1
NR 511 MIDTERM EXAM PREP Differential Diagnosis &
Primary Care | Chamberlain University 2026 Edition |
100 Practice Questions with Verified Answers &
Detailed Rationales
SECTION 1: CLINICAL DECISION-MAKING & DIAGNOSTIC REASONING
QUESTION 1:
A 45-year-old female presents with a 3-month history of fatigue, weight gain, and
cold intolerance. Physical examination reveals dry, coarse skin; periorbital edema;
and delayed relaxation phase of deep tendon reflexes. Which laboratory test
should the NP order FIRST to evaluate the suspected diagnosis?
A) Serum cortisol level
B) Thyroid-stimulating hormone (TSH) level
C) Fasting blood glucose
D) Serum ferritin level
RATIONALE: This presentation is classic for hypothyroidism. The combination of
fatigue, weight gain, cold intolerance, dry coarse skin, periorbital edema
(myxedema), and delayed deep tendon reflexes (pseudomyotonic reflexes) is
highly suggestive of thyroid hormone deficiency. The TSH level is the most
sensitive and specific initial screening test for primary hypothyroidism. In primary
hypothyroidism, TSH will be ELEVATED as the pituitary attempts to stimulate the
failing thyroid gland. If TSH is elevated, free T4 should then be checked (which will
be low in overt hypothyroidism). This stepwise approach follows the diagnostic
algorithm recommended by the American Thyroid Association. The delayed
relaxation phase of deep tendon reflexes is a classic physical finding in
hypothyroidism, resulting from decreased metabolic activity in muscle tissue.
Serum cortisol (Option A) would be appropriate for suspected adrenal
insufficiency (Addison disease), which can also cause fatigue but typically presents
with hyperpigmentation, weight loss, and hypotension. Fasting blood glucose
pg. 1
, 2
(Option C) screens for diabetes mellitus, which more commonly presents with
polyuria, polydipsia, and polyphagia. Serum ferritin (Option D) is the preferred
test for iron deficiency anemia, which causes fatigue but not the characteristic
skin changes or reflex abnormalities of hypothyroidism.
QUESTION 2:
A 28-year-old female presents with acute onset of right lower quadrant
abdominal pain, nausea, and low-grade fever. On examination, she has rebound
tenderness at McBurney's point and a positive Rovsing sign. The NP suspects
acute appendicitis. Which of the following is the MOST appropriate initial imaging
study?
A) Abdominal X-ray (KUB)
B) Abdominal CT scan with IV contrast
C) Abdominal ultrasound
D) MRI of the abdomen
RATIONALE: CT scan with IV contrast is the imaging modality of choice for
suspected appendicitis in adults. It offers high sensitivity (95-98%) and specificity
(92-97%) for diagnosing appendicitis, allows visualization of the appendix even
when it is in an atypical location, and can identify complications such as
perforation, abscess, or phlegmon. CT also provides excellent evaluation of
alternative diagnoses (ovarian pathology, diverticulitis, ureteral stones) when
appendicitis is not confirmed. However, in pregnant women and children,
ultrasound is often preferred as the initial study to avoid radiation exposure. The
classic signs described—rebound tenderness at McBurney's point (pain upon
release of pressure) and a positive Rovsing sign (RLQ pain when the LLQ is
palpated)—indicate peritoneal irritation consistent with appendicitis. Abdominal
X-ray (Option A) has very low sensitivity for appendicitis and is only useful if a
calcified appendicolith (fecalith) is visualized, which is uncommon. Ultrasound
(Option C) is an alternative for patients in whom radiation should be avoided
(pregnancy, pediatrics) but is operator-dependent and has lower sensitivity than
CT. MRI (Option D) is not a first-line study for acute appendicitis due to cost,
limited availability, and longer scan time.
pg. 2
, 3
QUESTION 3:
A 65-year-old male with a 50-pack-year smoking history presents with a chronic
cough, unintentional weight loss of 15 pounds over 3 months, and hemoptysis.
The NP suspects lung cancer. Which of the following is the MOST appropriate
initial diagnostic step?
A) Sputum cytology
B) Chest X-ray (posteroanterior and lateral)
C) PET scan
D) Bronchoscopy with biopsy
RATIONALE: Chest X-ray (PA and lateral views) is the appropriate INITIAL imaging
study for suspected lung cancer. It is widely available, relatively inexpensive, and
can identify masses, nodules, infiltrates, pleural effusions, and other
abnormalities. The combination of symptoms described—chronic cough,
significant weight loss, and hemoptysis in a heavy smoker—is highly concerning
for lung malignancy. A chest X-ray will identify most clinically significant lung
tumors. If the chest X-ray reveals a suspicious lesion, the next step is typically a CT
scan of the chest for better characterization, followed by tissue diagnosis (biopsy)
for definitive confirmation. Sputum cytology (Option A) can be a useful adjunct
but has limited sensitivity and specificity; a negative result does not rule out
malignancy. PET scan (Option C) is used for staging after a diagnosis of lung cancer
has been established, not for initial diagnosis. Bronchoscopy with biopsy (Option
D) is a definitive diagnostic procedure but is invasive and would only be
performed after imaging identifies a lesion suspicious for cancer.
QUESTION 4:
A 32-year-old female presents with a 6-month history of progressive dyspnea on
exertion, fatigue, and pallor. Laboratory studies reveal a hemoglobin of 9.2 g/dL,
MCV of 72 fL, and serum ferritin of 8 ng/mL. What is the MOST likely diagnosis?
A) Anemia of chronic disease
B) Iron deficiency anemia
C) Vitamin B12 deficiency anemia
D) Thalassemia trait
pg. 3
, 4
RATIONALE: This is a classic presentation of iron deficiency anemia (IDA). The key
laboratory findings are: low hemoglobin (anemia), low MCV (microcytic - small
red blood cells), and LOW serum ferritin (the most specific indicator of depleted
iron stores). A ferritin level below 15 ng/mL in adults is diagnostic of iron
deficiency. In premenopausal women, IDA is most commonly caused by menstrual
blood loss. Other causes include gastrointestinal bleeding (peptic ulcer disease,
colorectal cancer, angiodysplasia), inadequate dietary intake, and malabsorption.
The MCV of 72 fL confirms a microcytic anemia. Other microcytic anemias include
anemia of chronic disease and thalassemia, but these have DIFFERENT ferritin
levels. Anemia of chronic disease (Option A) typically has a NORMAL or ELEVATED
ferritin (ferritin is an acute phase reactant). Vitamin B12 deficiency (Option C)
causes MACROCYTIC anemia (elevated MCV), not microcytic anemia. Thalassemia
trait (Option D) is microcytic but has a NORMAL or ELEVATED ferritin level. The
combination of microcytosis and low ferritin is pathognomonic for iron deficiency.
QUESTION 5:
A 55-year-old postmenopausal female presents with a 4-week history of low back
pain that is worse at night and not relieved by rest or NSAIDs. She also reports
progressive fatigue and unintentional weight loss. The NP should consider which
of the following as the MOST likely underlying etiology?
A) Degenerative disc disease
B) Osteoporotic compression fracture
C) Multiple myeloma
D) Spinal stenosis
RATIONALE: The presentation of bone pain (particularly back pain) that is WORSE
at night and UNRELIEVED by rest, combined with fatigue and weight loss in an
older adult, is a classic presentation for multiple myeloma. Multiple myeloma is a
malignant proliferation of plasma cells in the bone marrow that causes: Bone
destruction (lytic lesions) leading to pain, pathologic fractures, and
hypercalcemia; bone marrow infiltration leading to anemia (causing fatigue); and
production of abnormal immunoglobulins (monoclonal proteins). The pain of
multiple myeloma is typically not relieved by rest (unlike mechanical back pain),
and night pain is common. Initial diagnostic testing should include: complete
pg. 4
NR 511 MIDTERM EXAM PREP Differential Diagnosis &
Primary Care | Chamberlain University 2026 Edition |
100 Practice Questions with Verified Answers &
Detailed Rationales
SECTION 1: CLINICAL DECISION-MAKING & DIAGNOSTIC REASONING
QUESTION 1:
A 45-year-old female presents with a 3-month history of fatigue, weight gain, and
cold intolerance. Physical examination reveals dry, coarse skin; periorbital edema;
and delayed relaxation phase of deep tendon reflexes. Which laboratory test
should the NP order FIRST to evaluate the suspected diagnosis?
A) Serum cortisol level
B) Thyroid-stimulating hormone (TSH) level
C) Fasting blood glucose
D) Serum ferritin level
RATIONALE: This presentation is classic for hypothyroidism. The combination of
fatigue, weight gain, cold intolerance, dry coarse skin, periorbital edema
(myxedema), and delayed deep tendon reflexes (pseudomyotonic reflexes) is
highly suggestive of thyroid hormone deficiency. The TSH level is the most
sensitive and specific initial screening test for primary hypothyroidism. In primary
hypothyroidism, TSH will be ELEVATED as the pituitary attempts to stimulate the
failing thyroid gland. If TSH is elevated, free T4 should then be checked (which will
be low in overt hypothyroidism). This stepwise approach follows the diagnostic
algorithm recommended by the American Thyroid Association. The delayed
relaxation phase of deep tendon reflexes is a classic physical finding in
hypothyroidism, resulting from decreased metabolic activity in muscle tissue.
Serum cortisol (Option A) would be appropriate for suspected adrenal
insufficiency (Addison disease), which can also cause fatigue but typically presents
with hyperpigmentation, weight loss, and hypotension. Fasting blood glucose
pg. 1
, 2
(Option C) screens for diabetes mellitus, which more commonly presents with
polyuria, polydipsia, and polyphagia. Serum ferritin (Option D) is the preferred
test for iron deficiency anemia, which causes fatigue but not the characteristic
skin changes or reflex abnormalities of hypothyroidism.
QUESTION 2:
A 28-year-old female presents with acute onset of right lower quadrant
abdominal pain, nausea, and low-grade fever. On examination, she has rebound
tenderness at McBurney's point and a positive Rovsing sign. The NP suspects
acute appendicitis. Which of the following is the MOST appropriate initial imaging
study?
A) Abdominal X-ray (KUB)
B) Abdominal CT scan with IV contrast
C) Abdominal ultrasound
D) MRI of the abdomen
RATIONALE: CT scan with IV contrast is the imaging modality of choice for
suspected appendicitis in adults. It offers high sensitivity (95-98%) and specificity
(92-97%) for diagnosing appendicitis, allows visualization of the appendix even
when it is in an atypical location, and can identify complications such as
perforation, abscess, or phlegmon. CT also provides excellent evaluation of
alternative diagnoses (ovarian pathology, diverticulitis, ureteral stones) when
appendicitis is not confirmed. However, in pregnant women and children,
ultrasound is often preferred as the initial study to avoid radiation exposure. The
classic signs described—rebound tenderness at McBurney's point (pain upon
release of pressure) and a positive Rovsing sign (RLQ pain when the LLQ is
palpated)—indicate peritoneal irritation consistent with appendicitis. Abdominal
X-ray (Option A) has very low sensitivity for appendicitis and is only useful if a
calcified appendicolith (fecalith) is visualized, which is uncommon. Ultrasound
(Option C) is an alternative for patients in whom radiation should be avoided
(pregnancy, pediatrics) but is operator-dependent and has lower sensitivity than
CT. MRI (Option D) is not a first-line study for acute appendicitis due to cost,
limited availability, and longer scan time.
pg. 2
, 3
QUESTION 3:
A 65-year-old male with a 50-pack-year smoking history presents with a chronic
cough, unintentional weight loss of 15 pounds over 3 months, and hemoptysis.
The NP suspects lung cancer. Which of the following is the MOST appropriate
initial diagnostic step?
A) Sputum cytology
B) Chest X-ray (posteroanterior and lateral)
C) PET scan
D) Bronchoscopy with biopsy
RATIONALE: Chest X-ray (PA and lateral views) is the appropriate INITIAL imaging
study for suspected lung cancer. It is widely available, relatively inexpensive, and
can identify masses, nodules, infiltrates, pleural effusions, and other
abnormalities. The combination of symptoms described—chronic cough,
significant weight loss, and hemoptysis in a heavy smoker—is highly concerning
for lung malignancy. A chest X-ray will identify most clinically significant lung
tumors. If the chest X-ray reveals a suspicious lesion, the next step is typically a CT
scan of the chest for better characterization, followed by tissue diagnosis (biopsy)
for definitive confirmation. Sputum cytology (Option A) can be a useful adjunct
but has limited sensitivity and specificity; a negative result does not rule out
malignancy. PET scan (Option C) is used for staging after a diagnosis of lung cancer
has been established, not for initial diagnosis. Bronchoscopy with biopsy (Option
D) is a definitive diagnostic procedure but is invasive and would only be
performed after imaging identifies a lesion suspicious for cancer.
QUESTION 4:
A 32-year-old female presents with a 6-month history of progressive dyspnea on
exertion, fatigue, and pallor. Laboratory studies reveal a hemoglobin of 9.2 g/dL,
MCV of 72 fL, and serum ferritin of 8 ng/mL. What is the MOST likely diagnosis?
A) Anemia of chronic disease
B) Iron deficiency anemia
C) Vitamin B12 deficiency anemia
D) Thalassemia trait
pg. 3
, 4
RATIONALE: This is a classic presentation of iron deficiency anemia (IDA). The key
laboratory findings are: low hemoglobin (anemia), low MCV (microcytic - small
red blood cells), and LOW serum ferritin (the most specific indicator of depleted
iron stores). A ferritin level below 15 ng/mL in adults is diagnostic of iron
deficiency. In premenopausal women, IDA is most commonly caused by menstrual
blood loss. Other causes include gastrointestinal bleeding (peptic ulcer disease,
colorectal cancer, angiodysplasia), inadequate dietary intake, and malabsorption.
The MCV of 72 fL confirms a microcytic anemia. Other microcytic anemias include
anemia of chronic disease and thalassemia, but these have DIFFERENT ferritin
levels. Anemia of chronic disease (Option A) typically has a NORMAL or ELEVATED
ferritin (ferritin is an acute phase reactant). Vitamin B12 deficiency (Option C)
causes MACROCYTIC anemia (elevated MCV), not microcytic anemia. Thalassemia
trait (Option D) is microcytic but has a NORMAL or ELEVATED ferritin level. The
combination of microcytosis and low ferritin is pathognomonic for iron deficiency.
QUESTION 5:
A 55-year-old postmenopausal female presents with a 4-week history of low back
pain that is worse at night and not relieved by rest or NSAIDs. She also reports
progressive fatigue and unintentional weight loss. The NP should consider which
of the following as the MOST likely underlying etiology?
A) Degenerative disc disease
B) Osteoporotic compression fracture
C) Multiple myeloma
D) Spinal stenosis
RATIONALE: The presentation of bone pain (particularly back pain) that is WORSE
at night and UNRELIEVED by rest, combined with fatigue and weight loss in an
older adult, is a classic presentation for multiple myeloma. Multiple myeloma is a
malignant proliferation of plasma cells in the bone marrow that causes: Bone
destruction (lytic lesions) leading to pain, pathologic fractures, and
hypercalcemia; bone marrow infiltration leading to anemia (causing fatigue); and
production of abnormal immunoglobulins (monoclonal proteins). The pain of
multiple myeloma is typically not relieved by rest (unlike mechanical back pain),
and night pain is common. Initial diagnostic testing should include: complete
pg. 4
