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Question 1 of 36
1. Question
The following vignette applies to the next 2 items.
Item 1 of 2
An 82-year-old man with a history of advanced Alzheimer dementia is brought to the hospital by his daughter, who is his power of attorney and caregiver. She says that her father is increasingly confused and verbally aggressive. He is admitted to the hospital and found to have a urinary tract infection. Intravenous antibiotics are initiated and he appears less disoriented and agitated but remains unable to recall nursing instructions throughout the day and is fairly nonverbal. Three days into his treatment, the antibiotic order expires and is missed by the physician, nurses, and pharmacy staff. The patient receives no medication for 2 days before the error is noted and corrected. There are no consequences to this error other than extension of his hospital stay by 2 days. Which of the following is the most appropriate course of action?
CorrectIncorrect -
Question 2 of 36
2. Question
Item 2 of 2
Over the next several months, there are more cases in which expired medications fail to be renewed. Finally, a patient on intravenous dobutamine for decompensated heart failure does not receive the medication for 6 hours and experiences worsening of her condition, with resulting hypotensive shock. Hospital administration convenes a committee to address this incident. Which of the following is the most appropriate next step in addressing this problem?
CorrectIncorrect -
Question 3 of 36
3. Question
A 26-year-old woman comes to the emergency department accompanied by her boyfriend for evaluation of a broken nose. With the boyfriend present, she explains that she tripped and fell in the bathroom, hitting her face on the countertop. When asked privately if she feels unsafe with her boyfriend, the patient says, “No, everything is fine. He just gets a little upset when he has too much to drink.” When questioned further about how she sustained her nasal fracture, she says, “He pushed me and I fell, but I’m sure it won’t happen again.” After assessing the extent of the injuries, which of the following statements by the physician is the most appropriate?
CorrectIncorrect -
Question 4 of 36
4. Question
A 79-year-old man is undergoing evaluation for hospital admission due to an exacerbation of chronic obstructive pulmonary disease. His wife expresses concern about his health due to multiple hospitalizations over the last year for various complications related to his comorbidities. The patient has smoked cigarettes daily for more than 50 years. Medical history includes coronary artery disease, type 2 diabetes mellitus, and obesity. After performing a thorough history and physical examination, the physician prepares to admit the patient and decides to continue his existing medications for diabetes and heart disease. Admission orders also include supplemental oxygen, bronchodilators, antibiotics, and systemic corticosteroids. Which of the following additional components is most critical to include during the admission process?
CorrectIncorrect -
Question 5 of 36
5. Question
A 13-year-old boy is brought to the physician by his mother for a routine physical examination and follow-up of type 1 diabetes mellitus. The patient appears irritated, and his mother begins the visit by exclaiming, “Here’s the doctor; he’s going to tell you how badly you’ve been doing.” Laboratory tests show a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal: <6%-7%). When the physician asks the patient how he is doing with his insulin, the mother interrupts and shouts, “He never remembers to use it!” When the boy is asked about his diet, the mother puts her hands on her hips, glares at her son, and says, “Pizza, soda, and candy!” After acknowledging the mother’s concerns regarding diabetic control, which of the following is the most appropriate course of action?
CorrectIncorrect -
Question 6 of 36
6. Question
A 38-year-old woman comes to the office due to worsening dysmenorrhea and tension headaches for the past 3 months. She was recently promoted to school principal and says, “It is more stressful than I anticipated; I often have to work late to catch up on paperwork and am not sleeping very well.” The patient is married and has no children. While answering questions regarding her sexual history, she bursts into tears. When the physician asks the patient what is upsetting her, she covers her face and says she was sexually abused as a child. Which of the following is the most appropriate response to the patient?
CorrectIncorrect -
Question 7 of 36
7. Question
A 35-year-old man comes to the office for a routine health maintenance evaluation. After separating from his wife, the patient recently moved to “make a fresh start” and start a new job. He has no chronic medical conditions and has had no surgeries. The patient is sexually active and has had 6 lifetime partners. When completing the rest of the sexual history, which of the following questions is most appropriate for the physician to ask?
CorrectIncorrect -
Question 8 of 36
8. Question
A 46-year-old man comes to the emergency department with chest pain that began 30 minutes ago. The patient describes the pain as a tight, squeezing sensation that radiates to the left arm. He also has increased sweating and nausea. ECG shows multi-lead ST-segment elevation, and cardiac troponin levels are high. The patient has a history of alcohol and cocaine abuse, but no history of cardiac disease. He undergoes emergency cardiac catheterization and is recovering appropriately in the postanesthetic care unit. The physician is approached by a distraught woman who says she is the patient’s wife and asks about his condition. She says, “I am so worried; please tell me if my husband is okay.” Which of the following is the most appropriate course of action?
CorrectIncorrect -
Question 9 of 36
9. Question
A 65-year-old man is admitted overnight to the hospital with abdominal pain. It is determined that he has an uncomplicated small bowel obstruction that will require surgery in the morning. Temperature is 37 C (98.6 F), blood pressure is 130/82 mm Hg, and pulse is 90/min. The resident meets with the patient and his adult son, who has accompanied him to the hospital, to discuss surgical intervention. After introducing herself, the resident learns that the patient speaks primarily Vietnamese and has limited English proficiency, although his son speaks both Vietnamese and English. The son shares that he is a critical care nurse and offers to interpret the conversation for his father. Which of the following responses to the patient’s son is the most appropriate?
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Question 10 of 36
10. Question
A 65-year-old man is brought to the emergency department by a friend who found the patient disoriented in his apartment. The patient’s medical history includes chronic obstructive pulmonary disease, hypertension, coronary artery disease, and tobacco use. He is unmarried and lives alone. The friend says that the patient has a sister who lives in the area but is unaware of when they last spoke. The friend has known the patient for 5 years and says that they are “good buddies.” He tells the physician that they have discussed dying and that he believes the patient would prefer to “go naturally” and would refuse any heroic measures, including “being hooked up to a ventilator.” Temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, pulse is 105/min, and respirations are 24/min. Oxygen saturation is 88% on room air and 93% on 2 L of oxygen. The patient is somnolent and unable to answer questions. The lungs have bilateral wheezing and decreased breath sounds. Chest x-ray reveals a right lower lobe infiltrate. Appropriate bronchodilator and antibiotic therapies are initiated. The physician is concerned about the need for intubation if the patient does not respond to initial treatment in the next 2-3 hours. Which of the following is the most appropriate course of action?
CorrectIncorrect -
Question 11 of 36
11. Question
A 49-year-old woman is transferred from a community hospital to a tertiary care center for management of an acute exacerbation of chronic obstructive pulmonary disease. The patient receives care overnight from a hospitalist, who transfers care to the teaching service in the morning. The medical team now responsible for the patient meets with her for the first time during morning rounds. The attending physician introduces the team and explains that the patient will be interviewed by the intern. The patient then addresses the intern by his first name and mentions, “You remind me so much of my son. He’s very smart and looks a lot like you.” Which of the following actions by the intern would be most appropriate to begin the interview?
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Question 12 of 36
12. Question
A 21-year-old man comes to the office due to recurrent ear drainage. He is accompanied by his girlfriend. He speaks in English. On examination, the patient has purulent otorrhea, a tympanic membrane perforation, and a pearly white mass behind the tympanic membrane consistent with a large cholesteatoma. He is told that he will need an operation on his ear to remove the mass. After listening to an explanation of the procedure and why it should be done, the patient nods briefly but does not ask questions. He is also given information sheets with a written description of the procedure and instructions on how to schedule surgery that he immediately hands to his girlfriend, who begins to read them. Review of the medical records shows he has been to the emergency department several times in the last year with this same concern and has not had a flu shot in the past 5 years. Which of the following is the most appropriate course of action?
CorrectIncorrect -
Question 13 of 36
13. Question
A 61-year-old woman is admitted to the hospital due to shortness of breath, fever, and confusion. Medical history includes stage III lung cancer treated with chemotherapy. The patient is unable to communicate but prepared an advance directive several weeks ago specifying “no intubation.” Despite supportive care, the patient’s condition worsens and she appears to be developing signs of respiratory failure that would warrant intubation. Her husband of 40 years, who accompanied her to the hospital, says, “My daughter is due to give birth to her first child in a week. I’m sure my wife would want a chance to see her grandchild. She would want to be intubated.” Which of the following is the most appropriate response?
CorrectIncorrect -
Question 14 of 36
14. Question
An 80-year-old woman is brought to the office for follow-up of hypertension. The patient is prescribed lisinopril but has not taken any in the past 2 weeks because she ran out of medication. She has tried to contact her son to pick up a refill but has been unable to reach him. The patient moved in with her son 2 months ago after he arranged for her house to be sold. She says he stays at his girlfriend’s house during the week, so she must find neighbors who are able to drive her places. Medical history includes a cerebrovascular accident with mild residual weakness on the left side. Temperature is 37 C (98.6 F), blood pressure is 156/88 mm Hg, and pulse is 80/min. The patient is fully oriented. Cardiopulmonary examination shows no abnormalities. Gait and voluntary movements are normal. On mental status examination, she appears tired and is wearing tattered clothing. Which of the following is the most appropriate next step in management of this patient?
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Question 15 of 36
15. Question
An intern attends a local dinner party and recognizes a colleague who works at the same hospital in another department. During the course of the evening, she observes her colleague responding to a number of routine medical calls from the hospital and consuming several alcoholic drinks. Later that evening, the physician notices that her colleague is giving medication orders over the phone and appears grossly intoxicated with slurred speech. The physician confronts her colleague, asking him to transfer on-call responsibilities for the sake of patient care. He insists that he is fine, is not drunk, and that his duties end in 30 minutes anyway. Which of the following is the most appropriate course of action?
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Question 16 of 36
16. Question
A 28-year-old woman comes to the gynecologist, who has provided routine care for the patient over the past 10 years. The patient has not menstruated for over 2 months and had a positive home pregnancy test last week. Although she hopes to have children in the future, she has been under a lot of stress lately and says that caring for a child is the last thing she needs right now. A pelvic ultrasound confirms an intrauterine pregnancy at 7 weeks gestation, and the patient requests that the gynecologist terminate the pregnancy as soon as possible. The gynecologist does not perform abortions on moral grounds but does have training in the procedure. Which of the following is the most appropriate course of action?
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Question 17 of 36
17. Question
A 28-year-old woman comes to the office for a regularly scheduled prenatal appointment. Her pregnancy has been going well and the patient says that she is thrilled to be having a baby after trying to become pregnant for several years. She and her husband experienced considerable strain in their marriage as they went through multiple unsuccessful fertility treatments. During the visit, the physician orders some blood work and performs a 1-hour glucose challenge test. The patient becomes apprehensive when this is mentioned and begins to ask questions about the purpose of the testing. When asked about her concern, she confides that the fetus is not her husband’s child. Her husband is also the physician’s patient, and she asks the physician not to tell him about this because “it will ruin everything.” Which of the following is the most appropriate response by the physician?
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Question 18 of 36
18. Question
A 64-year-old man comes to the office for follow-up after a myocardial infarction 6 months ago. The patient’s condition has slowly improved, although his clinical course was complicated by a pulmonary embolus and urinary tract infection. During the appointment, the patient gives the physician homemade cookies and a thank-you card containing 4 tickets to a professional basketball game. He says, “I would like to thank you for everything that you’ve done. Please accept these tickets and enjoy the game.” He tells the physician not to worry about the expense, saying, “I get season tickets every year but haven’t felt well enough to make it to the games. You have been such a wonderful doctor, and I wanted to give you something to express my gratitude.” Which of the following statements is the most appropriate?
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Question 19 of 36
19. Question
A 40-year-old unemployed man with chronic back pain comes to the office for an appointment with a new physician. The patient injured his back in a work accident years ago and has not worked since. He uses marijuana daily to “ease the pain” and admits that a portion of his income goes toward its purchase. The patient says that nothing has changed and asks the physician to sign a disability form so he can continue to collect disability benefits. When the physician asks about his disability and previous treatment, he replies angrily, “I wouldn’t be here re-applying for disability if anything had worked” and slams the disability form down on the table. Review of his medical records indicates a normal MRI one year earlier and inconsistent adherence with physical rehabilitation appointments. The patient walks normally with no apparent discomfort or limitations. Which of the following is the most appropriate response by the physician?
CorrectIncorrect -
Question 20 of 36
20. Question
A 17-year-old girl comes to the office for evaluation of worsening vaginal irritation and discharge. She has had multiple sexual partners in the past few months. The patient is adherent with oral contraceptives and inconsistently uses condoms. She has no prior medical conditions and takes no other medications. Urine pregnancy test is negative and urine gonorrhea test is positive. The patient does not want her parents to find out she is having sex and asks if the physician will tell her parents about today’s visit. Which of the following is the most appropriate response to this patient?
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Question 21 of 36
21. Question
A gastroenterologist notices one of her patients at the hospital cafeteria while waiting for her friend, a hospitalist, to meet her for lunch. The patient greets the gastroenterologist and has a brief conversation before leaving. The hospitalist arrives to the cafeteria and says, “I saw you talking to my old neighbor. He’s a close family friend, and I heard that he has colon cancer. I’ve been really worried about him, especially since his wife had a stroke recently. Are you treating him?” Which of the following is the most appropriate response by the gastroenterologist?
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Question 22 of 36
22. Question
A 78-year-old man with end-stage esophageal cancer is admitted to the hospital with severe malnutrition and failure to thrive. The patient’s caretaker says that he has not been able to eat or drink for the last 3 weeks. His weight dropped from 72.6 kg (160 lb) to 63.5 kg (140 lb) during that time. The cancer has spread to his lungs and liver. The patient does not wish to receive any further treatment for the cancer and specifies that he wants no heroic measures or interventions to keep him alive. His physician considers referral to hospice care. Which of the following is a requirement for referring a patient for hospice care?
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Question 23 of 36
23. Question
A 3-year-old boy is brought to the emergency department due to a fever and stiff neck. The child is hospitalized with a diagnosis of bacterial meningitis and begins treatment with intravenous antibiotics. On day 2 of hospitalization, the mother requests to take the child home and explains that she intends to treat him with homeopathic remedies. She has 4 other children at home who have “never needed vaccinations or medications” and are “strong and healthy.” The physician explains the risks of meningitis, including brain damage and death. After a long discussion, the mother says that she understands the risks but believes that homeopathic remedies will be adequate for treatment and remains unconvinced of the need for hospitalization. Which of the following is the most appropriate course of action?
CorrectIncorrect -
Question 24 of 36
24. Question
A 25-year-old woman comes to the office to follow up type 1 diabetes mellitus. She takes long- and short- acting insulin with good glycemic control and has no diabetes-related complications. She also has a history of hypothyroidism for which she takes levothyroxine. The patient has been covered under her parent’s medical insurance for the last several years, but she recently started working full time for a company that provides a broad variety of employee insurance choices. She requests advice in choosing a health insurance plan. The patient has no disability and says that her main priority is low monthly payments. Which of the following insurance options would be most appropriate for this patient?
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Question 25 of 36
25. Question
An 82-year-old man is admitted to the hospital in the middle of the night. He is noncommunicative and has multiple comorbidities, including end-stage lung cancer. The patient has neither a designated power of attorney nor an advance directive on file. His wife of many years, who is at the hospital with him, has an extensive conversation with the physician in charge of his care. During the conversation, she says that, on several occasions, the patient said not to resuscitate him if he were near death because he did not want to live “attached to machines or brain dead.” She says that he just wants to die in peace when the time comes. What would be the most appropriate course of action if the patient enters ventricular fibrillation?
CorrectIncorrect -
Question 26 of 36
26. Question
A 48-year-old deaf man comes to the office for a new patient visit. The patient recently moved to the area and is accompanied by a friend with whom he communicates using American Sign Language. The office staff informs the physician that the patient has also been communicating by reading lips, using gestures, and nodding his head in agreement. At the start of the appointment, the friend says that the patient has asthma and uses an inhaler as needed. The patient gives the physician a handwritten note indicating that he would like to try a longer-acting inhaler. Which of the following is the most appropriate next step in evaluation of this patient?
CorrectIncorrect -
Question 27 of 36
27. Question
A 36-year-old woman with well-controlled asthma and hypothyroidism comes to the office to review recent thyroid function tests with her primary care physician. She has been his patient for the past 8 years. During the visit, she mentions that she is recently divorced and has had difficulty meeting “smart and interesting” men. The patient, noticing the physician is not wearing a wedding ring, asks if he is single. The physician responds, “Yes, why do you ask?” The patient replies that she was wondering whether he would consider going out for dinner now that they are both single. The physician has always found the patient attractive and would like to accept the invitation. Which of the following is the most appropriate response to the patient’s request?
CorrectIncorrect -
Question 28 of 36
28. Question
A 4-year-old boy is brought to the emergency department by his mother due to an asthma exacerbation. He has a history of poorly controlled asthma, with nonadherence to medication and outpatient follow-up visits. The mother works 2 jobs to support the family and says she has difficulty bringing the patient to appointments. Initial physical examination shows expiratory wheezes in both lungs. The patient is given nebulized albuterol, and his breathing improves. On repeat examination, a healing, round burn mark is seen on the back. When asked about the burn, the patient says, “That happens when I’m bad.” His mother explains that it was an accident resulting from the boy “playing with the cigarette lighter in the car.” Which of the following is the most appropriate next step in management of this patient?
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Question 29 of 36
29. Question
A physician working on a rehabilitation unit discovers that a patient is experiencing an acute allergic reaction to a medication. The physician calls for nursing assistance. When the nurse arrives, the physician instructs the nurse to administer “25 mg of diphenhydramine IV push”. Which of the following responses from the nurse ensures a lower risk of communication errors?
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Question 30 of 36
30. Question
A 63-year-old man with a 30-pack-year smoking history is admitted to the hospital for evaluation of hemoptysis. Imaging studies reveal a right lung mass with features suggesting possible malignancy. On day 2 of hospitalization, he undergoes biopsy of the mass. The biopsy confirms the diagnosis of non–small cell lung cancer. However, staging studies have not yet been completed. As the physician enters the patient’s room after reviewing the biopsy results, the patient asks about the biopsy results and prognosis. Which of the following is the best way to approach this patient’s question?
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Question 31 of 36
31. Question
A 37-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the emergency department with her husband for heavy vaginal bleeding. An hour ago, she started to have bright red vaginal bleeding that has increased to large clots over the past few minutes. The patient has had mild abdominal cramping and minimal fetal movement. She has received no prenatal care during this pregnancy. Blood pressure is 90/64 mm Hg and pulse is 102/min. When the patient is told that a pelvic examination needs to be performed, she becomes uncomfortable and appears nervous. The patient requests a female health care provider for the examination. However, only male health care providers are available at this emergency department for the next several hours. Which of the following is the most appropriate course of action?
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Question 32 of 36
32. Question
A primary care physician is invited to give a presentation to a local employer. He is a member of a large multi-specialty medical group, which he joined less than a year ago after completing residency. During the presentation, the physician discusses the various medical specialties available within the group, as well as the range of ancillary services the group offers at its facilities. In the ensuing discussion, the physician learns that the employer has been facing financial difficulties. The employer wishes to continue offering health care coverage to its employees but needs to reduce expenditures. As a result, the employer would like to negotiate a contract in which the medical group would provide care to all the company’s employees in exchange for a set monthly fee per employee. Which of the following payment methods best describes this type of health care financing arrangement?
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Question 33 of 36
33. Question
A 19-year-old woman comes to the clinic due to nausea and abdominal pain. She struggles to describe the pain and frequently points to her lower abdomen. The patient shakes her head no when asked if she could be pregnant or is sexually active. When she is asked about her last menstrual period, she nods affirmatively and says “now.” She is single and immigrated to the United States from a country in South America several months ago. Physical examination shows moderate abdominal tenderness with no rebound or guarding and vital signs are stable. The patient is discharged home with a diagnosis of food poisoning. Later that day, she is taken by ambulance to the emergency department after experiencing severe abdominal pain followed by loss of consciousness. A diagnosis of ruptured ectopic pregnancy is made. Which of the following interventions would most likely have prevented the delay in diagnosis?
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Question 34 of 36
34. Question
A 40-year-old man comes to the office for evaluation of difficulty with concentration. After reading a book on adult attention deficit hyperactivity disorder (ADHD), he thinks that he has ADHD and requests treatment with stimulants. The patient has no history of childhood ADHD but states that his parents were unaware of the disorder and never had him evaluated. He currently does not experience hyperactivity or impulsivity but says, “I just get easily distracted some days and know I could be more productive at work.” The patient does not use alcohol or use recreational substances. Medical history is noncontributory. Vital signs and physical examination are normal. The physician shares that the patient’s symptoms are not consistent with a diagnosis of ADHD. The patient insists that he will benefit from stimulants. Which of the following is the most appropriate statement?
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Question 35 of 36
35. Question
A 26-year-old woman, gravida 1 para 0, at 38 weeks gestation is admitted to the hospital in active labor. Twelve hours after admission, she has a spontaneous vaginal delivery of a baby boy who weighs 3.8 kg (8.4 lb) and has Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The patient did not receive routine prenatal care. She has no chronic medical conditions and no medication allergies. After delivery, the patient is informed that her son will require erythromycin ointment to prevent an eye infection and possible blindness that can be caused by untreated gonorrhea. The patient says her son does not need treatment because she has never had a sexually transmitted infection. Which of the following is the most appropriate response to this patient?
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Question 36 of 36
36. Question
A 65-year-old man is admitted to the inpatient unit of a busy community hospital for worsening shortness of breath over the last few days. He has a 40-pack-year smoking history and was initially diagnosed with chronic obstructive pulmonary disease exacerbation and treated accordingly. Chest x-ray on admission shows a large hilar opacity, and CT scan confirms the presence of a 4-cm mass in the right hilum. During the process of obtaining informed consent for bronchoscopy with biopsy, the patient says, “Doc, please don’t tell me what they find, because if it’s cancer, I don’t want to know.” Which of the following is the most appropriate response to this patient’s request?
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