NURS 6531 FINAL EXAMINATION
Advanced Health Assessment and Diagnostic Reasoning
Family Nurse Practitioner Primary Care
Institution: Walden University Quarter: Spring 2026
Course: NURS 6531 Week: 11 (Cumulative Final)
Questions: 100 (Multiple Choice) Status: Graded A+ - All Answers Correct
Section 1: Comprehensive Health Assessment Across the Lifespan
Q1: A 68-year-old African American female presents to the primary care clinic for her
annual wellness visit. She reports occasional headaches, fatigue, and intermittent
blurred vision over the past three months. Her blood pressure readings in the office
today are 162/98 mmHg (right arm, seated) and 158/94 mmHg (left arm, seated). Her
previous blood pressure readings from six months ago were 138/86 mmHg. She has a
family history of hypertension and type 2 diabetes mellitus. Her body mass index (BMI)
is 31 kg/m2. Which of the following components is the MOST critical to include in her
focused cardiovascular history at this visit?
A. Detailed dietary recall including sodium, potassium, and caffeine intake over the past 7 days
with specific portion sizes
B. Assessment of medication adherence, home blood pressure monitoring log review, and screening for target organ
damage symptoms including chest pain, dyspnea, and nocturia **[CORRECT]**
C. Comprehensive sexual health history including contraceptive use and sexually transmitted
infection screening
D. Detailed family pedigree charting extending to second-degree relatives for autosomal
dominant conditions
Correct Answer: B
Rationale: This patient presents with Stage 2 hypertension (BP >160/100 mmHg per ACC/AHA 2017
guidelines) and has multiple risk factors including age, race, obesity, and family history. The most critical
component of the focused cardiovascular history is assessing medication adherence, reviewing any home
blood pressure logs, and screening for symptoms of target organ damage. Chest pain could indicate
hypertensive heart disease or coronary artery disease, dyspnea could signal heart failure, and nocturia
could suggest renal involvement. While dietary recall is important for lifestyle counseling, and family
history is relevant, the immediate clinical priority is determining the severity and chronicity of this
patient's hypertension to guide urgent management decisions. A comprehensive sexual health history is
not the priority in this hypertensive emergency workup.
Q2: A 4-year-old male is brought to the pediatric primary care clinic by his mother for a
well-child visit. The child was born at 38 weeks gestation with no complications. He is
meeting all developmental milestones. His vaccinations are up to date per the CDC
immunization schedule. The nurse practitioner notes that the child's height is at the
25th percentile, weight is at the 60th percentile, and BMI is above the 95th percentile
for age. The mother reports the child drinks approximately 32 ounces of whole milk per
day and watches approximately 4 hours of television daily. The child's father has type 2
,NURS 6531 Final Exam | Spring Quarter 2026 | Walden University 100 Questions | Graded A+
diabetes mellitus and hyperlipidemia. Which of the following is the MOST appropriate
next step in the assessment of this child?
A. Order a fasting lipid panel and hemoglobin A1c immediately given the family history and BMI
percentile
B. Reassure the mother that the child will likely outgrow the excess weight and schedule a
follow-up in 6 months
C. Obtain a detailed dietary and physical activity history, calculate daily caloric intake, and assess for cardiovascular risk
factors including blood pressure measurement **[CORRECT]**
D. Refer the child to a pediatric endocrinologist for evaluation of metabolic syndrome and
possible growth hormone deficiency
Correct Answer: C
Rationale: This child presents with a BMI above the 95th percentile, which meets the criteria for obesity
in pediatric patients. The AAP 2023 clinical practice guideline on the evaluation and treatment of children
and adolescents with obesity recommends a comprehensive assessment including a detailed dietary
history, physical activity assessment, and screening for cardiovascular risk factors. A fasting lipid panel is
recommended for children aged 9-11 years (or earlier if risk factors are present), and while this child has
a strong family history, the immediate priority is a thorough lifestyle assessment. Reassuring the mother
without intervention is inappropriate given the significant risk factors. Referral to pediatric endocrinology
is premature without initial laboratory screening and lifestyle intervention by the primary care provider.
Q3: A 52-year-old male presents to the primary care clinic with a chief complaint of
progressive difficulty swallowing solid foods over the past two months. He reports that
symptoms began intermittently but have worsened to the point where he now has
difficulty with most solid foods. He denies difficulty with liquids. He has experienced
an unintentional 15-pound weight loss over the past two months. He has a 40-pack-year
smoking history and drinks approximately 6 beers per day. On physical examination, he
appears cachectic with temporal wasting. His oral cavity examination reveals no
lesions. His neck examination reveals a single firm, non-tender, 1.5 cm left
supraclavicular lymph node. Which of the following physical examination findings
would be MOST consistent with the suspected diagnosis?
A. Diffuse thyroid enlargement with a bruit auscultated over the gland bilaterally
B. Epigastric tenderness to deep palpation with positive Murphy's sign on inspiration
C. Dilated esophageal veins (varices) visualized on upper endoscopy with portal hypertension
findings
D. Posterior pharyngeal wall mass or laryngeal immobility on indirect laryngoscopy with unilateral vocal cord paralysis
**[CORRECT]**
Correct Answer: D
Rationale: This patient presents with progressive dysphagia to solids, significant unintentional weight
loss, a 40-pack-year smoking history, heavy alcohol use, and a Virchow's node (left supraclavicular lymph
node), which is classically associated with gastric cancer but also seen with esophageal and lung
malignancies. The most concerning physical finding would be a posterior pharyngeal wall mass or
laryngeal immobility on indirect laryngoscopy suggesting direct tumor invasion or recurrent laryngeal
nerve involvement. Diffuse thyroid enlargement with a bruit would suggest Graves' disease or toxic
goiter, which would present with hypermetabolic symptoms rather than isolated dysphagia to solids.
Epigastric tenderness with Murphy's sign suggests cholecystitis, which is unrelated to this presentation.
While esophageal varices can cause dysphagia, they are more likely to present with hematemesis and are
associated with chronic liver disease rather than this malignancy picture.
Page 2
,NURS 6531 Final Exam | Spring Quarter 2026 | Walden University 100 Questions | Graded A+
Q4: A 28-year-old female presents for her initial prenatal visit at 10 weeks gestation,
confirmed by ultrasound. This is her first pregnancy. She reports no chronic medical
conditions and takes no medications other than a prenatal vitamin. Her pre-pregnancy
BMI was 22 kg/m2. She denies any vaginal bleeding, cramping, or discharge. Her blood
pressure is 112/68 mmHg. Which of the following assessments is MOST appropriate to
include at this initial prenatal visit?
A. Screening for gestational diabetes using the 1-hour 50-gram glucose challenge test
B. Complete blood count, blood type and Rh factor, antibody screen, rubella immunity, hepatitis B surface antigen, HIV
screening, syphilis screening, and urine culture **[CORRECT]**
C. Amniocentesis for genetic chromosomal analysis and alpha-fetoprotein measurement
D. Fetal nuchal translucency measurement and non-invasive prenatal testing (NIPT) for
aneuploidy screening
Correct Answer: B
Rationale: At the initial prenatal visit, ACOG recommends a comprehensive panel of laboratory tests
including CBC, blood type and Rh factor, antibody screen, rubella immunity, hepatitis B surface antigen,
HIV screening, syphilis screening (per CDC recommendations), and urine culture. These are standard of
care for all pregnant women at the first prenatal visit regardless of risk factors. The 1-hour glucose
challenge test for gestational diabetes is performed between 24-28 weeks gestation, not at 10 weeks.
Amniocentesis is an invasive diagnostic procedure typically offered at 15-20 weeks for women with
positive screening results or high-risk genetic indications, not as a routine initial visit test. NIPT and
nuchal translucency are first-trimester screening options for aneuploidy, typically performed between
11-13 weeks, but they are not the standard initial visit laboratory panel.
Q5: A 75-year-old male presents to the primary care clinic accompanied by his
daughter, who reports that he has become increasingly forgetful over the past six
months. He frequently misplaces his keys, forgets recent conversations, and got lost
while driving to a familiar grocery store two weeks ago. He has hypertension, type 2
diabetes mellitus, and hyperlipidemia, all managed with oral medications. His current
medications include lisinopril 20 mg daily, metformin 1000 mg twice daily, atorvastatin
40 mg daily, and a daily baby aspirin. His blood pressure today is 138/82 mmHg and his
fasting glucose is 142 mg/dL. Which of the following is the MOST appropriate initial
cognitive screening tool for this patient?
A. Clock Drawing Test as a standalone screening tool without any additional cognitive
assessment
B. Montreal Cognitive Assessment (MoCA) because it is more sensitive than the MMSE for detecting mild cognitive
impairment and evaluates multiple cognitive domains including executive function, attention, and memory
**[CORRECT]**
C. Mini-Mental State Examination (MMSE) as the gold standard for dementia screening in all
age groups and cognitive levels
D. PHQ-9 depression screening scale to rule out depression as the primary cause of his cognitive
complaints before proceeding to cognitive testing
Correct Answer: B
Rationale: The Montreal Cognitive Assessment (MoCA) is the most appropriate initial screening tool
because it has demonstrated superior sensitivity to the MMSE for detecting mild cognitive impairment
(MCI), which is the likely diagnosis given this patient's presentation. The MoCA evaluates multiple
cognitive domains including visuospatial/executive function, naming, attention, language, abstraction,
delayed recall, and orientation. While the MMSE is widely used, it lacks sensitivity for MCI and is better
suited for detecting moderate to severe dementia. The Clock Drawing Test alone is insufficient as a
standalone screening tool because it primarily assesses visuospatial and executive function but misses
Page 3
, NURS 6531 Final Exam | Spring Quarter 2026 | Walden University 100 Questions | Graded A+
other cognitive domains. While screening for depression (PHQ-9) is important and should be performed, it
should not delay or replace cognitive screening in a patient with clear cognitive complaints and functional
impairment such as getting lost while driving.
Q6: A 35-year-old female presents with a chief complaint of palpitations that occur
intermittently, lasting approximately 2-5 minutes each episode, over the past three
weeks. She describes the sensation as her heart racing and pounding in her chest. The
episodes occur at rest and are not associated with exertion, chest pain, shortness of
breath, dizziness, or syncope. She denies any significant medical history. She drinks
one cup of coffee daily and does not use tobacco, alcohol, or recreational drugs. She
reports increased stress at work recently. Her physical examination reveals a heart rate
of 72 bpm, blood pressure of 118/76 mmHg, respiratory rate of 16 breaths/min, and
oxygen saturation of 99% on room air. Her cardiac examination reveals a regular rate
and rhythm with no murmurs, gallops, or rubs. Which of the following is the MOST
appropriate next diagnostic step?
A. Immediate referral for cardiac catheterization and coronary angiography to evaluate for
coronary artery disease
B. 24-hour ambulatory Holter monitor to capture the rhythm during symptomatic episodes and correlate symptoms
with cardiac rhythm **[CORRECT]**
C. Order a comprehensive metabolic panel and thyroid-stimulating hormone (TSH) level to
evaluate for electrolyte imbalances and hyperthyroidism
D. Reassure the patient that the palpitations are benign and recommend lifestyle modifications
including stress reduction and caffeine elimination without further diagnostic workup
Correct Answer: B
Rationale: The most appropriate next step is obtaining a 24-hour (or up to 14-day) ambulatory Holter
monitor to capture the cardiac rhythm during symptomatic episodes. This allows correlation of the
patient's symptoms with the actual cardiac rhythm, which is essential for determining the etiology of the
palpitations. Cardiac catheterization is not indicated as the initial diagnostic step in a young patient with
no cardiovascular risk factors and no chest pain or exertional symptoms. While ordering a TSH is
reasonable to evaluate for hyperthyroidism as a secondary cause, the Holter monitor is the primary
diagnostic tool for characterizing the palpitations. Reassurance without diagnostic evaluation is
premature because the etiology of the palpitations has not been established; while they may be benign,
paroxysmal arrhythmias such as PSVT, atrial fibrillation, or PVCs need to be identified for appropriate
management.
Q7: A 45-year-old male with a 20-year history of type 2 diabetes mellitus presents for
his quarterly follow-up. His current hemoglobin A1c is 8.2%, and his most recent lipid
panel shows LDL 156 mg/dL, triglycerides 248 mg/dL, and HDL 34 mg/dL. His blood
pressure is 142/88 mmHg on lisinopril 20 mg daily. His creatinine is 1.4 mg/dL with an
eGFR of 58 mL/min/1.73 m2. His urine albumin-to-creatinine ratio (UACR) is 85
mcg/mg. A comprehensive foot examination reveals decreased light touch sensation to
the 10-gram monofilament on both feet, absent Achilles tendon reflexes bilaterally, and
dry, scaly skin with callus formation under the first metatarsal head of the right foot.
Which of the following findings represents the MOST urgent clinical concern requiring
immediate intervention?
A. The hemoglobin A1c of 8.2% indicating suboptimal glycemic control requiring intensification
of his diabetes regimen
B. The UACR of 85 mcg/mg indicating moderately increased albuminuria (formerly
microalbuminuria) suggestive of diabetic nephropathy requiring ACE inhibitor optimization
Page 4
Advanced Health Assessment and Diagnostic Reasoning
Family Nurse Practitioner Primary Care
Institution: Walden University Quarter: Spring 2026
Course: NURS 6531 Week: 11 (Cumulative Final)
Questions: 100 (Multiple Choice) Status: Graded A+ - All Answers Correct
Section 1: Comprehensive Health Assessment Across the Lifespan
Q1: A 68-year-old African American female presents to the primary care clinic for her
annual wellness visit. She reports occasional headaches, fatigue, and intermittent
blurred vision over the past three months. Her blood pressure readings in the office
today are 162/98 mmHg (right arm, seated) and 158/94 mmHg (left arm, seated). Her
previous blood pressure readings from six months ago were 138/86 mmHg. She has a
family history of hypertension and type 2 diabetes mellitus. Her body mass index (BMI)
is 31 kg/m2. Which of the following components is the MOST critical to include in her
focused cardiovascular history at this visit?
A. Detailed dietary recall including sodium, potassium, and caffeine intake over the past 7 days
with specific portion sizes
B. Assessment of medication adherence, home blood pressure monitoring log review, and screening for target organ
damage symptoms including chest pain, dyspnea, and nocturia **[CORRECT]**
C. Comprehensive sexual health history including contraceptive use and sexually transmitted
infection screening
D. Detailed family pedigree charting extending to second-degree relatives for autosomal
dominant conditions
Correct Answer: B
Rationale: This patient presents with Stage 2 hypertension (BP >160/100 mmHg per ACC/AHA 2017
guidelines) and has multiple risk factors including age, race, obesity, and family history. The most critical
component of the focused cardiovascular history is assessing medication adherence, reviewing any home
blood pressure logs, and screening for symptoms of target organ damage. Chest pain could indicate
hypertensive heart disease or coronary artery disease, dyspnea could signal heart failure, and nocturia
could suggest renal involvement. While dietary recall is important for lifestyle counseling, and family
history is relevant, the immediate clinical priority is determining the severity and chronicity of this
patient's hypertension to guide urgent management decisions. A comprehensive sexual health history is
not the priority in this hypertensive emergency workup.
Q2: A 4-year-old male is brought to the pediatric primary care clinic by his mother for a
well-child visit. The child was born at 38 weeks gestation with no complications. He is
meeting all developmental milestones. His vaccinations are up to date per the CDC
immunization schedule. The nurse practitioner notes that the child's height is at the
25th percentile, weight is at the 60th percentile, and BMI is above the 95th percentile
for age. The mother reports the child drinks approximately 32 ounces of whole milk per
day and watches approximately 4 hours of television daily. The child's father has type 2
,NURS 6531 Final Exam | Spring Quarter 2026 | Walden University 100 Questions | Graded A+
diabetes mellitus and hyperlipidemia. Which of the following is the MOST appropriate
next step in the assessment of this child?
A. Order a fasting lipid panel and hemoglobin A1c immediately given the family history and BMI
percentile
B. Reassure the mother that the child will likely outgrow the excess weight and schedule a
follow-up in 6 months
C. Obtain a detailed dietary and physical activity history, calculate daily caloric intake, and assess for cardiovascular risk
factors including blood pressure measurement **[CORRECT]**
D. Refer the child to a pediatric endocrinologist for evaluation of metabolic syndrome and
possible growth hormone deficiency
Correct Answer: C
Rationale: This child presents with a BMI above the 95th percentile, which meets the criteria for obesity
in pediatric patients. The AAP 2023 clinical practice guideline on the evaluation and treatment of children
and adolescents with obesity recommends a comprehensive assessment including a detailed dietary
history, physical activity assessment, and screening for cardiovascular risk factors. A fasting lipid panel is
recommended for children aged 9-11 years (or earlier if risk factors are present), and while this child has
a strong family history, the immediate priority is a thorough lifestyle assessment. Reassuring the mother
without intervention is inappropriate given the significant risk factors. Referral to pediatric endocrinology
is premature without initial laboratory screening and lifestyle intervention by the primary care provider.
Q3: A 52-year-old male presents to the primary care clinic with a chief complaint of
progressive difficulty swallowing solid foods over the past two months. He reports that
symptoms began intermittently but have worsened to the point where he now has
difficulty with most solid foods. He denies difficulty with liquids. He has experienced
an unintentional 15-pound weight loss over the past two months. He has a 40-pack-year
smoking history and drinks approximately 6 beers per day. On physical examination, he
appears cachectic with temporal wasting. His oral cavity examination reveals no
lesions. His neck examination reveals a single firm, non-tender, 1.5 cm left
supraclavicular lymph node. Which of the following physical examination findings
would be MOST consistent with the suspected diagnosis?
A. Diffuse thyroid enlargement with a bruit auscultated over the gland bilaterally
B. Epigastric tenderness to deep palpation with positive Murphy's sign on inspiration
C. Dilated esophageal veins (varices) visualized on upper endoscopy with portal hypertension
findings
D. Posterior pharyngeal wall mass or laryngeal immobility on indirect laryngoscopy with unilateral vocal cord paralysis
**[CORRECT]**
Correct Answer: D
Rationale: This patient presents with progressive dysphagia to solids, significant unintentional weight
loss, a 40-pack-year smoking history, heavy alcohol use, and a Virchow's node (left supraclavicular lymph
node), which is classically associated with gastric cancer but also seen with esophageal and lung
malignancies. The most concerning physical finding would be a posterior pharyngeal wall mass or
laryngeal immobility on indirect laryngoscopy suggesting direct tumor invasion or recurrent laryngeal
nerve involvement. Diffuse thyroid enlargement with a bruit would suggest Graves' disease or toxic
goiter, which would present with hypermetabolic symptoms rather than isolated dysphagia to solids.
Epigastric tenderness with Murphy's sign suggests cholecystitis, which is unrelated to this presentation.
While esophageal varices can cause dysphagia, they are more likely to present with hematemesis and are
associated with chronic liver disease rather than this malignancy picture.
Page 2
,NURS 6531 Final Exam | Spring Quarter 2026 | Walden University 100 Questions | Graded A+
Q4: A 28-year-old female presents for her initial prenatal visit at 10 weeks gestation,
confirmed by ultrasound. This is her first pregnancy. She reports no chronic medical
conditions and takes no medications other than a prenatal vitamin. Her pre-pregnancy
BMI was 22 kg/m2. She denies any vaginal bleeding, cramping, or discharge. Her blood
pressure is 112/68 mmHg. Which of the following assessments is MOST appropriate to
include at this initial prenatal visit?
A. Screening for gestational diabetes using the 1-hour 50-gram glucose challenge test
B. Complete blood count, blood type and Rh factor, antibody screen, rubella immunity, hepatitis B surface antigen, HIV
screening, syphilis screening, and urine culture **[CORRECT]**
C. Amniocentesis for genetic chromosomal analysis and alpha-fetoprotein measurement
D. Fetal nuchal translucency measurement and non-invasive prenatal testing (NIPT) for
aneuploidy screening
Correct Answer: B
Rationale: At the initial prenatal visit, ACOG recommends a comprehensive panel of laboratory tests
including CBC, blood type and Rh factor, antibody screen, rubella immunity, hepatitis B surface antigen,
HIV screening, syphilis screening (per CDC recommendations), and urine culture. These are standard of
care for all pregnant women at the first prenatal visit regardless of risk factors. The 1-hour glucose
challenge test for gestational diabetes is performed between 24-28 weeks gestation, not at 10 weeks.
Amniocentesis is an invasive diagnostic procedure typically offered at 15-20 weeks for women with
positive screening results or high-risk genetic indications, not as a routine initial visit test. NIPT and
nuchal translucency are first-trimester screening options for aneuploidy, typically performed between
11-13 weeks, but they are not the standard initial visit laboratory panel.
Q5: A 75-year-old male presents to the primary care clinic accompanied by his
daughter, who reports that he has become increasingly forgetful over the past six
months. He frequently misplaces his keys, forgets recent conversations, and got lost
while driving to a familiar grocery store two weeks ago. He has hypertension, type 2
diabetes mellitus, and hyperlipidemia, all managed with oral medications. His current
medications include lisinopril 20 mg daily, metformin 1000 mg twice daily, atorvastatin
40 mg daily, and a daily baby aspirin. His blood pressure today is 138/82 mmHg and his
fasting glucose is 142 mg/dL. Which of the following is the MOST appropriate initial
cognitive screening tool for this patient?
A. Clock Drawing Test as a standalone screening tool without any additional cognitive
assessment
B. Montreal Cognitive Assessment (MoCA) because it is more sensitive than the MMSE for detecting mild cognitive
impairment and evaluates multiple cognitive domains including executive function, attention, and memory
**[CORRECT]**
C. Mini-Mental State Examination (MMSE) as the gold standard for dementia screening in all
age groups and cognitive levels
D. PHQ-9 depression screening scale to rule out depression as the primary cause of his cognitive
complaints before proceeding to cognitive testing
Correct Answer: B
Rationale: The Montreal Cognitive Assessment (MoCA) is the most appropriate initial screening tool
because it has demonstrated superior sensitivity to the MMSE for detecting mild cognitive impairment
(MCI), which is the likely diagnosis given this patient's presentation. The MoCA evaluates multiple
cognitive domains including visuospatial/executive function, naming, attention, language, abstraction,
delayed recall, and orientation. While the MMSE is widely used, it lacks sensitivity for MCI and is better
suited for detecting moderate to severe dementia. The Clock Drawing Test alone is insufficient as a
standalone screening tool because it primarily assesses visuospatial and executive function but misses
Page 3
, NURS 6531 Final Exam | Spring Quarter 2026 | Walden University 100 Questions | Graded A+
other cognitive domains. While screening for depression (PHQ-9) is important and should be performed, it
should not delay or replace cognitive screening in a patient with clear cognitive complaints and functional
impairment such as getting lost while driving.
Q6: A 35-year-old female presents with a chief complaint of palpitations that occur
intermittently, lasting approximately 2-5 minutes each episode, over the past three
weeks. She describes the sensation as her heart racing and pounding in her chest. The
episodes occur at rest and are not associated with exertion, chest pain, shortness of
breath, dizziness, or syncope. She denies any significant medical history. She drinks
one cup of coffee daily and does not use tobacco, alcohol, or recreational drugs. She
reports increased stress at work recently. Her physical examination reveals a heart rate
of 72 bpm, blood pressure of 118/76 mmHg, respiratory rate of 16 breaths/min, and
oxygen saturation of 99% on room air. Her cardiac examination reveals a regular rate
and rhythm with no murmurs, gallops, or rubs. Which of the following is the MOST
appropriate next diagnostic step?
A. Immediate referral for cardiac catheterization and coronary angiography to evaluate for
coronary artery disease
B. 24-hour ambulatory Holter monitor to capture the rhythm during symptomatic episodes and correlate symptoms
with cardiac rhythm **[CORRECT]**
C. Order a comprehensive metabolic panel and thyroid-stimulating hormone (TSH) level to
evaluate for electrolyte imbalances and hyperthyroidism
D. Reassure the patient that the palpitations are benign and recommend lifestyle modifications
including stress reduction and caffeine elimination without further diagnostic workup
Correct Answer: B
Rationale: The most appropriate next step is obtaining a 24-hour (or up to 14-day) ambulatory Holter
monitor to capture the cardiac rhythm during symptomatic episodes. This allows correlation of the
patient's symptoms with the actual cardiac rhythm, which is essential for determining the etiology of the
palpitations. Cardiac catheterization is not indicated as the initial diagnostic step in a young patient with
no cardiovascular risk factors and no chest pain or exertional symptoms. While ordering a TSH is
reasonable to evaluate for hyperthyroidism as a secondary cause, the Holter monitor is the primary
diagnostic tool for characterizing the palpitations. Reassurance without diagnostic evaluation is
premature because the etiology of the palpitations has not been established; while they may be benign,
paroxysmal arrhythmias such as PSVT, atrial fibrillation, or PVCs need to be identified for appropriate
management.
Q7: A 45-year-old male with a 20-year history of type 2 diabetes mellitus presents for
his quarterly follow-up. His current hemoglobin A1c is 8.2%, and his most recent lipid
panel shows LDL 156 mg/dL, triglycerides 248 mg/dL, and HDL 34 mg/dL. His blood
pressure is 142/88 mmHg on lisinopril 20 mg daily. His creatinine is 1.4 mg/dL with an
eGFR of 58 mL/min/1.73 m2. His urine albumin-to-creatinine ratio (UACR) is 85
mcg/mg. A comprehensive foot examination reveals decreased light touch sensation to
the 10-gram monofilament on both feet, absent Achilles tendon reflexes bilaterally, and
dry, scaly skin with callus formation under the first metatarsal head of the right foot.
Which of the following findings represents the MOST urgent clinical concern requiring
immediate intervention?
A. The hemoglobin A1c of 8.2% indicating suboptimal glycemic control requiring intensification
of his diabetes regimen
B. The UACR of 85 mcg/mg indicating moderately increased albuminuria (formerly
microalbuminuria) suggestive of diabetic nephropathy requiring ACE inhibitor optimization
Page 4
