAIDs are contraindicated in patients with chronic kidney disease and a
history of peptic ulcer disease due to high risks of worsening renal function and gastrointestinal
bleeding. Option A can be used with renal dose adjustment. Option C and D are safe, effective
alternatives when systemic NSAIDs and colchicine cannot be used.
8. A 28-year-old female presents for pre-conception counseling. She has a history of well-
controlled generalized seizures managed effectively with valproic acid. What is the most critical
primary care counseling point regarding her anti-seizure medication?
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Advanced Assessment, Diagnosis, and Management Across the Lifespan
2. Primary Care Pharmacotherapy and Clinical Pharmacology
3. Health Promotion, Disease Prevention, and Screening Guidelines
4. Professional Role, Ethics, and Evidence-Based Practice Standards
5. Management of Acute and Chronic Complex Conditions in Primary Care
1. A 45-year-old male presents for a routine primary care evaluation with a 3-month history of
worsening fatigue, unintentional 15-pound weight loss, and generalized bone pain. Laboratory
results reveal a serum calcium of 11.8 mg/dL, serum creatinine of 2.1 mg/dL, and normocytic
anemia. Urinalysis shows 3+ protein with negative dipstick for blood, and serum protein
electrophoresis demonstrates an M-spike. What is the most likely diagnosis?
A. Chronic kidney disease secondary to diabetic nephropathy
B. Multiple myeloma
C. Hyperparathyroidism secondary to vitamin D deficiency
D. Metastatic prostate adenocarcinoma
CORRECT ANSWER : B
Rationale: The constellation of bone pain, hypercalcemia, renal impairment, normocytic anemia,
and a monoclonal protein (M-spike) on serum protein electrophoresis is classic for multiple
myeloma. Option A explains renal impairment but fails to account for hypercalcemia and the M-
spike. Option C presents with elevated parathyroid hormone rather than monoclonal protein
elevation. Option D typically presents with osteoblastic lesions and elevated prostate-specific
antigen rather than an M-protein.
,2. A 32-year-old female presents to the clinic complaining of palpitations, heat intolerance, weight
loss, and fine tremors over the past two months. Laboratory studies reveal a TSH of < 0.01
mIU/L and free T4 of 3.2 ng/dL. Thyroid receptor antibodies are elevated, and a radioactive
iodine uptake scan demonstrates diffuse, symmetrical increased uptake throughout the gland.
What is the preferred first-line pharmacological treatment for this patient?
A. Radioactive iodine ablation ($I-131$) immediately
B. Methimazole daily with monitoring for agranulocytosis
C. Propylthiouracil (PTU) for lifelong maintenance therapy
D. Subtotal thyroidectomy after beta-blocker initiation
CORRECT ANSWER : B
Rationale: Methimazole is the first-line pharmacotherapy for Graves' disease due to its
favorable once-daily dosing and lower incidence of severe hepatotoxicity compared to
propylthiouracil. Option A is definitive therapy but often deferred or used post-medical
stabilization. Option C is reserved for the first trimester of pregnancy or thyroid storm due to
liver failure risks. Option D is surgical intervention reserved for specific indications.
3. A 68-year-old male with a history of hypertension, type 2 diabetes mellitus, and stable chronic
kidney disease stage 3 presents for a medication review. His current regimen includes lisinopril,
metformin, atorvastatin, and hydrochlorothiazide. His latest laboratory results show a serum
creatinine increase of 25% from baseline and a serum potassium of 5.4 mEq/L. Which clinical
action is most appropriate?
A. Immediately discontinue atorvastatin and initiate ezetimibe
B. Evaluate for bilateral renal artery stenosis and consider reducing or holding lisinopril
C. Increase hydrochlorothiazide dosage to lower the serum potassium level
D. Double the metformin dosage to enhance glycemic control and renal protection
CORRECT ANSWER : B
Rationale: An acute rise in serum creatinine following the initiation or continuation of an ACE
inhibitor like lisinopril, especially in older adults with vascular disease, strongly suggests
bilateral renal artery stenosis, requiring caution or cessation. Option A is incorrect as statins do
not cause this specific electrolyte and creatinine shift. Option C does not address the primary
mechanism of hyperkalemia and renal hemodynamic decline. Option D is contraindicated given
the declining renal function.
,4. A 24-year-old female presents with a 2-week history of intermittent palpitations, anxiety, and
mild tremors. She reports recent upper respiratory symptoms. Physical examination reveals a
tender, enlarged thyroid gland. Laboratory studies demonstrate suppressed TSH, elevated free
T4, and a significantly depressed radioactive iodine uptake scan at 24 hours. What is the most
appropriate initial management strategy?
A. Initiate methimazole therapy immediately
B. Symptomatic management with non-selective beta-blockers (e.g., propranolol) and non-
steroidal anti-inflammatory drugs
C. Schedule urgent subtotal thyroidectomy
D. Administer high-dose radioactive iodine therapy
CORRECT ANSWER : B
Rationale: Subacute granulomatous thyroiditis is a self-limiting inflammatory condition typically
presenting with a painful thyroid and transient thyrotoxicosis; management focuses on symptom
control with beta-blockers and NSAIDs. Option A is ineffective because the hormone elevation
stems from preformed hormone release, not hyper-synthesis. Option C and D are completely
inappropriate for a transient, self-limiting inflammatory process.
5. A 55-year-old male with a 40 pack-year smoking history presents with a 3-month history of a
persistent, hacking cough, hemoptysis, and a 20-pound weight loss. A chest radiograph reveals a
central right hilar mass. Further workup confirms small cell lung cancer with evidence of
hyponatremia (serum sodium 124 mEq/L), low serum osmolality, and inappropriately
concentrated urine. What is the underlying pathophysiology of this electrolyte disturbance?
A. Primary adrenal insufficiency causing renal salt wasting
B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to
ectopic hormone production
C. Excessive diuretic use for occult peripheral edema
D. Nephrogenic diabetes insipidus caused by paraneoplastic destruction
CORRECT ANSWER : B
Rationale: Small cell lung cancer frequently causes SIADH through ectopic production of
antidiuretic hormone, leading to euvolemic hypotonic hyponatremia. Option A involves
hyperkalemia and hypotension, unlike SIADH. Option C would present with signs of volume
depletion. Option D causes hypernatremia and polyuria, opposing hyponatremia.
, 6. A 50-year-old female presents for health maintenance. She has a history of type 2 diabetes
mellitus, hypertension, and hyperlipidemia. Her blood pressure is 138/86 mmHg, and her fasting
lipid panel shows an LDL cholesterol of 130 mg/dL. According to current American Diabetes
Association guidelines, what is the appropriate statin intensity recommendation for this patient?
A. Low-intensity statin therapy
B. Moderate-to-high-intensity statin therapy
C. No statin indicated if lifestyle modifications succeed
D. Bile acid sequestrant monotherapy
CORRECT ANSWER : B
Rationale: Patients aged 40-75 with diabetes mellitus should be managed with at least
moderate-intensity statin therapy, and high-intensity therapy is recommended if additional
cardiovascular risk factors are present. Option A is insufficient for primary prevention in
diabetic patients over 40. Option C ignores established risk reduction guidelines. Option D does
not replace statin therapy.
7. A 60-year-old male presents with severe, acute pain and swelling in his right first
metatarsophalangeal joint. Arthrocentesis confirms negatively birefringent needle-shaped
crystals under polarized light microscopy. His past medical history includes gout, chronic kidney
disease stage 3, and peptic ulcer disease. Which medication is contraindicated for treating this
acute flare?
A. Oral colchicine
B. High-dose systemic non-steroidal anti-inflammatory drugs (NSAIDs)
C. Intra-articular corticosteroid injection
D. Oral prednisone taper
CORRECT ANSWER : B
Rationale: Systemic NSAIDs are contraindicated in patients with chronic kidney disease and a
history of peptic ulcer disease due to high risks of worsening renal function and gastrointestinal
bleeding. Option A can be used with renal dose adjustment. Option C and D are safe, effective
alternatives when systemic NSAIDs and colchicine cannot be used.
8. A 28-year-old female presents for pre-conception counseling. She has a history of well-
controlled generalized seizures managed effectively with valproic acid. What is the most critical
primary care counseling point regarding her anti-seizure medication?
