NR667 CEA Final Exam Study Guide ACTUAL
EXAM 2026/2027 | Nurse Practitioner | 100
Practice Questions | Verified Q&A | Pass
Guaranteed - A+ Graded
Domain 1: Assessment & Differential Diagnosis (Questions 1–20)
Q1: A 52-year-old female presents with a 3-week history of intermittent substernal chest pressure that
occurs during brisk walking and resolves within 5 minutes of stopping. She has hypertension treated
with HCTZ and a 30-pack-year smoking history. Resting ECG is normal. What is the most appropriate
next step?
A. Order a chest X-ray and complete blood count
B. Prescribe ibuprofen as needed for suspected musculoskeletal pain
C. Refer for an exercise stress test [CORRECT]
D. Reassure the patient and schedule a follow-up in 6 months
Correct Answer: C
Rationale: This patient has typical exertional chest pressure (stable angina) with two major cardiac risk
factors (HTN, smoking). An exercise stress test is indicated to evaluate for obstructive coronary artery
disease per ACC/AHA guidelines for intermediate-risk patients with stable chest pain. Option A is not
indicated without pulmonary symptoms or signs of infection. Option B is dangerous given the typical
angina pattern and could mask symptoms of an acute coronary syndrome. Option D delays diagnosis of
potentially life-threatening disease and violates standard of care for new-onset chest pain in high-risk
patients. (NR667 CEA Competency: Cardiovascular assessment and diagnostic reasoning; NONPF
Competency: Independent Practice.)
Clinical Pearl: Any new chest pain in a patient >40 years with cardiac risk factors requires cardiac
workup before attributing to musculoskeletal causes.
Q2: A 28-year-old male presents with sudden onset of unilateral facial droop, inability to close his right
eye, and decreased taste on the anterior two-thirds of his tongue. He denies limb weakness or speech
difficulties. On exam, he can raise his eyebrows symmetrically. Which diagnosis is most likely?
A. Central stroke (middle cerebral artery territory)
B. Bell's palsy (idiopathic facial nerve palsy) [CORRECT]
,C. Ramsay Hunt syndrome
D. Brainstem stroke
Correct Answer: B
Rationale: The presentation of isolated lower motor neuron facial weakness (forehead involvement with
inability to close eye) without other neurological deficits is classic for Bell's palsy. The preserved
eyebrow raising actually suggests upper motor neuron pattern (central), but the inability to close the
eye indicates lower motor neuron involvement of cranial nerve VII—this is the key distinguishing
feature. Option A would typically spare the forehead (upper face has bilateral cortical innervation) and
would likely include arm/leg weakness or aphasia. Option C would present with vesicular rash in the ear
canal. Option D would cause additional cranial nerve deficits or long tract signs. (NR667 CEA
Competency: Neurological assessment; NONPF Competency: Independent Practice.)
Clinical Pearl: In facial palsy, "forehead sparing" = upper motor neuron (central); "forehead
involvement" = lower motor neuron (peripheral/Bell's palsy).
Q3: A 45-year-old female presents with fatigue, weight gain, cold intolerance, and dry skin. Labs: TSH
12.4 mIU/L (normal 0.4–4.0), free T4 0.6 ng/dL (normal 0.8–1.8). She is trying to conceive. What is the
most appropriate initial treatment?
A. Begin levothyroxine 25 mcg daily and recheck TSH in 6 months
B. Begin levothyroxine 75 mcg daily with goal TSH <2.5 mIU/L [CORRECT]
C. Begin liothyronine (T3) 5 mcg BID for faster symptom relief
D. Reassure and monitor; subclinical hypothyroidism does not require treatment
Correct Answer: B
Rationale: This patient has overt hypothyroidism (elevated TSH, low free T4) with symptoms. For
women trying to conceive, the AACE/ATA guidelines recommend treatment with levothyroxine to
achieve TSH <2.5 mIU/L preconception to reduce risk of miscarriage and adverse fetal
neurodevelopmental outcomes. Option A underdoses a symptomatic patient and delays optimal
preconception TSH goals. Option C is inappropriate as T3 monotherapy is not recommended for primary
hypothyroidism and carries cardiovascular risks. Option D is incorrect because this is overt, not
subclinical, hypothyroidism with clear symptoms requiring treatment. (NR667 CEA Competency:
Endocrine management; NONPF Competency: Independent Practice.)
Clinical Pearl: Preconception TSH goal for hypothyroid women is <2.5; first-trimester goal is <2.5,
second/third trimester <3.0.
Q4: A 68-year-old male with HTN and DM presents for annual wellness visit. His blood pressure today is
152/88 mmHg. His home meds are lisinopril 10 mg daily and metformin 1000 mg BID. Last A1c was 7.2%
three months ago. What is the most appropriate next step?
,A. Increase lisinopril to 20 mg daily and add amlodipine 5 mg daily [CORRECT]
B. Add hydrochlorothiazide 25 mg daily to current regimen
C. Increase metformin to 1000 mg TID to improve glycemic control first
D. Reassure; blood pressure is acceptable for his age
Correct Answer: A
Rationale: Per ACC/AHA 2017 guidelines, target BP for patients with DM is <130/80. Current reading of
152/88 indicates uncontrolled hypertension requiring intensification. The patient is already on ACE
inhibitor at low dose; uptitrating to maximum tolerated dose (20–40 mg) is appropriate before adding
another agent. If BP remains >130/80 after maximum ACEI, add a calcium channel blocker (amlodipine)
per the "A+C" combination preferred for Black patients or those with DM. Option B is reasonable but
thiazides are less preferred in DM due to metabolic effects on glucose and potassium. Option C
addresses the wrong problem—A1c of 7.2% is at goal (<7.0% for many older adults). Option D is
dangerous; cardiovascular risk increases significantly with uncontrolled BP in diabetic patients. (NR667
CEA Competency: Cardiovascular pharmacology; NONPF Competency: Independent Practice.)
Clinical Pearl: In DM, treat BP to <130/80; start with ACEI/ARB, then add CCB before thiazide when
possible.
Q5: A 34-year-old female presents with a 2-day history of dysuria, frequency, and urgency. She denies
fever, flank pain, or vaginal discharge. Urinalysis shows positive nitrites, leukocyte esterase, and 25–50
WBC/hpf. Which is the most appropriate empiric antibiotic?
A. Ciprofloxacin 250 mg BID for 3 days
B. Nitrofurantoin 100 mg BID for 5 days [CORRECT]
C. Trimethoprim-sulfamethoxazole DS BID for 7 days
D. Amoxicillin 500 mg TID for 10 days
Correct Answer: B
Rationale: This is an uncomplicated lower UTI (cystitis) in a non-pregnant female. IDSA/ESMID guidelines
recommend nitrofurantoin for 5 days as first-line empiric therapy due to excellent efficacy and low
resistance rates. Option A (fluoroquinolone) is reserved for complicated UTIs or pyelonephritis due to
safety concerns (tendon rupture, QT prolongation, aortic aneurysm risk) and should not be first-line for
uncomplicated cystitis. Option C (TMP-SMX) is appropriate only if local resistance is <20% and no sulfa
allergy; however, nitrofurantoin is preferred when available. Option D (amoxicillin) has high resistance
rates (>20%) and is not recommended for empiric therapy. (NR667 CEA Competency: Infectious disease
pharmacology; NONPF Competency: Independent Practice.)
Clinical Pearl: First-line for uncomplicated cystitis: nitrofurantoin 5 days, TMP-SMX 3 days (if resistance
<20%), or fosfomycin single dose.
, Q6: A 19-year-old college student presents with sore throat, fever of 101.2°F, and tender anterior
cervical lymphadenopathy. She denies cough. Rapid strep test is negative. What is the next best action?
A. Prescribe amoxicillin empirically for presumed streptococcal pharyngitis
B. Send throat culture and treat only if positive [CORRECT]
C. Prescribe azithromycin to cover atypical organisms
D. Recommend symptomatic care only; viral pharyngitis is most likely
Correct Answer: B
Rationale: The Centor/McIsaac criteria (fever, tonsillar exudates, tender anterior cervical nodes,
absence of cough, age 3–14 = +1 point; age 15–44 = 0 points; age >45 = -1 point) estimate pre-test
probability. This patient scores 3–4 points, indicating moderate-high probability of group A
streptococcus (GAS). With a negative rapid antigen detection test (RADT), the IDSA guidelines
recommend sending a throat culture because RADT sensitivity is 70–90%; a backup culture is required
for children/adolescents to prevent missed rheumatic fever risk. Option A is inappropriate without
confirmed GAS—unnecessary antibiotics increase resistance and side effects. Option C is unnecessary as
atypicals do not cause pharyngitis. Option D misses the 10–20% false-negative rate of RADT in
moderate-high probability patients. (NR667 CEA Competency: Infectious disease diagnosis; NONPF
Competency: Independent Practice.)
Clinical Pearl: Negative RADT in adults with Centor 0–1: no culture needed. Centor ≥2 or children: send
backup culture.
Q7: A 55-year-old male presents with progressive dyspnea on exertion, orthopnea, and bilateral lower
extremity edema. He has a history of alcohol use disorder (1 pint vodka daily for 20 years). Physical
exam reveals elevated JVP, S3 gallop, and hepatomegaly. ECG shows sinus tachycardia and low voltage.
Chest X-ray shows cardiomegaly and pulmonary vascular congestion. Echocardiogram shows global
hypokinesis with EF 25%. Which type of cardiomyopathy is most likely?
A. Hypertrophic cardiomyopathy
B. Dilated cardiomyopathy [CORRECT]
C. Restrictive cardiomyopathy
D. Arrhythmogenic right ventricular cardiomyopathy
Correct Answer: B
Rationale: The clinical picture of systolic heart failure with global hypokinesis, reduced EF (25%),
cardiomegaly on CXR, and history of chronic alcohol abuse is classic for dilated cardiomyopathy (DCM).
Alcohol is a common toxic/metabolic cause of DCM. Option A (HCM) would show asymmetric septal
hypertrophy, preserved or hyperdynamic EF, and often dynamic outflow tract obstruction. Option C
(restrictive) would show preserved EF with diastolic dysfunction, biatrial enlargement, and often
amyloidosis or sarcoidosis history. Option D (ARVC) would show right ventricular dilation/fatty
EXAM 2026/2027 | Nurse Practitioner | 100
Practice Questions | Verified Q&A | Pass
Guaranteed - A+ Graded
Domain 1: Assessment & Differential Diagnosis (Questions 1–20)
Q1: A 52-year-old female presents with a 3-week history of intermittent substernal chest pressure that
occurs during brisk walking and resolves within 5 minutes of stopping. She has hypertension treated
with HCTZ and a 30-pack-year smoking history. Resting ECG is normal. What is the most appropriate
next step?
A. Order a chest X-ray and complete blood count
B. Prescribe ibuprofen as needed for suspected musculoskeletal pain
C. Refer for an exercise stress test [CORRECT]
D. Reassure the patient and schedule a follow-up in 6 months
Correct Answer: C
Rationale: This patient has typical exertional chest pressure (stable angina) with two major cardiac risk
factors (HTN, smoking). An exercise stress test is indicated to evaluate for obstructive coronary artery
disease per ACC/AHA guidelines for intermediate-risk patients with stable chest pain. Option A is not
indicated without pulmonary symptoms or signs of infection. Option B is dangerous given the typical
angina pattern and could mask symptoms of an acute coronary syndrome. Option D delays diagnosis of
potentially life-threatening disease and violates standard of care for new-onset chest pain in high-risk
patients. (NR667 CEA Competency: Cardiovascular assessment and diagnostic reasoning; NONPF
Competency: Independent Practice.)
Clinical Pearl: Any new chest pain in a patient >40 years with cardiac risk factors requires cardiac
workup before attributing to musculoskeletal causes.
Q2: A 28-year-old male presents with sudden onset of unilateral facial droop, inability to close his right
eye, and decreased taste on the anterior two-thirds of his tongue. He denies limb weakness or speech
difficulties. On exam, he can raise his eyebrows symmetrically. Which diagnosis is most likely?
A. Central stroke (middle cerebral artery territory)
B. Bell's palsy (idiopathic facial nerve palsy) [CORRECT]
,C. Ramsay Hunt syndrome
D. Brainstem stroke
Correct Answer: B
Rationale: The presentation of isolated lower motor neuron facial weakness (forehead involvement with
inability to close eye) without other neurological deficits is classic for Bell's palsy. The preserved
eyebrow raising actually suggests upper motor neuron pattern (central), but the inability to close the
eye indicates lower motor neuron involvement of cranial nerve VII—this is the key distinguishing
feature. Option A would typically spare the forehead (upper face has bilateral cortical innervation) and
would likely include arm/leg weakness or aphasia. Option C would present with vesicular rash in the ear
canal. Option D would cause additional cranial nerve deficits or long tract signs. (NR667 CEA
Competency: Neurological assessment; NONPF Competency: Independent Practice.)
Clinical Pearl: In facial palsy, "forehead sparing" = upper motor neuron (central); "forehead
involvement" = lower motor neuron (peripheral/Bell's palsy).
Q3: A 45-year-old female presents with fatigue, weight gain, cold intolerance, and dry skin. Labs: TSH
12.4 mIU/L (normal 0.4–4.0), free T4 0.6 ng/dL (normal 0.8–1.8). She is trying to conceive. What is the
most appropriate initial treatment?
A. Begin levothyroxine 25 mcg daily and recheck TSH in 6 months
B. Begin levothyroxine 75 mcg daily with goal TSH <2.5 mIU/L [CORRECT]
C. Begin liothyronine (T3) 5 mcg BID for faster symptom relief
D. Reassure and monitor; subclinical hypothyroidism does not require treatment
Correct Answer: B
Rationale: This patient has overt hypothyroidism (elevated TSH, low free T4) with symptoms. For
women trying to conceive, the AACE/ATA guidelines recommend treatment with levothyroxine to
achieve TSH <2.5 mIU/L preconception to reduce risk of miscarriage and adverse fetal
neurodevelopmental outcomes. Option A underdoses a symptomatic patient and delays optimal
preconception TSH goals. Option C is inappropriate as T3 monotherapy is not recommended for primary
hypothyroidism and carries cardiovascular risks. Option D is incorrect because this is overt, not
subclinical, hypothyroidism with clear symptoms requiring treatment. (NR667 CEA Competency:
Endocrine management; NONPF Competency: Independent Practice.)
Clinical Pearl: Preconception TSH goal for hypothyroid women is <2.5; first-trimester goal is <2.5,
second/third trimester <3.0.
Q4: A 68-year-old male with HTN and DM presents for annual wellness visit. His blood pressure today is
152/88 mmHg. His home meds are lisinopril 10 mg daily and metformin 1000 mg BID. Last A1c was 7.2%
three months ago. What is the most appropriate next step?
,A. Increase lisinopril to 20 mg daily and add amlodipine 5 mg daily [CORRECT]
B. Add hydrochlorothiazide 25 mg daily to current regimen
C. Increase metformin to 1000 mg TID to improve glycemic control first
D. Reassure; blood pressure is acceptable for his age
Correct Answer: A
Rationale: Per ACC/AHA 2017 guidelines, target BP for patients with DM is <130/80. Current reading of
152/88 indicates uncontrolled hypertension requiring intensification. The patient is already on ACE
inhibitor at low dose; uptitrating to maximum tolerated dose (20–40 mg) is appropriate before adding
another agent. If BP remains >130/80 after maximum ACEI, add a calcium channel blocker (amlodipine)
per the "A+C" combination preferred for Black patients or those with DM. Option B is reasonable but
thiazides are less preferred in DM due to metabolic effects on glucose and potassium. Option C
addresses the wrong problem—A1c of 7.2% is at goal (<7.0% for many older adults). Option D is
dangerous; cardiovascular risk increases significantly with uncontrolled BP in diabetic patients. (NR667
CEA Competency: Cardiovascular pharmacology; NONPF Competency: Independent Practice.)
Clinical Pearl: In DM, treat BP to <130/80; start with ACEI/ARB, then add CCB before thiazide when
possible.
Q5: A 34-year-old female presents with a 2-day history of dysuria, frequency, and urgency. She denies
fever, flank pain, or vaginal discharge. Urinalysis shows positive nitrites, leukocyte esterase, and 25–50
WBC/hpf. Which is the most appropriate empiric antibiotic?
A. Ciprofloxacin 250 mg BID for 3 days
B. Nitrofurantoin 100 mg BID for 5 days [CORRECT]
C. Trimethoprim-sulfamethoxazole DS BID for 7 days
D. Amoxicillin 500 mg TID for 10 days
Correct Answer: B
Rationale: This is an uncomplicated lower UTI (cystitis) in a non-pregnant female. IDSA/ESMID guidelines
recommend nitrofurantoin for 5 days as first-line empiric therapy due to excellent efficacy and low
resistance rates. Option A (fluoroquinolone) is reserved for complicated UTIs or pyelonephritis due to
safety concerns (tendon rupture, QT prolongation, aortic aneurysm risk) and should not be first-line for
uncomplicated cystitis. Option C (TMP-SMX) is appropriate only if local resistance is <20% and no sulfa
allergy; however, nitrofurantoin is preferred when available. Option D (amoxicillin) has high resistance
rates (>20%) and is not recommended for empiric therapy. (NR667 CEA Competency: Infectious disease
pharmacology; NONPF Competency: Independent Practice.)
Clinical Pearl: First-line for uncomplicated cystitis: nitrofurantoin 5 days, TMP-SMX 3 days (if resistance
<20%), or fosfomycin single dose.
, Q6: A 19-year-old college student presents with sore throat, fever of 101.2°F, and tender anterior
cervical lymphadenopathy. She denies cough. Rapid strep test is negative. What is the next best action?
A. Prescribe amoxicillin empirically for presumed streptococcal pharyngitis
B. Send throat culture and treat only if positive [CORRECT]
C. Prescribe azithromycin to cover atypical organisms
D. Recommend symptomatic care only; viral pharyngitis is most likely
Correct Answer: B
Rationale: The Centor/McIsaac criteria (fever, tonsillar exudates, tender anterior cervical nodes,
absence of cough, age 3–14 = +1 point; age 15–44 = 0 points; age >45 = -1 point) estimate pre-test
probability. This patient scores 3–4 points, indicating moderate-high probability of group A
streptococcus (GAS). With a negative rapid antigen detection test (RADT), the IDSA guidelines
recommend sending a throat culture because RADT sensitivity is 70–90%; a backup culture is required
for children/adolescents to prevent missed rheumatic fever risk. Option A is inappropriate without
confirmed GAS—unnecessary antibiotics increase resistance and side effects. Option C is unnecessary as
atypicals do not cause pharyngitis. Option D misses the 10–20% false-negative rate of RADT in
moderate-high probability patients. (NR667 CEA Competency: Infectious disease diagnosis; NONPF
Competency: Independent Practice.)
Clinical Pearl: Negative RADT in adults with Centor 0–1: no culture needed. Centor ≥2 or children: send
backup culture.
Q7: A 55-year-old male presents with progressive dyspnea on exertion, orthopnea, and bilateral lower
extremity edema. He has a history of alcohol use disorder (1 pint vodka daily for 20 years). Physical
exam reveals elevated JVP, S3 gallop, and hepatomegaly. ECG shows sinus tachycardia and low voltage.
Chest X-ray shows cardiomegaly and pulmonary vascular congestion. Echocardiogram shows global
hypokinesis with EF 25%. Which type of cardiomyopathy is most likely?
A. Hypertrophic cardiomyopathy
B. Dilated cardiomyopathy [CORRECT]
C. Restrictive cardiomyopathy
D. Arrhythmogenic right ventricular cardiomyopathy
Correct Answer: B
Rationale: The clinical picture of systolic heart failure with global hypokinesis, reduced EF (25%),
cardiomegaly on CXR, and history of chronic alcohol abuse is classic for dilated cardiomyopathy (DCM).
Alcohol is a common toxic/metabolic cause of DCM. Option A (HCM) would show asymmetric septal
hypertrophy, preserved or hyperdynamic EF, and often dynamic outflow tract obstruction. Option C
(restrictive) would show preserved EF with diastolic dysfunction, biatrial enlargement, and often
amyloidosis or sarcoidosis history. Option D (ARVC) would show right ventricular dilation/fatty
