NR 511 Midterm Differential Diagnosis & Primary
Care EXAM with Questions and Answers/Plus a
Rationale Updated 2026 A+/Instant Download PDF
EXAM COVERAGE
1. Clinical Reasoning and Diagnostic Process
2. Evidence-Based Practice in Primary Care
3. Skin and Soft Tissue Disorders
4. Respiratory System Disorders
5. Cardiovascular System Assessment and Management
6. Gastrointestinal Health and Common Conditions
7. Musculoskeletal Assessment and Differential Diagnosis
8. Neurological Screening and Presentations
9. Health Promotion and Disease Prevention
10.Pharmacological Principles in Primary Care
1. A 45-year-old patient presents with a persistent, non-healing ulcer on the lateral aspect of the
lower leg. The base is granular, and the surrounding skin exhibits hyperpigmentation and edema.
Peripheral pulses are 2+ bilaterally, and capillary refill is less than 2 seconds. Which of the
following is the most appropriate initial diagnostic approach?
, A. Arterial brachial index (ABI)
B. Venous duplex ultrasound
C. Punch biopsy of the ulcer edge
D. Immediate referral for surgical debridement
CORRECT ANSWER : B
Rationale: The clinical presentation is highly suggestive of venous stasis ulceration due to the
location and surrounding stasis dermatitis changes. Venous duplex ultrasound is the gold
standard for evaluating venous insufficiency. ABI (A) is used for arterial disease, which is less
likely given the intact pulses; a biopsy (C) is reserved for non-healing ulcers suspicious for
malignancy after vascular causes are ruled out; debridement (D) is a treatment, not an initial
diagnostic step.
2. A 62-year-old male with a history of hypertension presents with a sudden onset of "tearing"
chest pain radiating to the back. Physical exam reveals a blood pressure of 170/98 mmHg in the
right arm and 140/88 mmHg in the left arm. What is the most critical next action?
A. Order a D-dimer and chest X-ray
B. Administer sublingual nitroglycerin for pain
C. Immediate transfer to the emergency department for CT angiography
D. Perform an ECG to rule out myocardial infarction
CORRECT ANSWER : C
Rationale: The patient’s symptoms and asymmetric blood pressure readings are classic for
aortic dissection. This is a medical emergency requiring rapid imaging (CTA) and surgical
consultation. D-dimer (A) is not sensitive enough; nitroglycerin (B) could worsen the dissection
by increasing shear stress; an ECG (D) should be done, but it should not delay the emergent
transfer.
3. A 28-year-old female presents with episodic tachycardia, diaphoresis, and severe anxiety-like
symptoms. She reports headaches during these episodes. Blood pressure is 155/95 mmHg.
Which diagnostic test is most specific for identifying the suspected etiology?
A. Serum thyroid-stimulating hormone (TSH)
B. 24-hour ambulatory blood pressure monitoring
C. 24-hour urine fractionated metanephrines and catecholamines
, D. Echocardiogram
CORRECT ANSWER : C
Rationale: The patient's symptoms (headache, sweating, tachycardia) in the setting of
hypertension suggest pheochromocytoma. The 24-hour urine test for metanephrines is the most
sensitive and specific diagnostic test for this condition. TSH (A) would evaluate for
hyperthyroidism; ambulatory monitoring (B) does not identify the cause of secondary
hypertension; an echocardiogram (D) might show structural changes but does not diagnose the
endocrine source.
4. A 55-year-old patient complains of morning stiffness in the hands lasting 90 minutes, bilateral
swelling of the proximal interphalangeal (PIP) joints, and fatigue. Which laboratory finding
would be most supportive of the primary diagnosis?
A. Elevated uric acid
B. Positive Rheumatoid Factor (RF) and Anti-CCP antibodies
C. Positive ANA titer (1:320)
D. Decreased C-reactive protein (CRP)
CORRECT ANSWER : B
Rationale: The prolonged morning stiffness and bilateral PIP joint involvement are hallmark
signs of rheumatoid arthritis (RA). Anti-CCP is highly specific for RA. Uric acid (A) is for gout;
ANA (C) is non-specific and suggests SLE; CRP (D) would typically be elevated in inflammatory
conditions, not decreased.
5. A 35-year-old smoker presents with chronic cough, dyspnea on exertion, and wheezing.
Spirometry shows an $FEV_1/FVC$ ratio of 0.65 that does not improve significantly with
bronchodilators. What is the most likely diagnosis?
A. Asthma
B. Chronic Obstructive Pulmonary Disease (COPD)
C. Bronchiectasis
D. Interstitial lung disease
CORRECT ANSWER : B
Rationale: A fixed or post-bronchodilator $FEV_1/FVC$ ratio below 0.70 is the diagnostic
criteria for COPD. Asthma (A) typically demonstrates significant reversibility with
, bronchodilators; bronchiectasis (C) involves chronic sputum production and structural changes;
interstitial lung disease (D) presents with a restrictive pattern (normal or high $FEV_1/FVC$).
6. A 42-year-old female presents with fatigue, cold intolerance, and constipation. Physical exam
reveals delayed relaxation of deep tendon reflexes and a goiter. Which lab abnormality is most
expected?
A. Suppressed TSH and elevated Free T4
B. Elevated TSH and elevated Free T4
C. Elevated TSH and low Free T4
D. Normal TSH and low Free T3
CORRECT ANSWER : C
Rationale: The clinical signs are classic for primary hypothyroidism. An elevated TSH with a
low Free T4 confirms the diagnosis. Option A indicates hyperthyroidism, B indicates secondary
or tertiary hypothyroidism or pituitary resistance, and D is not a standard diagnostic profile for
primary hypothyroidism.
7. A patient with type 2 diabetes presents for follow-up. Their current A1c is 8.2%. They are
currently on Metformin 1000mg BID. What is the most appropriate next step in management
according to current guidelines?
A. Switch Metformin to a Sulfonylurea
B. Add an SGLT2 inhibitor or GLP-1 receptor agonist
C. Start Basal Insulin immediately
D. Increase Metformin to 2500mg daily
CORRECT ANSWER : B
Rationale: Current ADA guidelines suggest adding an SGLT2i or GLP-1 RA for patients not at
goal on Metformin, especially those with cardiovascular or renal considerations. Sulfonylureas
(A) are second-line but often avoided due to hypoglycemia risk; insulin (C) is usually saved for
later stages; Metformin max dose is generally 2000mg/day (D).
8. A 50-year-old male reports episodic "hot" and swollen right great toe, worsening at night. He
consumed steak and beer the night before. What is the most appropriate definitive diagnostic
test?
A. Serum Uric Acid level
Care EXAM with Questions and Answers/Plus a
Rationale Updated 2026 A+/Instant Download PDF
EXAM COVERAGE
1. Clinical Reasoning and Diagnostic Process
2. Evidence-Based Practice in Primary Care
3. Skin and Soft Tissue Disorders
4. Respiratory System Disorders
5. Cardiovascular System Assessment and Management
6. Gastrointestinal Health and Common Conditions
7. Musculoskeletal Assessment and Differential Diagnosis
8. Neurological Screening and Presentations
9. Health Promotion and Disease Prevention
10.Pharmacological Principles in Primary Care
1. A 45-year-old patient presents with a persistent, non-healing ulcer on the lateral aspect of the
lower leg. The base is granular, and the surrounding skin exhibits hyperpigmentation and edema.
Peripheral pulses are 2+ bilaterally, and capillary refill is less than 2 seconds. Which of the
following is the most appropriate initial diagnostic approach?
, A. Arterial brachial index (ABI)
B. Venous duplex ultrasound
C. Punch biopsy of the ulcer edge
D. Immediate referral for surgical debridement
CORRECT ANSWER : B
Rationale: The clinical presentation is highly suggestive of venous stasis ulceration due to the
location and surrounding stasis dermatitis changes. Venous duplex ultrasound is the gold
standard for evaluating venous insufficiency. ABI (A) is used for arterial disease, which is less
likely given the intact pulses; a biopsy (C) is reserved for non-healing ulcers suspicious for
malignancy after vascular causes are ruled out; debridement (D) is a treatment, not an initial
diagnostic step.
2. A 62-year-old male with a history of hypertension presents with a sudden onset of "tearing"
chest pain radiating to the back. Physical exam reveals a blood pressure of 170/98 mmHg in the
right arm and 140/88 mmHg in the left arm. What is the most critical next action?
A. Order a D-dimer and chest X-ray
B. Administer sublingual nitroglycerin for pain
C. Immediate transfer to the emergency department for CT angiography
D. Perform an ECG to rule out myocardial infarction
CORRECT ANSWER : C
Rationale: The patient’s symptoms and asymmetric blood pressure readings are classic for
aortic dissection. This is a medical emergency requiring rapid imaging (CTA) and surgical
consultation. D-dimer (A) is not sensitive enough; nitroglycerin (B) could worsen the dissection
by increasing shear stress; an ECG (D) should be done, but it should not delay the emergent
transfer.
3. A 28-year-old female presents with episodic tachycardia, diaphoresis, and severe anxiety-like
symptoms. She reports headaches during these episodes. Blood pressure is 155/95 mmHg.
Which diagnostic test is most specific for identifying the suspected etiology?
A. Serum thyroid-stimulating hormone (TSH)
B. 24-hour ambulatory blood pressure monitoring
C. 24-hour urine fractionated metanephrines and catecholamines
, D. Echocardiogram
CORRECT ANSWER : C
Rationale: The patient's symptoms (headache, sweating, tachycardia) in the setting of
hypertension suggest pheochromocytoma. The 24-hour urine test for metanephrines is the most
sensitive and specific diagnostic test for this condition. TSH (A) would evaluate for
hyperthyroidism; ambulatory monitoring (B) does not identify the cause of secondary
hypertension; an echocardiogram (D) might show structural changes but does not diagnose the
endocrine source.
4. A 55-year-old patient complains of morning stiffness in the hands lasting 90 minutes, bilateral
swelling of the proximal interphalangeal (PIP) joints, and fatigue. Which laboratory finding
would be most supportive of the primary diagnosis?
A. Elevated uric acid
B. Positive Rheumatoid Factor (RF) and Anti-CCP antibodies
C. Positive ANA titer (1:320)
D. Decreased C-reactive protein (CRP)
CORRECT ANSWER : B
Rationale: The prolonged morning stiffness and bilateral PIP joint involvement are hallmark
signs of rheumatoid arthritis (RA). Anti-CCP is highly specific for RA. Uric acid (A) is for gout;
ANA (C) is non-specific and suggests SLE; CRP (D) would typically be elevated in inflammatory
conditions, not decreased.
5. A 35-year-old smoker presents with chronic cough, dyspnea on exertion, and wheezing.
Spirometry shows an $FEV_1/FVC$ ratio of 0.65 that does not improve significantly with
bronchodilators. What is the most likely diagnosis?
A. Asthma
B. Chronic Obstructive Pulmonary Disease (COPD)
C. Bronchiectasis
D. Interstitial lung disease
CORRECT ANSWER : B
Rationale: A fixed or post-bronchodilator $FEV_1/FVC$ ratio below 0.70 is the diagnostic
criteria for COPD. Asthma (A) typically demonstrates significant reversibility with
, bronchodilators; bronchiectasis (C) involves chronic sputum production and structural changes;
interstitial lung disease (D) presents with a restrictive pattern (normal or high $FEV_1/FVC$).
6. A 42-year-old female presents with fatigue, cold intolerance, and constipation. Physical exam
reveals delayed relaxation of deep tendon reflexes and a goiter. Which lab abnormality is most
expected?
A. Suppressed TSH and elevated Free T4
B. Elevated TSH and elevated Free T4
C. Elevated TSH and low Free T4
D. Normal TSH and low Free T3
CORRECT ANSWER : C
Rationale: The clinical signs are classic for primary hypothyroidism. An elevated TSH with a
low Free T4 confirms the diagnosis. Option A indicates hyperthyroidism, B indicates secondary
or tertiary hypothyroidism or pituitary resistance, and D is not a standard diagnostic profile for
primary hypothyroidism.
7. A patient with type 2 diabetes presents for follow-up. Their current A1c is 8.2%. They are
currently on Metformin 1000mg BID. What is the most appropriate next step in management
according to current guidelines?
A. Switch Metformin to a Sulfonylurea
B. Add an SGLT2 inhibitor or GLP-1 receptor agonist
C. Start Basal Insulin immediately
D. Increase Metformin to 2500mg daily
CORRECT ANSWER : B
Rationale: Current ADA guidelines suggest adding an SGLT2i or GLP-1 RA for patients not at
goal on Metformin, especially those with cardiovascular or renal considerations. Sulfonylureas
(A) are second-line but often avoided due to hypoglycemia risk; insulin (C) is usually saved for
later stages; Metformin max dose is generally 2000mg/day (D).
8. A 50-year-old male reports episodic "hot" and swollen right great toe, worsening at night. He
consumed steak and beer the night before. What is the most appropriate definitive diagnostic
test?
A. Serum Uric Acid level
