MCPHS NUR 807 Final Exam Practice Questions
**1. A 74-year-old female with Parkinson's disease presents with dream-enactment behaviors
including punching and kicking in bed, and she has injured her spouse twice. What is the most likely
diagnosis and first-line treatment?**
A. Nightmare disorder; prazosin
B. REM sleep behavior disorder; melatonin 3-12 mg at bedtime
C. Sleep terrors; clonazepam
D. Periodic limb movement disorder; ropinirole
**Answer: B**
**Rationale:** REM sleep behavior disorder is common in synucleinopathies like Parkinson's disease
and Lewy body dementia. Melatonin is first-line due to better tolerability in older adults, while
clonazepam is effective but carries fall risk and cognitive side effects .
---
**2. An 80-year-old man with mild cognitive impairment and anxiety is started on lorazepam 0.5 mg
twice daily as needed. One month later, his daughter reports increased confusion and a fall. What is
the most appropriate action?**
A. Increase lorazepam to 1 mg to better control anxiety
B. Discontinue lorazepam and initiate scheduled buspirone or an SSRI
C. Add donepezil to treat the cognitive impairment
D. Continue lorazepam but add fall precautions
**Answer: B**
**Rationale:** Benzodiazepines are associated with cognitive impairment and falls in older adults.
The medication should be discontinued with tapering and replaced with a safer alternative like
buspirone or an SSRI for anxiety management .
---
**3. According to the American Geriatrics Society Beers Criteria, which of the following medications is
considered potentially inappropriate for chronic use in older adults due to a high risk of
hyponatremia?**
,A. Trazodone
B. Escitalopram
C. Mirtazapine
D. Bupropion
**Answer: B**
**Rationale:** All SSRIs and SNRIs carry a risk of SIADH and hyponatremia, especially in older adults.
The Beers Criteria specifically note that SSRIs are potentially inappropriate in older adults with a
history of hyponatremia .
---
**4. Which of the following medications is most anticholinergic and should be avoided in older adults
per the Beers Criteria?**
A. Citalopram
B. Amitriptyline
C. Sertraline
D. Escitalopram
**Answer: B**
**Rationale:** Amitriptyline is a tricyclic antidepressant with strong anticholinergic properties. It is
listed in the Beers Criteria as a medication to avoid in older adults due to risks of confusion,
constipation, and urinary retention .
---
**5. An 88-year-old woman with moderate dementia is hospitalized for pneumonia. On the second
night, she becomes agitated, tries to climb out of bed, and screams that people are trying to kill her.
Which nonpharmacologic intervention should be attempted first?**
A. Soft wrist restraints
B. Haloperidol 0.5 mg IV
C. Reorientation, family presence, noise reduction, and sleep hygiene
D. Transfer to a psychiatric unit
**Answer: C**
,**Rationale:** Delirium management begins with nonpharmacologic approaches including
reorientation, minimizing sensory deficits with glasses and hearing aids, reducing disruptions,
involving family, and promoting sleep. Antipsychotics are reserved for patients in danger or extreme
distress .
---
**6. A 68-year-old male with type 2 diabetes, hypertension, and chronic kidney disease with an eGFR
of 35 mL/min is diagnosed with major depression. Which antidepressant requires dose adjustment
based on renal function?**
A. Escitalopram
B. Duloxetine
C. Sertraline
D. Bupropion
**Answer: B**
**Rationale:** Duloxetine is contraindicated or requires dose reduction in severe renal impairment
with eGFR less than 30. In moderate impairment, caution is advised. Escitalopram, sertraline, and
bupropion are generally safe without dose adjustment in chronic kidney disease .
---
**7. Which of the following is a characteristic feature of Lewy body dementia that helps distinguish it
from Alzheimer's disease?**
A. Early and prominent short-term memory loss
B. Fluctuating cognition, visual hallucinations, and parkinsonism
C. Aphasia and apraxia
D. Preservation of executive function
**Answer: B**
**Rationale:** Core features of dementia with Lewy bodies include fluctuating cognition, recurrent
well-formed visual hallucinations, REM sleep behavior disorder, and parkinsonism. Memory
impairment may be less prominent early on compared to Alzheimer's disease .
---
, **8. A 76-year-old with atrial fibrillation on warfarin has an INR of 8.2 without any bleeding. What is
the best action to manage this elevated INR?**
A. Give vitamin K orally
B. Administer IV vitamin K
C. Hold warfarin only
D. Give fresh frozen plasma
**Answer: A**
**Rationale:** Oral vitamin K is preferred for significantly elevated INR without bleeding. This
approach reverses the anticoagulant effect gradually while avoiding the risks associated with IV
administration or more aggressive interventions .
---
**9. Which assessment finding is most concerning in a patient with acute decompensated heart
failure?**
A. Bibasilar crackles
B. S3 heart sound
C. Hypotension and cold extremities
D. Mild pedal edema
**Answer: C**
**Rationale:** Hypoperfusion and hypotension indicate cardiogenic shock requiring immediate
intervention. While crackles and S3 heart sounds are concerning, hypotension with cold extremities
suggests end-organ hypoperfusion and is the most urgent finding .
---
**10. A patient on amiodarone develops fatigue, weight gain, and bradycardia. What laboratory test
should be prioritized?**
A. AST and ALT liver function tests
B. TSH to check thyroid function
C. BNP for heart failure
D. Serum potassium level
**1. A 74-year-old female with Parkinson's disease presents with dream-enactment behaviors
including punching and kicking in bed, and she has injured her spouse twice. What is the most likely
diagnosis and first-line treatment?**
A. Nightmare disorder; prazosin
B. REM sleep behavior disorder; melatonin 3-12 mg at bedtime
C. Sleep terrors; clonazepam
D. Periodic limb movement disorder; ropinirole
**Answer: B**
**Rationale:** REM sleep behavior disorder is common in synucleinopathies like Parkinson's disease
and Lewy body dementia. Melatonin is first-line due to better tolerability in older adults, while
clonazepam is effective but carries fall risk and cognitive side effects .
---
**2. An 80-year-old man with mild cognitive impairment and anxiety is started on lorazepam 0.5 mg
twice daily as needed. One month later, his daughter reports increased confusion and a fall. What is
the most appropriate action?**
A. Increase lorazepam to 1 mg to better control anxiety
B. Discontinue lorazepam and initiate scheduled buspirone or an SSRI
C. Add donepezil to treat the cognitive impairment
D. Continue lorazepam but add fall precautions
**Answer: B**
**Rationale:** Benzodiazepines are associated with cognitive impairment and falls in older adults.
The medication should be discontinued with tapering and replaced with a safer alternative like
buspirone or an SSRI for anxiety management .
---
**3. According to the American Geriatrics Society Beers Criteria, which of the following medications is
considered potentially inappropriate for chronic use in older adults due to a high risk of
hyponatremia?**
,A. Trazodone
B. Escitalopram
C. Mirtazapine
D. Bupropion
**Answer: B**
**Rationale:** All SSRIs and SNRIs carry a risk of SIADH and hyponatremia, especially in older adults.
The Beers Criteria specifically note that SSRIs are potentially inappropriate in older adults with a
history of hyponatremia .
---
**4. Which of the following medications is most anticholinergic and should be avoided in older adults
per the Beers Criteria?**
A. Citalopram
B. Amitriptyline
C. Sertraline
D. Escitalopram
**Answer: B**
**Rationale:** Amitriptyline is a tricyclic antidepressant with strong anticholinergic properties. It is
listed in the Beers Criteria as a medication to avoid in older adults due to risks of confusion,
constipation, and urinary retention .
---
**5. An 88-year-old woman with moderate dementia is hospitalized for pneumonia. On the second
night, she becomes agitated, tries to climb out of bed, and screams that people are trying to kill her.
Which nonpharmacologic intervention should be attempted first?**
A. Soft wrist restraints
B. Haloperidol 0.5 mg IV
C. Reorientation, family presence, noise reduction, and sleep hygiene
D. Transfer to a psychiatric unit
**Answer: C**
,**Rationale:** Delirium management begins with nonpharmacologic approaches including
reorientation, minimizing sensory deficits with glasses and hearing aids, reducing disruptions,
involving family, and promoting sleep. Antipsychotics are reserved for patients in danger or extreme
distress .
---
**6. A 68-year-old male with type 2 diabetes, hypertension, and chronic kidney disease with an eGFR
of 35 mL/min is diagnosed with major depression. Which antidepressant requires dose adjustment
based on renal function?**
A. Escitalopram
B. Duloxetine
C. Sertraline
D. Bupropion
**Answer: B**
**Rationale:** Duloxetine is contraindicated or requires dose reduction in severe renal impairment
with eGFR less than 30. In moderate impairment, caution is advised. Escitalopram, sertraline, and
bupropion are generally safe without dose adjustment in chronic kidney disease .
---
**7. Which of the following is a characteristic feature of Lewy body dementia that helps distinguish it
from Alzheimer's disease?**
A. Early and prominent short-term memory loss
B. Fluctuating cognition, visual hallucinations, and parkinsonism
C. Aphasia and apraxia
D. Preservation of executive function
**Answer: B**
**Rationale:** Core features of dementia with Lewy bodies include fluctuating cognition, recurrent
well-formed visual hallucinations, REM sleep behavior disorder, and parkinsonism. Memory
impairment may be less prominent early on compared to Alzheimer's disease .
---
, **8. A 76-year-old with atrial fibrillation on warfarin has an INR of 8.2 without any bleeding. What is
the best action to manage this elevated INR?**
A. Give vitamin K orally
B. Administer IV vitamin K
C. Hold warfarin only
D. Give fresh frozen plasma
**Answer: A**
**Rationale:** Oral vitamin K is preferred for significantly elevated INR without bleeding. This
approach reverses the anticoagulant effect gradually while avoiding the risks associated with IV
administration or more aggressive interventions .
---
**9. Which assessment finding is most concerning in a patient with acute decompensated heart
failure?**
A. Bibasilar crackles
B. S3 heart sound
C. Hypotension and cold extremities
D. Mild pedal edema
**Answer: C**
**Rationale:** Hypoperfusion and hypotension indicate cardiogenic shock requiring immediate
intervention. While crackles and S3 heart sounds are concerning, hypotension with cold extremities
suggests end-organ hypoperfusion and is the most urgent finding .
---
**10. A patient on amiodarone develops fatigue, weight gain, and bradycardia. What laboratory test
should be prioritized?**
A. AST and ALT liver function tests
B. TSH to check thyroid function
C. BNP for heart failure
D. Serum potassium level
