AGNP MIDTERM 2025 EXAM QUESTIONS
WITH COMPLETE SOLUTIONS!!
1 of 89
Term
An 80-year-old woman has recently had occasional episodes of
feeling "off balance and wobbly." She fell once in the past month
when she lost her balance while walking at a mall where she goes to
exercise. There has been no recent respiratory, gastrointestinal, or
urinary tract infection. History includes osteoarthritis of the hands,
for which she occasionally takes acetaminophen. She takes no other
medications.
On examination, blood pressure is normal, with no orthostatic
hypotension or tachyarrhythmia. There is no evidence of depression
or cognitive decline, as assessed using the Patient Health
Questionnaire-2 and Mini-Mental State Examination. Visual acuity is
,20/30 bilaterally. The whisper test result is positive.
Multifactorial fall risk assessment, including the Timed Up and Go
test, is unremarkable.
Which one of the following is the most likely cause of her
symptoms?
(A) Saccular and semicircular canal dysfunc
Give this one a try later!
(D) Refer to occupational therapy.
For many older adults, driving remains a vital link to community, independence,
mobility, and quality of life. A recommendation not to drive would have major
quality-of-life implications for this socially engaged woman. Occupational
therapists may improve functional abilities in both basic and instrumental
activities of daily living. This patient should be referred to an occupational
therapist with additional training and subspecialty certification in driver
evaluation and treatment. An occupational therapist engaged in driver safety
programs will be able to look both at the patient and her vehicle and provide
adjustments or adaptive equipment (eg, better rearview mirrors) to help her
compensate for deficits (SOE=C). (Options A, D)
The patient’s difficulty with range of motion in her neck and the reported
accidents while backing up her car both suggest that her driving limitation is due
to her neck disease. Exercises involving neck range of motion, as offered in
physical therapy, are helpful in pain management but unlikely to improve range
of motion sufficiently to compensate for her driving difficulties. (Option B)
Although hearing loss is a risk factor for impaired driving, the mild nature of the
patient’s disorder and her major difficulty with cervical arthritis make audiology
evaluation a much lower priority. (Option C)
, (A) Saccular and semicircular canal
Loss of vestibular function is prominent among older adults. Use of the
head impulse test, a measure of semicircular canal function, identified
abnormalities in 35% of adults >70 years old and in 66% of adults ≥80 years
old (SOE=B). Findings on the Modified Romberg Test, a global measure of
the ability to use vestibular information, suggest a prevalence of vestibular
dysfunction ranging from 59% to 69% among adults 70-79 years old and
from 85% to 100% among adults ≥80 years old (SOE=B). This patient's
presentation and symptoms are typical of saccular and semicircular canal
dysfunction. (Option A)
The inner ear includes the cochlea, saccule, semicircular canal, and utricle.
The cochlea provides the auditory function. The saccule is an otolith organ
involved in detecting vertical linear movement and sensing gravitational
change (eg, vertical acceleration when going up in an elevator). The
semicircular canals detect rotational movement of the head, and the
sensory cells in the utricle are sensitive to change in horizontal movement.
In older adults with high-frequency hearing loss, abnormal amplitudes are
evident on cervical vestibular-evoked myogenic potential (c-VEMP) testing
in response to air-conducted sound, which assesses saccular function. The
association between hearing loss and reduced saccular function holds
even after adjusting for shared risk factors, such as increasing age and
noise exposure (SOE=B). In contrast, hearing loss is not associated with
utricular function, confirming preservation of utricular structures with aging.
(A) AsPkohsesribw lyh, atht ebrain
ssgoschiaetriojonyb
. etween cochlear and saccular functions may be
because of their shared embryologic origin. It has been speculated that
This pparte
iesnbtyhcaus isnt(e agrseti-triael alutendg hdeisaerainsge,lo
a scsh)rm
ona iyc,bleifea- c ocithinlegocso
lim ac
ncduitliaorn. She
woulddb eg ee
en nfeitrafrtiovm
e pardovcaenscseincawrh
eicphlasnancin
cu
glator oe tnos u re that her medical care helps
her maintain good quality of life and achieve her goals. This visit is to establish
care; it is an opportunity to get to know her. An effective approach is to ask what
is most important to her in life, such as asking what brings her joy (SOE=C).
(Option A)
Once there is some understanding of what makes life meaningful to this patient,
it would be useful to explore what medical treatments might help her meet her
goals. For patients with serious, life-limiting illness who seek to avoid prolonged
hospitalization and aggressive interventions, it may be appropriate to
recommend a "do not resuscitate" order. However, this recommendation would
be premature without first learning more about the patient's values and goals.
(Option B)
A medical power of attorney is a type of advance directive. It is a legal document
that designates a health care agent to make decisions on a patient's behalf, and
specifies whether it should be put into effect immediately or only in the event
that the patient has an incapacitating medical condition. All patients should be
, encouraged to designate a health care agent, but at this appointment it is more
important to gain a sense of what the patient values. (Option C)
Spirituality is important to many patients, especially when discussing advance
care planning. Many health care providers fear that religiously observant patients
might be hesitant to discuss advance directives. However, in a recent qualitative
study of religious leaders from a variety of backgrounds, leaders were
supportive of discussions of advance directives, especially if spiritual
considerations are included and acknowledged (SOE=C). (Optio
(D) Arrange for her to see an ophthalmologist this week.
Hard drusen—submacular yellow lipoprotein deposits—do not typically cause
loss of vision but are a marker for increased risk of conversion to the wet form of
age-related macular degeneration (AMD), which is characterized by
angiogenesis or choroidal neovascularization. Development of choroidal
neovascularization is signaled by sudden loss or distortion of vision, as this
patient has experienced. Because untreated disease can lead to severe central
vision loss, this patient requires urgent evaluation. (Option D)
The second Age-Related Eye Disease Study (AREDS2) found that the risk of
choroidal neovascularization could be reduced when patients with larger, more
numerous drusen (high-risk drusen) take a combination of zinc, cupric acid,
lutein, zeaxanthin, and vitamins C and E twice daily. Vascular endothelial growth
factor (VEGF) inhibitors are used to treat neovascularization in wet AMD,
preserving vision in most patients and restoring vision in a significant minority
(SOE=A). VEGF inhibitors are administered intraocularly by ophthalmologists.
AREDS2 is recommended for patients with intermediate or advanced dry AMD
and at all stages of wet AMD. This patient would benefit from AREDS2 therapy,
but the more urgent need is for immediate assessment by an ophthalmologist
and consideration for vision sparing/restoring therapy with a VEGF inhibitor.
Smoking increases the risk of macular degeneration. Smoking cessation
combined with AREDS2 treatment is recommended; whether this will prevent
blindness is not known, but unlikely. It is too early to make a low-vision referral
for this patient, and she may regain sufficient vision with VEGF therapy to make
that referral unnecessary. (Options A, B, C)
Don't know?
2 of 89
WITH COMPLETE SOLUTIONS!!
1 of 89
Term
An 80-year-old woman has recently had occasional episodes of
feeling "off balance and wobbly." She fell once in the past month
when she lost her balance while walking at a mall where she goes to
exercise. There has been no recent respiratory, gastrointestinal, or
urinary tract infection. History includes osteoarthritis of the hands,
for which she occasionally takes acetaminophen. She takes no other
medications.
On examination, blood pressure is normal, with no orthostatic
hypotension or tachyarrhythmia. There is no evidence of depression
or cognitive decline, as assessed using the Patient Health
Questionnaire-2 and Mini-Mental State Examination. Visual acuity is
,20/30 bilaterally. The whisper test result is positive.
Multifactorial fall risk assessment, including the Timed Up and Go
test, is unremarkable.
Which one of the following is the most likely cause of her
symptoms?
(A) Saccular and semicircular canal dysfunc
Give this one a try later!
(D) Refer to occupational therapy.
For many older adults, driving remains a vital link to community, independence,
mobility, and quality of life. A recommendation not to drive would have major
quality-of-life implications for this socially engaged woman. Occupational
therapists may improve functional abilities in both basic and instrumental
activities of daily living. This patient should be referred to an occupational
therapist with additional training and subspecialty certification in driver
evaluation and treatment. An occupational therapist engaged in driver safety
programs will be able to look both at the patient and her vehicle and provide
adjustments or adaptive equipment (eg, better rearview mirrors) to help her
compensate for deficits (SOE=C). (Options A, D)
The patient’s difficulty with range of motion in her neck and the reported
accidents while backing up her car both suggest that her driving limitation is due
to her neck disease. Exercises involving neck range of motion, as offered in
physical therapy, are helpful in pain management but unlikely to improve range
of motion sufficiently to compensate for her driving difficulties. (Option B)
Although hearing loss is a risk factor for impaired driving, the mild nature of the
patient’s disorder and her major difficulty with cervical arthritis make audiology
evaluation a much lower priority. (Option C)
, (A) Saccular and semicircular canal
Loss of vestibular function is prominent among older adults. Use of the
head impulse test, a measure of semicircular canal function, identified
abnormalities in 35% of adults >70 years old and in 66% of adults ≥80 years
old (SOE=B). Findings on the Modified Romberg Test, a global measure of
the ability to use vestibular information, suggest a prevalence of vestibular
dysfunction ranging from 59% to 69% among adults 70-79 years old and
from 85% to 100% among adults ≥80 years old (SOE=B). This patient's
presentation and symptoms are typical of saccular and semicircular canal
dysfunction. (Option A)
The inner ear includes the cochlea, saccule, semicircular canal, and utricle.
The cochlea provides the auditory function. The saccule is an otolith organ
involved in detecting vertical linear movement and sensing gravitational
change (eg, vertical acceleration when going up in an elevator). The
semicircular canals detect rotational movement of the head, and the
sensory cells in the utricle are sensitive to change in horizontal movement.
In older adults with high-frequency hearing loss, abnormal amplitudes are
evident on cervical vestibular-evoked myogenic potential (c-VEMP) testing
in response to air-conducted sound, which assesses saccular function. The
association between hearing loss and reduced saccular function holds
even after adjusting for shared risk factors, such as increasing age and
noise exposure (SOE=B). In contrast, hearing loss is not associated with
utricular function, confirming preservation of utricular structures with aging.
(A) AsPkohsesribw lyh, atht ebrain
ssgoschiaetriojonyb
. etween cochlear and saccular functions may be
because of their shared embryologic origin. It has been speculated that
This pparte
iesnbtyhcaus isnt(e agrseti-triael alutendg hdeisaerainsge,lo
a scsh)rm
ona iyc,bleifea- c ocithinlegocso
lim ac
ncduitliaorn. She
woulddb eg ee
en nfeitrafrtiovm
e pardovcaenscseincawrh
eicphlasnancin
cu
glator oe tnos u re that her medical care helps
her maintain good quality of life and achieve her goals. This visit is to establish
care; it is an opportunity to get to know her. An effective approach is to ask what
is most important to her in life, such as asking what brings her joy (SOE=C).
(Option A)
Once there is some understanding of what makes life meaningful to this patient,
it would be useful to explore what medical treatments might help her meet her
goals. For patients with serious, life-limiting illness who seek to avoid prolonged
hospitalization and aggressive interventions, it may be appropriate to
recommend a "do not resuscitate" order. However, this recommendation would
be premature without first learning more about the patient's values and goals.
(Option B)
A medical power of attorney is a type of advance directive. It is a legal document
that designates a health care agent to make decisions on a patient's behalf, and
specifies whether it should be put into effect immediately or only in the event
that the patient has an incapacitating medical condition. All patients should be
, encouraged to designate a health care agent, but at this appointment it is more
important to gain a sense of what the patient values. (Option C)
Spirituality is important to many patients, especially when discussing advance
care planning. Many health care providers fear that religiously observant patients
might be hesitant to discuss advance directives. However, in a recent qualitative
study of religious leaders from a variety of backgrounds, leaders were
supportive of discussions of advance directives, especially if spiritual
considerations are included and acknowledged (SOE=C). (Optio
(D) Arrange for her to see an ophthalmologist this week.
Hard drusen—submacular yellow lipoprotein deposits—do not typically cause
loss of vision but are a marker for increased risk of conversion to the wet form of
age-related macular degeneration (AMD), which is characterized by
angiogenesis or choroidal neovascularization. Development of choroidal
neovascularization is signaled by sudden loss or distortion of vision, as this
patient has experienced. Because untreated disease can lead to severe central
vision loss, this patient requires urgent evaluation. (Option D)
The second Age-Related Eye Disease Study (AREDS2) found that the risk of
choroidal neovascularization could be reduced when patients with larger, more
numerous drusen (high-risk drusen) take a combination of zinc, cupric acid,
lutein, zeaxanthin, and vitamins C and E twice daily. Vascular endothelial growth
factor (VEGF) inhibitors are used to treat neovascularization in wet AMD,
preserving vision in most patients and restoring vision in a significant minority
(SOE=A). VEGF inhibitors are administered intraocularly by ophthalmologists.
AREDS2 is recommended for patients with intermediate or advanced dry AMD
and at all stages of wet AMD. This patient would benefit from AREDS2 therapy,
but the more urgent need is for immediate assessment by an ophthalmologist
and consideration for vision sparing/restoring therapy with a VEGF inhibitor.
Smoking increases the risk of macular degeneration. Smoking cessation
combined with AREDS2 treatment is recommended; whether this will prevent
blindness is not known, but unlikely. It is too early to make a low-vision referral
for this patient, and she may regain sufficient vision with VEGF therapy to make
that referral unnecessary. (Options A, B, C)
Don't know?
2 of 89
