NR 601 Final Exam 2023/2024
An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg,
pulse 69 beats per min, and respiratory rate 18 breaths per min. She is well appearing and reports she is
up to date on her routine vaccinations. She introduces her partner of 35 years whom she would like to
make medical decisions for her in case she becomes unable to make decisions for herself. She reports
that she and her partner are not married. She asks if she needs any further documentation to ensure her
goals of care are followed. Which one of the following would be the most appropriate recommendation
for this patient and her partner? - CORRECT ANSWER Advise them to file an advanced directive.
. An 81-year-old transgender female with history of depression and hyperlipidemia presents to your
clinic for routine care. She endorses a history of smoking, currently smoking 1 pack per day, and
occasionally drinks a glass of wine, although she denies illicit drug use. She reports she takes atorvastatin
20 mg and subcutaneous estrogen therapy. - CORRECT ANSWER Counseling on smoking cessation
An 84-year-old male with history of stroke without residual deficit, systolic heart failure, and type 2
diabetes presents to clinic for follow-up. He is independently living in a retirement community and still
works part time on a golf course. He currently takes aspirin 81 mg, metoprolol tartrate 25 mg BID (twice
a day), furosemide 20 mg BID, and lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago,
with no abnormality. He reports he is sexually active with men and women, engaging in receptive oral,
receptive anal, and penetrative sex. He states he has had over three sexual partners in the last year with
intermittent condom use. What sexually transmitted infection testing should be offered? - CORRECT
ANSWER Urine testing, blood testing, anal swab, and oropharyngeal swab
Which of the following is true about tolterodine? - CORRECT ANSWER It has greater risk of adverse
effects with its twice-daily formulation.
An 82-year-old man, Mr. A, complains of worsening nocturia, occurring four times per night. His other
lower urinary tract symptoms are slow stream, occasional urgency, and urgency-related leakage once
weekly. Medical problems include poorly controlled hypertension, diastolic heart failure, hyperlipidemia,
osteoarthritis, and prediabetes. His medications include lisinopril 20 mg daily, metoprolol succinate 75
mg daily, atorvastatin 10 mg daily, metformin 500 mg twice daily, hydrocodone-acetaminophen as
needed, and aspirin 81 mg daily. Amlodipine 5 mg daily was recently added by his cardiologist. On review
of systems, Mr. A complains that nocturia is causing daytime fatigue, and he is more constipated.
Physical examination is notable for blood pressure 162/83 mmHg, heart rate 60 beats per minute, clear
,lungs, soft abdomen, enlarged prostate, and 21 pretibial edema. Your next step in management should
be: - CORRECT ANSWER Stop amlodipine and increase lisinopril.
The daughter of a 79-year-old woman notes that her mother, who has dementia and lives with her, is
wetting herself when she attends her new day program. Program staff have requested that "something
be done" as she is requiring a clothes change nearly every time she is there. She cannot describe the
circumstances of leakage, saying "it just comes." Leakage is uncommon at home. Her medications
include donepezil and acetaminophen. Physical examination is normal. Initial treatment approach will
require intervention by which of the following? - CORRECT ANSWER Day program staff
. Ms. J, who is 82 years old, complains of urine leakage while playing golf. This has gotten worse over the
past year, and she rarely makes it through nine holes without feeling like she needs to "run into the
bushes and go." Leakage is usually small volume, but causes her extreme embarrassment because she is
afraid she will smell of urine. She has tried limiting caffeine in the morning before she golfs and avoiding
drinking water while playing, to no effect. She also tried "those Kegler" exercises in the past without
success. Which of the following is the most appropriate recommendation for Ms. J? - CORRECT ANSWER
Bladder training
What is the most common cause of erectile dysfunction in older men? - CORRECT ANSWER
Atherosclerosis
Which is the most reasonable first step in the treatment of older men with erectile dysfunction? -
CORRECT ANSWER Sildenafil
A 72-year-old woman reports vaginal dryness that interferes with coitus. Her medical history includes
type 2 diabetes, hypertension, and osteoarthritis. Medications are glyburide, chlorthalidone, and
acetaminophen. What would be your first step in therapy? - CORRECT ANSWER Stop chlorthalidone
A 70-year-old woman reports sexual pain with deep penetration only. What is the most likely cause of
her problem? - CORRECT ANSWER High-tone pelvic floor dysfunction
A 79-year-old woman with a 1.5-cm breast cancer underwent lumpectomy. Pathology revealed ductal
carcinoma that is hormone receptor negative (estrogen receptor 0%, progesterone receptor 1%) and
HER2/neu negative. Surgical margins were adequate and uninvolved with cancer. Sentinel lymph node
sampling was negative for lymph node involvement. She has good performance status and no activities
of daily living (ADL) or instrumental (IADL) dependencies. What treatment would you recommend? -
CORRECT ANSWER Hormonal therapy only
, An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is
evaluated for a urinary tract infection associated with urinary retention. The consulting urologist places a
Foley catheter and sends a prostate-specific antigen (PSA) level that comes back 12 ng/mL. Three
months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is
still 10 ng/mL. What is the appropriate next step in managing this man's prostate problem? - CORRECT
ANSWER Repeat PSA in 6 months
In which of the following patients is chemical or surgical castration likely to prolong survival? - CORRECT
ANSWER A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10
years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph
node, and a bone scan is positive in the pelvis.
On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right
breast. The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and
obvious pain. The patient has no children and had lived alone until recently, when a neighbor became
concerned for what appeared to be a progressive loss of memory and neglect of the house. A nephew
living in another city eventually came to take care of the situation and arranged for the admission. The
patient appears confused and withdrawn; her appearance is disheveled, but she seems to be
independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive
her own car until shortly before this admission. The nephew does not wish to authorize hospice "right
now." A positron-emission tomography scan was negative for metastatic disease. In addition to
determining the cause of her delirium, which of the following is the best way to address the breast
mass? - CORRECT ANSWER The mass should be biopsied to study hormone receptor and HER2/neu
antigen status.
A 78-year-old man has an emergency partial colectomy for lower gastrointestinal bleeding. A localized
colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic
sampling. The patient wants to know if he should have chemotherapy. Should he? - CORRECT ANSWER
No because he can be followed with serial carcinoembryonic antigens and CT scans.
An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly
complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal
CT is performed. It reveals well-circumscribed pelvic masses, the largest adherent to the ovarian
ligament. The best first step is: - CORRECT ANSWER Invite her to return with a family member and
have a long talk about the diagnostic and therapeutic options.
An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg,
pulse 69 beats per min, and respiratory rate 18 breaths per min. She is well appearing and reports she is
up to date on her routine vaccinations. She introduces her partner of 35 years whom she would like to
make medical decisions for her in case she becomes unable to make decisions for herself. She reports
that she and her partner are not married. She asks if she needs any further documentation to ensure her
goals of care are followed. Which one of the following would be the most appropriate recommendation
for this patient and her partner? - CORRECT ANSWER Advise them to file an advanced directive.
. An 81-year-old transgender female with history of depression and hyperlipidemia presents to your
clinic for routine care. She endorses a history of smoking, currently smoking 1 pack per day, and
occasionally drinks a glass of wine, although she denies illicit drug use. She reports she takes atorvastatin
20 mg and subcutaneous estrogen therapy. - CORRECT ANSWER Counseling on smoking cessation
An 84-year-old male with history of stroke without residual deficit, systolic heart failure, and type 2
diabetes presents to clinic for follow-up. He is independently living in a retirement community and still
works part time on a golf course. He currently takes aspirin 81 mg, metoprolol tartrate 25 mg BID (twice
a day), furosemide 20 mg BID, and lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago,
with no abnormality. He reports he is sexually active with men and women, engaging in receptive oral,
receptive anal, and penetrative sex. He states he has had over three sexual partners in the last year with
intermittent condom use. What sexually transmitted infection testing should be offered? - CORRECT
ANSWER Urine testing, blood testing, anal swab, and oropharyngeal swab
Which of the following is true about tolterodine? - CORRECT ANSWER It has greater risk of adverse
effects with its twice-daily formulation.
An 82-year-old man, Mr. A, complains of worsening nocturia, occurring four times per night. His other
lower urinary tract symptoms are slow stream, occasional urgency, and urgency-related leakage once
weekly. Medical problems include poorly controlled hypertension, diastolic heart failure, hyperlipidemia,
osteoarthritis, and prediabetes. His medications include lisinopril 20 mg daily, metoprolol succinate 75
mg daily, atorvastatin 10 mg daily, metformin 500 mg twice daily, hydrocodone-acetaminophen as
needed, and aspirin 81 mg daily. Amlodipine 5 mg daily was recently added by his cardiologist. On review
of systems, Mr. A complains that nocturia is causing daytime fatigue, and he is more constipated.
Physical examination is notable for blood pressure 162/83 mmHg, heart rate 60 beats per minute, clear
,lungs, soft abdomen, enlarged prostate, and 21 pretibial edema. Your next step in management should
be: - CORRECT ANSWER Stop amlodipine and increase lisinopril.
The daughter of a 79-year-old woman notes that her mother, who has dementia and lives with her, is
wetting herself when she attends her new day program. Program staff have requested that "something
be done" as she is requiring a clothes change nearly every time she is there. She cannot describe the
circumstances of leakage, saying "it just comes." Leakage is uncommon at home. Her medications
include donepezil and acetaminophen. Physical examination is normal. Initial treatment approach will
require intervention by which of the following? - CORRECT ANSWER Day program staff
. Ms. J, who is 82 years old, complains of urine leakage while playing golf. This has gotten worse over the
past year, and she rarely makes it through nine holes without feeling like she needs to "run into the
bushes and go." Leakage is usually small volume, but causes her extreme embarrassment because she is
afraid she will smell of urine. She has tried limiting caffeine in the morning before she golfs and avoiding
drinking water while playing, to no effect. She also tried "those Kegler" exercises in the past without
success. Which of the following is the most appropriate recommendation for Ms. J? - CORRECT ANSWER
Bladder training
What is the most common cause of erectile dysfunction in older men? - CORRECT ANSWER
Atherosclerosis
Which is the most reasonable first step in the treatment of older men with erectile dysfunction? -
CORRECT ANSWER Sildenafil
A 72-year-old woman reports vaginal dryness that interferes with coitus. Her medical history includes
type 2 diabetes, hypertension, and osteoarthritis. Medications are glyburide, chlorthalidone, and
acetaminophen. What would be your first step in therapy? - CORRECT ANSWER Stop chlorthalidone
A 70-year-old woman reports sexual pain with deep penetration only. What is the most likely cause of
her problem? - CORRECT ANSWER High-tone pelvic floor dysfunction
A 79-year-old woman with a 1.5-cm breast cancer underwent lumpectomy. Pathology revealed ductal
carcinoma that is hormone receptor negative (estrogen receptor 0%, progesterone receptor 1%) and
HER2/neu negative. Surgical margins were adequate and uninvolved with cancer. Sentinel lymph node
sampling was negative for lymph node involvement. She has good performance status and no activities
of daily living (ADL) or instrumental (IADL) dependencies. What treatment would you recommend? -
CORRECT ANSWER Hormonal therapy only
, An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is
evaluated for a urinary tract infection associated with urinary retention. The consulting urologist places a
Foley catheter and sends a prostate-specific antigen (PSA) level that comes back 12 ng/mL. Three
months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is
still 10 ng/mL. What is the appropriate next step in managing this man's prostate problem? - CORRECT
ANSWER Repeat PSA in 6 months
In which of the following patients is chemical or surgical castration likely to prolong survival? - CORRECT
ANSWER A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10
years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph
node, and a bone scan is positive in the pelvis.
On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right
breast. The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and
obvious pain. The patient has no children and had lived alone until recently, when a neighbor became
concerned for what appeared to be a progressive loss of memory and neglect of the house. A nephew
living in another city eventually came to take care of the situation and arranged for the admission. The
patient appears confused and withdrawn; her appearance is disheveled, but she seems to be
independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive
her own car until shortly before this admission. The nephew does not wish to authorize hospice "right
now." A positron-emission tomography scan was negative for metastatic disease. In addition to
determining the cause of her delirium, which of the following is the best way to address the breast
mass? - CORRECT ANSWER The mass should be biopsied to study hormone receptor and HER2/neu
antigen status.
A 78-year-old man has an emergency partial colectomy for lower gastrointestinal bleeding. A localized
colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic
sampling. The patient wants to know if he should have chemotherapy. Should he? - CORRECT ANSWER
No because he can be followed with serial carcinoembryonic antigens and CT scans.
An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly
complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal
CT is performed. It reveals well-circumscribed pelvic masses, the largest adherent to the ovarian
ligament. The best first step is: - CORRECT ANSWER Invite her to return with a family member and
have a long talk about the diagnostic and therapeutic options.
