NP PREDICTOR EXAM 2026 –
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Rationales/Graded A+/2026
Update/100% Correct /Instant
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Instructions: Choose the single best answer. Correct answers are highlighted in
bold.
SECTION 1: ADVANCED PATHOPHYSIOLOGY (Questions 1–15)
1. A 58-year-old man with hypertension presents with acute-onset severe
“tearing” chest pain radiating to the back. Blood pressure is 160/90 in right
arm and 100/60 in left arm. What is the most likely pathophysiology?
• A. Intramural coronary thrombus formation
• B. Inflammation of the pericardial layers
• C. Intimal tear of the aortic media with dissection
Rationale : Aortic dissection presents with tearing pain, pulse/BP
differential, and medial degeneration. Options A/B/D do not cause
differential arm BPs.
• D. Transmural myocardial ischemia
2. A 72-year-old woman with diabetes has dull flank pain and recurrent UTIs.
Urinalysis shows pH 8.5, ammonia crystals, and Proteus mirabilis. Which
stone type is most likely?
• A. Calcium oxalate
• B. Cystine
, • C. Struvite
Rationale : Proteus produces urease → ammonia → alkaline urine →
struvite (magnesium ammonium phosphate) stones. Calcium oxalate is
acidic; cystine is genetic; uric acid is acidic/neutral.
• D. Uric acid
3. A patient with chronic alcoholism presents with painful proximal muscle
weakness and dark urine. Labs: CK 12,000 U/L, K+ 2.8 mEq/L, PO4 1.5
mg/dL. What is the most likely mechanism?
• A. Autoimmune rhabdomyolysis from anti-HMGCR antibodies
• B. Mitochondrial toxin accumulation from statin use
• C. Hypophosphatemia-induced ATP depletion causing myocyte necrosis
*Rationale : Alcoholism + low PO4 → severe hypophosphatemia → ATP
depletion → rhabdomyolysis. CK elevation and hypokalemia are
supportive.*
• D. Direct ethanol myotoxicity
4. A 65-year-old male with CKD stage 4 has fatigue, bone pain, and serum
calcium 9.8 mg/dL, phosphate 4.9 mg/dL, PTH 450 pg/mL. What is the
driving pathophysiology?
• A. Primary hyperparathyroidism from parathyroid adenoma
• B. Secondary hyperparathyroidism from decreased renal 1-alpha-
hydroxylase activity
Rationale : CKD → low activated vitamin D → hypocalcemia (though Ca
may be normalish late) → high PTH. Phosphate retention further stimulates
PTH.
• C. Malignancy-associated hypercalcemia
• D. Thyroid medullary carcinoma
5. A 45-year-old obese woman has fatigue, proximal weakness, moon facies,
and wide purple striae. ACTH is undetectable. Which finding is expected on
adrenal imaging?
• A. Unilateral adrenal mass
Rationale : Undetectable ACTH points to primary adrenal (cortisol-
, producing adenoma/carcinoma). Bilateral hyperplasia would have high
ACTH (pituitary). Ectopic ACTH has high ACTH.
• B. Bilateral adrenal hyperplasia
• C. Normal adrenal glands
• D. Pituitary microadenoma
6. A 62-year-old man with a 40-pack-year smoking history develops weight
loss, hemoptysis, and new-onset hyponatremia (Na 122 mEq/L, serum
osmolality 250 mOsm/kg, urine Na 60 mEq/L). What is the pathophysiology?
• A. Inappropriate antidiuretic hormone (SIADH) from small cell lung cancer
Rationale : Small cell → ectopic ADH secretion → euvolemic hypotonic
hyponatremia with high urine Na and Uosm >100.
• B. Renal salt wasting from cisplatin toxicity
• C. Primary polydipsia
• D. Adrenal insufficiency
7. A 68-year-old man with acute pancreatitis has foul, floating stools, weight
loss, and HbA1c 7.8% (new). What exocrine/endocrine link explains both
diabetes and steatorrhea?
• A. Islet cell autoantibodies destroying beta cells
• B. Pancreatic necrosis reducing both lipase and insulin secretion
*Rationale : Severe pancreatitis → destruction of acinar (lipase =
steatorrhea) and islet (insulin = diabetes) tissue. Not autoimmune (type 1).*
• C. Bile duct obstruction causing secondary diabetes
• D. Glucagonoma syndrome
8. A 55-year-old woman with rheumatoid arthritis on long-term prednisone
presents with acute hip pain. X-ray shows subchondral lucency and collapse
of femoral head. What is the most likely mechanism?
• A. Glucocorticoid-induced osteocyte apoptosis and fat emboli in
subchondral vessels
Rationale : Steroids → avascular necrosis of femoral head. Mechanism
includes fat microemboli and increased intraosseous pressure.
FULL-LENGTH TOPIC
TEST||Questions And Answers With
Rationales/Graded A+/2026
Update/100% Correct /Instant
Download
Instructions: Choose the single best answer. Correct answers are highlighted in
bold.
SECTION 1: ADVANCED PATHOPHYSIOLOGY (Questions 1–15)
1. A 58-year-old man with hypertension presents with acute-onset severe
“tearing” chest pain radiating to the back. Blood pressure is 160/90 in right
arm and 100/60 in left arm. What is the most likely pathophysiology?
• A. Intramural coronary thrombus formation
• B. Inflammation of the pericardial layers
• C. Intimal tear of the aortic media with dissection
Rationale : Aortic dissection presents with tearing pain, pulse/BP
differential, and medial degeneration. Options A/B/D do not cause
differential arm BPs.
• D. Transmural myocardial ischemia
2. A 72-year-old woman with diabetes has dull flank pain and recurrent UTIs.
Urinalysis shows pH 8.5, ammonia crystals, and Proteus mirabilis. Which
stone type is most likely?
• A. Calcium oxalate
• B. Cystine
, • C. Struvite
Rationale : Proteus produces urease → ammonia → alkaline urine →
struvite (magnesium ammonium phosphate) stones. Calcium oxalate is
acidic; cystine is genetic; uric acid is acidic/neutral.
• D. Uric acid
3. A patient with chronic alcoholism presents with painful proximal muscle
weakness and dark urine. Labs: CK 12,000 U/L, K+ 2.8 mEq/L, PO4 1.5
mg/dL. What is the most likely mechanism?
• A. Autoimmune rhabdomyolysis from anti-HMGCR antibodies
• B. Mitochondrial toxin accumulation from statin use
• C. Hypophosphatemia-induced ATP depletion causing myocyte necrosis
*Rationale : Alcoholism + low PO4 → severe hypophosphatemia → ATP
depletion → rhabdomyolysis. CK elevation and hypokalemia are
supportive.*
• D. Direct ethanol myotoxicity
4. A 65-year-old male with CKD stage 4 has fatigue, bone pain, and serum
calcium 9.8 mg/dL, phosphate 4.9 mg/dL, PTH 450 pg/mL. What is the
driving pathophysiology?
• A. Primary hyperparathyroidism from parathyroid adenoma
• B. Secondary hyperparathyroidism from decreased renal 1-alpha-
hydroxylase activity
Rationale : CKD → low activated vitamin D → hypocalcemia (though Ca
may be normalish late) → high PTH. Phosphate retention further stimulates
PTH.
• C. Malignancy-associated hypercalcemia
• D. Thyroid medullary carcinoma
5. A 45-year-old obese woman has fatigue, proximal weakness, moon facies,
and wide purple striae. ACTH is undetectable. Which finding is expected on
adrenal imaging?
• A. Unilateral adrenal mass
Rationale : Undetectable ACTH points to primary adrenal (cortisol-
, producing adenoma/carcinoma). Bilateral hyperplasia would have high
ACTH (pituitary). Ectopic ACTH has high ACTH.
• B. Bilateral adrenal hyperplasia
• C. Normal adrenal glands
• D. Pituitary microadenoma
6. A 62-year-old man with a 40-pack-year smoking history develops weight
loss, hemoptysis, and new-onset hyponatremia (Na 122 mEq/L, serum
osmolality 250 mOsm/kg, urine Na 60 mEq/L). What is the pathophysiology?
• A. Inappropriate antidiuretic hormone (SIADH) from small cell lung cancer
Rationale : Small cell → ectopic ADH secretion → euvolemic hypotonic
hyponatremia with high urine Na and Uosm >100.
• B. Renal salt wasting from cisplatin toxicity
• C. Primary polydipsia
• D. Adrenal insufficiency
7. A 68-year-old man with acute pancreatitis has foul, floating stools, weight
loss, and HbA1c 7.8% (new). What exocrine/endocrine link explains both
diabetes and steatorrhea?
• A. Islet cell autoantibodies destroying beta cells
• B. Pancreatic necrosis reducing both lipase and insulin secretion
*Rationale : Severe pancreatitis → destruction of acinar (lipase =
steatorrhea) and islet (insulin = diabetes) tissue. Not autoimmune (type 1).*
• C. Bile duct obstruction causing secondary diabetes
• D. Glucagonoma syndrome
8. A 55-year-old woman with rheumatoid arthritis on long-term prednisone
presents with acute hip pain. X-ray shows subchondral lucency and collapse
of femoral head. What is the most likely mechanism?
• A. Glucocorticoid-induced osteocyte apoptosis and fat emboli in
subchondral vessels
Rationale : Steroids → avascular necrosis of femoral head. Mechanism
includes fat microemboli and increased intraosseous pressure.
