NSG 554 Exam 4 V3 | NSG 554 Nurse Practitioners
in Primary Care I | Wilkes University | 2026 Q&A
with Rationale (Wilkes NSG554 Exam 4 2026)
ENDOCRINE DISORDERS
1. A 45-year-old female presents with fatigue, weight gain, cold intolerance, and
constipation. Lab results show TSH 8.5 mIU/L (normal 0.5-4.7) and free T4 0.6
ng/dL (normal 0.8-1.8). What is the most appropriate initial management?
• A. Refer to endocrinology for further evaluation
• B. Start levothyroxine 25 mcg daily
• C. Start levothyroxine 100 mcg daily
• D. Repeat labs in 6 weeks
Answer: B
Rationale: This patient has overt primary hypothyroidism (elevated TSH, low free
T4). Levothyroxine should be initiated at a low dose (25-50 mcg daily) in younger,
healthy patients, with dose titration based on TSH response. Starting at 100 mcg
may cause overtreatment and cardiac symptoms.
2. Which of the following is a contraindication to starting levothyroxine therapy
in a patient with newly diagnosed hypothyroidism?
• A. History of myocardial infarction within the past 6 months
• B. Age over 65 years
• C. Concurrent pregnancy
• D. History of type 2 diabetes
,Answer: A
Rationale: In patients with known or suspected coronary artery disease,
levothyroxine should be started at a low dose (12.5-25 mcg) and titrated slowly
due to the risk of precipitating angina or myocardial infarction. Pregnancy is not a
contraindication—thyroid hormone requirements typically increase.
3. A 28-year-old woman presents with palpitations, weight loss, heat
intolerance, and tremors. Thyroid examination reveals a diffusely enlarged, non-
tender gland. Which diagnostic test is most appropriate to confirm the
diagnosis?
• A. Thyroid ultrasound
• B. TSH, free T4, and T3 levels
• C. Thyroid peroxidase antibodies
• D. Radioactive iodine uptake scan
Answer: B
Rationale: Initial testing for suspected hyperthyroidism should include TSH, free T4,
and T3 levels. A suppressed TSH with elevated free T4 confirms hyperthyroidism.
Graves' disease is the most likely etiology given the diffuse goiter. TPO antibodies
can support autoimmune etiology but are not diagnostic.
4. A patient with hyperthyroidism is started on methimazole. What adverse
effect requires immediate discontinuation of the medication?
• A. Mild rash
• B. Agranulocytosis (fever, sore throat)
• C. Weight gain
• D. Headache
, Answer: B
Rationale: Methimazole can cause agranulocytosis, a potentially life-threatening
adverse effect. Patients should be instructed to report fever, sore throat, or other
signs of infection immediately and discontinue the medication. Mild rash may be
managed with antihistamines.
5. A patient with type 2 diabetes presents with an A1C of 8.5% on metformin
1000 mg twice daily. What is the most appropriate next step in management?
• A. Add a sulfonylurea (glipizide)
• B. Add a GLP-1 receptor agonist (semaglutide)
• C. Add insulin therapy
• D. Increase metformin to 1500 mg twice daily
Answer: B
Rationale: For a patient with type 2 diabetes not at goal on metformin, adding a
second agent such as a GLP-1 receptor agonist or SGLT-2 inhibitor is preferred due
to cardiovascular and renal benefits. If cost is a concern, a sulfonylurea may be
considered, but GLP-1s are preferred when available.
6. A 58-year-old patient with type 2 diabetes and CKD stage 3 has an A1C of
7.8%. Which medication is preferred given their renal status?
• A. Metformin
• B. Glyburide
• C. SGLT-2 inhibitor (empagliflozin)
• D. Pioglitazone
Answer: C
Rationale: SGLT-2 inhibitors are preferred in patients with type 2 diabetes and CKD
due to their renal protective benefits. Metformin should be used cautiously with
in Primary Care I | Wilkes University | 2026 Q&A
with Rationale (Wilkes NSG554 Exam 4 2026)
ENDOCRINE DISORDERS
1. A 45-year-old female presents with fatigue, weight gain, cold intolerance, and
constipation. Lab results show TSH 8.5 mIU/L (normal 0.5-4.7) and free T4 0.6
ng/dL (normal 0.8-1.8). What is the most appropriate initial management?
• A. Refer to endocrinology for further evaluation
• B. Start levothyroxine 25 mcg daily
• C. Start levothyroxine 100 mcg daily
• D. Repeat labs in 6 weeks
Answer: B
Rationale: This patient has overt primary hypothyroidism (elevated TSH, low free
T4). Levothyroxine should be initiated at a low dose (25-50 mcg daily) in younger,
healthy patients, with dose titration based on TSH response. Starting at 100 mcg
may cause overtreatment and cardiac symptoms.
2. Which of the following is a contraindication to starting levothyroxine therapy
in a patient with newly diagnosed hypothyroidism?
• A. History of myocardial infarction within the past 6 months
• B. Age over 65 years
• C. Concurrent pregnancy
• D. History of type 2 diabetes
,Answer: A
Rationale: In patients with known or suspected coronary artery disease,
levothyroxine should be started at a low dose (12.5-25 mcg) and titrated slowly
due to the risk of precipitating angina or myocardial infarction. Pregnancy is not a
contraindication—thyroid hormone requirements typically increase.
3. A 28-year-old woman presents with palpitations, weight loss, heat
intolerance, and tremors. Thyroid examination reveals a diffusely enlarged, non-
tender gland. Which diagnostic test is most appropriate to confirm the
diagnosis?
• A. Thyroid ultrasound
• B. TSH, free T4, and T3 levels
• C. Thyroid peroxidase antibodies
• D. Radioactive iodine uptake scan
Answer: B
Rationale: Initial testing for suspected hyperthyroidism should include TSH, free T4,
and T3 levels. A suppressed TSH with elevated free T4 confirms hyperthyroidism.
Graves' disease is the most likely etiology given the diffuse goiter. TPO antibodies
can support autoimmune etiology but are not diagnostic.
4. A patient with hyperthyroidism is started on methimazole. What adverse
effect requires immediate discontinuation of the medication?
• A. Mild rash
• B. Agranulocytosis (fever, sore throat)
• C. Weight gain
• D. Headache
, Answer: B
Rationale: Methimazole can cause agranulocytosis, a potentially life-threatening
adverse effect. Patients should be instructed to report fever, sore throat, or other
signs of infection immediately and discontinue the medication. Mild rash may be
managed with antihistamines.
5. A patient with type 2 diabetes presents with an A1C of 8.5% on metformin
1000 mg twice daily. What is the most appropriate next step in management?
• A. Add a sulfonylurea (glipizide)
• B. Add a GLP-1 receptor agonist (semaglutide)
• C. Add insulin therapy
• D. Increase metformin to 1500 mg twice daily
Answer: B
Rationale: For a patient with type 2 diabetes not at goal on metformin, adding a
second agent such as a GLP-1 receptor agonist or SGLT-2 inhibitor is preferred due
to cardiovascular and renal benefits. If cost is a concern, a sulfonylurea may be
considered, but GLP-1s are preferred when available.
6. A 58-year-old patient with type 2 diabetes and CKD stage 3 has an A1C of
7.8%. Which medication is preferred given their renal status?
• A. Metformin
• B. Glyburide
• C. SGLT-2 inhibitor (empagliflozin)
• D. Pioglitazone
Answer: C
Rationale: SGLT-2 inhibitors are preferred in patients with type 2 diabetes and CKD
due to their renal protective benefits. Metformin should be used cautiously with
