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SECTION 1: ASSESSMENT & DIAGNOSTIC REASONING
(QUESTIONS 1–25)
Question 1
A 52-year-old man presents with sudden onset of tearing chest pain radiating to his
back. His blood pressure is 168/92 mmHg in the right arm and 138/78 mmHg in the
left arm. Chest X-ray shows a widened mediastinum. Which diagnosis is MOST likely?
A. Acute myocardial infarction B. Aortic dissection C. Pulmonary embolism D.
Pericarditis
Correct Answer: B
Rationale: Aortic dissection presents with tearing chest/back pain, pulse deficit,
blood pressure differential >20 mmHg between arms, and widened mediastinum on
CXR. Acute MI (A) typically shows ST changes and troponin elevation without BP
differential; PE (C) presents with dyspnea, tachypnea, and D-dimer elevation;
pericarditis (D) features friction rub and diffuse ST elevation. This reflects ANCC FNP-
BC emergency assessment competency and AHA aortic dissection red flag
recognition.
Question 2
A 28-year-old woman presents with acute scrotal pain, nausea, and vomiting.
Physical examination reveals a high-riding testis with absent cremasteric reflex.
Which action is MOST appropriate?
,A. Prescribe antibiotics for epididymitis and schedule follow-up in 1 week B. Order
Doppler ultrasound and prepare for emergent urologic consultation C. Recommend
scrotal support and NSAIDs for suspected torsion D. Order urinalysis and culture to
rule out infection
Correct Answer: B
Rationale: Testicular torsion is a surgical emergency presenting with acute scrotal
pain, nausea/vomiting, absent cremasteric reflex, and high-riding testis. Doppler
ultrasound confirms absent blood flow, but treatment should not be delayed—
emergent urology consultation for orchiopexy within 6 hours preserves viability.
Antibiotics (A) and NSAIDs (C) are inappropriate; urinalysis (D) delays critical
intervention. This reflects ANCC FNP-BC emergency recognition and time-critical
management per AUA guidelines.
Question 3
A 35-year-old woman presents with sudden-onset severe headache described as "the
worst headache of my life," neck stiffness, photophobia, and vomiting. She is alert
but agitated. Which is the BEST initial diagnostic step?
A. Lumbar puncture immediately B. Non-contrast head CT scan C. MRI with contrast
D. Cerebral angiography
Correct Answer: B
Rationale: Subarachnoid hemorrhage (SAH) presents with thunderclap headache,
meningismus, and autonomic symptoms. Non-contrast head CT is the initial imaging
of choice, detecting >95% of SAH within 6 hours. If CT is negative but suspicion
remains high, lumbar puncture (A) follows for xanthochromia. MRI (C) and
angiography (D) are subsequent studies for aneurysm identification. This reflects
ANCC FNP-BC neuroemergency assessment and AHA/ASA SAH diagnostic algorithm.
Question 4
,A 24-year-old woman presents with acute lower abdominal pain, vaginal spotting,
and a positive urine pregnancy test. She has right adnexal tenderness and rebound.
Her BP is 94/62 mmHg, HR 118 bpm. Which diagnosis is MOST likely, and what is the
priority action?
A. Threatened abortion; expectant management with serial hCG B. Ectopic pregnancy;
emergent surgical consultation and IV resuscitation C. Ovarian cyst rupture;
outpatient observation with analgesics D. Pelvic inflammatory disease; outpatient
antibiotic therapy
Correct Answer: B
Rationale: Ectopic pregnancy presents with abdominal/pelvic pain, vaginal bleeding,
positive pregnancy test, adnexal mass/tenderness, and hemodynamic instability
indicates rupture with hemorrhagic shock. This is a surgical emergency requiring
immediate IV resuscitation, type and crossmatch, and emergent OB/GYN
consultation. Threatened abortion (A) does not present with peritoneal signs and
shock; ovarian cyst (C) and PID (D) do not cause hemodynamic collapse in this
context. This reflects ANCC FNP-BC emergency gynecologic assessment and ACOG
ectopic pregnancy management.
Question 5
A 45-year-old man presents with acute low back pain radiating to both legs, urinary
retention, and numbness in the perineal region. Which condition is present, and what
is the required intervention?
A. Lumbar radiculopathy; physical therapy referral B. Cauda equina syndrome;
emergent MRI and neurosurgical consultation C. Sciatica; NSAIDs and activity
modification D. Spinal stenosis; epidural steroid injection
Correct Answer: B
Rationale: Cauda equina syndrome is a surgical emergency characterized by saddle
anesthesia, urinary retention/incontinence, fecal incontinence, bilateral leg weakness,
and loss of anal sphincter tone. Emergent MRI confirms compression, and immediate
neurosurgical consultation is required to prevent permanent paralysis and
, incontinence. Lumbar radiculopathy (A), sciatica (C), and spinal stenosis (D) do not
present with bilateral neurologic deficits and bowel/bladder dysfunction. This reflects
ANCC FNP-BC red flag recognition and emergency intervention competency.
Question 6
A 62-year-old man presents with fever, severe headache, and neck stiffness. On
examination, he has positive Kernig and Brudzinski signs. Petechial rash is noted on
his lower extremities. Which is the MOST appropriate immediate action?
A. Start empiric antibiotics and obtain emergent lumbar puncture B. Order MRI brain
with contrast C. Administer acetaminophen and observe for 24 hours D. Start antiviral
therapy for suspected viral meningitis
Correct Answer: A
Rationale: Fever, headache, nuchal rigidity, positive Kernig/Brudzinski signs, and
petechial rash indicate bacterial meningitis (likely meningococcemia), a life-
threatening emergency. Empiric antibiotics (ceftriaxone + vancomycin ± ampicillin if
>50 years) must be administered within 30 minutes—before LP if the patient is
unstable. MRI (B) delays treatment; observation (C) is fatal; antivirals (D) are for HSV
encephalitis, not this presentation. This reflects ANCC FNP-BC infectious emergency
management and IDSA meningitis guidelines.
Question 7
A screening test for disease X has sensitivity 85% and specificity 90%. In a population
with disease prevalence 10%, what is the positive predictive value (PPV)?
A. 48.6% B. 85.0% C. 90.0% D. 99.4%
Correct Answer: A
Rationale: Using a 2×2 table with 1000 people: True positives = 85 (85% of 100 with
disease); False positives = 90 (10% of 900 without disease). PPV = TP/(TP+FP) =
85/(85+90) = 85/175 = 48.6%. PPV depends on prevalence—lower prevalence yields