1
Barkley Family Nurse Practitioner Predictor Exam | 100
Board-Style Questions and Rationales
Barkley Family Nurse Practitioner Predictor Exam — 100 Board-Style Questions
with Full Rationales
1. A 62-year-old man with a history of hypertension and a 40-pack-year smoking
history presents with a 2-week history of a pulsatile, tender mass in the right
popliteal fossa. He denies trauma. On physical exam, a palpable, pulsatile mass
is noted behind the right knee. The left leg is unremarkable. What is the most
likely diagnosis and the greatest risk associated with this condition?
A. Popliteal artery aneurysm; rupture and acute limb ischemia
B. Baker’s cyst; rupture and pseudothrombophlebitis
C. Femoral artery aneurysm; dissection
D. Deep vein thrombosis; pulmonary embolism
: Correct Answer : A
Rationale: A popliteal artery aneurysm (PAA) is defined as a focal dilation of the
popliteal artery >1.5 cm. It is strongly associated with other aneurysms (especially
abdominal aortic aneurysm) and atherosclerotic disease. The classic presentation
is a pulsatile popliteal mass. The most serious complications are thrombosis or
distal embolization leading to acute limb ischemia (limb-threatening), and rupture
(less common). Baker’s cyst (B) is a fluid-filled synovial sac in the popliteal fossa; it
is non-pulsatile and often associated with knee joint pathology or rheumatoid
arthritis. Rupture of a Baker’s cyst causes calf pain and swelling, mimicking a DVT
(pseudothrombophlebitis). A femoral artery aneurysm (C) would present with a
pulsatile mass in the groin. DVT (D) causes calf tenderness, warmth, and edema,
not a pulsatile mass. The correct answer highlights the critical risk of acute limb
ischemia.
2. A 54-year-old woman with a history of atrial fibrillation (not on
anticoagulation) presents with acute onset of severe, diffuse abdominal pain.
She is diaphoretic and hypotensive. The abdomen is soft with mild tenderness,
no rebound, no guarding. Lactate is 6.2 mmol/L. ECG shows atrial fibrillation
with rapid ventricular response. What is the most likely diagnosis?
pg. 1
,2
A. Acute pancreatitis
B. Mesenteric ischemia
C. Ruptured abdominal aortic aneurysm
D. Diverticulitis with perforation
: Correct Answer : B
Rationale: The combination of atrial fibrillation (a source for emboli), severe
abdominal pain out of proportion to physical exam findings (pain
disproportionate to tenderness), and elevated lactate strongly suggests acute
mesenteric ischemia (AMI). AMI can be embolic (often from AF) or thrombotic. CT
angiography of the abdomen is the diagnostic test. Pancreatitis (A) would have
epigastric pain radiating to the back, elevated lipase. Ruptured AAA (C) would
present with back/flank pain, hypotension, pulsatile abdominal mass.
Diverticulitis with perforation (D) would have peritoneal signs (rigidity, rebound).
This vignette underscores the classic “pain out of proportion” presentation of
AMI.
3. A 38-year-old woman with no significant medical history presents with
palpitations, dyspnea on exertion, and a systolic murmur best heard at the left
upper sternal border that increases with inspiration. The murmur is harsh,
crescendo-decrescendo, and radiates to the back. An echocardiogram is
ordered. Which valvular abnormality is most consistent with these findings?
A. Mitral valve prolapse
B. Tricuspid regurgitation
C. Pulmonic stenosis
D. Aortic stenosis
: Correct Answer : C
Rationale: Pulmonic stenosis is a congenital heart defect that often presents in
adulthood with a harsh, crescendo-decrescendo systolic murmur best heard at
the left upper sternal border (pulmonic area). The murmur increases with
inspiration (Carvallo sign for right-sided murmurs) and may radiate to the back or
left shoulder. Mitral valve prolapse (A) gives a mid-systolic click with or without a
late systolic murmur at the apex. Tricuspid regurgitation (B) is holosystolic at left
lower sternal border, increasing with inspiration. Aortic stenosis (D) is heard at
pg. 2
,3
the right upper sternal border, radiates to carotids, does not increase with
inspiration. The inspiratory augmentation is key for right-sided events.
4. A 72-year-old woman with type 2 diabetes and chronic kidney disease (eGFR
32 mL/min) presents with a 2-day history of confusion, myoclonic jerks, and
asterixis. Her medications include metformin 1000 mg BID, lisinopril, and
atorvastatin. Laboratory results: creatinine 3.8 mg/dL (baseline 2.0), BUN 58
mg/dL, potassium 5.8 mEq/L, lactate 9.2 mmol/L. ABG: pH 7.12, PCO2 30 mmHg.
What is the most likely cause of her acute presentation?
A. Uremic encephalopathy
B. Metformin-associated lactic acidosis (MALA)
C. Hyperosmolar hyperglycemic state
D. Sepsis-related encephalopathy
: Correct Answer : B
Rationale: Metformin is contraindicated when eGFR <30 mL/min due to the risk
of lactic acidosis. This patient had a recent rise in creatinine (acute kidney injury
on CKD), continued metformin, and now has severe lactic acidosis with
neurological symptoms. Metformin-associated lactic acidosis (MALA) presents
with nausea, vomiting, abdominal pain, altered mental status, and severe
metabolic acidosis with elevated lactate. Uremic encephalopathy (A) can cause
similar symptoms but typically with a gradual creatinine rise, no severe lactic
acidosis. HHS (C) would have marked hyperglycemia. Sepsis (D) would have a
source, fever, and likely not isolated severe lactic acidosis with this medication
history. The key is metformin in renal failure.
5. A 65-year-old man with COPD presents with increasing dyspnea, purulent
sputum, and wheezing. His baseline FEV1 is 45% predicted. He has had 2
exacerbations in the past year. He is currently on tiotropium and albuterol as
needed. What is the most appropriate next step in pharmacologic
management?
A. Add a long-acting beta-agonist (LABA) plus inhaled corticosteroid (ICS)
combination
B. Add a leukotriene receptor antagonist
C. Add theophylline
D. Initiate roflumilast
pg. 3
, 4
: Correct Answer : A
Rationale: For GOLD group E (high symptom burden, frequent exacerbations), the
recommended initial pharmacotherapy is a LABA plus LAMA combination.
However, if the patient is already on a LAMA (tiotropium) and continues to have
exacerbations, escalation to triple therapy (LAMA + LABA + ICS) is recommended.
In this case, the question asks for the next step; adding a LABA/ICS combination to
tiotropium achieves triple therapy, which reduces exacerbations and improves
lung function. Theophylline (C) is a third-line agent due to narrow therapeutic
index. Roflumilast (D) is a PDE4 inhibitor for severe COPD with chronic bronchitis
and frequent exacerbations, but usually added after triple therapy. Montelukast
(B) is not indicated for COPD. Thus, A is the correct guideline-based approach.
6. A 24-year-old woman presents with sudden onset of right-sided chest pain
and dyspnea. She is 10 days postpartum after a cesarean section. She has no
fever. CT pulmonary angiogram reveals a segmental pulmonary embolism. Her
blood pressure is stable, heart rate 102 bpm, O2 sat 95% on room air. She has
no history of bleeding disorders. What is the most appropriate initial
treatment?
A. Unfractionated heparin IV
B. Low molecular weight heparin (LMWH) subcutaneously
C. Direct oral anticoagulant (apixaban or rivaroxaban)
D. Thrombolytic therapy
: Correct Answer : C
Rationale: For a hemodynamically stable (non-massive) pulmonary embolism,
direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban are first-line
therapy in the outpatient or inpatient setting, provided there are no
contraindications. They are at least as effective as warfarin with fewer bleeding
complications and do not require bridging. LMWH (B) or unfractionated heparin
(A) may be used initially for hospitalized patients, but many protocols now start
DOACs immediately. Thrombolytics (D) are reserved for massive PE
(hemodynamic instability). The postpartum state is not a contraindication to
DOACs, but warfarin is used if breastfeeding because it does not pass into breast
milk; however, some guidelines allow DOACs. In this question, the best answer
reflecting current guidelines is a DOAC. However, some guidelines still
pg. 4
Barkley Family Nurse Practitioner Predictor Exam | 100
Board-Style Questions and Rationales
Barkley Family Nurse Practitioner Predictor Exam — 100 Board-Style Questions
with Full Rationales
1. A 62-year-old man with a history of hypertension and a 40-pack-year smoking
history presents with a 2-week history of a pulsatile, tender mass in the right
popliteal fossa. He denies trauma. On physical exam, a palpable, pulsatile mass
is noted behind the right knee. The left leg is unremarkable. What is the most
likely diagnosis and the greatest risk associated with this condition?
A. Popliteal artery aneurysm; rupture and acute limb ischemia
B. Baker’s cyst; rupture and pseudothrombophlebitis
C. Femoral artery aneurysm; dissection
D. Deep vein thrombosis; pulmonary embolism
: Correct Answer : A
Rationale: A popliteal artery aneurysm (PAA) is defined as a focal dilation of the
popliteal artery >1.5 cm. It is strongly associated with other aneurysms (especially
abdominal aortic aneurysm) and atherosclerotic disease. The classic presentation
is a pulsatile popliteal mass. The most serious complications are thrombosis or
distal embolization leading to acute limb ischemia (limb-threatening), and rupture
(less common). Baker’s cyst (B) is a fluid-filled synovial sac in the popliteal fossa; it
is non-pulsatile and often associated with knee joint pathology or rheumatoid
arthritis. Rupture of a Baker’s cyst causes calf pain and swelling, mimicking a DVT
(pseudothrombophlebitis). A femoral artery aneurysm (C) would present with a
pulsatile mass in the groin. DVT (D) causes calf tenderness, warmth, and edema,
not a pulsatile mass. The correct answer highlights the critical risk of acute limb
ischemia.
2. A 54-year-old woman with a history of atrial fibrillation (not on
anticoagulation) presents with acute onset of severe, diffuse abdominal pain.
She is diaphoretic and hypotensive. The abdomen is soft with mild tenderness,
no rebound, no guarding. Lactate is 6.2 mmol/L. ECG shows atrial fibrillation
with rapid ventricular response. What is the most likely diagnosis?
pg. 1
,2
A. Acute pancreatitis
B. Mesenteric ischemia
C. Ruptured abdominal aortic aneurysm
D. Diverticulitis with perforation
: Correct Answer : B
Rationale: The combination of atrial fibrillation (a source for emboli), severe
abdominal pain out of proportion to physical exam findings (pain
disproportionate to tenderness), and elevated lactate strongly suggests acute
mesenteric ischemia (AMI). AMI can be embolic (often from AF) or thrombotic. CT
angiography of the abdomen is the diagnostic test. Pancreatitis (A) would have
epigastric pain radiating to the back, elevated lipase. Ruptured AAA (C) would
present with back/flank pain, hypotension, pulsatile abdominal mass.
Diverticulitis with perforation (D) would have peritoneal signs (rigidity, rebound).
This vignette underscores the classic “pain out of proportion” presentation of
AMI.
3. A 38-year-old woman with no significant medical history presents with
palpitations, dyspnea on exertion, and a systolic murmur best heard at the left
upper sternal border that increases with inspiration. The murmur is harsh,
crescendo-decrescendo, and radiates to the back. An echocardiogram is
ordered. Which valvular abnormality is most consistent with these findings?
A. Mitral valve prolapse
B. Tricuspid regurgitation
C. Pulmonic stenosis
D. Aortic stenosis
: Correct Answer : C
Rationale: Pulmonic stenosis is a congenital heart defect that often presents in
adulthood with a harsh, crescendo-decrescendo systolic murmur best heard at
the left upper sternal border (pulmonic area). The murmur increases with
inspiration (Carvallo sign for right-sided murmurs) and may radiate to the back or
left shoulder. Mitral valve prolapse (A) gives a mid-systolic click with or without a
late systolic murmur at the apex. Tricuspid regurgitation (B) is holosystolic at left
lower sternal border, increasing with inspiration. Aortic stenosis (D) is heard at
pg. 2
,3
the right upper sternal border, radiates to carotids, does not increase with
inspiration. The inspiratory augmentation is key for right-sided events.
4. A 72-year-old woman with type 2 diabetes and chronic kidney disease (eGFR
32 mL/min) presents with a 2-day history of confusion, myoclonic jerks, and
asterixis. Her medications include metformin 1000 mg BID, lisinopril, and
atorvastatin. Laboratory results: creatinine 3.8 mg/dL (baseline 2.0), BUN 58
mg/dL, potassium 5.8 mEq/L, lactate 9.2 mmol/L. ABG: pH 7.12, PCO2 30 mmHg.
What is the most likely cause of her acute presentation?
A. Uremic encephalopathy
B. Metformin-associated lactic acidosis (MALA)
C. Hyperosmolar hyperglycemic state
D. Sepsis-related encephalopathy
: Correct Answer : B
Rationale: Metformin is contraindicated when eGFR <30 mL/min due to the risk
of lactic acidosis. This patient had a recent rise in creatinine (acute kidney injury
on CKD), continued metformin, and now has severe lactic acidosis with
neurological symptoms. Metformin-associated lactic acidosis (MALA) presents
with nausea, vomiting, abdominal pain, altered mental status, and severe
metabolic acidosis with elevated lactate. Uremic encephalopathy (A) can cause
similar symptoms but typically with a gradual creatinine rise, no severe lactic
acidosis. HHS (C) would have marked hyperglycemia. Sepsis (D) would have a
source, fever, and likely not isolated severe lactic acidosis with this medication
history. The key is metformin in renal failure.
5. A 65-year-old man with COPD presents with increasing dyspnea, purulent
sputum, and wheezing. His baseline FEV1 is 45% predicted. He has had 2
exacerbations in the past year. He is currently on tiotropium and albuterol as
needed. What is the most appropriate next step in pharmacologic
management?
A. Add a long-acting beta-agonist (LABA) plus inhaled corticosteroid (ICS)
combination
B. Add a leukotriene receptor antagonist
C. Add theophylline
D. Initiate roflumilast
pg. 3
, 4
: Correct Answer : A
Rationale: For GOLD group E (high symptom burden, frequent exacerbations), the
recommended initial pharmacotherapy is a LABA plus LAMA combination.
However, if the patient is already on a LAMA (tiotropium) and continues to have
exacerbations, escalation to triple therapy (LAMA + LABA + ICS) is recommended.
In this case, the question asks for the next step; adding a LABA/ICS combination to
tiotropium achieves triple therapy, which reduces exacerbations and improves
lung function. Theophylline (C) is a third-line agent due to narrow therapeutic
index. Roflumilast (D) is a PDE4 inhibitor for severe COPD with chronic bronchitis
and frequent exacerbations, but usually added after triple therapy. Montelukast
(B) is not indicated for COPD. Thus, A is the correct guideline-based approach.
6. A 24-year-old woman presents with sudden onset of right-sided chest pain
and dyspnea. She is 10 days postpartum after a cesarean section. She has no
fever. CT pulmonary angiogram reveals a segmental pulmonary embolism. Her
blood pressure is stable, heart rate 102 bpm, O2 sat 95% on room air. She has
no history of bleeding disorders. What is the most appropriate initial
treatment?
A. Unfractionated heparin IV
B. Low molecular weight heparin (LMWH) subcutaneously
C. Direct oral anticoagulant (apixaban or rivaroxaban)
D. Thrombolytic therapy
: Correct Answer : C
Rationale: For a hemodynamically stable (non-massive) pulmonary embolism,
direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban are first-line
therapy in the outpatient or inpatient setting, provided there are no
contraindications. They are at least as effective as warfarin with fewer bleeding
complications and do not require bridging. LMWH (B) or unfractionated heparin
(A) may be used initially for hospitalized patients, but many protocols now start
DOACs immediately. Thrombolytics (D) are reserved for massive PE
(hemodynamic instability). The postpartum state is not a contraindication to
DOACs, but warfarin is used if breastfeeding because it does not pass into breast
milk; however, some guidelines allow DOACs. In this question, the best answer
reflecting current guidelines is a DOAC. However, some guidelines still
pg. 4
