Osteoarthritis is diagnosed clinically far more often than radiographically, and the first task is separating it from inflammatory arthritis — morning stiffness under 30 minutes is the classic discriminator. These questions cover that distinction, the stepwise progression from exercise and weight management through topical and oral therapy, injection options, and when referral for joint replacement is appropriate. Every rationale ties back to what Family Nurse Practitioner (FNP-C and FNP-BC) candidates are expected to recognise.
Question 1
A 72-year-old male reports unilateral left knee pain that has progressively worsened over two years. He experiences stiffness lasting fifteen minutes upon waking. Examination notes coarse crepitus during active flexion.
- A) Diffuse osteopenia around the joint
- B) Symmetrical joint space narrowing
- C) Subchondral bone cyst formation✓
- D) Marginal erosions of the patella
💡 Key Takeaway
Osteoarthritis presents with brief morning stiffness, crepitus, and radiographic findings including subchondral cysts and sclerosis.
Show rationale
The patient's unilateral presentation, short duration of morning stiffness, and crepitus are hallmark clinical signs of osteoarthritis. Radiographically, osteoarthritis is characterized by subchondral bone cysts, osteophytes, and asymmetrical joint space narrowing due to mechanical wear. Option A, Option B, and Option D are classic radiographic findings associated with rheumatoid arthritis, which is an inflammatory autoimmune process that typically presents symmetrically and with prolonged morning stiffness lasting greater than one hour.
Question 2
68-year-old woman presents with severe morning stiffness in her shoulders and hips. Exam reveals spongy swelling in the metacarpophalangeal joints bilaterally. Labs show an ESR of 55 mm/hr and a positive anti-cyclic citrullinated peptide. Which diagnosis is most appropriate?
- A) Polymyalgia rheumatica
- B) Erosive osteoarthritis
- C) Rheumatoid arthritis✓
- D) Reactive arthritis
💡 Key Takeaway
Small joint swelling and positive anti-CCP differentiate late-onset rheumatoid arthritis from polymyalgia rheumatica.
Show rationale
Establishing the primary diagnosis requires distinguishing between overlapping rheumatologic conditions. While proximal stiffness and elevated ESR can be seen in polymyalgia rheumatica, the presence of spongy swelling in the small joints of the hands and a positive anti-cyclic citrullinated peptide are highly specific for rheumatoid arthritis. Polymyalgia rheumatica typically spares the small peripheral joints and lacks autoantibodies like anti-CCP or rheumatoid factor. Erosive osteoarthritis can affect the hands, but it typically involves the distal interphalangeal joints, lacks spongy synovial swelling, and does not produce a highly elevated ESR or positive anti-CCP. Reactive arthritis usually presents as an asymmetric oligoarthritis in the lower extremities following a gastrointestinal or genitourinary infection, which does not fit this patient's symmetrical, upper-extremity-heavy presentation.
Question 3
An 85-year-old with bone metastases is receiving a fentanyl transdermal patch 50 mcg/hr. Over the past 48 hours, she has required six doses of oral morphine concentrate for breakthrough pain, and she reports her baseline pain remains at an 8 out of 10.
- A) Continue the current regimen and add a corticosteroid.
- B) Replace the oral morphine with a nonsteroidal anti-inflammatory.
- C) Decrease the fentanyl patch to prevent opioid tolerance.
- D) Increase the fentanyl patch dose based on usage.✓
💡 Key Takeaway
Frequent use of breakthrough opioids with high baseline pain indicates the need to increase the basal opioid.
Show rationale
Evaluating this plan of care reveals that the baseline fentanyl transdermal patch is ineffective, as evidenced by high breakthrough pain medication usage and a persistently high pain score. The standard of care requires increasing the basal opioid dose by calculating the total daily breakthrough opioid requirement. Adding a corticosteroid (A) might help bone pain but does not address the inadequate basal opioid dose. Replacing morphine with an NSAID (B) is insufficient for severe breakthrough cancer pain. Decreasing the fentanyl patch (C) would worsen her already uncontrolled pain, not prevent tolerance.
Question 4
A 60-year-old female demonstrates limited active and passive range of motion in her left shoulder. She reports a dull, aching pain that worsens with overhead activity. Which assessment finding best differentiates osteoarthritis from adhesive capsulitis?
- A) Palpable crepitus during active joint rotation✓
- B) Symmetrical loss of active passive motion
- C) Severe pain elicited at range limits
- D) Visible atrophy of the deltoid muscles
💡 Key Takeaway
Palpable crepitus during range of motion testing helps differentiate glenohumeral osteoarthritis from adhesive capsulitis.
Show rationale
The patient's age and pain with overhead activity raise suspicion for shoulder osteoarthritis. Palpable crepitus during active joint rotation is highly indicative of the cartilage loss seen in osteoarthritis. Symmetrical loss of both active and passive motion is the hallmark physical exam finding of adhesive capsulitis, not osteoarthritis. Severe pain elicited at range limits can occur in both conditions but does not reliably differentiate between the two. Visible atrophy of the deltoid muscles is a non-specific finding related to disuse and can be present in chronic rotator cuff tears, adhesive capsulitis, or advanced osteoarthritis.
Question 5
A 65-year-old female with symptomatic knee osteoarthritis and major depressive disorder reports inadequate pain relief from acetaminophen. She has a documented severe allergy to all NSAIDs.
- A) Prescribe oral tramadol for daily pain management.
- B) Initiate oral duloxetine for dual symptom control.✓
- C) Recommend oral pregabalin to reduce joint pain.
- D) Administer systemic methylprednisolone for acute joint inflammation.
💡 Key Takeaway
Duloxetine effectively treats knee osteoarthritis pain while simultaneously managing comorbid major depressive disorder symptoms.
Show rationale
This patient has symptomatic knee osteoarthritis alongside major depressive disorder and a severe allergy to all NSAIDs. Initiating oral duloxetine is the optimal choice because it is an SNRI that is FDA-approved for both musculoskeletal pain and depression, addressing both conditions simultaneously. Prescribing oral tramadol introduces opioid risks and potential serotonin syndrome, making it suboptimal. Recommending oral pregabalin is inappropriate as it targets neuropathic pain, not osteoarthritic nociceptive pain. Administering systemic methylprednisolone is not indicated for osteoarthritis management and carries significant systemic side effects.
Question 6
A 68-year-old with a history of peptic ulcer disease reports localized osteoarthritis of the hands that persists despite inadequate relief from acetaminophen. Which pharmacologic treatment is most appropriate?
- A) Prescribe scheduled oral meloxicam therapy
- B) Initiate scheduled oral celecoxib therapy
- C) Start low-dose oral tramadol therapy
- D) Recommend topical diclofenac gel therapy✓
💡 Key Takeaway
Topical NSAIDs provide effective localized pain relief while avoiding the gastrointestinal risks of oral NSAIDs.
Show rationale
Topical NSAIDs like diclofenac gel are strongly recommended for localized osteoarthritis in older adults because they provide effective targeted relief with minimal systemic absorption. This completely avoids the high risk of gastrointestinal bleeding associated with oral NSAIDs like meloxicam or celecoxib, which are contraindicated given the patient's ulcer history. Tramadol introduces unnecessary central nervous system risks, including falls and confusion, and should be reserved for severe pain that fails both topical and safer oral interventions.
Question 7
A 78-year-old with knee osteoarthritis returns for a 4-week follow-up after starting a topical NSAID and physical therapy. The patient's pain score remains 6/10, but the patient reports walking to the mailbox independently and sleeping through the night.
- A) Continue current treatment plan and schedule a routine follow-up.✓
- B) Discontinue the topical medication and initiate a low-dose oral opioid.
- C) Refer the patient for an intra-articular corticosteroid joint injection.
- D) Add a daily oral nonsteroidal anti-inflammatory drug to the regimen.
💡 Key Takeaway
Functional improvement indicates a successful chronic pain plan despite unchanged numerical pain scores.
Show rationale
In older adults with chronic pain, functional status improvement is the primary goal of therapy, often superseding absolute pain score reduction. Since the patient is now walking independently and sleeping better, the current plan is highly effective. Option A is correct because continuing the successful regimen is indicated. Option B is incorrect because opioids are high-risk and unnecessary given the functional gains. Option C is incorrect because invasive interventions are not indicated when conservative measures are working. Option D is incorrect because adding oral NSAIDs increases the risk of gastrointestinal and renal adverse events in older adults without offering necessary benefits over the currently effective topical and physical therapy plan.
Question 8
A 52-year-old female presents with bilateral hand pain. Morning stiffness lasts 90 minutes. Exam shows swelling at MCP and PIP joints, sparing the DIP joints.
- A) Primary osteoarthritis
- B) Rheumatoid arthritis✓
- C) Psoriatic arthropathy
- D) Erosive osteoarthritis
💡 Key Takeaway
Rheumatoid arthritis features prolonged morning stiffness and symmetric swelling of the MCP and PIP joints.
Show rationale
Rheumatoid arthritis is an autoimmune condition presenting with symmetric polyarthritis, prolonged morning stiffness lasting over an hour, and classic involvement of the metacarpophalangeal and proximal interphalangeal joints. The patient's prolonged morning stiffness and specific MCP and PIP swelling are hallmark features. Primary osteoarthritis typically involves the DIP joints and presents with brief morning stiffness. Psoriatic arthropathy often involves the DIP joints and is usually asymmetrical. Erosive osteoarthritis primarily affects the DIP and PIP joints but lacks the extensive morning stiffness and MCP involvement seen in this scenario.
Question 9
A 75-year-old male with moderate osteoarthritis reports he cannot afford his prescribed medications this month. He recently moved in with his daughter and mentions she now handles his pension checks to "make things easier." Which action should the nurse practitioner take next?
- A) Prescribe a less expensive alternative medication to improve his medication adherence.
- B) Contact the daughter to discuss the importance of purchasing his prescribed medications.
- C) Ask direct, open-ended questions about how his financial decisions are currently managed.✓
- D) Refer the patient to a medical social worker for immediate community financial assistance.
💡 Key Takeaway
Sudden inability to afford essentials after relinquishing financial control requires direct subjective assessment.
Show rationale
The patient's inability to afford medications despite having a pension, combined with relinquishing financial control to his daughter, is a red flag for financial abuse. The clinician must first gather subjective information by exploring the financial arrangement directly with the patient. Option A ignores the potential underlying abuse. Option B breaches confidentiality and could endanger the patient if abuse is occurring. Option D is a helpful intervention later but skips the essential initial assessment step.
Question 10
A 60-year-old female with osteoarthritis of the knees has a routine physical. A previous provider ordered a rheumatoid factor, which returned low-positive. She reports no hand pain or morning stiffness.
- A) Refer her to a rheumatologist for early disease modifying therapy.
- B) Explain that low-positive rheumatoid factor commonly occurs with normal aging.✓
- C) Order an anti-CCP test to confirm early stage rheumatoid arthritis.
- D) Initiate nonsteroidal anti-inflammatory drugs to prevent future joint space narrowing.
💡 Key Takeaway
Rheumatoid factor can be positive in healthy older adults without indicating autoimmune disease.
Show rationale
A low-positive rheumatoid factor can frequently be found in healthy individuals, particularly as they age, and does not inherently indicate autoimmune disease in the absence of clinical symptoms. Because the patient lacks classic signs like hand pain or morning stiffness, option B is the most appropriate and reassuring response. Option A is incorrect because referring an asymptomatic patient for disease-modifying therapy is unnecessary and inappropriate. Option C is incorrect because ordering an anti-CCP without clinical suspicion of inflammatory arthritis leads to overtesting and unnecessary anxiety. Option D is incorrect because NSAIDs do not prevent joint space narrowing in osteoarthritis or rheumatoid arthritis; they only provide symptomatic relief, which this patient does not currently require for her hands.
