NR511 FINAL EXAM 2026/2027 | Differential Diagnosis &
Primary Care Practicum | Latest Q&A Verified | Chamberlain |
Pass Guaranteed - A+ Graded
Q1: A 58-year-old male presents with crushing substernal chest pain radiating to his left
arm, onset 30 minutes ago while mowing lawn. He is diaphoretic, nauseated, and has a
blood pressure of 88/52 mmHg with heart rate 110 bpm. EKG shows ST elevations in
leads V1-V4. Which is the most appropriate immediate management?
A. Administer aspirin 325 mg, sublingual nitroglycerin, and schedule urgent stress test
for tomorrow
B. Give aspirin 325 mg, clopidogrel 600 mg loading dose, and arrange for immediate
percutaneous coronary intervention (PCI) within 90 minutes [CORRECT]
C. Administer aspirin, start heparin drip, and observe in emergency department for 24
hours
D. Give aspirin, morphine 4 mg IV, and obtain CT coronary angiography to confirm
diagnosis
Correct Answer: B
Rationale: Correct: This patient presents with an ST-elevation myocardial infarction
(STEMI) based on the classic presentation of crushing substernal chest pain with
radiation, autonomic symptoms (diaphoresis, nausea), hypotension, tachycardia, and
EKG findings of ST elevations in the anteroseptal leads (V1-V4). The 2013 ACCF/AHA
Guideline for the Management of STEMI mandates immediate reperfusion therapy.
Primary PCI is the preferred strategy with a door-to-balloon time of ≤90 minutes. Dual
antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or
prasugrel) is standard. The patient's hemodynamic instability (hypotension) further
supports the need for immediate revascularization.
,Incorrect Options:
● A is incorrect because stress testing is contraindicated in acute STEMI and
urgent PCI is required, not delayed testing.
● C is incorrect because observation alone without reperfusion therapy results in
unacceptable mortality; fibrinolysis or PCI must be performed.
● D is incorrect because CT coronary angiography is not indicated in STEMI and
delays critical reperfusion therapy; morphine should be used cautiously and is
not the priority over reperfusion.
Clinical Pearl: "Time is muscle" in STEMI—door-to-balloon ≤90 minutes or door-to-needle
≤30 minutes if PCI unavailable. Always obtain a 12-lead EKG within 10 minutes of arrival
for suspected ACS.
Guideline Reference: 2013 ACCF/AHA Guideline for the Management of ST-Elevation
Myocardial Infarction; 2021 ACC/AHA/Society for Cardiovascular Angiography and
Interventions Guideline for Coronary Artery Revascularization.
Q2: A 45-year-old female with a history of hypertension presents with episodic
headaches described as bilateral pressure, band-like, lasting 4-6 hours, associated with
neck stiffness but no nausea, photophobia, or phonophobia. She reports high stress at
work. Physical exam is unremarkable. Which is the most likely diagnosis?
A. Migraine without aura
B. Tension-type headache [CORRECT]
C. Cluster headache
D. Medication overuse headache
Correct Answer: B
Rationale: Correct: This patient has tension-type headache (TTH), the most common
primary headache disorder. The ICHD-3 criteria (2018) require at least two of: bilateral
location, pressing/tightening quality, mild/moderate intensity, and not aggravated by
,routine physical activity. She has no nausea/vomiting (though mild
photophobia/phonophobia allowed in infrequent episodic TTH) and has pericranial
muscle tenderness (neck stiffness). The stress trigger and band-like quality are classic.
TTH is classified as infrequent episodic (<1 day/month), frequent episodic (1-14
days/month), or chronic (≥15 days/month).
Incorrect Options:
● A is incorrect because migraines are typically unilateral, pulsating,
moderate/severe, aggravated by activity, and associated with nausea and/or
photophobia and phonophobia—none of which are present.
● C is incorrect because cluster headaches are strictly unilateral,
orbital/supraorbital/temporal, severe, with autonomic features (lacrimation, nasal
congestion, ptosis) and restlessness, lasting 15-180 minutes.
● D is incorrect because there is no history of frequent analgesic use (≥10-15
days/month depending on medication class) required for this diagnosis.
Clinical Pearl: Tension-type headache is often responsive to NSAIDs or acetaminophen.
For chronic TTH, amitriptyline is first-line prophylaxis. Stress management and physical
therapy for pericranial muscle tension are important non-pharmacologic interventions.
Guideline Reference: International Classification of Headache Disorders, 3rd Edition
(ICHD-3), 2018; American Headache Society Guidelines, 2019.
Q3: A 32-year-old female presents with dysuria, frequency, and urgency for 2 days. She
denies fever, flank pain, or vaginal discharge. Urinalysis shows positive nitrites,
leukocyte esterase, and 50-100 WBCs/hpf. She is not pregnant and has no drug
allergies. Which is the most appropriate empiric antibiotic therapy?
A. Ciprofloxacin 500 mg BID for 3 days
B. Trimethoprim-sulfamethoxazole (TMP-SMX) DS 1 tab BID for 3 days
C. Nitrofurantoin 100 mg BID for 5 days [CORRECT]
D. Amoxicillin 500 mg TID for 7 days
, Correct Answer: C
Rationale: Correct: This patient has uncomplicated cystitis (lower urinary tract infection)
in a non-pregnant female. The 2010 IDSA/ESMID guidelines and 2024 updates
recommend nitrofurantoin as first-line empiric therapy due to excellent efficacy and
minimal resistance. Nitrofurantoin 100 mg twice daily for 5 days achieves high urinary
concentrations without significant systemic absorption, preserving gut flora and
reducing resistance. It is safe in pregnancy (Category B) except at term (38-42 weeks).
Fosfomycin 3g single dose and pivmecillinam (where available) are alternatives.
Incorrect Options:
● A is incorrect because fluoroquinolones are reserved for complicated UTIs or
when first-line agents cannot be used due to adverse effects on
collagen/connective tissue, QT prolongation, and rising resistance; 3-day course
is insufficient.
● B is incorrect because TMP-SMX resistance exceeds 20% in many regions; it
should only be used if local resistance <20% and patient has no sulfa allergy;
3-day regimen is standard but nitrofurantoin is preferred first-line.
● D is incorrect because amoxicillin has high resistance rates (>30%) and is not
recommended for empiric therapy; 7-day course is longer than necessary for
uncomplicated cystitis.
Clinical Pearl: Always obtain urine culture before starting antibiotics in complicated
UTIs, recurrent infections, or atypical presentations. For uncomplicated cystitis, urine
culture is not routinely needed unless symptoms persist after treatment.
Guideline Reference: IDSA/ESMID Guidelines for Treatment of Uncomplicated Urinary
Tract Infections, 2010 (updated 2024); AUA Best Practice Statement, 2022.
Q4: A 67-year-old male with COPD (GOLD Group D) presents with increased dyspnea,
sputum volume, and purulence for 3 days. He is afebrile, oxygen saturation 88% on
room air, and has diffuse wheezing. Which is the most appropriate initial management?
Primary Care Practicum | Latest Q&A Verified | Chamberlain |
Pass Guaranteed - A+ Graded
Q1: A 58-year-old male presents with crushing substernal chest pain radiating to his left
arm, onset 30 minutes ago while mowing lawn. He is diaphoretic, nauseated, and has a
blood pressure of 88/52 mmHg with heart rate 110 bpm. EKG shows ST elevations in
leads V1-V4. Which is the most appropriate immediate management?
A. Administer aspirin 325 mg, sublingual nitroglycerin, and schedule urgent stress test
for tomorrow
B. Give aspirin 325 mg, clopidogrel 600 mg loading dose, and arrange for immediate
percutaneous coronary intervention (PCI) within 90 minutes [CORRECT]
C. Administer aspirin, start heparin drip, and observe in emergency department for 24
hours
D. Give aspirin, morphine 4 mg IV, and obtain CT coronary angiography to confirm
diagnosis
Correct Answer: B
Rationale: Correct: This patient presents with an ST-elevation myocardial infarction
(STEMI) based on the classic presentation of crushing substernal chest pain with
radiation, autonomic symptoms (diaphoresis, nausea), hypotension, tachycardia, and
EKG findings of ST elevations in the anteroseptal leads (V1-V4). The 2013 ACCF/AHA
Guideline for the Management of STEMI mandates immediate reperfusion therapy.
Primary PCI is the preferred strategy with a door-to-balloon time of ≤90 minutes. Dual
antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or
prasugrel) is standard. The patient's hemodynamic instability (hypotension) further
supports the need for immediate revascularization.
,Incorrect Options:
● A is incorrect because stress testing is contraindicated in acute STEMI and
urgent PCI is required, not delayed testing.
● C is incorrect because observation alone without reperfusion therapy results in
unacceptable mortality; fibrinolysis or PCI must be performed.
● D is incorrect because CT coronary angiography is not indicated in STEMI and
delays critical reperfusion therapy; morphine should be used cautiously and is
not the priority over reperfusion.
Clinical Pearl: "Time is muscle" in STEMI—door-to-balloon ≤90 minutes or door-to-needle
≤30 minutes if PCI unavailable. Always obtain a 12-lead EKG within 10 minutes of arrival
for suspected ACS.
Guideline Reference: 2013 ACCF/AHA Guideline for the Management of ST-Elevation
Myocardial Infarction; 2021 ACC/AHA/Society for Cardiovascular Angiography and
Interventions Guideline for Coronary Artery Revascularization.
Q2: A 45-year-old female with a history of hypertension presents with episodic
headaches described as bilateral pressure, band-like, lasting 4-6 hours, associated with
neck stiffness but no nausea, photophobia, or phonophobia. She reports high stress at
work. Physical exam is unremarkable. Which is the most likely diagnosis?
A. Migraine without aura
B. Tension-type headache [CORRECT]
C. Cluster headache
D. Medication overuse headache
Correct Answer: B
Rationale: Correct: This patient has tension-type headache (TTH), the most common
primary headache disorder. The ICHD-3 criteria (2018) require at least two of: bilateral
location, pressing/tightening quality, mild/moderate intensity, and not aggravated by
,routine physical activity. She has no nausea/vomiting (though mild
photophobia/phonophobia allowed in infrequent episodic TTH) and has pericranial
muscle tenderness (neck stiffness). The stress trigger and band-like quality are classic.
TTH is classified as infrequent episodic (<1 day/month), frequent episodic (1-14
days/month), or chronic (≥15 days/month).
Incorrect Options:
● A is incorrect because migraines are typically unilateral, pulsating,
moderate/severe, aggravated by activity, and associated with nausea and/or
photophobia and phonophobia—none of which are present.
● C is incorrect because cluster headaches are strictly unilateral,
orbital/supraorbital/temporal, severe, with autonomic features (lacrimation, nasal
congestion, ptosis) and restlessness, lasting 15-180 minutes.
● D is incorrect because there is no history of frequent analgesic use (≥10-15
days/month depending on medication class) required for this diagnosis.
Clinical Pearl: Tension-type headache is often responsive to NSAIDs or acetaminophen.
For chronic TTH, amitriptyline is first-line prophylaxis. Stress management and physical
therapy for pericranial muscle tension are important non-pharmacologic interventions.
Guideline Reference: International Classification of Headache Disorders, 3rd Edition
(ICHD-3), 2018; American Headache Society Guidelines, 2019.
Q3: A 32-year-old female presents with dysuria, frequency, and urgency for 2 days. She
denies fever, flank pain, or vaginal discharge. Urinalysis shows positive nitrites,
leukocyte esterase, and 50-100 WBCs/hpf. She is not pregnant and has no drug
allergies. Which is the most appropriate empiric antibiotic therapy?
A. Ciprofloxacin 500 mg BID for 3 days
B. Trimethoprim-sulfamethoxazole (TMP-SMX) DS 1 tab BID for 3 days
C. Nitrofurantoin 100 mg BID for 5 days [CORRECT]
D. Amoxicillin 500 mg TID for 7 days
, Correct Answer: C
Rationale: Correct: This patient has uncomplicated cystitis (lower urinary tract infection)
in a non-pregnant female. The 2010 IDSA/ESMID guidelines and 2024 updates
recommend nitrofurantoin as first-line empiric therapy due to excellent efficacy and
minimal resistance. Nitrofurantoin 100 mg twice daily for 5 days achieves high urinary
concentrations without significant systemic absorption, preserving gut flora and
reducing resistance. It is safe in pregnancy (Category B) except at term (38-42 weeks).
Fosfomycin 3g single dose and pivmecillinam (where available) are alternatives.
Incorrect Options:
● A is incorrect because fluoroquinolones are reserved for complicated UTIs or
when first-line agents cannot be used due to adverse effects on
collagen/connective tissue, QT prolongation, and rising resistance; 3-day course
is insufficient.
● B is incorrect because TMP-SMX resistance exceeds 20% in many regions; it
should only be used if local resistance <20% and patient has no sulfa allergy;
3-day regimen is standard but nitrofurantoin is preferred first-line.
● D is incorrect because amoxicillin has high resistance rates (>30%) and is not
recommended for empiric therapy; 7-day course is longer than necessary for
uncomplicated cystitis.
Clinical Pearl: Always obtain urine culture before starting antibiotics in complicated
UTIs, recurrent infections, or atypical presentations. For uncomplicated cystitis, urine
culture is not routinely needed unless symptoms persist after treatment.
Guideline Reference: IDSA/ESMID Guidelines for Treatment of Uncomplicated Urinary
Tract Infections, 2010 (updated 2024); AUA Best Practice Statement, 2022.
Q4: A 67-year-old male with COPD (GOLD Group D) presents with increased dyspnea,
sputum volume, and purulence for 3 days. He is afebrile, oxygen saturation 88% on
room air, and has diffuse wheezing. Which is the most appropriate initial management?
