NR 606 WEEK 8 FINAL EXAM QUESTIONS AND ANSWERS
|FALL 2026/2027 UPDATE | 100% CORRECT LATEST
Question 1
A 57-year-old patient with poorly controlled type 2 diabetes presents with new-onset peripheral
neuropathy symptoms. During assessment, the patient describes burning pain in both feet that
worsens at night. What is the most evidence-based first-line pharmacologic therapy for painful
diabetic neuropathy?
Answer: Gabapentin
Rationale:
Gabapentin is recommended as a first-line therapy for painful diabetic neuropathy due to strong
evidence supporting its effectiveness in reducing neuropathic pain via calcium channel α2-δ
ligand binding. It reduces excitatory neurotransmitter release. Alternatives such as amitriptyline
or duloxetine are also used, but gabapentin offers superior tolerability for many patients and is
preferred when sedation or anticholinergic load must be minimized. Tight glucose control and
lifestyle interventions remain essential adjuncts.
Question 2
A 42-year-old woman reports palpitations, anxiety, tremor, unintentional weight loss, and heat
intolerance. Physical exam reveals warm skin and a fine tremor. TSH is <0.01 mIU/L and free T4
is elevated. What is the most appropriate diagnostic step to distinguish Graves’ disease from
other causes of hyperthyroidism?
Answer: Order a radioactive iodine uptake (RAIU) scan
Rationale:
An RAIU scan is the gold standard for differentiating Graves’ disease, toxic multinodular goiter,
thyroiditis, and other etiologies. Graves’ typically presents with diffuse high uptake, whereas
thyroiditis shows low uptake due to preformed hormone release. Thyroid antibody testing is
adjunctive but cannot reliably differentiate all causes. Accurate etiology guides appropriate
treatment (antithyroid drugs vs. beta blockers vs. radioactive iodine).
Question 3
,A 70-year-old man with COPD presents with an acute increase in dyspnea, cough, and sputum
production. His oxygen saturation is 86% on room air. What intervention should be initiated
first?
Answer: Administer supplemental oxygen to maintain SpO₂ 88–92%
Rationale:
COPD exacerbation management begins with controlled oxygen therapy, targeting 88–92% to
avoid suppressing hypoxic respiratory drive and preventing CO₂ retention. After oxygen,
bronchodilators, corticosteroids, and antibiotics (if indicated) are initiated. Ensuring correct
oxygen titration is the most critical early step.
Question 4
A 29-year-old patient presents with right lower quadrant pain, fever, nausea, and leukocytosis.
Abdominal exam reveals rebound tenderness and guarding. What is the next most appropriate
diagnostic step?
Answer: Obtain an abdominal CT scan with contrast
Rationale:
CT abdomen with contrast is the gold standard for diagnosing appendicitis in adults. Ultrasound
is preferred in pregnancy or pediatric cases, but CT provides highest sensitivity and specificity in
adults, guiding surgical decision-making.
Question 5
A patient taking warfarin has an INR of 6.1 but no signs of bleeding. What is the recommended
management?
Answer: Hold warfarin and administer oral vitamin K
Rationale:
According to ACCP guidelines, an INR >6 without bleeding warrants holding warfarin and giving
oral vitamin K 2.5–5 mg to reduce risk of hemorrhage. Parenteral vitamin K is reserved for
serious bleeding. Monitoring INR within 24 hours is essential.
Question 6
,A 54-year-old patient has persistent hypertension despite being on an ACE inhibitor, calcium
channel blocker, and diuretic. The patient has hypokalemia and a BP of 168/104. What condition
must be evaluated for?
Answer: Primary hyperaldosteronism
Rationale:
Resistant hypertension combined with unexplained hypokalemia strongly suggests primary
aldosteronism. Screening includes plasma aldosterone concentration/plasma renin activity ratio.
Early detection improves cardiovascular outcomes.
Question 7
A patient taking metformin develops increasing fatigue, myalgias, and abdominal discomfort.
Labs show lactate of 6 mmol/L, HCO₃ 17, and pH 7.28. What is the likely diagnosis?
Answer: Metformin-associated lactic acidosis
Rationale:
Metformin can rarely cause lactic acidosis, especially in renal impairment, hypoxia, or sepsis.
Elevated lactate with metabolic acidosis is classic. Immediate discontinuation of metformin,
supportive management, and treatment of underlying causes are required.
Question 8
A 63-year-old male with a long history of uncontrolled hypertension presents with sudden,
severe chest pain radiating to the back. His blood pressure is 192/108 in the right arm and
158/92 in the left arm. Physical exam reveals diminished pulses in the lower extremities. What is
the most appropriate immediate diagnostic test?
Answer: CT angiography of the chest
Rationale:
A widened pulse pressure difference, tearing chest pain radiating to the back, and asymmetric
pulses strongly indicate acute aortic dissection. CT angiography is the fastest, most sensitive,
and widely available imaging modality for confirming dissection in hemodynamically stable
patients. Transesophageal echocardiography is preferred if unstable or if CT is unavailable. Early
diagnosis is critical due to high mortality, and immediate BP control (beta blockers) is required.
Question 9
, A 35-year-old diabetic patient presents with unilateral periorbital swelling, fever, pain with eye
movement, and decreased visual acuity. CT orbit shows inflammation behind the orbital
septum. What is the most appropriate management?
Answer: Start IV broad-spectrum antibiotics and admit for emergent ophthalmology
evaluation
Rationale:
The patient has orbital cellulitis, a medical emergency. Management includes immediate IV
antibiotics (vancomycin + ceftriaxone or ampicillin-sulbactam) and ophthalmology consultation
to prevent permanent vision loss or intracranial spread. Preseptal cellulitis may be outpatient-
treated, but postseptal involvement requires hospital admission.
Question 10
A 72-year-old patient presents with new cognitive decline, urinary incontinence, and gait
instability described as “magnetic gait.” MRI shows enlarged ventricles with normal cortical
volume. What is the most likely diagnosis?
Answer: Normal pressure hydrocephalus (NPH)
Rationale:
NPH presents with the classic triad: gait disturbance, urinary incontinence, and cognitive
impairment. Ventriculomegaly without cortical atrophy supports the diagnosis. Improvement
after large-volume CSF tap test supports shunt candidacy.
Question 11
A 48-year-old woman with newly diagnosed rheumatoid arthritis asks about the best initial
disease-modifying therapy. What is the evidence-based first-line DMARD?
Answer: Methotrexate
Rationale:
Methotrexate is the cornerstone first-line DMARD due to strong evidence for slowing disease
progression, reducing joint destruction, and controlling systemic inflammation. Biologics are
added if methotrexate fails or in aggressive disease. Monitoring liver function, CBC, and giving
folic acid supplementation are mandatory.
|FALL 2026/2027 UPDATE | 100% CORRECT LATEST
Question 1
A 57-year-old patient with poorly controlled type 2 diabetes presents with new-onset peripheral
neuropathy symptoms. During assessment, the patient describes burning pain in both feet that
worsens at night. What is the most evidence-based first-line pharmacologic therapy for painful
diabetic neuropathy?
Answer: Gabapentin
Rationale:
Gabapentin is recommended as a first-line therapy for painful diabetic neuropathy due to strong
evidence supporting its effectiveness in reducing neuropathic pain via calcium channel α2-δ
ligand binding. It reduces excitatory neurotransmitter release. Alternatives such as amitriptyline
or duloxetine are also used, but gabapentin offers superior tolerability for many patients and is
preferred when sedation or anticholinergic load must be minimized. Tight glucose control and
lifestyle interventions remain essential adjuncts.
Question 2
A 42-year-old woman reports palpitations, anxiety, tremor, unintentional weight loss, and heat
intolerance. Physical exam reveals warm skin and a fine tremor. TSH is <0.01 mIU/L and free T4
is elevated. What is the most appropriate diagnostic step to distinguish Graves’ disease from
other causes of hyperthyroidism?
Answer: Order a radioactive iodine uptake (RAIU) scan
Rationale:
An RAIU scan is the gold standard for differentiating Graves’ disease, toxic multinodular goiter,
thyroiditis, and other etiologies. Graves’ typically presents with diffuse high uptake, whereas
thyroiditis shows low uptake due to preformed hormone release. Thyroid antibody testing is
adjunctive but cannot reliably differentiate all causes. Accurate etiology guides appropriate
treatment (antithyroid drugs vs. beta blockers vs. radioactive iodine).
Question 3
,A 70-year-old man with COPD presents with an acute increase in dyspnea, cough, and sputum
production. His oxygen saturation is 86% on room air. What intervention should be initiated
first?
Answer: Administer supplemental oxygen to maintain SpO₂ 88–92%
Rationale:
COPD exacerbation management begins with controlled oxygen therapy, targeting 88–92% to
avoid suppressing hypoxic respiratory drive and preventing CO₂ retention. After oxygen,
bronchodilators, corticosteroids, and antibiotics (if indicated) are initiated. Ensuring correct
oxygen titration is the most critical early step.
Question 4
A 29-year-old patient presents with right lower quadrant pain, fever, nausea, and leukocytosis.
Abdominal exam reveals rebound tenderness and guarding. What is the next most appropriate
diagnostic step?
Answer: Obtain an abdominal CT scan with contrast
Rationale:
CT abdomen with contrast is the gold standard for diagnosing appendicitis in adults. Ultrasound
is preferred in pregnancy or pediatric cases, but CT provides highest sensitivity and specificity in
adults, guiding surgical decision-making.
Question 5
A patient taking warfarin has an INR of 6.1 but no signs of bleeding. What is the recommended
management?
Answer: Hold warfarin and administer oral vitamin K
Rationale:
According to ACCP guidelines, an INR >6 without bleeding warrants holding warfarin and giving
oral vitamin K 2.5–5 mg to reduce risk of hemorrhage. Parenteral vitamin K is reserved for
serious bleeding. Monitoring INR within 24 hours is essential.
Question 6
,A 54-year-old patient has persistent hypertension despite being on an ACE inhibitor, calcium
channel blocker, and diuretic. The patient has hypokalemia and a BP of 168/104. What condition
must be evaluated for?
Answer: Primary hyperaldosteronism
Rationale:
Resistant hypertension combined with unexplained hypokalemia strongly suggests primary
aldosteronism. Screening includes plasma aldosterone concentration/plasma renin activity ratio.
Early detection improves cardiovascular outcomes.
Question 7
A patient taking metformin develops increasing fatigue, myalgias, and abdominal discomfort.
Labs show lactate of 6 mmol/L, HCO₃ 17, and pH 7.28. What is the likely diagnosis?
Answer: Metformin-associated lactic acidosis
Rationale:
Metformin can rarely cause lactic acidosis, especially in renal impairment, hypoxia, or sepsis.
Elevated lactate with metabolic acidosis is classic. Immediate discontinuation of metformin,
supportive management, and treatment of underlying causes are required.
Question 8
A 63-year-old male with a long history of uncontrolled hypertension presents with sudden,
severe chest pain radiating to the back. His blood pressure is 192/108 in the right arm and
158/92 in the left arm. Physical exam reveals diminished pulses in the lower extremities. What is
the most appropriate immediate diagnostic test?
Answer: CT angiography of the chest
Rationale:
A widened pulse pressure difference, tearing chest pain radiating to the back, and asymmetric
pulses strongly indicate acute aortic dissection. CT angiography is the fastest, most sensitive,
and widely available imaging modality for confirming dissection in hemodynamically stable
patients. Transesophageal echocardiography is preferred if unstable or if CT is unavailable. Early
diagnosis is critical due to high mortality, and immediate BP control (beta blockers) is required.
Question 9
, A 35-year-old diabetic patient presents with unilateral periorbital swelling, fever, pain with eye
movement, and decreased visual acuity. CT orbit shows inflammation behind the orbital
septum. What is the most appropriate management?
Answer: Start IV broad-spectrum antibiotics and admit for emergent ophthalmology
evaluation
Rationale:
The patient has orbital cellulitis, a medical emergency. Management includes immediate IV
antibiotics (vancomycin + ceftriaxone or ampicillin-sulbactam) and ophthalmology consultation
to prevent permanent vision loss or intracranial spread. Preseptal cellulitis may be outpatient-
treated, but postseptal involvement requires hospital admission.
Question 10
A 72-year-old patient presents with new cognitive decline, urinary incontinence, and gait
instability described as “magnetic gait.” MRI shows enlarged ventricles with normal cortical
volume. What is the most likely diagnosis?
Answer: Normal pressure hydrocephalus (NPH)
Rationale:
NPH presents with the classic triad: gait disturbance, urinary incontinence, and cognitive
impairment. Ventriculomegaly without cortical atrophy supports the diagnosis. Improvement
after large-volume CSF tap test supports shunt candidacy.
Question 11
A 48-year-old woman with newly diagnosed rheumatoid arthritis asks about the best initial
disease-modifying therapy. What is the evidence-based first-line DMARD?
Answer: Methotrexate
Rationale:
Methotrexate is the cornerstone first-line DMARD due to strong evidence for slowing disease
progression, reducing joint destruction, and controlling systemic inflammation. Biologics are
added if methotrexate fails or in aggressive disease. Monitoring liver function, CBC, and giving
folic acid supplementation are mandatory.
