Barkley Board Certification Readiness Exam – 100
Comprehensive NP Questions & Verified Answers 2026-
2027
SECTION 1: ASSESSMENT & DIAGNOSIS (Questions 1-25)
1. A 55-year-old woman presents with fatigue, weight gain, constipation, and cold
intolerance. Her TSH is elevated and free T4 is low. What is the most likely
diagnosis?
A. Graves' disease
B. Hashimoto's thyroiditis
C. Subclinical hyperthyroidism
D. Sick euthyroid syndrome
Answer: B
Rationale: Elevated TSH with low free T4 indicates primary hypothyroidism. The most
common cause in the U.S. is Hashimoto's thyroiditis, an autoimmune destruction of the
thyroid gland.
2. A 70-year-old man reports a progressively worsening tremor when his hands are
at rest, along with rigidity and a slow, shuffling gait. Which diagnosis is most
likely?
A. Essential tremor
B. Parkinson's disease
C. Normal pressure hydrocephalus
D. Amyotrophic lateral sclerosis
Answer: B
,Rationale: The classic triad of Parkinson's disease is resting tremor, rigidity, and
bradykinesia. Postural instability and shuffling gait are additional features. Essential
tremor is an action tremor, not a resting tremor.
3. A 62-year-old woman presents with fever, flank pain, and dysuria. Urinalysis
shows >10 WBC/hpf, nitrites, and leukocyte esterase. What is the most likely
diagnosis?
A. Uncomplicated cystitis
B. Acute pyelonephritis
C. Renal abscess
D. Interstitial nephritis
Answer: B
Rationale: Fever, flank pain (CVA tenderness), and pyuria indicate an upper urinary tract
infection (pyelonephritis) rather than simple cystitis, which would present with dysuria
and frequency without systemic symptoms.
4. A 34-year-old woman has a discrete, mobile, rubbery lump in her right breast.
She reports no pain, and there is no nipple discharge. She is premenopausal. What
is the most appropriate next step?
A. Reassure her that it is likely benign
B. Order a diagnostic mammogram and ultrasound
C. Schedule a fine-needle aspiration in 6 months
D. Refer for genetic testing
Answer: B
Rationale: In a woman ≥30 years with a palpable breast mass, the standard evaluation
is a diagnostic mammogram and targeted ultrasound to characterize the lesion.
Fibroadenomas are common in this age group but imaging is required to confirm.
,5. Which of the following is a first-line screening test for colorectal cancer in an
average-risk 50-year-old?
A. Barium enema every 5 years
B. Colonoscopy every 10 years
C. CT colonography every 10 years
D. Fecal immunochemical test (FIT) annually
Answer: D
Rationale: The USPSTF recommends screening with high-sensitivity FIT annually,
colonoscopy every 10 years, or other methods. FIT is a Grade A recommendation and is
a stool-based first-line option.
6. A 48-year-old man presents with crushing substernal chest pain radiating to the
left arm, diaphoresis, and nausea. ECG shows ST-segment elevation in leads II, III,
and aVF. What artery is most likely occluded?
A. Left anterior descending
B. Right coronary artery
C. Left circumflex
D. Left main
Answer: B
Rationale: ST elevation in inferior leads (II, III, aVF) typically indicates an inferior wall MI,
most often due to occlusion of the right coronary artery in right-dominant circulation.
7. A 25-year-old woman has sudden-onset severe lower abdominal pain and
amenorrhea for 6 weeks. She is tachycardic and hypotensive. Pregnancy test is
positive. What is the priority diagnosis to rule out?
A. Appendicitis
B. Ruptured ovarian cyst
, C. Ectopic pregnancy
D. Pelvic inflammatory disease
Answer: C
Rationale: Positive pregnancy test with acute abdominal pain and hemodynamic
instability strongly suggests a ruptured ectopic pregnancy, which is a life-threatening
emergency requiring immediate surgical intervention.
8. 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. What is the most likely diagnosis and the greatest risk?
A. Popliteal artery aneurysm; rupture and acute limb ischemia
B. Baker's cyst; rupture and pseudothrombophlebitis
C. Femoral artery aneurysm; thrombosis
D. Deep vein thrombosis; pulmonary embolism
Answer: A
Rationale: A popliteal artery aneurysm (PAA) is defined as focal dilation >1.5 cm,
strongly associated with other aneurysms and atherosclerotic disease. The most serious
complications are thrombosis or distal embolization leading to acute limb ischemia, and
rupture. Baker's cyst is non-pulsatile and associated with knee joint pathology.
9. A 54-year-old woman with a history of atrial fibrillation presents with acute
onset of severe, diffuse abdominal pain. She is diaphoretic and hypotensive. The
abdomen is soft with mild tenderness. Lactate is 6.2 mmol/L. What is the most
likely diagnosis?
A. Acute pancreatitis
B. Mesenteric ischemia
C. Ruptured abdominal aortic aneurysm
D. Diverticulitis with perforation
Comprehensive NP Questions & Verified Answers 2026-
2027
SECTION 1: ASSESSMENT & DIAGNOSIS (Questions 1-25)
1. A 55-year-old woman presents with fatigue, weight gain, constipation, and cold
intolerance. Her TSH is elevated and free T4 is low. What is the most likely
diagnosis?
A. Graves' disease
B. Hashimoto's thyroiditis
C. Subclinical hyperthyroidism
D. Sick euthyroid syndrome
Answer: B
Rationale: Elevated TSH with low free T4 indicates primary hypothyroidism. The most
common cause in the U.S. is Hashimoto's thyroiditis, an autoimmune destruction of the
thyroid gland.
2. A 70-year-old man reports a progressively worsening tremor when his hands are
at rest, along with rigidity and a slow, shuffling gait. Which diagnosis is most
likely?
A. Essential tremor
B. Parkinson's disease
C. Normal pressure hydrocephalus
D. Amyotrophic lateral sclerosis
Answer: B
,Rationale: The classic triad of Parkinson's disease is resting tremor, rigidity, and
bradykinesia. Postural instability and shuffling gait are additional features. Essential
tremor is an action tremor, not a resting tremor.
3. A 62-year-old woman presents with fever, flank pain, and dysuria. Urinalysis
shows >10 WBC/hpf, nitrites, and leukocyte esterase. What is the most likely
diagnosis?
A. Uncomplicated cystitis
B. Acute pyelonephritis
C. Renal abscess
D. Interstitial nephritis
Answer: B
Rationale: Fever, flank pain (CVA tenderness), and pyuria indicate an upper urinary tract
infection (pyelonephritis) rather than simple cystitis, which would present with dysuria
and frequency without systemic symptoms.
4. A 34-year-old woman has a discrete, mobile, rubbery lump in her right breast.
She reports no pain, and there is no nipple discharge. She is premenopausal. What
is the most appropriate next step?
A. Reassure her that it is likely benign
B. Order a diagnostic mammogram and ultrasound
C. Schedule a fine-needle aspiration in 6 months
D. Refer for genetic testing
Answer: B
Rationale: In a woman ≥30 years with a palpable breast mass, the standard evaluation
is a diagnostic mammogram and targeted ultrasound to characterize the lesion.
Fibroadenomas are common in this age group but imaging is required to confirm.
,5. Which of the following is a first-line screening test for colorectal cancer in an
average-risk 50-year-old?
A. Barium enema every 5 years
B. Colonoscopy every 10 years
C. CT colonography every 10 years
D. Fecal immunochemical test (FIT) annually
Answer: D
Rationale: The USPSTF recommends screening with high-sensitivity FIT annually,
colonoscopy every 10 years, or other methods. FIT is a Grade A recommendation and is
a stool-based first-line option.
6. A 48-year-old man presents with crushing substernal chest pain radiating to the
left arm, diaphoresis, and nausea. ECG shows ST-segment elevation in leads II, III,
and aVF. What artery is most likely occluded?
A. Left anterior descending
B. Right coronary artery
C. Left circumflex
D. Left main
Answer: B
Rationale: ST elevation in inferior leads (II, III, aVF) typically indicates an inferior wall MI,
most often due to occlusion of the right coronary artery in right-dominant circulation.
7. A 25-year-old woman has sudden-onset severe lower abdominal pain and
amenorrhea for 6 weeks. She is tachycardic and hypotensive. Pregnancy test is
positive. What is the priority diagnosis to rule out?
A. Appendicitis
B. Ruptured ovarian cyst
, C. Ectopic pregnancy
D. Pelvic inflammatory disease
Answer: C
Rationale: Positive pregnancy test with acute abdominal pain and hemodynamic
instability strongly suggests a ruptured ectopic pregnancy, which is a life-threatening
emergency requiring immediate surgical intervention.
8. 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. What is the most likely diagnosis and the greatest risk?
A. Popliteal artery aneurysm; rupture and acute limb ischemia
B. Baker's cyst; rupture and pseudothrombophlebitis
C. Femoral artery aneurysm; thrombosis
D. Deep vein thrombosis; pulmonary embolism
Answer: A
Rationale: A popliteal artery aneurysm (PAA) is defined as focal dilation >1.5 cm,
strongly associated with other aneurysms and atherosclerotic disease. The most serious
complications are thrombosis or distal embolization leading to acute limb ischemia, and
rupture. Baker's cyst is non-pulsatile and associated with knee joint pathology.
9. A 54-year-old woman with a history of atrial fibrillation presents with acute
onset of severe, diffuse abdominal pain. She is diaphoretic and hypotensive. The
abdomen is soft with mild tenderness. Lactate is 6.2 mmol/L. What is the most
likely diagnosis?
A. Acute pancreatitis
B. Mesenteric ischemia
C. Ruptured abdominal aortic aneurysm
D. Diverticulitis with perforation
