Nurse practitioner certification, exam by exam

A 70-year-old man reports unsteadiness that is worse in the dark. During your neurologic examination, which test best assesses proprioceptive (dorsal column) function contributing to balance?

1. Romberg test
   Romberg removes vision: a patient who stands steadily with eyes open but sways or falls once they close has lost proprioceptive (dorsal column) input, which fits imbalance that worsens in the dark.
2. Deep tendon reflex testing
   Reflexes test the segmental reflex arc; they can be reduced in neuropathy but do not measure the position sense that balance in the dark relies on.
3. Finger-to-nose test
   Finger-to-nose detects cerebellar dysmetria and intention tremor, a different cause of unsteadiness that does not depend on whether the eyes are open.
4. Rapid alternating movements
   Rapid alternating movements test cerebellar coordination (dysdiadochokinesia); they stay abnormal with eyes open and do not isolate joint-position sense.

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A 2-year-old has had weight faltering since 12 months with abdominal distension, frequent loose foul-smelling stools, and irritability. The child eats wheat products daily. Which test is MOST appropriate to screen for the suspected diagnosis?

1. tTG-IgA plus total serum IgA
   Chronic diarrhea, distension, and weight faltering in a toddler eating gluten point to celiac disease. The screen is tTG-IgA while gluten is in the diet, paired with a total IgA level so that IgA deficiency cannot hide a true positive.
2. HLA-DQ2/DQ8 genetic typing
   HLA typing is useful to rule celiac disease out, because almost everyone with it carries DQ2 or DQ8, but a positive result is common in the general population and cannot screen or confirm.
3. tTG-IgA alone
   Ordering tTG-IgA without a total IgA misses the child with IgA deficiency, which is more common in celiac disease and makes the tTG-IgA falsely negative.
4. sweat chloride test
   Sweat chloride is the test for cystic fibrosis, the malabsorption differential that usually adds recurrent respiratory infections and often shows up in infancy or on the newborn screen.

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A ventilated 3-week-old with evolving BPD receives PN at a GIR of 16 mg/kg/min with lipid 2 g/kg/day. PaCO2 has risen from 50 to 62 mmHg with no change in lung findings. The most likely nutritional cause is

1. Lipid emulsion impairing diffusion
   Blaming the lipid is a common reflex, but 2 g/kg/day does not raise PaCO2; lipid has the lowest respiratory quotient of the macronutrients.
2. Glucose excess causing lipogenesis
   Glucose given beyond the oxidative capacity of about 12 mg/kg/min is turned into fat, a process with a respiratory quotient above 1, so CO2 production rises in an infant with little ventilatory reserve; lowering the GIR helps.
3. High protein oxidation producing CO2
   Protein oxidation yields less CO2 per calorie than glucose, so it cannot explain a CO2 rise that tracks a very high GIR.

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Which medication is FDA-approved and considered first-line for bulimia nervosa?

1. Fluoxetine
   Fluoxetine is the only medication FDA-approved for bulimia nervosa, and its labeled dose of 60 mg/day is higher than the usual depression dose.
2. Lisdexamfetamine
   Lisdexamfetamine is FDA-approved for moderate to severe binge-eating disorder, not bulimia; this choice mixes up the two binge-eating conditions.
3. Alprazolam
   A benzodiazepine adds dependence risk and does nothing for the binge-purge cycle; no benzodiazepine is indicated for bulimia.
4. Bupropion
   Bupropion is contraindicated in current or past bulimia or anorexia because purging-related electrolyte shifts raise its seizure risk; choosing it for weight effects is a dangerous error.

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A 58-year-old has dyspareunia from genitourinary syndrome of menopause. Lubricants have not helped, she declines any estrogen product, and she prefers an oral medication. The most appropriate option is

1. Ospemifene
   Ospemifene is an oral selective estrogen receptor modulator that acts as an estrogen agonist on vaginal epithelium and is FDA-approved for moderate to severe dyspareunia from menopause, so it fits a patient who wants a pill but no estrogen product.
2. Flibanserin
   Flibanserin treats acquired hypoactive sexual desire disorder in premenopausal women; choosing it confuses low desire with pain from atrophic tissue, which it does not reverse.
3. Oral estradiol
   Oral estradiol would relieve atrophy, but it is an estrogen product she has declined; systemic estrogen is also more than isolated genitourinary symptoms need.

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A 72-year-old's colon adenocarcinoma shows loss of MLH1 and PMS2 on immunohistochemistry, and a BRAF V600E mutation is detected. The most likely cause of the mismatch repair loss is:

1. MLH1 promoter hypermethylation
   BRAF V600E in a tumor with paired MLH1/PMS2 loss points to acquired promoter methylation that silences MLH1, the usual mechanism in sporadic MSI-high colon cancer of older adults, so germline testing is usually not needed unless the family history is strong.
2. germline PMS2 pathogenic variant
   PMS2 disappears in this pattern only because it needs MLH1 to stay stable; a primary PMS2 defect shows isolated PMS2 loss with MLH1 intact.
3. germline MLH1 pathogenic variant
   This is the Lynch syndrome explanation for MLH1/PMS2 loss, but it overlooks the BRAF V600E result, which is rarely found in Lynch-associated colorectal cancers and points to a sporadic cause.
4. an IHC staining artifact
   Paired loss of MLH1 and its partner PMS2 is a coherent biological pattern, and the BRAF result supports a real defect; dismissing it as artifact discards an MSI-high tumor.

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