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ABFM HALM practice questions

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Question 1Health Promotion and Disease Prevention

A 55-year-old adult with no cardiovascular risk factors asks which colorectal cancer screening strategy is appropriate. Which option is an accepted United States Preventive Services Task Force recommendation for average-risk adults aged 50 to 75?

  1. CT colonography every 15 years
  2. Barium enema every 2 years
  3. Annual colonoscopy
  4. Annual fecal immunochemical testing Correct answer.

Explanation

Average-risk adults aged 45 to 75 should be screened, and annual stool-based testing with fecal immunochemical testing is an accepted strategy. Colonoscopy is recommended every 10 years, not annually, and CT colonography every 5 years. Barium enema is no longer a preferred option in current guidance.

Question 2Health Promotion and Disease Prevention

A healthy 30-year-old woman has never received human papillomavirus vaccination. What is the most appropriate recommendation?

  1. Vaccination only after an abnormal Pap result
  2. No vaccination because she is older than the upper age limit
  3. Vaccination with a catch-up series up to age 26 Correct answer.
  4. Vaccination only if she has not been sexually active

Explanation

Routine HPV vaccination is recommended at ages 11 to 12, with catch-up vaccination recommended through age 26 for those not previously vaccinated. Shared clinical decision-making may extend vaccination to age 45. Sexual history and Pap results do not determine eligibility for catch-up vaccination.

Question 3Health Promotion and Disease Prevention

A 68-year-old man with hypertension and diabetes has no history of atherosclerotic cardiovascular disease. Which preventive strategy best reflects current guidance for reducing his cardiovascular risk?

  1. Recommend aspirin routinely regardless of bleeding risk
  2. Defer lipid-lowering therapy until symptoms develop
  3. Estimate 10-year ASCVD risk and offer a moderate-intensity statin if risk is elevated Correct answer.
  4. Start a statin only if LDL exceeds 190 mg/dL

Explanation

For adults aged 40 to 75 without clinical ASCVD, statin therapy is guided by estimated 10-year ASCVD risk and risk-enhancing factors. Moderate-intensity statin is recommended for those with diabetes and for those with elevated estimated risk. Aspirin is no longer routinely recommended for primary prevention in older adults because bleeding risk offsets benefit.

Question 4Health Promotion and Disease Prevention

A 24-year-old college student presents with a deep puncture wound from a dirty nail. He received a primary tetanus series as a child but has not had a booster in 12 years. What is the appropriate management?

  1. No prophylaxis needed because he had a primary series
  2. Tetanus toxoid booster plus tetanus immune globulin Correct answer.
  3. Tetanus toxoid booster only
  4. Tetanus immune globulin only

Explanation

For a dirty or puncture wound, a tetanus booster is indicated if more than 5 years have elapsed since the last dose. Tetanus immune globulin is added when the primary series is incomplete or unknown, but in this case the primary series was completed, so immune globulin is not strictly required; however, many references recommend both for contaminated wounds with an interval over 10 years. The safest answer reflecting contaminated-wound management combines toxoid with immune globulin when the interval is long, though the key point is that a booster is required and immune globulin is considered for contaminated wounds.

Question 5Health Promotion and Disease Prevention

A 60-year-old woman asks about osteoporosis screening. She has no prior fractures and no secondary causes. Which statement reflects current preventive guidance?

  1. Bone density testing should be repeated annually for all postmenopausal women
  2. Bone density testing is recommended for women aged 65 and older Correct answer.
  3. Routine bone density testing is recommended for all women beginning at age 50
  4. Bone density testing is not recommended at any age without a fracture

Explanation

Osteoporosis screening with bone densitometry is recommended for women aged 65 and older and for younger postmenopausal women at increased risk. Routine screening of all women at age 50 is not recommended. Repeat intervals are individualized and generally not annual.

Question 6Health Promotion and Disease Prevention

A 45-year-old man with obesity and a sedentary lifestyle is being counseled on preventive care. Which intervention has the strongest evidence for preventing progression to type 2 diabetes in adults with prediabetes?

  1. Annual fasting glucose testing alone
  2. Intensive lifestyle intervention targeting 7% weight loss and 150 minutes of activity weekly Correct answer.
  3. Metformin for all adults with prediabetes
  4. Low-carbohydrate diet without physical activity

Explanation

Intensive lifestyle intervention with modest weight loss and regular physical activity is the most effective strategy for preventing progression from prediabetes to type 2 diabetes. Metformin is considered for selected higher-risk patients but is not recommended for all. Testing alone does not prevent progression.

Question 7Health Promotion and Disease Prevention

A 35-year-old woman is planning pregnancy and asks about folic acid. What is the recommended supplement dose for a woman at average risk of neural tube defects?

  1. 1 mg weekly throughout pregnancy
  2. 4 mg daily beginning at conception
  3. 0.4 mg daily beginning at least 1 month before conception Correct answer.
  4. No supplementation if she eats fortified cereals

Explanation

Women at average risk should take 0.4 mg of folic acid daily starting at least 1 month before conception and continuing through early pregnancy. A higher dose of 4 mg daily is reserved for women with a prior affected pregnancy or specific risk factors. Dietary intake alone is often insufficient to reach the recommended level.

Question 8Health Promotion and Disease Prevention

A 70-year-old man with a 40 pack-year smoking history and no symptoms asks about lung cancer screening. Which statement is correct?

  1. Screening should begin at age 40 for all adults
  2. Screening with chest radiography annually is recommended
  3. Screening is recommended only for current smokers, not former smokers
  4. Screening with annual low-dose CT is recommended for eligible adults aged 50 to 80 with significant smoking history Correct answer.

Explanation

Annual low-dose CT lung cancer screening is recommended for adults aged 50 to 80 with at least a 20 pack-year history who currently smoke or quit within the past 15 years. Chest radiography is not an accepted screening test. Former smokers within the quit window remain eligible.

Question 9Health Promotion and Disease Prevention

A 28-year-old woman has a body mass index of 31 and no other chronic conditions. She is not pregnant. Which screening is recommended specifically because of her obesity?

  1. Routine colonoscopy before age 45
  2. Annual electrocardiography
  3. Annual chest radiography
  4. Screening for prediabetes and type 2 diabetes Correct answer.

Explanation

Adults with overweight or obesity should be screened for prediabetes and type 2 diabetes, typically beginning at age 35 or earlier when risk factors are present. Obesity alone does not warrant annual electrocardiography or chest radiography. Colonoscopy timing is based on age and family history, not obesity.

Question 10Health Promotion and Disease Prevention

A 50-year-old woman with a history of treated cervical precancer asks about follow-up. Which principle best guides her long-term surveillance?

  1. She can resume routine screening intervals immediately after treatment
  2. She should continue surveillance for at least 25 years after treatment Correct answer.
  3. She should have annual screening for life regardless of results
  4. She can stop screening after hysterectomy for any indication

Explanation

After treatment for cervical precancer, surveillance should continue for at least 25 years, even beyond age 65, because of persistent elevated risk. Routine intervals resume only after prolonged negative surveillance. Hysterectomy for benign disease may allow cessation if criteria are met, but that does not apply here.

Question 11Health Promotion and Disease Prevention

A 66-year-old woman is being evaluated for breast cancer screening. She is asymptomatic and has no prior breast disease. Which statement reflects current guidance?

  1. Screening MRI is recommended for all women over age 65
  2. Breast self-examination is recommended as a primary screening method
  3. Screening mammography is not recommended after age 60
  4. Screening mammography is recommended every 2 years for women aged 50 to 74 Correct answer.

Explanation

Biennial screening mammography is recommended for women aged 50 to 74, with individualized decisions for those 40 to 49 and 75 and older. Breast self-examination is not recommended as a primary screening method. MRI is reserved for women at high risk, such as BRCA mutation carriers.

Question 12Health Promotion and Disease Prevention

A 40-year-old man has a fasting glucose of 108 mg/dL and a body mass index of 29. What is the most appropriate next step in preventive care?

  1. Start a sulfonylurea empirically
  2. Reassure him that no follow-up is needed
  3. Recommend lifestyle counseling and periodic glucose monitoring Correct answer.
  4. Diagnose type 2 diabetes and start insulin

Explanation

A fasting glucose of 108 mg/dL falls in the prediabetes range of 100 to 125 mg/dL. The appropriate response is lifestyle counseling with periodic monitoring, often annually, to detect progression to diabetes. Pharmacologic therapy is not indicated at this stage for most patients.

Question 13Health Promotion and Disease Prevention

A 32-year-old woman is being counseled on alcohol use. She reports drinking four standard drinks on weekends. Which statement reflects recommended screening and counseling?

  1. Any alcohol use should prompt referral to inpatient detoxification
  2. Screening for unhealthy alcohol use should be done annually with brief counseling for those exceeding limits Correct answer.
  3. Brief counseling is effective only in specialty addiction clinics
  4. Screening is recommended only for patients with abnormal liver enzymes

Explanation

Annual screening for unhealthy alcohol use with brief behavioral counseling is recommended for adults, including pregnant women. Brief intervention in primary care is effective for risky drinking. Referral to specialty care is reserved for more severe use disorder.

Question 14Health Promotion and Disease Prevention

A 58-year-old man with a 30 pack-year smoking history asks about abdominal aortic aneurysm screening. He has never had vascular imaging. What is the recommended approach?

  1. Annual CT angiography beginning at age 50
  2. No screening unless he has abdominal pain
  3. Screening only if he has hypertension
  4. Screening ultrasonography once for men aged 65 to 75 who have ever smoked Correct answer.

Explanation

One-time ultrasonography is recommended for men aged 65 to 75 who have ever smoked. Screening is not recommended for men who never smoked. CT angiography is not a screening tool, and abdominal pain prompts diagnostic evaluation rather than screening.

Question 15Health Promotion and Disease Prevention

A 22-year-old man is due for routine immunizations. Which vaccine is recommended for all adults in this age group without contraindications?

  1. Hepatitis A vaccination for all adults
  2. Zoster recombinant vaccination
  3. Annual influenza vaccination Correct answer.
  4. Pneumococcal conjugate vaccination

Explanation

Annual influenza vaccination is recommended for all adults without contraindications. Pneumococcal vaccination is recommended based on age and risk factors, not routinely for healthy young adults. Zoster vaccination is recommended starting at age 50, and hepatitis A is recommended for specific risk groups.

Question 16Health Promotion and Disease Prevention

A 48-year-old woman with a body mass index of 34 has no other risk factors. Which screening recommendation is most appropriate?

  1. Screening with hemoglobin A1c every 5 years only
  2. No screening until age 55
  3. Screening for diabetes beginning at age 35 with overweight or obesity present Correct answer.
  4. Screening for diabetes only at age 45 regardless of weight

Explanation

Adults with overweight or obesity should begin diabetes screening at age 35, with repeat testing at least every 3 years if results are normal. Age 45 alone is not the sole criterion. Earlier and more frequent screening applies when risk factors are present.

Question 17Health Promotion and Disease Prevention

A 72-year-old woman is being counseled on fall prevention. Which intervention has the strongest evidence for reducing falls in community-dwelling older adults?

  1. Routine use of hip protectors
  2. Home modifications alone without exercise
  3. Vitamin D supplementation for all older adults regardless of level
  4. Exercise programs that include balance and strength training Correct answer.

Explanation

Exercise programs incorporating balance, strength, and gait training reduce falls in community-dwelling older adults. Vitamin D supplementation is recommended for those with deficiency rather than universally. Hip protectors are used in institutional settings for high-risk individuals.

Question 18Health Promotion and Disease Prevention

A 30-year-old woman is being screened for depression. Which approach is recommended for adults in primary care?

  1. Screening only during pregnancy
  2. Routine screening with a validated instrument and follow-up for positive results Correct answer.
  3. Screening with a single yes-or-no question
  4. Screening only when the patient reports symptoms

Explanation

Routine screening for depression is recommended for adults, including pregnant and postpartum women, using validated instruments with systems in place for follow-up and treatment. Screening only when symptoms are reported misses many cases. A single question is not a validated screening instrument.

Question 19Health Promotion and Disease Prevention

A 55-year-old man with a history of colorectal adenomas asks about surveillance. He had two tubular adenomas removed 3 years ago. Which statement reflects recommended surveillance?

  1. Repeat colonoscopy every 10 years regardless of findings
  2. Surveillance colonoscopy is not needed after polypectomy
  3. Surveillance intervals are based on findings; 3 years is appropriate for several small adenomas Correct answer.
  4. Repeat colonoscopy in 1 year for all patients with adenomas

Explanation

Post-polypectomy surveillance intervals are risk-stratified based on the number, size, and histology of adenomas. Patients with multiple small tubular adenomas typically return in 3 years, while those with advanced adenomas may need earlier follow-up. A 10-year interval applies only to average-risk screening without findings.

Question 20Health Promotion and Disease Prevention

A 19-year-old college student has not received meningococcal vaccination. Which recommendation is appropriate for first-year students living in residence halls?

  1. Only the polysaccharide vaccine is recommended
  2. Meningococcal vaccination is not recommended for college students
  3. Vaccination is recommended only after exposure to a case
  4. Meningococcal conjugate vaccination is recommended, with boosters as indicated Correct answer.

Explanation

Meningococcal conjugate vaccination is recommended for first-year college students living in residence halls and for other high-risk groups. A booster is recommended if the primary dose was given before age 16. Polysaccharide vaccine has largely been replaced by conjugate formulations.

Question 21Health Promotion and Disease Prevention

A 64-year-old woman with no symptoms asks about screening for hepatitis C. What is the recommended approach?

  1. Screening only if she has a history of injection drug use
  2. No screening unless liver enzymes are elevated
  3. Screening every 5 years for all adults
  4. One-time screening for all adults aged 18 to 79 Correct answer.

Explanation

One-time hepatitis C screening is recommended for all adults aged 18 to 79, regardless of risk factors, and for pregnant women during each pregnancy. Screening only based on risk misses many infections. Elevated liver enzymes are not required for screening.

Question 22Health Promotion and Disease Prevention

A 26-year-old woman is considering contraception and asks about preventive health services. Which service is recommended without cost sharing under most insurance plans?

  1. Routine vitamin supplementation for all adults
  2. Contraceptive counseling and FDA-approved contraceptive methods Correct answer.
  3. Elective fertility treatment
  4. Cosmetic dermatologic procedures

Explanation

Contraceptive counseling and FDA-approved contraceptive methods are recommended preventive services for women. Cosmetic procedures, elective fertility treatment, and routine multivitamins for all adults are not covered preventive services under these requirements.

Question 23Health Promotion and Disease Prevention

A 70-year-old man with chronic obstructive pulmonary disease and diabetes asks which vaccines he should receive. Which combination is recommended for him?

  1. No vaccines because of his age
  2. Influenza, pneumococcal, and recombinant zoster vaccines Correct answer.
  3. Only influenza vaccine
  4. Hepatitis B vaccine alone

Explanation

Adults aged 65 and older, and those with chronic conditions such as COPD and diabetes, should receive influenza and pneumococcal vaccines, and recombinant zoster vaccine is recommended from age 50. COVID-19 vaccination is also recommended per current guidance. Age is not a reason to forgo vaccination.

Question 24Health Promotion and Disease Prevention

A 38-year-old man is being counseled on tobacco cessation. He smokes one pack daily and is ready to quit. Which approach is recommended as first-line pharmacotherapy?

  1. No pharmacotherapy; counseling alone is always preferred
  2. Clonidine as first-line therapy
  3. Varenicline, bupropion, or nicotine replacement therapy combined with counseling Correct answer.
  4. Nortriptyline as first-line therapy

Explanation

First-line pharmacotherapy for tobacco cessation includes varenicline, bupropion, and nicotine replacement therapy, ideally combined with behavioral counseling. Nortriptyline and clonidine are second-line agents. Combining medication with counseling improves success rates.

Question 25Health Promotion and Disease Prevention

A 45-year-old woman is diagnosed with latent tuberculosis infection after screening. She has no symptoms and a normal chest radiograph. What is the recommended approach?

  1. No treatment because she is asymptomatic
  2. Immediate four-drug therapy for active tuberculosis
  3. Isolation for 6 months
  4. Treatment of latent tuberculosis infection to prevent progression to active disease Correct answer.

Explanation

Latent tuberculosis infection should be treated with a recommended regimen to prevent progression to active disease. Treatment regimens are shorter than those for active disease. Isolation is not required for latent infection, and asymptomatic latent infection still warrants treatment.

Question 26Health Promotion and Disease Prevention

A 52-year-old woman with no symptoms asks about screening for osteoporosis. She has no prior fractures and is not taking glucocorticoids. Which statement best reflects the recommended approach for her age group?

  1. Routine bone density screening is recommended for women aged 65 and older, so she does not yet meet the standard age threshold Correct answer.
  2. Screening should be repeated annually once started in any woman over age 40
  3. Bone density screening is not recommended at any age because it does not change outcomes
  4. Bone density screening should begin at age 50 for all women regardless of risk factors

Explanation

Osteoporosis screening with bone densitometry is recommended for all women aged 65 years and older, and for younger postmenopausal women whose fracture risk is elevated by a formal risk assessment tool. A 52-year-old woman without risk factors does not meet the routine age threshold.

Question 27Health Promotion and Disease Prevention

A 34-year-old man is seen for a routine visit. He has no chronic medical conditions, and his blood pressure today is 118/74 mm Hg. Which statement about screening for hypertension in adults is most accurate?

  1. Screening with home monitoring is preferred over office measurement for initial detection
  2. Screening should be repeated only if the patient develops symptoms such as headache
  3. Screening is recommended at every routine clinical encounter with office blood pressure measurement Correct answer.
  4. Screening is recommended once at age 18 and then only after age 50

Explanation

Hypertension screening is recommended for all adults at every routine health encounter using office blood pressure measurement, because elevated readings are common and often asymptomatic. Confirmation outside the office is used to verify a diagnosis, not to replace initial office screening.

Question 28Health Promotion and Disease Prevention

A 41-year-old woman with type 2 diabetes, a body mass index of 33, and no other chronic illness asks about immunizations. She has completed primary series but has not received a pneumococcal vaccine. Which recommendation is most appropriate?

  1. Pneumococcal vaccination is indicated now because diabetes and obesity increase risk, using the age-appropriate conjugate schedule Correct answer.
  2. Pneumococcal vaccination should be deferred until she reaches age 65 regardless of her diabetes
  3. She should receive a 23-valent polysaccharide vaccine only, given once at this visit
  4. No pneumococcal vaccination is indicated because she is younger than 65

Explanation

Adults with diabetes and other conditions that increase the risk of invasive pneumococcal disease are recommended to receive pneumococcal vaccination before age 65, following the current conjugate-based schedule. Age alone is not the deciding factor when a risk condition is present.

Question 29Health Promotion and Disease Prevention

A 29-year-old woman reports that her mother was diagnosed with breast cancer at age 44. The patient is asymptomatic and has no personal history of cancer. Which principle best guides her evaluation for inherited breast and ovarian cancer risk?

  1. She should follow average-risk screening because only a personal history of cancer matters
  2. She should undergo genetic risk assessment because a first-degree relative with early-onset breast cancer raises suspicion Correct answer.
  3. She should begin annual mammography immediately at her current age
  4. She should be tested for BRCA mutations only after she develops symptoms

Explanation

A first-degree relative with breast cancer diagnosed before age 50 is a recognized flag for inherited cancer susceptibility, and formal risk assessment determines whether genetic testing and earlier screening are warranted. Family history, not just personal history, drives this evaluation.

Question 30Health Promotion and Disease Prevention

A 60-year-old man is being counseled about prostate cancer screening. He is asymptomatic, has no family history, and wants to make an informed decision. Which statement best reflects current guidance?

  1. Screening with prostate-specific antigen should be offered to all men beginning at age 40
  2. Screening should rely on digital rectal examination alone because prostate-specific antigen testing is not useful
  3. Screening should be discouraged entirely because the harms always outweigh benefits
  4. Screening decisions should be individualized through shared decision-making, with prostate-specific antigen testing discussed starting around age 55 Correct answer.

Explanation

Prostate cancer screening is not a universal recommendation; the decision should follow a discussion of benefits and harms with men in the age range where screening is considered, generally starting around age 55 for average-risk men. The preference-sensitive nature of the decision is the central point.

Question 31Cardiovascular Health and Hypertension

A 52-year-old man has an average home blood pressure of 148/94 mm Hg confirmed on repeated readings. He has no diabetes, kidney disease, or other comorbidity. Which initial pharmacologic approach is most appropriate?

  1. Start a thiazide-type diuretic, an ACE inhibitor, an ARB, or a calcium channel blocker as first-line monotherapy Correct answer.
  2. Start an alpha blocker as first-line therapy because it improves lipid profiles
  3. Start a loop diuretic because it produces the greatest reduction in systolic pressure
  4. Start a beta blocker as first-line therapy for uncomplicated hypertension

Explanation

For stage 1 or 2 hypertension without compelling indications, first-line agents are thiazide-type diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers. Beta blockers and alpha blockers are not preferred initial monotherapy for uncomplicated hypertension.

Question 32Cardiovascular Health and Hypertension

Which blood pressure threshold defines hypertension in adults using office measurements according to the 2017 ACC/AHA guideline?

  1. 130/80 mm Hg Correct answer.
  2. 140/90 mm Hg
  3. 120/70 mm Hg
  4. 150/95 mm Hg

Explanation

The 2017 ACC/AHA guideline classifies hypertension as office blood pressure of 130/80 mm Hg or higher. The older 140/90 threshold now corresponds to stage 2 hypertension.

Question 33Cardiovascular Health and Hypertension

A 68-year-old woman with hypertension and type 2 diabetes has an eGFR of 55 mL/min/1.73 m2 and a urine albumin-to-creatinine ratio of 120 mg/g. Which medication class provides the strongest kidney and cardiovascular protection in addition to blood pressure control?

  1. A loop diuretic
  2. A thiazide-type diuretic
  3. An ACE inhibitor or ARB Correct answer.
  4. A beta blocker

Explanation

In patients with hypertension and diabetes with albuminuria, ACE inhibitors or ARBs reduce progression of kidney disease and cardiovascular events. These agents are preferred when albuminuria is present.

Question 34Cardiovascular Health and Hypertension

A 74-year-old man with hypertension and no diabetes has an estimated 10-year atherosclerotic cardiovascular disease risk of 14%. His blood pressure is 138/84 mm Hg after lifestyle changes. What is the recommended next step?

  1. Start antihypertensive medication in addition to lifestyle modification Correct answer.
  2. Continue lifestyle modification alone because his blood pressure is below 140/90
  3. Obtain ambulatory monitoring before any medication decision
  4. Start a statin alone and defer antihypertensive therapy

Explanation

For adults aged 65 years or older with hypertension, pharmacologic therapy is recommended when systolic pressure is 130 mm Hg or higher and 10-year ASCVD risk is 10% or greater. His risk and pressure meet criteria for starting medication.

Question 35Cardiovascular Health and Hypertension

Which finding on physical examination most suggests that a patient's hypertension is secondary to primary aldosteronism?

  1. Orthostatic hypotension with tachycardia
  2. Widened pulse pressure with warm extremities
  3. Bradycardia with hyperkalemia
  4. Spontaneous hypokalemia with metabolic alkalosis Correct answer.

Explanation

Primary aldosteronism causes sodium retention and potassium wasting, producing hypokalemia and metabolic alkalosis in a subset of patients. It should be suspected in resistant hypertension or unexplained hypokalemia.

Question 36Cardiovascular Health and Hypertension

A patient with hypertension reports ankle swelling after starting a dihydropyridine calcium channel blocker. Which management strategy is most appropriate if blood pressure is at goal and symptoms are mild?

  1. Switch to a beta blocker regardless of other indications
  2. Stop the drug immediately and never use calcium channel blockers again
  3. Add a loop diuretic to counteract the edema
  4. Continue the drug and consider reducing the dose or adding a renin-angiotensin system blocker Correct answer.

Explanation

Peripheral edema from dihydropyridine calcium channel blockers is dose-related and often improves with dose reduction or co-administration of an ACE inhibitor or ARB. The edema is not primarily due to volume overload, so loop diuretics are not the preferred solution.

Question 37Cardiovascular Health and Hypertension

Which combination of antihypertensive agents should generally be avoided because of an increased risk of hyperkalemia and acute kidney injury?

  1. An ACE inhibitor plus a calcium channel blocker
  2. An ACE inhibitor plus an ARB Correct answer.
  3. A thiazide diuretic plus a calcium channel blocker
  4. A thiazide diuretic plus an ARB

Explanation

Combining an ACE inhibitor with an ARB (dual renin-angiotensin blockade) increases hyperkalemia and acute kidney injury without added benefit. Guideline-recommended combinations pair agents from different classes such as a thiazide with a calcium channel blocker or an ACE inhibitor/ARB with a calcium channel blocker or thiazide.

Question 38Cardiovascular Health and Hypertension

A 60-year-old woman with resistant hypertension is being evaluated. Which criterion best defines resistant hypertension?

  1. Blood pressure that rises during the winter months
  2. A single office reading above 160/100 mm Hg
  3. Blood pressure above goal despite three antihypertensive agents of different classes including a diuretic, or controlled on four or more agents Correct answer.
  4. Blood pressure above goal on any two antihypertensive medications

Explanation

Resistant hypertension is defined as blood pressure above goal despite use of three agents of different classes including a diuretic, or blood pressure controlled with four or more agents. Pseudoresistance from measurement error or nonadherence should be excluded first.

Question 39Cardiovascular Health and Hypertension

A 58-year-old man with hypertension and gout requires a diuretic. Which agent is least likely to precipitate a gout flare?

  1. Chlorthalidone
  2. Hydrochlorothiazide
  3. Losartan Correct answer.
  4. Furosemide

Explanation

Thiazide and loop diuretics raise serum urate and can precipitate gout, whereas losartan has a uricosuric effect and lowers urate. In a patient with gout, an ARB such as losartan is a favorable choice.

Question 40Cardiovascular Health and Hypertension

Which lifestyle intervention produces the largest average reduction in systolic blood pressure in adults with hypertension?

  1. Moderate alcohol reduction alone
  2. Adding a daily multivitamin
  3. Increasing dietary potassium without other changes
  4. Weight loss of about 1 kg per kg of excess body weight Correct answer.

Explanation

Weight loss produces a dose-dependent reduction in blood pressure, roughly 1 mm Hg per kilogram of weight lost, making it one of the most effective lifestyle measures. Other measures such as sodium restriction, DASH diet, and exercise also lower pressure but weight loss has a large graded effect.

Question 41Cardiovascular Health and Hypertension

A 70-year-old man with isolated systolic hypertension and a wide pulse pressure is started on therapy. Which class is particularly effective for reducing systolic pressure in older adults with stiff arteries?

  1. A central alpha-2 agonist
  2. A thiazide-type diuretic or a dihydropyridine calcium channel blocker Correct answer.
  3. A direct renin inhibitor
  4. An alpha-1 blocker

Explanation

Thiazide-type diuretics and dihydropyridine calcium channel blockers are especially effective for isolated systolic hypertension in older adults. Trials such as SHEP and Syst-Eur support these classes in this population.

Question 42Cardiovascular Health and Hypertension

A 45-year-old woman has hypertension and recurrent episodes of palpitations, headache, and diaphoresis with markedly elevated blood pressure during episodes. Which initial test is most appropriate to evaluate for pheochromocytoma?

  1. Serum aldosterone-to-renin ratio
  2. Overnight dexamethasone suppression test
  3. Plasma free metanephrines Correct answer.
  4. Renal artery duplex ultrasound

Explanation

Pheochromocytoma is best screened with plasma free metanephrines or 24-hour urinary fractionated metanephrines. The paroxysmal triad of headache, palpitations, and diaphoresis with severe hypertension is classic.

Question 43Cardiovascular Health and Hypertension

Which statement about white-coat hypertension is most accurate?

  1. It always warrants immediate initiation of two antihypertensive agents
  2. It refers to normal office blood pressure with elevated ambulatory readings
  3. It refers to elevated office blood pressure with normal out-of-office readings and generally carries a better prognosis than sustained hypertension Correct answer.
  4. It is diagnosed using a single office measurement above 180/110 mm Hg

Explanation

White-coat hypertension is elevated office pressure with normal ambulatory or home readings and has a lower cardiovascular risk than sustained hypertension. Confirming with out-of-office measurement avoids overtreatment.

Question 44Cardiovascular Health and Hypertension

A 66-year-old man with hypertension and chronic kidney disease has an eGFR of 28 mL/min/1.73 m2. Which diuretic is most appropriate for volume and blood pressure control?

  1. Chlorthalidone
  2. Hydrochlorothiazide
  3. Furosemide Correct answer.
  4. Spironolactone

Explanation

Loop diuretics remain effective at low eGFR, whereas thiazide-type diuretics lose efficacy when eGFR falls below about 30 mL/min/1.73 m2. Spironolactone risks hyperkalemia in advanced CKD.

Question 45Cardiovascular Health and Hypertension

A patient with hypertension and heart failure with reduced ejection fraction is being optimized. Which antihypertensive agents improve survival in this condition?

  1. A thiazide diuretic and a direct renin inhibitor
  2. An ACE inhibitor or ARB, a beta blocker, and a mineralocorticoid receptor antagonist Correct answer.
  3. A dihydropyridine calcium channel blocker and an alpha blocker
  4. Hydralazine alone without a nitrate

Explanation

In heart failure with reduced ejection fraction, ACE inhibitors/ARBs, evidence-based beta blockers, and mineralocorticoid receptor antagonists reduce mortality. These agents also lower blood pressure and are preferred when HFrEF coexists with hypertension.

Question 46Cardiovascular Health and Hypertension

A 34-year-old woman with hypertension is planning pregnancy. Which antihypertensive is contraindicated because of fetal toxicity?

  1. Lisinopril Correct answer.
  2. Labetalol
  3. Methyldopa
  4. Nifedipine

Explanation

ACE inhibitors and ARBs are contraindicated in pregnancy because they cause fetal renal failure, oligohydramnios, and skull hypoplasia. Labetalol, nifedipine, and methyldopa are preferred options during pregnancy.

Question 47Cardiovascular Health and Hypertension

A 72-year-old man with hypertension and benign prostatic hyperplasia has persistent elevation despite a thiazide. Which additional agent offers dual benefit?

  1. Spironolactone
  2. Clonidine
  3. Doxazosin Correct answer.
  4. Hydralazine

Explanation

Alpha-1 blockers such as doxazosin relax both vascular and prostatic smooth muscle, improving lower urinary tract symptoms while lowering blood pressure. They are useful add-on therapy when BPH coexists, though not first-line monotherapy for hypertension.

Question 48Cardiovascular Health and Hypertension

A patient presents with blood pressure 224/128 mm Hg, headache, and confusion, with no focal neurologic deficit. Which action is most appropriate?

  1. Admit for controlled blood pressure reduction, generally lowering mean arterial pressure by no more than about 25% in the first hour Correct answer.
  2. Lower blood pressure rapidly to normal within 30 minutes using sublingual nifedipine
  3. Withhold all antihypertensives until a full secondary workup is complete
  4. Give oral captopril and discharge home if the pressure falls below 160/100 mm Hg

Explanation

This presentation suggests a hypertensive emergency with end-organ symptoms, requiring monitored parenteral therapy and controlled reduction, typically no more than about 25% of mean arterial pressure in the first hour. Overly rapid reduction can cause cerebral, coronary, or renal ischemia.

Question 49Cardiovascular Health and Hypertension

Which statement best describes the effect of dietary sodium reduction on blood pressure?

  1. Sodium restriction lowers blood pressure only in patients with kidney disease
  2. Sodium restriction is effective only when combined with potassium supplementation
  3. Sodium restriction has no measurable effect on blood pressure
  4. Reducing sodium intake lowers blood pressure in a dose-dependent manner, with greater effects in older adults and in Black patients Correct answer.

Explanation

Randomized trials show a dose-dependent blood pressure reduction with lower sodium intake, with larger effects in older adults and in Black patients. Current guidelines recommend sodium intake below about 1,500 to 2,300 mg per day.

Question 50Cardiovascular Health and Hypertension

A 55-year-old man with hypertension has a serum potassium of 3.1 mmol/L and metabolic alkalosis while taking hydrochlorothiazide. Which explanation is most likely?

  1. Thiazide-induced renal potassium wasting with secondary aldosterone effect Correct answer.
  2. Primary renal potassium retention
  3. Loop diuretic effect from the thiazide
  4. Excess potassium intake from diet

Explanation

Thiazide diuretics increase distal sodium delivery and enhance potassium and hydrogen excretion, producing hypokalemia and metabolic alkalosis. Potassium should be repleted and the regimen reviewed.