AANPCB Family Nurse Practitioner (FNP) Exam — All Questions

A 3-week-old boy has had forceful, nonbilious vomiting after feeds for 4 days. He is eager to feed again right after vomiting, has fewer wet diapers, and has visible waves across the upper abdomen after feeding. What is the most likely diagnosis?

• a.Physiologic gastroesophageal reflux
• b.Cow's milk protein allergy
• c.Intussusception
• d.Hypertrophic pyloric stenosis✓

Pyloric stenosis typically begins around 3 weeks of age with forceful vomiting, visible peristaltic waves after feeding, hunger after vomiting, and signs of dehydration, because the thickened pylorus blocks gastric emptying. Physiologic reflux causes effortless spit-ups in a thriving infant, intussusception presents with colicky pain and bloody stools in older infants, and milk protein allergy more often causes bloody stools and eczema than projectile vomiting.

A 9-month-old has episodes of sudden, loud crying every 15 to 20 minutes, drawing his knees to his chest, with quiet periods between. He then passes a stool that looks like red currant jelly. What is the most likely diagnosis?

• a.Intussusception✓
• b.Infant colic
• c.Viral gastroenteritis
• d.Pyloric stenosis

Intermittent, colicky abdominal pain with knees drawn up, followed by a currant-jelly stool, is the classic presentation of intussusception, which most often affects children between 5 months and 3 years and is a surgical emergency. Colic does not cause bloody stools, pyloric stenosis presents with vomiting in the first weeks of life, and gastroenteritis does not produce this pattern of recurring pain with quiet intervals.

A 12-year-old boy with obesity has had a limp and aching knee pain for 3 weeks without injury. His knee exam is normal. A hip radiograph shows the femoral head displaced from the femoral neck at the growth plate. What is the diagnosis?

• a.Patellofemoral pain syndrome
• b.Slipped capital femoral epiphysis✓
• c.Developmental hip dysplasia
• d.Osgood-Schlatter disease

Slipped capital femoral epiphysis is separation of the femoral head from the femur at the upper growth plate; it is more common in children with obesity and often presents with a limp and pain referred to the knee, which is why the hip must be examined when the knee exam is normal. Osgood-Schlatter and patellofemoral pain are knee disorders with knee findings, and developmental dysplasia is a problem of the acetabulum present from infancy.

A 13-year-old soccer player has had pain for 2 months just below the kneecap that worsens with running, jumping, and climbing stairs. There is a tender, swollen bump over the tibial tubercle. The knee joint is stable without effusion. What is the most likely diagnosis?

• a.Slipped capital femoral epiphysis
• b.Septic arthritis of the knee
• c.Osgood-Schlatter disease✓
• d.Anterior cruciate ligament tear

Osgood-Schlatter disease is painful swelling of the anterior tibial tubercle from repetitive quadriceps pull during a growth spurt, common in adolescents who run and jump. An ACL tear causes instability and an effusion after injury, septic arthritis causes a hot, swollen joint with fever, and a slipped capital femoral epiphysis is a hip disorder without a tender tibial tubercle.

A 6-year-old had a mild cold last week and now has bright red cheeks, followed by a lacy, itchy rash on his arms and trunk. He is playful and afebrile. What is the most likely diagnosis?

• a.Scarlet fever
• b.Measles (rubeola)
• c.Fifth disease✓
• d.Impetigo

A bright red 'slapped cheek' rash followed by a lacy rash on the arms, legs, and trunk in a well-appearing school-age child is characteristic of fifth disease, caused by parvovirus B19. Scarlet fever produces a sandpaper-like rash with sore throat and fever, measles causes high fever with cough, coryza, and conjunctivitis, and impetigo forms honey-crusted lesions.

A 2-year-old had a runny nose and low-grade fever for 2 days. Tonight she developed a barking cough, hoarse voice, and a harsh noise when breathing in. What is the most likely diagnosis?

• a.Croup✓
• b.Asthma exacerbation
• c.Bronchiolitis
• d.Epiglottitis

Croup follows a mild cold with a barking cough, hoarseness, and inspiratory stridor from swelling around the vocal cords, is worse at night, and typically affects children aged 3 months to 5 years. Bronchiolitis produces wheezing and crackles in the lower airways, epiglottitis causes sudden high fever, drooling, and toxicity rather than a barking cough, and asthma causes expiratory wheeze.

A 7-year-old has had fever and a sore throat for a day. A red rash that feels like sandpaper began on the neck and chest and has spread to the trunk. What is the most likely diagnosis?

• a.Hand, foot, and mouth disease
• b.Scarlet fever✓
• c.Fifth disease
• d.Roseola

Scarlet fever is group A strep pharyngitis with a toxin-mediated rash that starts on the neck and chest, spreads over the body, and feels like sandpaper; the texture matters more than the look. Fifth disease starts with slapped cheeks and no sore throat, hand-foot-mouth disease causes oral ulcers and blisters on the hands and feet, and roseola's rash appears after the fever breaks.

A 52-year-old man has an average of 134/78 mm Hg on properly measured readings over several visits. How is his blood pressure classified?

• a.Stage 2 hypertension
• b.Stage 1 hypertension✓
• c.Normal blood pressure
• d.Elevated blood pressure

Blood pressure categories used by NHLBI and the AHA/ACC guideline are: normal, below 120/80; elevated, 120-129 systolic with diastolic below 80; stage 1, 130-139 systolic or 80-89 diastolic; stage 2, 140 or higher systolic or 90 or higher diastolic. A systolic of 134 places him in stage 1, even with a diastolic under 80.

A 48-year-old woman has an A1C of 6.1% and a fasting plasma glucose of 112 mg/dL. She has no symptoms. What do these results indicate?

• a.Normal glucose metabolism
• b.Type 1 diabetes
• c.Type 2 diabetes
• d.Prediabetes✓

Using ADA criteria cited by NIDDK, an A1C of 5.7% to 6.4% and a fasting glucose of 100 to 125 mg/dL are both in the prediabetes range. Diabetes requires an A1C of 6.5% or higher or a fasting glucose of 126 or higher, and normal values are below 5.7% and 99 mg/dL or lower.

A 71-year-old man reports 3 weeks of increased thirst and frequent urination. A random plasma glucose is 246 mg/dL. What does this indicate?

• a.Prediabetes
• b.Diabetes✓
• c.Normal glucose metabolism
• d.Stress hyperglycemia that needs no follow-up

A random plasma glucose of 200 mg/dL or higher in a person with classic symptoms of hyperglycemia meets the diagnostic criterion for diabetes. Random glucose is not used to define prediabetes, and dismissing a symptomatic value of 246 mg/dL as stress would miss the diagnosis.

A 24-year-old woman has a thin, gray, homogeneous vaginal discharge with a fishy odor that worsens after intercourse. Vaginal pH is 5.0, the whiff test is positive, and clue cells are seen on microscopy. What is the diagnosis?

• a.Trichomoniasis
• b.Vulvovaginal candidiasis
• c.Bacterial vaginosis✓
• d.Chlamydial cervicitis

She meets all four Amsel criteria for bacterial vaginosis: thin homogeneous discharge, pH above 4.5, a positive whiff test, and clue cells. Candidiasis typically has a normal pH and pseudohyphae, trichomoniasis is diagnosed by finding motile trichomonads or a positive NAAT, and chlamydia infects the cervix and does not produce clue cells.

A sexually active 21-year-old woman has lower abdominal pain for 3 days. Her pregnancy test is negative and no other cause is found. Which pelvic exam finding meets one of CDC's minimum criteria for starting empiric treatment for pelvic inflammatory disease?

• a.Cervical motion tenderness✓
• b.Oral temperature above 38.3 C (101 F)
• c.Mucopurulent cervical discharge
• d.White blood cells on saline microscopy

CDC recommends presumptive PID treatment for sexually active young women with pelvic or lower abdominal pain, no other identified cause, and at least one of three minimum criteria: cervical motion tenderness, uterine tenderness, or adnexal tenderness. Fever, mucopurulent discharge, and white cells on microscopy are additional criteria that raise specificity but are not required to begin treatment.

A 26-year-old woman whose last period was 7 weeks ago has a positive pregnancy test, vaginal spotting, and sudden severe one-sided pelvic pain with pain in her right shoulder. She is lightheaded. What is the most likely diagnosis?

• a.Ruptured ectopic pregnancy✓
• b.Threatened miscarriage
• c.Round ligament pain
• d.Corpus luteum cyst without rupture

Sudden severe pelvic pain, shoulder pain from blood irritating the diaphragm, and weakness in early pregnancy are signs that an ectopic pregnancy has ruptured, causing internal bleeding; this is an emergency. A threatened miscarriage causes bleeding without these signs of hemorrhage, round ligament pain is a brief, benign ache later in pregnancy, and an unruptured cyst does not produce shoulder pain or lightheadedness.

A 23-year-old woman has fewer than eight menstrual periods a year, acne, and coarse hair growth on her chin. Her pregnancy test is negative. Which diagnosis best fits?

• a.Hyperprolactinemia from a pituitary adenoma
• b.Polycystic ovary syndrome✓
• c.Primary ovarian insufficiency
• d.Endometriosis

Irregular or infrequent periods (fewer than eight a year) together with signs of excess androgens, such as acne and hirsutism, is the typical picture of polycystic ovary syndrome. Endometriosis causes painful periods with regular cycles, primary ovarian insufficiency causes low estrogen symptoms rather than androgen excess, and a prolactinoma typically causes galactorrhea.

A 29-year-old woman has menstrual cramps that have become steadily more painful over several years, deep pain during intercourse, and chronic low back and pelvic pain. She has been unable to conceive for 14 months. What is the most likely diagnosis?

• a.Irritable bowel syndrome
• b.Endometriosis✓
• c.Bacterial vaginosis
• d.Polycystic ovary syndrome

Endometriosis classically causes progressively worsening dysmenorrhea, deep dyspareunia, chronic pelvic and low back pain, and infertility. PCOS causes irregular cycles with androgen excess rather than cyclic pain, bacterial vaginosis causes discharge and odor, and IBS does not explain deep dyspareunia and infertility.

A 51-year-old woman has hot flashes and has not had a menstrual period for 12 months. She takes no hormonal medication. Which term applies?

• a.Menopause✓
• b.Premature ovarian insufficiency
• c.Perimenopause
• d.Secondary amenorrhea from pregnancy

ACOG defines menopause as the permanent end of menstrual periods, confirmed after 1 year without a period. Perimenopause is the years of fluctuating cycles leading up to that point, ovarian insufficiency refers to loss of ovarian function before age 40, and pregnancy would not explain 12 months of amenorrhea.

A 58-year-old woman has fatigue, cold intolerance, constipation, dry skin, and a 4 kg weight gain. Her TSH is elevated and free T4 is low. What is the most likely diagnosis?

• a.Primary hypothyroidism✓
• b.Secondary (pituitary) hypothyroidism
• c.Hyperthyroidism
• d.Subclinical hypothyroidism

Symptoms of a slowed metabolism with a high TSH and a low free T4 indicate primary hypothyroidism: the failing thyroid makes too little hormone and the pituitary raises TSH in response. Hyperthyroidism causes heat intolerance with a low TSH, pituitary hypothyroidism has a low or inappropriately normal TSH, and subclinical hypothyroidism has a normal free T4.

A 30-year-old woman has weight loss despite a good appetite, heat intolerance, tremor, palpitations, and bulging eyes. TSH is suppressed and free T4 is high. What is the most likely cause?

• a.Generalized anxiety disorder
• b.Pheochromocytoma
• c.Hashimoto disease
• d.Graves disease✓

Graves disease is the most common cause of hyperthyroidism, and eye involvement with bulging eyes points specifically to it. Hashimoto disease usually causes hypothyroidism, and pheochromocytoma and anxiety can cause tremor and palpitations but do not suppress TSH or raise free T4.

A 24-year-old woman with heavy menstrual periods reports fatigue. Hemoglobin is 9.8 g/dL with small, pale red cells, and serum ferritin is low. What is the most likely diagnosis?

• a.Anemia of chronic disease
• b.Iron deficiency anemia✓
• c.Vitamin B12 deficiency anemia
• d.Beta-thalassemia trait

Low ferritin reflects depleted iron stores and, with microcytic anemia in a woman with heavy menstrual losses, establishes iron deficiency anemia. B12 deficiency produces large (macrocytic) cells, anemia of chronic disease typically has normal or high ferritin, and thalassemia trait causes small cells with normal iron stores.

A 68-year-old man woke at 2 a.m. with severe pain, redness, warmth, and swelling of his right big toe joint. He had a similar episode last year that resolved in about a week. What is the most likely diagnosis?

• a.Plantar fasciitis
• b.Rheumatoid arthritis
• c.Osteoarthritis of the first MTP joint
• d.Gout flare✓

Gout flares often begin suddenly at night with intense pain, redness, warmth, and swelling, commonly in the big toe, and resolve over a week or two. Osteoarthritis causes gradual pain with activity and brief stiffness, rheumatoid arthritis is a symmetric polyarthritis of the hands and feet, and plantar fasciitis causes heel pain with first steps.

A 48-year-old woman has 4 months of pain and swelling in the small joints of both hands and both wrists, with morning stiffness lasting about 90 minutes. Which diagnosis is most likely?

• a.Fibromyalgia syndrome
• b.Rheumatoid arthritis✓
• c.Osteoarthritis
• d.Chronic tophaceous gout

Rheumatoid arthritis typically involves the wrists and small joints of the hands in a symmetric pattern, with morning stiffness lasting longer than 30 minutes. Osteoarthritis causes stiffness usually lasting under 30 minutes, gout presents as acute flares often in a single joint, and fibromyalgia causes widespread pain without joint swelling.

A 72-year-old woman has right knee pain that worsens with walking and improves with rest. After sitting, her knee is stiff for about 10 minutes. There is bony enlargement without warmth. What is the most likely diagnosis?

• a.Gout flare
• b.Osteoarthritis✓
• c.Septic arthritis
• d.Rheumatoid arthritis

Pain with use that eases with rest, short-lived stiffness after inactivity (usually under 30 minutes), and bony enlargement without warmth are typical of osteoarthritis. Rheumatoid arthritis causes prolonged morning stiffness and symmetric small-joint swelling, while septic arthritis and gout cause a hot, red, acutely painful joint.

A 16-year-old has pain that began around his navel yesterday and has moved to the right lower abdomen. He has lost his appetite, is nauseated, and has a low-grade fever. The right lower quadrant is tender to pressure. What is the most likely diagnosis?

• a.Viral gastroenteritis
• b.Constipation
• c.Acute appendicitis✓
• d.Mesenteric adenitis after a cold

Appendicitis classically begins with periumbilical or upper abdominal pain that becomes sharper and moves to the right lower abdomen, with anorexia, nausea, low-grade fever, and right lower quadrant tenderness. Gastroenteritis causes diffuse cramping with diarrhea, and constipation does not produce fever with pain that migrates and localizes. Mesenteric adenitis can mimic appendicitis, but it is a diagnosis made after appendicitis is excluded, not the most likely one here.

A 70-year-old man has nocturia three times a night, a weak and interrupted urine stream, and dribbling after voiding. He has no fever, dysuria, or hematuria, and his urinalysis is normal. What is the most likely cause?

• a.Acute bacterial prostatitis
• b.Urolithiasis
• c.Cystitis
• d.Benign prostatic hyperplasia✓

An enlarged prostate squeezes the urethra and causes lower urinary tract symptoms such as a weak or interrupted stream, post-void dribbling, and nocturia. Acute prostatitis and cystitis cause fever or dysuria with an abnormal urinalysis, and kidney stones cause colicky flank pain, often with hematuria.

A 76-year-old woman reports episodes of fluttering in her chest and fatigue. Her pulse is irregularly irregular at 112 beats per minute, and the ECG shows no discernible P waves. What is the rhythm?

• a.Atrial fibrillation✓
• b.Premature ventricular contractions
• c.Sinus tachycardia
• d.First-degree AV block

An irregularly irregular pulse with absent P waves is atrial fibrillation, in which the atria beat irregularly and do not coordinate with the ventricles; its risk rises with age. Sinus tachycardia is regular with normal P waves, first-degree AV block is a regular rhythm with a prolonged PR interval, and PVCs occur against an otherwise regular underlying rhythm.

A 71-year-old man has a rhythmic tremor of his right hand that is most noticeable when his hand rests in his lap and looks like he is rolling a pill. His wife says he moves more slowly and his arm swing has decreased. What is the most likely diagnosis?

• a.Hyperthyroidism
• b.Cerebellar infarction
• c.Essential tremor
• d.Parkinson disease✓

A rhythmic 'pill-rolling' tremor most obvious at rest, together with slowed movement, is characteristic of Parkinson disease. Essential tremor is mainly an action tremor, a cerebellar stroke causes tremor on intentional movement with sudden onset, and hyperthyroidism causes a fine postural tremor with weight loss and heat intolerance.

A 27-year-old woman has recurrent throbbing headaches on one side of her head, with nausea and sensitivity to light and noise. About 20 minutes before each headache she sees zigzag lines that last less than an hour. What is the most likely diagnosis?

• a.Medication overuse headache
• b.Cluster headache
• c.Migraine with aura✓
• d.Tension-type headache

Moderate to severe one-sided throbbing pain with nausea and light and sound sensitivity is typical of migraine, and visual symptoms such as zigzags that start 10 to 60 minutes before the headache and last under an hour are an aura. Tension-type headache is usually a mild, band-like pain without nausea or aura, cluster headache causes brief severe pain around one eye with tearing, and medication overuse headache requires frequent analgesic use.

A 72-year-old woman had 3 days of burning pain on the left side of her chest, and now a band of clustered blisters has appeared in the same area, stopping at the midline. What is the most likely diagnosis?

• a.Pleurisy
• b.Impetigo
• c.Herpes zoster✓
• d.Contact dermatitis

Herpes zoster typically begins with pain, tingling, or burning on one side of the body, followed by clustered vesicles in the distribution of a single dermatome that do not cross the midline. Contact dermatitis follows the pattern of exposure, impetigo forms honey-crusted lesions, and pleurisy causes pleuritic chest pain without a rash.

A 4-month-old had 2 days of runny nose and mild cough, then developed wheezing, fast breathing, and crackles during winter. What is the most likely diagnosis?

• a.Asthma
• b.Croup
• c.Bronchiolitis✓
• d.Pertussis in the paroxysmal stage

Bronchiolitis affects children under 2 years (peak 3 to 6 months), is most often caused by RSV, and starts as a mild upper respiratory infection before wheezing, cough, tachypnea, and crackles develop. Croup causes a barking cough and stridor, asthma is not diagnosed from a first viral wheeze in a young infant, and paroxysmal pertussis produces coughing fits with a whoop or apnea rather than diffuse crackles.

A 5-year-old has itchy blisters near his nostrils that have broken open and formed yellow, honey-colored crusts. The lesions are spreading where he scratches. What is the most likely diagnosis?

• a.Herpes simplex (cold sore)
• b.Hand, foot, and mouth disease
• c.Atopic dermatitis
• d.Impetigo✓

Impetigo produces itchy blisters filled with yellow or honey-colored fluid that ooze and crust over and spread by scratching. Herpes simplex forms grouped vesicles on a red base on the lip, atopic dermatitis causes dry, itchy plaques without honey crusts, and hand-foot-mouth disease causes oral lesions and blisters on the palms and soles.

A 67-year-old man has had nasal discharge and daytime cough for 12 days with no improvement. He has no fever. Which diagnosis do these features support?

• a.Allergic rhinitis
• b.Uncomplicated viral cold
• c.Acute bronchitis
• d.Acute bacterial rhinosinusitis✓

CDC guidance diagnoses acute bacterial rhinosinusitis when symptoms are persistent for more than 10 days without improvement, severe for 3 to 4 days, or worsening after initial improvement. Twelve days without improvement meets the persistent criterion, whereas a viral cold usually improves within 10 days. Allergic rhinitis is recurrent and itchy rather than an acute illness, and bronchitis does not explain persistent nasal discharge.