NRNP 6540 EXAM ACTUAL QUESTIONS AND CORRECT
ANSWERS WITH RATIONALE NEW UPDATE 2026-2027
ALREADY GRADED A+
The NRNP 6540 course, "Advanced Practice Care of Older Adults," is a 3-credit
didactic course at Walden University designed for nurse practitioner students in the
Adult-Gerontology Primary and Acute Care tracks. This course focuses on
applying advanced pathophysiology, pharmacology, and physical assessment to
manage complex health conditions in the geriatric population. It emphasizes
comprehensive care planning, functional assessment, and recognition of atypical
disease presentations in older adults, such as delirium. Concurrently, students
complete the 160-hour clinical practicum, PRAC 6540, to apply these skills with
patients aged 55 and older.
1. An 82-year-old woman presents with confusion and a cough. Her daughter
reports that she has been "not herself" for 2 days. She has no history of dementia.
Which of the following best explains this presentation?
A) Older adults always present with classic symptoms of infection
B) Delirium is often the only presenting sign of an acute illness such as infection in
older adults
C) Confusion in older adults is usually due to dementia
D) Older adults do not develop fever in response to infection
Answer: B) Delirium is often the only presenting sign of an acute illness such as
infection in older adults
Rationale: Older adults frequently present atypically with acute illnesses. Rather
than the classic symptoms of a specific disease, they may present with a "geriatric
syndrome" such as delirium, falls, functional decline, or generalized weakness. A
urinary tract infection, pneumonia, or even myocardial infarction may present
primarily as confusion or delirium in an older adult, especially in those with
underlying cognitive impairment. This is often referred to as "atypical disease
presentation" and is a hallmark of geriatric medicine. Absence of fever is also
common due to altered thermoregulation and immune senescence .
,2. A 78-year-old patient is noted to have a creatinine of 1.1 mg/dL, which is within
the normal laboratory reference range. However, his estimated glomerular filtration
rate (eGFR) is 48 mL/min/1.73 m². This discrepancy is best explained by:
A) Laboratory error
B) The normal age-related decline in muscle mass, which reduces serum creatinine
independent of renal function
C) Increased hepatic production of creatinine
D) Overhydration
Answer: B) The normal age-related decline in muscle mass, which reduces serum
creatinine independent of renal function
Rationale: Serum creatinine is a function of both renal elimination and muscle
production. As individuals age, they lose skeletal muscle mass (sarcopenia),
resulting in lower creatinine production. Consequently, a "normal" serum
creatinine in an older adult often reflects significantly impaired renal function. The
eGFR, which incorporates age, sex, and sometimes race, provides a more accurate
assessment. The Cockcroft-Gault or CKD-EPI equations should always be used to
estimate renal function in older adults before prescribing renally cleared
medications .
3. Which of the following is a normal age-related change in the cardiovascular
system?
A) Increased maximal heart rate response to exercise
B) Decreased arterial compliance and increased systolic blood pressure
C) Increased left ventricular compliance during diastole
D) Increased sensitivity to beta-adrenergic stimulation
Answer: B) Decreased arterial compliance and increased systolic blood pressure
Rationale: Normal cardiovascular aging includes stiffening of the large arteries
(arteriosclerosis) due to fragmentation of elastin and increased collagen deposition.
This reduces arterial compliance, leading to increased systolic blood pressure
(often with a normal or decreased diastolic pressure, widening pulse pressure) and
increased afterload on the left ventricle. The left ventricle undergoes concentric
hypertrophy in response to this increased afterload .
4. Oxybutynin is started for urge incontinence in a 70-year-old woman. Which side
effect is of greatest concern in this patient?
A) Dry mouth
B) Constipation
C) Confusion and cognitive decline
D) Urinary retention
Answer: C) Confusion and cognitive decline
,Rationale: Oxybutynin is a potent anticholinergic medication. Anticholinergic
drugs readily cross the blood-brain barrier and block muscarinic receptors, causing
central side effects including confusion, memory impairment, and even delirium,
especially in older adults with pre-existing cognitive impairment or cholinergic
deficit. Oxybutynin is on the Beers Criteria list of potentially inappropriate
medications for older adults .
5. Which of the following is an expected age-related change in the immune system
("immunosenescence")?
A) Increased response to new vaccines
B) Decreased susceptibility to infections
C) Decreased antibody response to vaccines and increased risk of herpes zoster
reactivation
D) Increased production of naive T cells
Answer: C) Decreased antibody response to vaccines and increased risk of herpes
zoster reactivation
Rationale: Immunosenescence involves a decline in both humoral and cell-
mediated immunity. There is decreased antibody production in response to new
antigens (reduced vaccine efficacy), decreased delayed-type hypersensitivity
(anergy on TB testing), reactivation of latent infections (herpes zoster,
tuberculosis), and increased susceptibility to infections. This is why higher -dose or
adjuvanted influenza vaccines and the recombinant zoster vaccine (Shingrix) are
recommended for older adults .
6. A 65-year-old man asks about prostate cancer screening. He has no symptoms
and no family history. The NP should:
A) Order an annual PSA test
B) Engage in shared decision-making, discussing the potential benefits and harms
C) Perform a digital rectal exam only
D) Order a prostate MRI
Answer: B) Engage in shared decision-making, discussing the potential benefits
and harms
Rationale: Screening for prostate cancer with PSA is controversial. The U.S.
Preventive Services Task Force recommends shared decision-making for men aged
55 to 69. The potential benefit is a small reduction in prostate cancer mortality.
Harms include false positives, overdiagnosis, and treatment complications such as
urinary incontinence and erectile dysfunction. For men over 70, routine screening
is generally not recommended .
, 7. Which of the following best describes "homeostenosis" in the context of
geriatric physiology?
A) The normal maintenance of homeostasis throughout life
B) The enhanced ability to respond to stress in older adults
C) The progressive narrowing of physiologic reserve and diminished ability to
maintain homeostasis under stress
D) A condition unique to centenarians
Answer: C) The progressive narrowing of physiologic reserve and diminished
ability to maintain homeostasis under stress
Rationale: Homeostenosis refers to the age-related decline in the functional reserve
of multiple organ systems, resulting in a reduced capacity to maintain homeostasis
when faced with a stressor (e.g., illness, dehydration, medication change). Even a
minor insult can precipitate a cascade of decompensation (e.g., a UTI leading to
delirium, immobility, pressure ulcers, and functional decline). This concept
underlies the "geriatric syndromes" .
8. An 80-year-old patient is admitted to the hospital with pneumonia. On day 3, he
becomes acutely confused, agitated, and is pulling at his IV lines. His family says
this is not his baseline. The NP's priority is to:
A) Administer haloperidol immediately
B) Restrain the patient for safety
C) Evaluate for underlying causes including hypoxia, infection, electrolyte
imbalances, and medication effects
D) Discharge the patient to a nursing home
Answer: C) Evaluate for underlying causes including hypoxia, infection,
electrolyte imbalances, and medication effects
Rationale: Delirium is an acute, fluctuating disturbance in attention, awareness,
and cognition. It is always due to an underlying medical condition or medication
and should be considered a medical emergency. The priority is to identify and treat
the underlying cause(s) while providing supportive care. Common causes include
infections (especially UTI, pneumonia), electrolyte disturbances, hypoxia,
medications (especially anticholinergics, benzodiazepines, opioids), untreated pain,
and urinary retention .
9. Which age-related change increases the risk of drug toxicity in older adults?
A) Increased lean body mass
B) Decreased body fat
C) Decreased glomerular filtration rate
D) Increased hepatic blood flow
Answer: C) Decreased glomerular filtration rate
ANSWERS WITH RATIONALE NEW UPDATE 2026-2027
ALREADY GRADED A+
The NRNP 6540 course, "Advanced Practice Care of Older Adults," is a 3-credit
didactic course at Walden University designed for nurse practitioner students in the
Adult-Gerontology Primary and Acute Care tracks. This course focuses on
applying advanced pathophysiology, pharmacology, and physical assessment to
manage complex health conditions in the geriatric population. It emphasizes
comprehensive care planning, functional assessment, and recognition of atypical
disease presentations in older adults, such as delirium. Concurrently, students
complete the 160-hour clinical practicum, PRAC 6540, to apply these skills with
patients aged 55 and older.
1. An 82-year-old woman presents with confusion and a cough. Her daughter
reports that she has been "not herself" for 2 days. She has no history of dementia.
Which of the following best explains this presentation?
A) Older adults always present with classic symptoms of infection
B) Delirium is often the only presenting sign of an acute illness such as infection in
older adults
C) Confusion in older adults is usually due to dementia
D) Older adults do not develop fever in response to infection
Answer: B) Delirium is often the only presenting sign of an acute illness such as
infection in older adults
Rationale: Older adults frequently present atypically with acute illnesses. Rather
than the classic symptoms of a specific disease, they may present with a "geriatric
syndrome" such as delirium, falls, functional decline, or generalized weakness. A
urinary tract infection, pneumonia, or even myocardial infarction may present
primarily as confusion or delirium in an older adult, especially in those with
underlying cognitive impairment. This is often referred to as "atypical disease
presentation" and is a hallmark of geriatric medicine. Absence of fever is also
common due to altered thermoregulation and immune senescence .
,2. A 78-year-old patient is noted to have a creatinine of 1.1 mg/dL, which is within
the normal laboratory reference range. However, his estimated glomerular filtration
rate (eGFR) is 48 mL/min/1.73 m². This discrepancy is best explained by:
A) Laboratory error
B) The normal age-related decline in muscle mass, which reduces serum creatinine
independent of renal function
C) Increased hepatic production of creatinine
D) Overhydration
Answer: B) The normal age-related decline in muscle mass, which reduces serum
creatinine independent of renal function
Rationale: Serum creatinine is a function of both renal elimination and muscle
production. As individuals age, they lose skeletal muscle mass (sarcopenia),
resulting in lower creatinine production. Consequently, a "normal" serum
creatinine in an older adult often reflects significantly impaired renal function. The
eGFR, which incorporates age, sex, and sometimes race, provides a more accurate
assessment. The Cockcroft-Gault or CKD-EPI equations should always be used to
estimate renal function in older adults before prescribing renally cleared
medications .
3. Which of the following is a normal age-related change in the cardiovascular
system?
A) Increased maximal heart rate response to exercise
B) Decreased arterial compliance and increased systolic blood pressure
C) Increased left ventricular compliance during diastole
D) Increased sensitivity to beta-adrenergic stimulation
Answer: B) Decreased arterial compliance and increased systolic blood pressure
Rationale: Normal cardiovascular aging includes stiffening of the large arteries
(arteriosclerosis) due to fragmentation of elastin and increased collagen deposition.
This reduces arterial compliance, leading to increased systolic blood pressure
(often with a normal or decreased diastolic pressure, widening pulse pressure) and
increased afterload on the left ventricle. The left ventricle undergoes concentric
hypertrophy in response to this increased afterload .
4. Oxybutynin is started for urge incontinence in a 70-year-old woman. Which side
effect is of greatest concern in this patient?
A) Dry mouth
B) Constipation
C) Confusion and cognitive decline
D) Urinary retention
Answer: C) Confusion and cognitive decline
,Rationale: Oxybutynin is a potent anticholinergic medication. Anticholinergic
drugs readily cross the blood-brain barrier and block muscarinic receptors, causing
central side effects including confusion, memory impairment, and even delirium,
especially in older adults with pre-existing cognitive impairment or cholinergic
deficit. Oxybutynin is on the Beers Criteria list of potentially inappropriate
medications for older adults .
5. Which of the following is an expected age-related change in the immune system
("immunosenescence")?
A) Increased response to new vaccines
B) Decreased susceptibility to infections
C) Decreased antibody response to vaccines and increased risk of herpes zoster
reactivation
D) Increased production of naive T cells
Answer: C) Decreased antibody response to vaccines and increased risk of herpes
zoster reactivation
Rationale: Immunosenescence involves a decline in both humoral and cell-
mediated immunity. There is decreased antibody production in response to new
antigens (reduced vaccine efficacy), decreased delayed-type hypersensitivity
(anergy on TB testing), reactivation of latent infections (herpes zoster,
tuberculosis), and increased susceptibility to infections. This is why higher -dose or
adjuvanted influenza vaccines and the recombinant zoster vaccine (Shingrix) are
recommended for older adults .
6. A 65-year-old man asks about prostate cancer screening. He has no symptoms
and no family history. The NP should:
A) Order an annual PSA test
B) Engage in shared decision-making, discussing the potential benefits and harms
C) Perform a digital rectal exam only
D) Order a prostate MRI
Answer: B) Engage in shared decision-making, discussing the potential benefits
and harms
Rationale: Screening for prostate cancer with PSA is controversial. The U.S.
Preventive Services Task Force recommends shared decision-making for men aged
55 to 69. The potential benefit is a small reduction in prostate cancer mortality.
Harms include false positives, overdiagnosis, and treatment complications such as
urinary incontinence and erectile dysfunction. For men over 70, routine screening
is generally not recommended .
, 7. Which of the following best describes "homeostenosis" in the context of
geriatric physiology?
A) The normal maintenance of homeostasis throughout life
B) The enhanced ability to respond to stress in older adults
C) The progressive narrowing of physiologic reserve and diminished ability to
maintain homeostasis under stress
D) A condition unique to centenarians
Answer: C) The progressive narrowing of physiologic reserve and diminished
ability to maintain homeostasis under stress
Rationale: Homeostenosis refers to the age-related decline in the functional reserve
of multiple organ systems, resulting in a reduced capacity to maintain homeostasis
when faced with a stressor (e.g., illness, dehydration, medication change). Even a
minor insult can precipitate a cascade of decompensation (e.g., a UTI leading to
delirium, immobility, pressure ulcers, and functional decline). This concept
underlies the "geriatric syndromes" .
8. An 80-year-old patient is admitted to the hospital with pneumonia. On day 3, he
becomes acutely confused, agitated, and is pulling at his IV lines. His family says
this is not his baseline. The NP's priority is to:
A) Administer haloperidol immediately
B) Restrain the patient for safety
C) Evaluate for underlying causes including hypoxia, infection, electrolyte
imbalances, and medication effects
D) Discharge the patient to a nursing home
Answer: C) Evaluate for underlying causes including hypoxia, infection,
electrolyte imbalances, and medication effects
Rationale: Delirium is an acute, fluctuating disturbance in attention, awareness,
and cognition. It is always due to an underlying medical condition or medication
and should be considered a medical emergency. The priority is to identify and treat
the underlying cause(s) while providing supportive care. Common causes include
infections (especially UTI, pneumonia), electrolyte disturbances, hypoxia,
medications (especially anticholinergics, benzodiazepines, opioids), untreated pain,
and urinary retention .
9. Which age-related change increases the risk of drug toxicity in older adults?
A) Increased lean body mass
B) Decreased body fat
C) Decreased glomerular filtration rate
D) Increased hepatic blood flow
Answer: C) Decreased glomerular filtration rate
