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NR 603 – ADVANCED CLINICAL DIAGNOSIS AND
PRACTICE ACROSS THE LIFESPAN WEEK 1
PRACTICE TEST BANK – 250 QUESTIONS WITH
CORRECT ANSWERS AND RATIONALES LATEST
UPDATE – CLINICAL REASONING &
DIFFERENTIAL DIAGNOSIS
SECTION 1: NEUROLOGIC DISORDERS (Questions 1–40)
1. A 45-year-old man presents with sudden onset of severe, "thunderclap" headache
reaching maximum intensity within 1 minute. Which diagnosis must be ruled out first?
A) Migraine with aura
B) Tension headache
C) Subarachnoid hemorrhage
D) Cluster headache
Answer: C
Rationale: Thunderclap headache is a red flag for subarachnoid hemorrhage. Non-contrast
head CT is the initial test of choice, followed by lumbar puncture if CT negative.
2. A 68-year-old woman with atrial fibrillation presents with sudden-onset left-sided
weakness and slurred speech. What is the most likely diagnosis?
A) Complex migraine
B) Ischemic stroke
C) Seizure
D) Bell's palsy
Answer: B
Rationale: Atrial fibrillation is a major risk factor for cardioembolic stroke. Sudden-onset
unilateral weakness with speech disturbance is consistent with acute ischemic stroke.
3. Which finding on non-contrast head CT suggests acute ischemic stroke within the first
few hours?
A) Hyperdense middle cerebral artery sign
B) White matter hyperintensities
C) Subdural hematoma
D) Intraparenchymal hemorrhage
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Answer: A
Rationale: The hyperdense MCA sign indicates a thrombus/embolus in the MCA and can be
seen within the first hours of ischemic stroke.
4. A 72-year-old man with Parkinson's disease presents with visual hallucinations after
starting pramipexole. What is the first step?
A) Increase pramipexole dose
B) Add quetiapine
C) Reduce or discontinue pramipexole
D) Start donepezil
Answer: C
Rationale: Dopamine agonists commonly cause hallucinations. The first step is to reduce or
discontinue the dopamine agonist.
5. What is the most appropriate initial treatment for an acute exacerbation of multiple
sclerosis?
A) Interferon beta-1a
B) Glatiramer acetate
C) High-dose IV methylprednisolone
D) Rituximab
Answer: C
*Rationale: Acute MS exacerbations are treated with high-dose corticosteroids (IV
methylprednisolone 1g daily for 3-5 days) to reduce inflammation and accelerate recovery.
Disease-modifying therapies are for relapse prevention.*
6. A 35-year-old presents with acute-onset unilateral vision loss and pain with eye
movement. Visual acuity is 20/200 in the affected eye. What is the most likely diagnosis?
A) Optic neuritis
B) Retinal detachment
C) Central retinal artery occlusion
D) Migraine with visual aura
Answer: A
Rationale: Optic neuritis presents with subacute monocular vision loss, pain with eye
movement, and relative afferent pupillary defect (Marcus Gunn pupil). It is often the
presenting symptom of multiple sclerosis.
7. A patient presents with acute vertigo, nystagmus, and inability to stand. Nystagmus is
direction-changing and not suppressed with visual fixation. What is the most likely
diagnosis?
A) Benign paroxysmal positional vertigo (BPPV)
,3|Page
B) Vestibular neuritis
C) Cerebellar stroke
D) Labyrinthitis
Answer: C
Rationale: Central causes of vertigo (posterior circulation stroke) produce direction-
changing or vertical nystagmus that is NOT suppressed with visual fixation. Severe
imbalance is also a central sign.
8. A 25-year-old woman presents with episodes of throbbing unilateral headache preceded
by visual aura. Headache lasts 4-12 hours with nausea and photophobia. What is the most
likely diagnosis?
A) Tension-type headache
B) Migraine with aura
C) Cluster headache
D) Medication overuse headache
Answer: B
Rationale: Migraine with aura is characterized by reversible focal neurologic symptoms
(visual aura) preceding or accompanying headache. Headache is unilateral, throbbing,
moderate-severe, with nausea and photophobia.
9. Which medication is first-line for migraine prophylaxis when headaches occur ≥4 days
per month?
A) Sumatriptan PRN
B) Propranolol or topiramate
C) Ondansetron as needed
D) Caffeine daily
Answer: B
Rationale: First-line migraine prophylaxis includes beta-blockers (propranolol,
metoprolol), topiramate, amitriptyline, and valproic acid. Sumatriptan is for acute
treatment only.
10. A 45-year-old with migraine with aura presents with a new "worst headache of life"
reaching maximum intensity in 30 seconds. What is the next step?
A) Prescribe sumatriptan
B) Non-contrast head CT
C) Reassurance and discharge
D) MRI brain
, 4|Page
Answer: B
Rationale: Thunderclap headache (sudden, severe, maximal at onset) is a red flag for
subarachnoid hemorrhage. Non-contrast head CT is the initial test.
11. A patient with chronic migraine uses triptans 12 days per month. What complication
should be considered?
A) Serotonin syndrome
B) Medication overuse headache (rebound headache)
C) Triptan resistance
D) Hypertension
Answer: B
*Rationale: Medication overuse headache (rebound headache) occurs when acute
medications are used ≥10 days/month for >3 months. Triptan discontinuation is required.*
12. A 70-year-old man presents with gradual onset of resting tremor in the right hand,
cogwheel rigidity, and bradykinesia. What is the most likely diagnosis?
A) Essential tremor
B) Parkinson's disease
C) Huntington's disease
D) Drug-induced parkinsonism
Answer: B
*Rationale: Parkinson's disease classically presents with asymmetric resting tremor (4-6
Hz), rigidity (cogwheeling), bradykinesia, and postural instability (later).*
13. A patient with Parkinson's disease on carbidopa-levodopa reports "wearing off" of
medication effect before the next dose. What is the appropriate next step?
A) Increase levodopa dose
B) Add entacapone (COMT inhibitor)
C) Decrease carbidopa dose
D) Add benztropine
Answer: B
Rationale: "Wearing off" phenomenon is managed with addition of a COMT inhibitor
(entacapone) which prolongs levodopa half-life, or adjusting dosing frequency.
14. A 72-year-old with history of falls and cognitive impairment has short-step, shuffling
gait, postural instability, and urinary incontinence. What is the most likely diagnosis?
A) Parkinson's disease
B) Normal pressure hydrocephalus (NPH)
C) Cerebellar ataxia
D) Cervical myelopathy
NR 603 – ADVANCED CLINICAL DIAGNOSIS AND
PRACTICE ACROSS THE LIFESPAN WEEK 1
PRACTICE TEST BANK – 250 QUESTIONS WITH
CORRECT ANSWERS AND RATIONALES LATEST
UPDATE – CLINICAL REASONING &
DIFFERENTIAL DIAGNOSIS
SECTION 1: NEUROLOGIC DISORDERS (Questions 1–40)
1. A 45-year-old man presents with sudden onset of severe, "thunderclap" headache
reaching maximum intensity within 1 minute. Which diagnosis must be ruled out first?
A) Migraine with aura
B) Tension headache
C) Subarachnoid hemorrhage
D) Cluster headache
Answer: C
Rationale: Thunderclap headache is a red flag for subarachnoid hemorrhage. Non-contrast
head CT is the initial test of choice, followed by lumbar puncture if CT negative.
2. A 68-year-old woman with atrial fibrillation presents with sudden-onset left-sided
weakness and slurred speech. What is the most likely diagnosis?
A) Complex migraine
B) Ischemic stroke
C) Seizure
D) Bell's palsy
Answer: B
Rationale: Atrial fibrillation is a major risk factor for cardioembolic stroke. Sudden-onset
unilateral weakness with speech disturbance is consistent with acute ischemic stroke.
3. Which finding on non-contrast head CT suggests acute ischemic stroke within the first
few hours?
A) Hyperdense middle cerebral artery sign
B) White matter hyperintensities
C) Subdural hematoma
D) Intraparenchymal hemorrhage
,2|Page
Answer: A
Rationale: The hyperdense MCA sign indicates a thrombus/embolus in the MCA and can be
seen within the first hours of ischemic stroke.
4. A 72-year-old man with Parkinson's disease presents with visual hallucinations after
starting pramipexole. What is the first step?
A) Increase pramipexole dose
B) Add quetiapine
C) Reduce or discontinue pramipexole
D) Start donepezil
Answer: C
Rationale: Dopamine agonists commonly cause hallucinations. The first step is to reduce or
discontinue the dopamine agonist.
5. What is the most appropriate initial treatment for an acute exacerbation of multiple
sclerosis?
A) Interferon beta-1a
B) Glatiramer acetate
C) High-dose IV methylprednisolone
D) Rituximab
Answer: C
*Rationale: Acute MS exacerbations are treated with high-dose corticosteroids (IV
methylprednisolone 1g daily for 3-5 days) to reduce inflammation and accelerate recovery.
Disease-modifying therapies are for relapse prevention.*
6. A 35-year-old presents with acute-onset unilateral vision loss and pain with eye
movement. Visual acuity is 20/200 in the affected eye. What is the most likely diagnosis?
A) Optic neuritis
B) Retinal detachment
C) Central retinal artery occlusion
D) Migraine with visual aura
Answer: A
Rationale: Optic neuritis presents with subacute monocular vision loss, pain with eye
movement, and relative afferent pupillary defect (Marcus Gunn pupil). It is often the
presenting symptom of multiple sclerosis.
7. A patient presents with acute vertigo, nystagmus, and inability to stand. Nystagmus is
direction-changing and not suppressed with visual fixation. What is the most likely
diagnosis?
A) Benign paroxysmal positional vertigo (BPPV)
,3|Page
B) Vestibular neuritis
C) Cerebellar stroke
D) Labyrinthitis
Answer: C
Rationale: Central causes of vertigo (posterior circulation stroke) produce direction-
changing or vertical nystagmus that is NOT suppressed with visual fixation. Severe
imbalance is also a central sign.
8. A 25-year-old woman presents with episodes of throbbing unilateral headache preceded
by visual aura. Headache lasts 4-12 hours with nausea and photophobia. What is the most
likely diagnosis?
A) Tension-type headache
B) Migraine with aura
C) Cluster headache
D) Medication overuse headache
Answer: B
Rationale: Migraine with aura is characterized by reversible focal neurologic symptoms
(visual aura) preceding or accompanying headache. Headache is unilateral, throbbing,
moderate-severe, with nausea and photophobia.
9. Which medication is first-line for migraine prophylaxis when headaches occur ≥4 days
per month?
A) Sumatriptan PRN
B) Propranolol or topiramate
C) Ondansetron as needed
D) Caffeine daily
Answer: B
Rationale: First-line migraine prophylaxis includes beta-blockers (propranolol,
metoprolol), topiramate, amitriptyline, and valproic acid. Sumatriptan is for acute
treatment only.
10. A 45-year-old with migraine with aura presents with a new "worst headache of life"
reaching maximum intensity in 30 seconds. What is the next step?
A) Prescribe sumatriptan
B) Non-contrast head CT
C) Reassurance and discharge
D) MRI brain
, 4|Page
Answer: B
Rationale: Thunderclap headache (sudden, severe, maximal at onset) is a red flag for
subarachnoid hemorrhage. Non-contrast head CT is the initial test.
11. A patient with chronic migraine uses triptans 12 days per month. What complication
should be considered?
A) Serotonin syndrome
B) Medication overuse headache (rebound headache)
C) Triptan resistance
D) Hypertension
Answer: B
*Rationale: Medication overuse headache (rebound headache) occurs when acute
medications are used ≥10 days/month for >3 months. Triptan discontinuation is required.*
12. A 70-year-old man presents with gradual onset of resting tremor in the right hand,
cogwheel rigidity, and bradykinesia. What is the most likely diagnosis?
A) Essential tremor
B) Parkinson's disease
C) Huntington's disease
D) Drug-induced parkinsonism
Answer: B
*Rationale: Parkinson's disease classically presents with asymmetric resting tremor (4-6
Hz), rigidity (cogwheeling), bradykinesia, and postural instability (later).*
13. A patient with Parkinson's disease on carbidopa-levodopa reports "wearing off" of
medication effect before the next dose. What is the appropriate next step?
A) Increase levodopa dose
B) Add entacapone (COMT inhibitor)
C) Decrease carbidopa dose
D) Add benztropine
Answer: B
Rationale: "Wearing off" phenomenon is managed with addition of a COMT inhibitor
(entacapone) which prolongs levodopa half-life, or adjusting dosing frequency.
14. A 72-year-old with history of falls and cognitive impairment has short-step, shuffling
gait, postural instability, and urinary incontinence. What is the most likely diagnosis?
A) Parkinson's disease
B) Normal pressure hydrocephalus (NPH)
C) Cerebellar ataxia
D) Cervical myelopathy
