Cognitive behavioural therapy for insomnia outperforms medication for chronic insomnia and is the recommended first-line treatment, which is exactly what the exam wants you to know. These questions cover assessing sleep complaints, CBT-I and sleep hygiene, screening for obstructive sleep apnoea with STOP-BANG, when polysomnography is indicated, and the risks of long-term hypnotics. The 8 items of STOP-BANG appear here as the Family Nurse Practitioner boards use them: a screening threshold, not a diagnosis.
Question 1
A 9-year-old boy takes extended-release methylphenidate at 8 AM daily. His academic performance has improved significantly but he now cannot fall asleep until 11 PM most nights. Which adjustment is the most appropriate initial step?
- A) Add a low dose of trazodone at bedtime.
- B) Change to a short-acting methylphenidate dosed twice daily.✓
- C) Increase the morning dose of the extended-release stimulant.
- D) Switch to an extended-release amphetamine given at breakfast.
💡 Key Takeaway
Changing to a shorter-acting stimulant formulation is a primary strategy for managing medication-induced insomnia.
Show rationale
Stimulant medications frequently cause sleep-onset insomnia especially when extended-release formulations are used. If sleep hygiene interventions fail, the most appropriate pharmacological step is to switch to a short-acting formulation to ensure the medication clears the system before bedtime. Option A introduces unnecessary polypharmacy to treat a side effect of another drug. Option C would likely worsen the insomnia by increasing the overall serum concentration of the stimulant. Option D does not solve the problem because extended-release amphetamines also last 10 to 12 hours and will continue to disrupt sleep.
Question 2
A 42-year-old female presents with new-onset hypertension of 158/98 mmHg. She reports recent unexplained weight gain and worsening fatigue. Physical examination reveals violaceous abdominal striae and noticeable proximal muscle weakness when rising from a chair. Her fasting blood glucose is elevated at 126 mg/dL. Which underlying condition is the most probable cause?
- A) Primary adrenal hyperaldosteronism
- B) Obstructive sleep apnea
- C) Cushing syndrome disorder✓
- D) Renal artery stenosis
💡 Key Takeaway
Hypertension accompanied by central weight gain, violaceous striae, and proximal weakness strongly indicates Cushing syndrome.
Show rationale
This patient's new-onset hypertension, combined with unexplained weight gain, violaceous abdominal striae, proximal muscle weakness, and hyperglycemia, forms the classic clinical picture of a Cushing syndrome disorder. The excess cortisol promotes sodium retention, insulin resistance, and characteristic fat redistribution. Primary adrenal hyperaldosteronism causes hypertension and weakness due to hypokalemia, but it does not cause violaceous striae or rapid central weight gain. Obstructive sleep apnea is associated with obesity and hypertension but typically presents with snoring and daytime sleepiness rather than proximal muscle weakness and purple striae. Renal artery stenosis presents with an abdominal bruit and isolated hypertension, lacking the systemic metabolic and dermatologic changes seen in hypercortisolism.
Question 3
A 65-year-old female on CPAP therapy reports persistent morning headaches and daytime fatigue despite documented 100% adherence and an average AHI of 2 events/hour. Which action should the nurse practitioner take?
- A) Increase the continuous positive airway pressure.
- B) Switch to a bilevel positive machine.
- C) Evaluate for alternative sleep disorder diagnoses.✓
- D) Recommend an over-the-counter mild daily analgesic.
💡 Key Takeaway
When CPAP therapy is objectively effective but symptoms persist, providers must investigate alternative causes of fatigue.
Show rationale
When CPAP efficacy is objectively confirmed by excellent adherence and an apnea-hypopnea index under five, persistent symptoms like fatigue and morning headaches suggest a different underlying etiology. The APRN must evaluate for other conditions such as restless legs syndrome, narcolepsy, depression, or thyroid dysfunction. Increasing the airway pressure or switching to a bilevel machine is inappropriate because her sleep apnea is already well controlled based on the objective data. Recommending an analgesic merely masks the headache without identifying the root cause of her ongoing fatigue.
Question 4
A 48-year-old male with a BMI of 32 and obstructive sleep apnea has an office blood pressure of 126/78 mm Hg. His home blood pressure log shows an average of 142/90 mm Hg. How should the nurse practitioner interpret these findings?
- A) The patient exhibits classic signs of isolated systolic hypertension.
- B) The patient exhibits classic signs of white coat hypertension.
- C) The patient exhibits classic signs of masked clinical hypertension.✓
- D) The patient exhibits classic signs of nocturnal dipping hypertension.
💡 Key Takeaway
Masked hypertension presents with normal office blood pressure readings but elevated out-of-office blood pressure averages.
Show rationale
Masked hypertension occurs when office readings are normal but out-of-office readings are elevated. This patient's normal office blood pressure and elevated home blood pressure indicate masked hypertension, making Option C correct. Option B is the exact opposite scenario where office readings are high but home readings are normal. Option A is incorrect because both systolic and diastolic values are elevated at home. Option D refers to a normal physiologic drop in blood pressure during sleep, which does not apply to daytime home averages.
Question 5
A 29-year-old female requires migraine prophylaxis. She reports concurrent insomnia and depression and has a body mass index of 19 kg/m2. Which medication is the best choice for this patient?
- A) Start daily oral propranolol.
- B) Start daily oral topiramate.
- C) Start daily oral amitriptyline.✓
- D) Start daily oral divalproex.
💡 Key Takeaway
Amitriptyline provides dual benefits for migraine prevention and the management of comorbid depression and insomnia.
Show rationale
Amitriptyline is a tricyclic antidepressant that effectively prevents migraines while simultaneously treating her comorbid depression and insomnia. Topiramate is a strong preventive but often causes weight loss, which is undesirable given her low normal BMI. Propranolol and divalproex are effective for migraine prevention but do not optimally address her mood or sleep disturbances.
Question 6
A 26-year-old software developer reports chronic insomnia. She states she regularly spends three hours awake in bed while watching videos on her phone to help her mind wind down. Which sleep hygiene instruction should the nurse practitioner provide?
- A) Remain in the bed with eyes closed until sleep eventually occurs.
- B) Leave the bedroom if unable to sleep and return when tired.✓
- C) Switch to reading a physical book while remaining in the bed.
- D) Take a brief daytime nap to recover sleep lost at the night.
💡 Key Takeaway
Stimulus control therapy requires leaving the bed when awake to break the association between bed and wakefulness.
Show rationale
Stimulus control therapy aims to reassociate the bed exclusively with sleep. The patient should leave the bedroom if unable to sleep within 20 minutes to break the association between bed and wakefulness. Option A reinforces the negative association of lying awake and frustrated in bed. Option C still involves doing wakeful, engaging activities in bed, which directly violates stimulus control principles. Option D decreases the homeostatic sleep drive, which will only worsen her nighttime insomnia and perpetuate the cycle.
Question 7
A 68-year-old female reports two months of severe fatigue, specifically noting she is exhausted when walking up stairs. She also reports waking up twice nightly to urinate over the same period. She has a history of hypertension. Her lungs are clear to auscultation, but she has trace bilateral pedal edema. Which of the following is the most likely differential diagnosis?
- A) Exacerbation of chronic pulmonary disease
- B) Unrecognized major depressive disorder episode
- C) Undiagnosed obstructive sleep apnea syndrome
- D) New onset congestive heart failure✓
💡 Key Takeaway
Exertional fatigue combined with nocturia and peripheral edema in older adults strongly suggests decreased cardiac output.
Show rationale
New onset congestive heart failure is the primary differential because exertional fatigue, nocturia, and trace pedal edema strongly suggest decreased cardiac output and fluid retention. Exacerbation of chronic pulmonary disease is unlikely given the clear lung fields and lack of cough or wheezing. Unrecognized major depressive disorder episode might cause generalized fatigue but does not explain the exertional nature of the exhaustion or the physical signs of edema. Undiagnosed obstructive sleep apnea syndrome causes fatigue and nocturia but typically presents with snoring and daytime sleepiness rather than specific exertional intolerance. Recognizing atypical heart failure symptoms prevents misattributing them to normal aging.
Question 8
A husband brings his wife to the clinic at 2 weeks postpartum. He reports she has not slept in 48 hours, is constantly pacing, and claims the baby needs to be protected from the shadows. What is the most appropriate action?
- A) Administer the Edinburgh Postnatal Depression Scale tool immediately.
- B) Prescribe a sedative to help her sleep tonight.
- C) Arrange for an immediate emergency psychiatric facility evaluation.✓
- D) Reassure the husband about severe postpartum sleep deprivation.
💡 Key Takeaway
Severe insomnia, agitation, and delusional ideation postpartum indicate psychosis requiring immediate emergency psychiatric evaluation.
Show rationale
Symptoms of severe insomnia, psychomotor agitation, and delusional beliefs are hallmark signs of postpartum psychosis, which is a psychiatric emergency carrying a high risk of infanticide and suicide. The patient requires immediate emergency evaluation and likely inpatient stabilization. Option A is incorrect because the EPDS screens for depression, not acute psychosis. Option B is dangerous as it merely masks symptoms without treating the underlying life-threatening condition. Option D ignores glaring red flags for a severe psychotic break.
Question 9
A 32-year-old woman is twelve weeks postpartum. She has attended weekly cognitive behavioral therapy for 8 weeks. Her Edinburgh Postnatal Depression Scale score was 14 and is now 15. She reports persistent anhedonia and insomnia. Which action is most appropriate?
- A) Increase the frequency of cognitive behavioral therapy sessions.
- B) Recommend adding a daily vigorous aerobic exercise routine.
- C) Refer her for an inpatient psychiatric hospital admission.
- D) Initiate a selective serotonin reuptake inhibitor medication daily.✓
💡 Key Takeaway
Step up to pharmacotherapy when moderate postpartum depression fails to improve with psychotherapy alone.
Show rationale
Evaluating the effectiveness of non-pharmacological interventions involves monitoring symptom progression over an adequate timeframe. After eight weeks of consistent therapy, this patient’s score has slightly worsened, and she is experiencing persistent anhedonia and insomnia. Option D is the correct choice because clinical guidelines recommend initiating a pharmacological intervention when moderate to severe symptoms do not improve with psychotherapy alone. Option A is incorrect; simply doing more of an ineffective therapy delays necessary medical treatment. Option B is a helpful lifestyle modification but is insufficient as a standalone step-up treatment for worsening clinical depression. Option C is an overreaction; while her symptoms are persistent and distressing, there is no indication of acute suicidality or psychosis that would justify an inpatient hospital admission. Stepping up to an antidepressant is the appropriate evidence-based next step.
Question 10
A 52-year-old male with a BMI of 36 kg/m2 presents for an annual exam. He is currently treated for hypertension and his wife reports his loud snoring forces her to sleep in another room. Based on his STOP-BANG score, what is the most appropriate action?
- A) Order a comprehensive home sleep apnea test✓
- B) Recommend a trial of soft cervical collars
- C) Prescribe a daytime stimulant like oral modafinil
- D) Advise strict adherence to sleep hygiene rules
💡 Key Takeaway
A STOP-BANG score of 5 or higher indicates a high risk for OSA requiring objective diagnostic testing.
Show rationale
This patient has a STOP-BANG score of 5 (age over 50, male, BMI over 35, hypertension, and snoring), which places him at high risk for OSA. A score of 5 to 8 warrants objective testing, making a home sleep apnea test the most appropriate next step. Recommending a cervical collar does not diagnose or treat obstructive sleep apnea. Prescribing modafinil inappropriately masks daytime symptoms without addressing the underlying airway obstruction. Advising sleep hygiene is generally helpful but entirely insufficient for a high-risk patient requiring formal diagnostic evaluation.
