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WAPCP Primary practice questions

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Question 1Adult & Geriatric Medicine

An 82-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 5 and a HAS-BLED score of 3. Which action best reflects guideline-based anticoagulation practice?

  1. Withhold anticoagulation because the HAS-BLED score is elevated
  2. Start an anticoagulant and address modifiable bleeding risk factors Correct answer.
  3. Prescribe aspirin alone as a safer alternative
  4. Refer for left atrial appendage occlusion before any anticoagulant trial

Explanation

A high HAS-BLED score identifies modifiable bleeding risks (blood pressure, NSAIDs, alcohol, labile INR) that should be corrected; it is not a reason to withhold anticoagulation. A CHA2DS2-VASc score of 5 confers a high stroke risk, so anticoagulation should proceed while mitigating bleeding hazards. Aspirin is inferior for stroke prevention and carries its own bleeding risk.

Question 2Adult & Geriatric Medicine

A 78-year-old man has a serum sodium of 118 mmol/L that developed gradually over several weeks. Which initial correction approach is safest?

  1. Slow correction with a rise of no more than 8 to 10 mmol/L in the first 24 hours Correct answer.
  2. Fluid restriction alone with no monitoring of sodium change
  3. Rapid correction with hypertonic saline to reach 135 mmol/L within 12 hours
  4. Free water restriction plus a loop diuretic to accelerate sodium rise

Explanation

Chronic hyponatremia should be corrected slowly because overly rapid correction risks osmotic demyelination. A rise of roughly 8 to 10 mmol/L in 24 hours is the accepted ceiling. Symptomatic severe hyponatremia may require hypertonic saline, but the target is a controlled small initial rise, not normalization within hours.

Question 3Adult & Geriatric Medicine

Which finding most strongly suggests that an older adult's cognitive decline is due to delirium rather than dementia?

  1. Fluctuating attention with an acute onset over days Correct answer.
  2. Stable symptoms across multiple clinic visits
  3. Insidious progression over several years
  4. Preserved ability to perform instrumental activities of daily living

Explanation

Delirium is characterized by acute onset, fluctuating course, and inattention, often triggered by illness, medications, or surgery. Dementia typically has an insidious, progressive course with relatively stable day-to-day performance. The key discriminator is acuity and fluctuation of attention.

Question 4Adult & Geriatric Medicine

A 75-year-old woman on furosemide, lisinopril, and spironolactone presents with weakness. Potassium is 6.4 mmol/L with peaked T waves. Which step should come first after confirming the ECG findings?

  1. Start a potassium binder and reassess in 24 hours
  2. Give intravenous sodium bicarbonate as the sole therapy
  3. Give intravenous calcium gluconate to stabilize the myocardium Correct answer.
  4. Reduce the furosemide dose and recheck in one week

Explanation

Hyperkalemia with ECG changes is a medical emergency; intravenous calcium stabilizes cardiac membranes within minutes while measures to shift and remove potassium are arranged. Potassium binders and diuretic adjustments act too slowly to address acute cardiotoxicity. Bicarbonate is an adjunct, not a substitute for membrane stabilization.

Question 5Adult & Geriatric Medicine

Which medication class is most strongly associated with an increased risk of falls in older adults because of its anticholinergic and sedating properties?

  1. Statin medications
  2. Thiazide diuretics
  3. Proton pump inhibitors
  4. Benzodiazepines Correct answer.

Explanation

Benzodiazepines cause sedation, impaired balance, and psychomotor slowing, all of which raise fall and fracture risk in older adults and are flagged on Beers-type criteria. Diuretics can contribute through hypotension or electrolyte disturbance but are not primarily sedating. PPIs and statins are not recognized as sedating fall-risk agents.

Question 6Adult & Geriatric Medicine

An 84-year-old man with advanced dementia has poor oral intake and recurrent aspiration. His daughter requests a percutaneous feeding tube. Which consideration is most appropriate to discuss?

  1. Percutaneous placement eliminates the need for advance care planning
  2. A feeding tube is mandatory once oral intake falls below 50 percent
  3. Tube feeding has not been shown to prolong survival or improve quality of life in advanced dementia Correct answer.
  4. Feeding tubes reliably prevent aspiration pneumonia in advanced dementia

Explanation

In advanced dementia, feeding tubes have not been demonstrated to prolong survival, reduce aspiration pneumonia, or improve quality of life, and they carry procedural and restraint-related harms. Hand feeding with careful positioning is generally preferred. Discussion should focus on goals of care rather than on a default procedural intervention.

Question 7Adult & Geriatric Medicine

Which blood pressure target is most consistent with current guidance for most community-dwelling adults aged 65 and older with hypertension?

  1. Systolic below 160 mmHg only
  2. Diastolic below 60 mmHg as the primary goal
  3. Systolic below 120 mmHg for all patients
  4. Systolic below 130 mmHg when tolerated Correct answer.

Explanation

Contemporary guidelines favor a systolic target of less than 130 mmHg for most older adults who tolerate treatment, with individualized relaxation for frailty or limited life expectancy. Universal targets below 120 mmHg are not recommended for all older patients. A diastolic goal below 60 mmHg is generally avoided because of coronary perfusion concerns.

Question 8Adult & Geriatric Medicine

A 70-year-old woman reports a two-year history of progressive resting tremor, bradykinesia, and rigidity. Which medication is most appropriate to initiate for symptom control?

  1. Diphenhydramine as chronic monotherapy
  2. Metoclopramide
  3. Levodopa combined with carbidopa Correct answer.
  4. Haloperidol

Explanation

Levodopa with carbidopa is the most effective symptomatic therapy for Parkinson disease and remains the mainstay for motor symptoms. Dopamine-blocking agents such as haloperidol and metoclopramide can worsen parkinsonism and should be avoided. Antihistamines are not appropriate chronic monotherapy for progressive disease.

Question 9Adult & Geriatric Medicine

Which feature best distinguishes vascular dementia from Alzheimer disease on clinical grounds?

  1. Stepwise decline with focal neurological deficits Correct answer.
  2. Prominent early word-finding difficulty with preserved gait
  3. Uniformly insidious decline without focal signs
  4. Early prominent visual hallucinations

Explanation

Vascular dementia often shows a stepwise or fluctuating course with focal neurological findings such as gait disturbance, pseudobulbar signs, or asymmetric weakness, reflecting discrete infarcts. Alzheimer disease typically has a gradual amnestic onset without focal motor signs. Early visual hallucinations suggest Lewy body dementia rather than either.

Question 10Adult & Geriatric Medicine

An older adult develops confusion and tremor three days after starting a new medication. Which agent is the most likely culprit?

  1. Amlodipine
  2. Lisinopril
  3. Oxybutynin Correct answer.
  4. Atorvastatin

Explanation

Oxybutynin is a strongly anticholinergic agent that commonly precipitates delirium, confusion, and tremor in older adults, and it is listed among medications to avoid in this population. Calcium channel blockers, ACE inhibitors, and statins are not classically associated with acute anticholinergic delirium.

Question 11Adult & Geriatric Medicine

A 79-year-old woman has a hemoglobin of 9.2 g/dL, MCV of 104 fL, and a normal peripheral smear. Which evaluation is most appropriate next?

  1. Bone marrow biopsy as the first test
  2. Iron studies to confirm iron deficiency
  3. Serum vitamin B12, folate, and TSH Correct answer.
  4. Empiric erythropoietin therapy

Explanation

A macrocytic anemia warrants assessment of vitamin B12, folate, and thyroid status, along with review for alcohol and medications such as methotrexate or hydroxyurea. Iron studies are indicated for microcytic anemia, not macrocytic. Bone marrow biopsy and empiric erythropoietin are premature before common causes are excluded.

Question 12Adult & Geriatric Medicine

Which intervention most effectively reduces the risk of contrast-induced acute kidney injury in an older adult with chronic kidney disease undergoing elective contrast imaging?

  1. Intravenous sodium bicarbonate given as the only preventive measure
  2. Pre-procedure hemodialysis for all patients with an eGFR below 60
  3. High-dose loop diuretics before the procedure
  4. Adequate volume expansion with isotonic saline Correct answer.

Explanation

Intravascular volume expansion with isotonic saline is the best-supported preventive measure for contrast-associated kidney injury. Hemodialysis is not indicated prophylactically for moderate CKD, and loop diuretics may worsen renal perfusion by causing volume depletion. Bicarbonate is at most an adjunct and is not superior as monotherapy.

Question 13Adult & Geriatric Medicine

An 80-year-old man with heart failure with reduced ejection fraction is on guideline-directed therapy but remains symptomatic. Which addition has been shown to reduce mortality in this population?

  1. Sodium-glucose cotransporter-2 inhibitor Correct answer.
  2. Verapamil
  3. Diltiazem
  4. Pioglitazone

Explanation

SGLT2 inhibitors reduce cardiovascular death and heart failure hospitalization in heart failure with reduced ejection fraction, including in older adults. Non-dihydropyridine calcium channel blockers such as diltiazem and verapamil are negative inotropes and are generally avoided in reduced ejection fraction. Pioglitazone causes fluid retention and is contraindicated in symptomatic heart failure.

Question 14Adult & Geriatric Medicine

Which finding on history is most suggestive of an adverse drug reaction as the cause of a new geriatric syndrome such as falls or confusion?

  1. Symptoms began shortly after a new prescription or dose change Correct answer.
  2. Symptoms are worse only after strenuous exercise
  3. Symptoms have been stable for ten years
  4. Symptoms resolve with increased dietary salt

Explanation

A temporal relationship with a new medication or dose escalation is a key clue to an adverse drug reaction, particularly when the presentation is a geriatric syndrome such as falls, confusion, or incontinence. Chronic stable symptoms are less likely to reflect a recent drug change. The other options do not establish a drug temporal association.

Question 15Adult & Geriatric Medicine

A 76-year-old woman has a urinary tract infection and an eGFR of 28 mL/min/1.73 m2. Which prescribing principle is most important?

  1. Double the dose to overcome reduced absorption
  2. Use standard adult doses because renal function does not affect drug levels
  3. Choose renally cleared antibiotics and adjust the dose to renal function Correct answer.
  4. Avoid all antibiotics and rely on hydration alone

Explanation

Many antibiotics are renally eliminated, so dose or interval adjustment is required when the eGFR is markedly reduced to avoid toxicity. Standard adult dosing can cause accumulation and adverse effects. Antibiotics remain necessary for treating infection; hydration alone does not treat a bacterial UTI.

Question 16Adult & Geriatric Medicine

Which statement about advance care planning is most accurate?

  1. Surrogate decision-makers are bound to follow their own preferences
  2. Advance directives cannot be changed once signed
  3. Advance care planning should be revisited when health status changes Correct answer.
  4. A signed living will eliminates the need for any discussion with family

Explanation

Advance care planning is an ongoing process that should be revisited as health status, prognosis, and values change. Documents support but do not replace conversation with family and clinicians. Surrogates are expected to apply the patient's expressed values rather than their own preferences.

Question 17Adult & Geriatric Medicine

A 72-year-old man has a fasting glucose of 132 mg/dL and an HbA1c of 7.4 percent. He is functionally independent. Which initial approach is most appropriate?

  1. Sulfonylurea monotherapy as first-line therapy
  2. No treatment because he is older than 70
  3. Intensive insulin therapy to achieve an HbA1c below 6 percent
  4. Lifestyle modification with metformin if targets are not met Correct answer.

Explanation

For an independent older adult with type 2 diabetes, lifestyle change plus metformin is the usual first step, with an individualized HbA1c target. Very tight glycemic control increases hypoglycemia risk without clear benefit in this age group. Sulfonylureas are not preferred first-line because of hypoglycemia risk.

Question 18Adult & Geriatric Medicine

Which feature of a pressure injury most strongly suggests a deep tissue injury rather than a superficial abrasion?

  1. A shallow ulcer with a clean, granulating bed
  2. Superficial epidermal loss with a pink, moist base
  3. Full-thickness loss with visible subcutaneous fat
  4. Intact skin with a localized area of persistent purple or maroon discoloration Correct answer.

Explanation

A deep tissue pressure injury presents as intact or non-intact skin with persistent purple or maroon discoloration, reflecting damage to underlying tissue. Superficial loss with a moist pink base describes a stage 2 injury. Full-thickness loss with visible fat indicates a stage 3 injury.

Question 19Adult & Geriatric Medicine

An 85-year-old woman with osteoporosis and a prior vertebral fracture asks about treatment. Which agent is appropriate for reducing vertebral fracture risk?

  1. Fluoride supplementation
  2. Calcium and vitamin D alone
  3. Estrogen therapy as first-line treatment
  4. Alendronate with calcium and vitamin D Correct answer.

Explanation

Bisphosphonates such as alendronate reduce vertebral and nonvertebral fracture risk and are first-line therapy for osteoporosis with prior fragility fracture. Calcium and vitamin D are supportive but insufficient alone for fracture reduction. Estrogen is not first-line in older women because of cardiovascular and breast cancer risks.

Question 20Adult & Geriatric Medicine

A 68-year-old man has a serum creatinine of 1.4 mg/dL and reports progressive fatigue. Which calculation is most useful for estimating his kidney function?

  1. Cockcroft-Gault creatinine clearance Correct answer.
  2. Urine specific gravity
  3. Blood urea nitrogen level
  4. Serum creatinine alone

Explanation

Creatinine-based estimates such as Cockcroft-Gault creatinine clearance or eGFR equations account for age and sex and are more informative than creatinine alone for drug dosing and staging. Serum creatinine by itself can appear normal despite substantial loss of function in older adults with low muscle mass. BUN and specific gravity are not measures of filtration.

Question 21Adult & Geriatric Medicine

Which clinical feature best supports a diagnosis of Lewy body dementia rather than Alzheimer disease?

  1. Early prominent visuospatial deficits with fluctuating cognition and parkinsonism Correct answer.
  2. A stepwise decline following a stroke
  3. Predominant early amnesia with preserved gait
  4. Marked early aphasia with preserved executive function

Explanation

Lewy body dementia is characterized by fluctuating cognition, visual hallucinations, parkinsonism, and prominent visuospatial deficits, often with REM sleep behavior disorder. Alzheimer disease typically begins with amnestic decline and lacks early parkinsonism. A stepwise post-stroke course suggests vascular dementia.

Question 22Adult & Geriatric Medicine

An older adult with atrial fibrillation and a mechanical mitral valve requires anticoagulation. Which agent is appropriate?

  1. Rivaroxaban
  2. Dabigatran
  3. Apixaban
  4. Warfarin Correct answer.

Explanation

Warfarin is the recommended anticoagulant for patients with mechanical heart valves, because direct oral anticoagulants have been associated with increased thromboembolic events in this setting. DOACs are appropriate for nonvalvular atrial fibrillation but not for mechanical valves. This distinction is clinically important when selecting therapy.

Question 23Adult & Geriatric Medicine

A 74-year-old woman is admitted with confusion, fever, and a urinary source. Which factor most increases her risk of developing delirium during this admission?

  1. Use of a proton pump inhibitor
  2. A single episode of mild hypertension
  3. Male sex
  4. Pre-existing cognitive impairment Correct answer.

Explanation

Pre-existing cognitive impairment is one of the strongest predisposing factors for delirium, which often becomes manifest when a precipitating illness such as infection occurs. The other listed factors are not established strong predisposing risks for delirium in this setting. Recognizing baseline cognitive vulnerability helps guide prevention and monitoring.

Question 24Adult & Geriatric Medicine

Which symptom pattern is most consistent with overactive bladder in an older adult?

  1. Difficulty initiating stream with post-void dribbling
  2. Urgency with frequency and nocturia, often with urge incontinence Correct answer.
  3. Painless gross hematuria
  4. Continuous leakage without any sense of urgency

Explanation

Overactive bladder is characterized by urgency, usually with frequency and nocturia, and may include urge incontinence. Painless hematuria requires evaluation for malignancy rather than a diagnosis of overactive bladder. Obstructive voiding symptoms suggest prostatic obstruction, and continuous leakage suggests a different mechanism such as fistula or overflow.

Question 25Adult & Geriatric Medicine

A 77-year-old man with COPD has an oxygen saturation of 88 percent at rest. Which oxygen target is most appropriate during an acute exacerbation?

  1. Maintain saturation at 88 to 92 percent Correct answer.
  2. Maintain saturation at 99 to 100 percent
  3. Avoid supplemental oxygen entirely
  4. Maintain saturation below 85 percent

Explanation

In acute COPD exacerbation, controlled oxygen therapy targeting an oxygen saturation of 88 to 92 percent reduces the risk of hypercapnia and respiratory acidosis while correcting hypoxemia. Overoxygenation can worsen carbon dioxide retention in patients with chronic hypercapnia. Withholding oxygen would leave significant hypoxemia untreated.

Question 26Adult & Geriatric Medicine

An 81-year-old woman living in long-term care has had three unprovoked falls in the past month. She takes oxybutynin, zolpidem, and hydrochlorothiazide. Which action is the most appropriate first step in reducing her fall risk?

  1. Review and reduce the anticholinergic and sedative medication burden Correct answer.
  2. Restrict her to bed rest until the falls are fully explained
  3. Order a brain MRI to exclude normal pressure hydrocephalus
  4. Start vitamin D at a dose of 400 IU daily

Explanation

Medication review is a core element of multifactorial fall risk assessment, and sedative-hypnotics, anticholinergics, and antihypertensives are among the drug classes most strongly associated with falls in older adults. Deprescribing or substituting these agents addresses a modifiable cause before pursuing low-yield investigations. Restraint through bed rest accelerates deconditioning and increases risk.

Question 27Adult & Geriatric Medicine

A 78-year-old man is brought in after a mechanical fall. He is on apixaban. He has a small scalp laceration and no focal deficits but reports a brief loss of consciousness. Which management step is most appropriate?

  1. Perform skull radiography to exclude fracture
  2. Obtain a noncontrast head CT and observe for delayed deterioration Correct answer.
  3. Discharge home after wound closure if he is back to baseline
  4. Reassure him that anticoagulation excludes intracranial bleeding

Explanation

Older adults on anticoagulants who sustain head trauma with loss of consciousness warrant urgent noncontrast head CT because intracranial hemorrhage can occur with minimal external signs. Observation is also appropriate given the risk of delayed bleeding. Skull films do not identify intracranial injury.

Question 28Adult & Geriatric Medicine

Which finding is most characteristic of delirium rather than dementia in an older hospitalized adult?

  1. Insidious decline in memory over several years
  2. Stable cognitive performance across the day
  3. Preserved attention with isolated word-finding difficulty
  4. Acute onset with fluctuating attention and altered level of consciousness Correct answer.

Explanation

Delirium is defined by acute onset, fluctuating course, inattention, and disturbance of consciousness, and it typically develops over hours to days. Dementia is a chronic, progressive decline with relatively preserved consciousness until late stages. Attention is the cardinal domain impaired in delirium.

Question 29Adult & Geriatric Medicine

A 75-year-old woman has a BMI of 21, a prior hip fracture, and a T-score of -2.8 at the femoral neck. She has normal renal function and no history of venous thromboembolism. Which pharmacologic choice is most appropriate?

  1. Teriparatide as first-line therapy
  2. Alendronate with calcium and vitamin D Correct answer.
  3. Conjugated equine estrogen
  4. Calcitriol monotherapy

Explanation

A bisphosphonate such as alendronate is first-line therapy for postmenopausal osteoporosis with a fragility fracture and low bone mineral density when renal function is adequate. Adequate calcium and vitamin D intake is a required adjunct. Estrogen is not first-line for osteoporosis treatment because of its risk profile.

Question 30Adult & Geriatric Medicine

An 82-year-old man with benign prostatic hyperplasia and normal renal function develops a urinary tract infection. Which oral antibiotic is most appropriate when local resistance rates are low?

  1. Ciprofloxacin for 14 days
  2. Amoxicillin for 3 days
  3. Nitrofurantoin for 7 days
  4. Trimethoprim-sulfamethoxazole for 7 days Correct answer.

Explanation

Trimethoprim-sulfamethoxazole is an appropriate oral option for uncomplicated urinary tract infection when local resistance is low and renal function is adequate. Nitrofurantoin achieves poor prostatic and tissue concentrations and should be avoided in men with suspected prostatic involvement. Fluoroquinolones are reserved because of collateral damage and adverse effects.

Question 31Adult & Geriatric Medicine

Which physiologic change of aging most directly explains the increased risk of volume depletion in older adults during illness?

  1. Enhanced renin-angiotensin-aldosterone responsiveness
  2. Increased total body water as a proportion of body weight
  3. Increased glomerular filtration rate
  4. Reduced renal concentrating ability and impaired thirst perception Correct answer.

Explanation

Aging reduces the kidney's ability to concentrate urine and blunts thirst and osmoreceptor sensitivity, so older adults lose water readily and drink less in response. Total body water also declines with age because of reduced lean mass, narrowing the margin for losses. These changes explain the vulnerability to dehydration.

Question 32Adult & Geriatric Medicine

A 70-year-old woman has a hemoglobin A1c of 8.9 percent, an eGFR of 45 mL/min/1.73 m2, and heart failure with reduced ejection fraction. Which glucose-lowering agent is most appropriate to add?

  1. Pioglitazone
  2. Glyburide
  3. Empagliflozin Correct answer.
  4. Sitagliptin

Explanation

SGLT2 inhibitors such as empagliflozin reduce heart failure hospitalizations and slow chronic kidney disease progression, making them preferred in patients with heart failure and reduced eGFR. Glyburide is avoided in older adults because of prolonged hypoglycemia, and pioglitazone causes fluid retention that worsens heart failure.

Question 33Adult & Geriatric Medicine

An 86-year-old woman with moderate dementia and preserved mobility has been incontinent of urine for two weeks. Which initial approach is most appropriate?

  1. Screen for reversible causes such as urinary tract infection and constipation, then trial prompted voiding Correct answer.
  2. Place an indwelling catheter to protect the skin
  3. Begin long-term antibiotic prophylaxis
  4. Restrict oral fluids to reduce leakage

Explanation

New urinary incontinence in an older adult with dementia warrants evaluation for reversible contributors such as infection, constipation, medications, and impaired mobility. Prompted voiding is a first-line behavioral intervention that suits patients with cognitive impairment. Catheters and fluid restriction introduce harm.

Question 34Adult & Geriatric Medicine

Which statement best describes the purpose of a geriatric comprehensive assessment?

  1. It focuses exclusively on the patient's list of diagnoses
  2. It is limited to patients who live in nursing homes
  3. It identifies and addresses medical, functional, cognitive, and social contributors to an older adult's health Correct answer.
  4. It replaces the need for specialist referral in all cases

Explanation

Comprehensive geriatric assessment is a multidimensional, interdisciplinary process that evaluates medical, functional, cognitive, psychological, and social domains and feeds into a coordinated care plan. It is not restricted to institutionalized patients and does not replace specialist input. The goal is to detect modifiable problems that affect independence.

Question 35Adult & Geriatric Medicine

A 76-year-old man is admitted with community-acquired pneumonia. He is alert and oriented, has a respiratory rate of 22, a blood pressure of 100/60 mmHg, and a blood urea nitrogen of 25 mg/dL. Which tool is most appropriate to guide his site-of-care decision?

  1. Mini-Cog
  2. Braden scale
  3. CURB-65 score Correct answer.
  4. CHA2DS2-VASc score

Explanation

CURB-65 estimates 30-day mortality in community-acquired pneumonia using confusion, urea, respiratory rate, blood pressure, and age 65 or older, and it informs decisions about outpatient versus inpatient care. The other tools measure stroke risk, cognition, and pressure injury risk, respectively.

Question 36Adult & Geriatric Medicine

An 80-year-old woman with advanced chronic obstructive pulmonary disease and a life expectancy of months has dyspnea refractory to maximal inhalers and oral opioids. Which additional intervention is most appropriate for symptom relief?

  1. Intermittent boluses of intravenous furosemide
  2. Noninvasive ventilation used continuously at home
  3. High-dose oral corticosteroids continued indefinitely
  4. Low-dose oral morphine titrated to dyspnea Correct answer.

Explanation

Systemic opioids are the mainstay for refractory dyspnea in advanced disease and can be titrated safely to relieve breathlessness. Inhaled bronchodilators and oxygen where hypoxemic remain adjuncts. Long-term high-dose corticosteroids cause substantial harm without sustained benefit.

Question 37Adult & Geriatric Medicine

Which laboratory test is most appropriate for monitoring for toxicity in a frail older adult who has been taking lithium for many years?

  1. Serum lactate dehydrogenase
  2. Serum amylase
  3. Serum lithium level with creatinine and thyroid function Correct answer.
  4. Serum ferritin

Explanation

Lithium has a narrow therapeutic index, is renally cleared, and can cause nephrogenic diabetes insipidus, chronic kidney disease, and hypothyroidism. Monitoring serum levels together with renal and thyroid function is standard. The other tests do not assess lithium toxicity.

Question 38Adult & Geriatric Medicine

An 84-year-old woman with severe osteoarthritis of the knee and a history of peptic ulcer disease asks about pain control. Her renal function is normal. Which option is most appropriate?

  1. Oral naproxen at the maximum dose
  2. Oral ketorolac for long-term use
  3. Oral indomethacin with a proton pump inhibitor
  4. Topical diclofenac with scheduled acetaminophen Correct answer.

Explanation

Topical NSAIDs provide local analgesia for knee osteoarthritis with minimal systemic exposure, which is important given her ulcer history. Scheduled acetaminophen is a reasonable adjunct. Systemic NSAIDs increase the risk of gastrointestinal bleeding, renal injury, and cardiovascular events in older adults.

Question 39Adult & Geriatric Medicine

A 73-year-old man has a serum sodium of 118 mmol/L after several days of vomiting and poor intake. He is confused but hemodynamically stable. Which correction strategy is safest?

  1. Give rapid isotonic saline boluses until symptoms resolve
  2. Correct to 135 mmol/L within 6 hours using hypertonic saline
  3. Restrict free water and recheck in 48 hours
  4. Raise serum sodium gradually, generally by no more than 8 to 10 mmol/L in 24 hours Correct answer.

Explanation

Rapid correction of chronic hyponatremia can cause osmotic demyelination, so sodium is typically raised by no more than 8 to 10 mmol/L in the first 24 hours. Symptomatic severe hyponatremia may warrant hypertonic saline with close monitoring, but the target is limited correction rather than full normalization.

Question 40Adult & Geriatric Medicine

Which finding is most consistent with normal pressure hydrocephalus rather than Alzheimer disease?

  1. Stepwise cognitive decline with focal neurologic deficits
  2. Fluctuating attention with visual hallucinations
  3. Prominent early anomia with preserved gait
  4. Gait disturbance out of proportion to cognitive impairment, with urinary incontinence Correct answer.

Explanation

The classic triad of normal pressure hydrocephalus is gait disturbance, urinary incontinence, and cognitive impairment, with gait typically the earliest and most prominent feature. Alzheimer disease presents with progressive memory loss and preserved gait early on. Stepwise decline suggests vascular dementia, and fluctuating attention with hallucinations suggests Lewy body disease.

Question 41Adult & Geriatric Medicine

An 88-year-old man with advanced dementia is bedbound and has a stage 2 pressure injury over the sacrum. Which intervention is most important in promoting healing?

  1. Massaging the area around the wound several times daily
  2. Applying a heating pad to increase local blood flow
  3. Repositioning on a scheduled turning program with pressure-redistributing support Correct answer.
  4. Keeping the wound open to air without dressing

Explanation

Pressure redistribution through scheduled repositioning and an appropriate support surface is central to pressure injury healing because sustained pressure causes ischemia. Moist wound healing with an appropriate dressing is also standard. Massage and heat increase tissue damage and are avoided.

Question 42Adult & Geriatric Medicine

A 69-year-old woman has had a persistent cough for three months and takes lisinopril. Which step is most appropriate?

  1. Obtain a chest CT immediately
  2. Add an inhaled corticosteroid
  3. Start a leukotriene receptor antagonist
  4. Discontinue lisinopril and reassess the cough after several weeks Correct answer.

Explanation

ACE inhibitor cough is a common, class-specific adverse effect that typically resolves within weeks of stopping the drug. Substituting an angiotensin receptor blocker is reasonable because it does not cause bradykinin-mediated cough. Further pulmonary workup is warranted only if the cough persists after withdrawal.

Question 43Adult & Geriatric Medicine

A 79-year-old woman with a history of falls has a blood pressure of 158/88 mmHg measured in clinic while seated. Which consideration most influences the decision to intensify antihypertensive therapy?

  1. The presence of mild aortic sclerosis on echocardiography
  2. The time of day the reading was taken
  3. The patient's reported salt intake
  4. Measurement of standing blood pressure to detect orthostatic hypotension Correct answer.

Explanation

Older adults frequently have orthostatic hypotension, and intensifying therapy without checking standing pressures risks syncope and falls. Standing blood pressure should be measured after a period of quiet standing. Salt intake and timing do not determine the safety of intensification.

Question 44Adult & Geriatric Medicine

Which statement about the Beers criteria is most accurate?

  1. They are mandatory prohibitions that apply to all patients over 65
  2. They apply only to nursing home residents
  3. They list only medications that are contraindicated in renal failure
  4. They identify potentially inappropriate medications for older adults and are intended to support, not replace, clinical judgment Correct answer.

Explanation

The Beers criteria list potentially inappropriate medications for adults 65 and older, organized by drug class and clinical context, and serve as a decision support tool. They are not absolute prohibitions and must be individualized. They apply across care settings.

Question 45Adult & Geriatric Medicine

A 77-year-old man with a history of myocardial infarction and an ejection fraction of 30 percent is on a beta-blocker, an ACE inhibitor, and a statin but remains symptomatic with dyspnea on minimal exertion. Which addition is most appropriate?

  1. A mineralocorticoid receptor antagonist Correct answer.
  2. A nonsteroidal anti-inflammatory drug
  3. A thiazolidinedione
  4. A dihydropyridine calcium channel blocker

Explanation

Mineralocorticoid receptor antagonists reduce mortality in heart failure with reduced ejection fraction and are indicated when the patient remains symptomatic despite standard therapy, provided renal function and potassium are monitored. Thiazolidinediones and NSAIDs cause fluid retention and worsen heart failure.

Question 46Adult & Geriatric Medicine

An 83-year-old woman is admitted with confusion and a temperature of 38.6 C. Her daughter reports she was independent two days ago. Which factor most strongly suggests delirium rather than dementia?

  1. A family history of Alzheimer disease
  2. A change from her documented baseline over one to two days Correct answer.
  3. A history of hypertension
  4. A Mini-Mental State Examination score of 22

Explanation

Acute change from a known baseline is a defining feature of delirium and distinguishes it from a chronic dementia trajectory. A single cognitive score cannot distinguish the two because it does not capture baseline function or fluctuation. Comorbidities and family history do not establish acuity.

Question 47Adult & Geriatric Medicine

A 74-year-old man has an eGFR of 32 mL/min/1.73 m2 and is prescribed apixaban for nonvalvular atrial fibrillation. Which prescribing approach is most appropriate?

  1. Switch to dabigatran because it requires no renal adjustment
  2. Replace apixaban with aspirin for stroke prevention
  3. Continue apixaban with dose reduction according to labeling criteria and monitor renal function Correct answer.
  4. Discontinue anticoagulation because of renal impairment

Explanation

Apixaban can be used in chronic kidney disease with dose reduction based on age, weight, and creatinine criteria, and renal function should be monitored periodically. Dabigatran is more renally cleared and generally avoided at this level of function. Aspirin is inferior to anticoagulation for stroke prevention in atrial fibrillation.

Question 48Adult & Geriatric Medicine

Which screening approach is recommended for colorectal cancer in an 80-year-old man with a life expectancy of more than ten years and no prior screening?

  1. Refer directly for colectomy
  2. Offer screening after discussing the balance of benefits and burdens Correct answer.
  3. Withhold screening solely because of his age
  4. Recommend screening only if he has symptoms

Explanation

Guidelines recommend individualized colorectal cancer screening decisions for adults over 75 based on life expectancy, prior screening, and patient preference rather than a fixed age cutoff. A patient with substantial life expectancy may still benefit. Symptom-driven testing is diagnostic, not screening.

Question 49Adult & Geriatric Medicine

A 71-year-old man has a body mass index of 22, has lost 8 percent of body weight in six months, and reports poor appetite. Which initial step is most appropriate?

  1. Screen for depression, dysphagia, dental problems, and medication contributors with a focused workup Correct answer.
  2. Place a feeding tube
  3. Reassure him that weight loss is expected with aging
  4. Start high-calorie oral supplements without further evaluation

Explanation

Unintentional weight loss in an older adult warrants a structured search for reversible causes including depression, malignancy, malabsorption, dental disease, dysphagia, and medications. Supplements without diagnosis may mask treatable disease. Involuntary weight loss is not a normal consequence of aging.

Question 50Adult & Geriatric Medicine

An 85-year-old woman with end-stage renal disease on hemodialysis has an advance directive specifying comfort-focused care. She develops a fever and hypotension during dialysis. Which action is most consistent with her stated goals?

  1. Place a central line for vasopressors without further discussion
  2. Start broad-spectrum antibiotics without discussing goals of care
  3. Provide symptom-directed treatment and involve palliative care, avoiding burdensome interventions Correct answer.
  4. Admit to the intensive care unit for routine full-code management

Explanation

When an advance directive specifies comfort-focused care, treatment should emphasize symptom relief and align with the patient's documented values, with palliative care involvement. Revisiting goals with the patient and surrogate is appropriate as the clinical situation evolves. Escalating to intensive care without regard to the directive disregards autonomy.