NR 509 Mid-Term Study Questions

Chapter 7

(no chapter 5 or 6)

Chapter 1

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Chapter 3

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A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located?

a. Aortorenal b. Iliac pudendal c. Common femoral d. Superficial femoral e. Popliteal

A first-year medical student is examining a standardized patient with a structurally normal heart. The student is having difficulty auscultating the splitting of the second heart sound. At what area on the patient's chest would the student have the best opportunity of hearing this sound?

a. Apex b. Right second interspace c. Left second and third interspace d. Lower left sternal border e. Midsternum

The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed?

a. Arterial arch of the foot b. Posterior tibial c. Dorsalis pedis d. Popliteal e. Femoral

A 73-year-old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x-ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms?

a. Dissecting aortic aneurysm b. Coarctation of the aorta c. Myocardial infarction (MI) d. Pulmonary embolism (PE) e. Pericarditis

Which of the following complaints/findings is considered to be a patient identifier for mental health screening?

a. High use of health services due to chronic unstable medical diagnoses b. Symptoms lasting for >2 weeks c. Acute pain syndromes of 10 days' duration that require opiates for relief d. Substance abuse e. A patient with type I diabetes and neuropathic pain

A theoretical new laboratory test for strep throat has high specificity. When a test has high specificity, clinicians can be confident in which of the following aspects?

a. If the test result is positive, the patient probably has strep throat. b. If the test result is positive, the patient probably does not have strep throat. c. If the test result is negative, the patient probably has strep throat. d. If the test result is negative, the patient probably does not have strep throat. e. If the test result is positive, a confirmatory test should be performed.

A 13-year-old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis?

a. Aspiration of a foreign body b. Anxiety c. Asthma d. Left-sided heart failure e. Pneumonia

A 59-year-old patient presents to his primary care provider with a history of several episodes of sharp epigastric pain. His father died of pancreatic cancer at age 52 years, and the patient recalls to the clinician that, "His pain was just like mine is now ..." The patient then pauses several seconds. The clinician replies, "Just like?" after which the patient restarts his narrative. Which of the following is an example of the interviewing techniques employed by the clinician?

a. Clarifying b. Echoing c. Encouraging with continuers d. Eliciting a graded response e. Asking a leading question

A 65-year-old retired pilot visits the clinic because of recurrent headache. The patient reports dizziness of recent onset (previous 2 weeks) and occasional numbness on the left side. Which of the following systems or regions should be examined in the clinician's focused assessment?

a. Nervous b. Cardiovascular c. Musculoskeletal d. Respiratory e. Gastrointestinal

Chapter 12

No 11

A 29-year-old electrician complains of persistent cough and wheezing, particularly when he exercises. He says he smokes "occasionally" but rarely so much that he needs to purchase cigarettes: "Mostly, I bum them," he says, chuckling. Upon hearing this information, what is the best next step on the part of the clinician?

a. Determine the patient's exercise regimen. b. Determine the number of pack-years the patient smokes. c. Conduct a mental status examination. d. Explain the relationship between smoking and cancer. e. Determine the patient's immunization history.

A 33-year-old nurse presents with a history of weight gain, decreased energy, and menorrhagia over the past several months. Review of her family history reveals Hashimoto thyroiditis and hypothyroidism in four female first-degree relatives (her mother and three sisters). Which of the following skin findings best supports a diagnosis of clinical hypothyroidism?

a. Discoid rash, alopecia, oral ulcers, and Raynaud phenomenon b. Warm moist skin, hyperpigmentation, and pretibial myxedema c. Dry skin, myxedema, alopecia of the eyebrows, and brittle nails d. Spider angiomas, telangiectasia, palmar erythema, and Terry nails e. Thickened, taut skin with sclerodactyly and telangiectasia

A 14-year-old male presents to a new primary care provider after his family relocates to a state. The patient underwent treatment for sarcoma when he was age 11 years, including an above-the-knee amputation. He has learned to successfully navigate with a prosthetic leg and even engage in competitive athletics at school. He does not like to speak of his experience with cancer and often makes up humorous stories to tell new acquaintances about his amputation (such as, "I got bit by a squirrel and they had to amputate."). Although he is very well engaged in most of the visit with the new clinician, when the topic of cancer arises, he demurs to his father, who accompanies him to this appointment. Which of the following statements is most likely to be helpful in cementing the patient's trust in the new provider?

a. "That sounds like a frightening experience that you are recovering well from." b. "You are becoming an adult and must be able to talk about your health." c. "You need to see a counselor since you have not adjusted well to your new condition." d. "You have recovered well and should start moving on with your life." e. "You cannot rely on your father for support forever."

An 87-year-old woman who is generally healthy and cognitively sharp complains to the clinician of slow loss of vision, with similar problems in both eyes, particularly when she looks straight ahead. She is having difficulty reading of late. What is a reasonable response to her?

a. "This is a common occurrence with aging and unlikely to have a diagnosis." b. "This is an unusual occurrence, even among elderly, and may be due to a problem within the brain (since it is bilateral)." c. "Are you experiencing depression or stress?" d. "This may be the onset of macular degeneration, which an ophthalmologist should confirm." e. "This is a classic 'floater' and no cause for concern."

The negative predictive value of a test is calculated as the number of true negatives identified by the test divided by the total negatives found by the test. If a novel test for strep throat yields 85 true-negative results and 15 false-negative results, what is the negative predictive value of this test?

a. 10% b. 15% c. 75% d. 85% e. 99%

The positive predictive value of a test is calculated as the number of true positives identified by the test divided by the total positives found by the test. If a novel test for strep throat yields 150 true-positive results and 150 false-positive results, what is the positive predictive value of this test?

a. 10% b. 25% c. 50% d. 75% e. 100%

A 45-year-old physician is placed on a β-blocker for hypertension. Prior to medication administration, the patient's heart rate is 75 beats per minute with a cardiac output of 5 liters per minute. Following initiation of the medication, the heart rate decreases to 60 beats per minute without a change in stroke volume. What would be the expected new cardiac output?

a. 3 liters per minute b. 4 liters per minute c. 5 liters per minute d. 6 liters per minute e. 10 liters per minute

A 55-year-old actress sustains a heart attack and the follow-up electrocardiogram demonstrates a left bundle branch block. What would be the likely duration of the QRS complex?

a. 75 milliseconds b. 90 milliseconds c. 95 milliseconds d. 100 milliseconds e. 125 milliseconds

Weight change may indicate the presence of important underlying pathology requiring further investigation. Which of the following best describes a significant weight change that requires further evaluation?

a. A 45-year-old male with baseline weight of 280 lb who decides to undertake a light exercise regimen and loses 15% of his total body weight in 3 months b. A 32-year-old female with a baseline weight of 175 lb who checks her weight irregularly but reports a 5-lb unintended weight loss over 3 months c. A 45-year-old recently menopausal female who gains 5% beyond her baseline weight of 140 lb in 6 months d. A 26-year-old female with a baseline body mass index (BMI) of 25 who loses 5% of her body weight with 6 months of diet and exercise modification e. A 31-year-old male with a baseline body mass index (BMI) of 20 who loses 3 lb after a prolonged bout of infectious gastroenteritis

A 26-year-old homeless male presents for a new-patient evaluation at a community health center. He has a history of intravenous drug use, from which he contracted hepatitis C. He also suffers from uncontrolled asthma that he has had since childhood, with treatment including frequent doses of oral steroids when he cannot keep inhalers in his possession. Two years ago, he was diagnosed with bipolar disorder. On today's visit, his main concern is a small abscess in his right antecubital fossa at a heroin injection site. Which of the following is the best approach to the health history for this patient at his first visit?

a. A clinician-centered health history b. A health history with only yes-no options c. A review of systems (ROS) only d. A problem-focused health history e. A comprehensive health history

A 70-year-old man complains of double vision. Which of the following associated symptoms or signs would be worrying about an underlying neurological problem (as opposed to pathology in the eye)?

a. Abnormality in extraocular movements on examination b. Diplopia persisting in the right eye when the left eye is closed c. An associated conjunctivitis d. Worsening vision bilaterally on examination e. Symptoms of flashing lights

When assessing for the femoral pulse, where should the clinician begin deeply palpating?

a. Above the inguinal ligament, just lateral to the symphysis pubis b. Above the inguinal ligament, just medial to the anterior superior iliac spine c. Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis d. Below the inguinal ligament, just lateral to the symphysis pubis e. Below the inguinal ligament, just medial to the anterior superior iliac spine

A 16-year-old male high school student presents with a primary concern of acne. He relates a history of 2 years of moderate mild acne and closed comedones (whiteheads), which have recently worsened such that a classmate started calling him a pirate due to a large pustule that developed at the tip of his nose. He has increasing outbreaks of cyst-like acne as well as a generally poor complexion with pitting and scarring from prior outbreaks. Which of the following best describes this condition in the adolescent population?

a. Acne vulgaris affects <50% of the adolescent population. b. Acne vulgaris is associated with an identified virus for which there is no definitive treatment. c. Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and heavy sweating as well as other contributory factors. d. The primary hormonal stimulus for acne vulgaris is estrogen, causing preferentially worse cases in females and males with lower testosterone levels. e. Acne vulgaris is always associated with underlying endocrine disorders and/or pituitary dysfunction.

1. A 23-year-old physician assistant (PA) student found that she felt nervous when called upon to examine men in her age group. On one occasion, she encountered a young male patient who appeared embarrassed to see her walk into the room. What should the PA do to minimize their mutual discomfort?

a. Adjust lighting so it is tangential to the patient's body. b. Explain how the examination will proceed. c. Ask the patient where he comes from. d. Explain that she is a PA student. e. Provide ongoing interpretation of findings.

A 68-year-old retired college professor presents for routine physical examination. After the patient has been reading a novel in the waiting room for ~20 minutes, the technician records his blood pressure in both arms using an automated device. The technician notes a 20-mm Hg difference in systolic blood pressure between the right and left arms; he repeats the readings 10 minutes later and records the same asymmetrical systolic blood pressure. Which of the following is true regarding this physical finding?

a. An arm-to-arm difference of up to 20 mm Hg in systolic blood pressure is considered the upper limits of normal. b. The difference is likely secondary to white coat hypertension and should be followed up with three subsequent monthly readings to confirm. c. The patient should undergo ambulatory blood pressure monitoring in both arms for 24 hours to confirm conflicting measurements in the office. d. This finding is clearly abnormal and requires immediate evaluation for possible cardiovascular emergency. e. The patient should commence an antihypertensive medication and return in 6 weeks to assure normalization of the asymmetry between the arms.

Abstract thinking is an important component of the human thought process. A person's ability to understand questions that test his or her ability to answer appropriately is dependent upon a number of factors. Which one of the following answers is true in identifying a patient with concrete thinking and a reduced ability to think abstractly?

a. An inability to correctly perform serial 7s b. An inability to spell "world" backward c. An inability to name the occupations of common well-known public figures such as the President and Vice President d. An inability to draw a clock correctly including all numbers and make it tell time as requested (i.e., 10:15) e. An inability to discern the similarity between two words (e.g., a cat and a mouse by answering "The cat chases the mouse.")

A 77-year-old man is experiencing progressive shortness of breath and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valvular condition?

a. Aortic insufficiency b. Mitral stenosis c. Aortic stenosis d. Mitral regurgitation e. Pulmonic stenosis

An elderly patient with a history of smoking two packs of cigarettes a day for 50 years complains to her physician of progressive shortness of breath. On cardiac examination, the physician feels the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what condition?

a. Aortic stenosis b. Hypertrophic cardiomyopathy c. Hypertension d. Pulmonary hypertension e. Mitral regurgitation

A 36-year-old female air traffic controller presents to her primary care provider for a routine visit 3 months after losing her spouse to a lengthy battle with a neurodegenerative disease. The patient denies any psychiatric symptoms on review of systems and, in fact, states that she has slept better in the last month than she had in the previous years. She endorses a healthy support system, including the extended family of her deceased spouse, with whom she is still close. She becomes wistful and briefly tearful when speaking of the plans that they had when they first married that were never fulfilled; she then changes the subject rapidly to whether her Pap smear is due. Which of the following is an example of an empathetic response to this patient?

a. Assuming that the event caused her to become depressed and expressing the same feeling on behalf of the patient b. Recognizing the patient's emotions by asking or confirming how she feels about the event c. By allowing the crying patient to look around the room for tissues to permit her an excuse to hide her face and defer her emotions d. Presuming that the patient's emotions meet social expectations, such as being depressed and even traumatized by her spouse's death e. Narrowing the understanding of the patient's emotional response to only thoughts and feelings that have been verbalized

After examining a patient who is in the hospital for shortness of breath, the clinician records the following for lung examination: "There is dullness to percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice sounds." Which of the following is the most likely diagnosis?

a. Atelectasis b. Left-sided heart failure c. Pneumonia d. Pneumothorax e. Chronic obstructive pulmonary disease (COPD)

One important examination technique involves using the third fingers of each hand to determine the health of internal organs. What is the name of this technique?

a. Auscultation b. Percussion c. Inspection d. Palpation e. Listening

On routine physical examination, a 40-year-old teacher is found to have a single second heart sound. The most likely explanation for this finding is what?

a. Auscultation occurred during inspiration. b. The patient has pulmonic stenosis. c. Auscultation occurred during expiration. d. The patient has a right bundle branch block. e. The patient has a left bundle branch block.

A student is practicing the performance of a lung examination on a classmate. Which of the following is the correct order for performing the components of the lung examination?

a. Auscultation, inspection, palpation, and percussion b. Auscultation, percussion, palpation, and inspection c. Inspection, palpation, percussion, and auscultation d. Auscultation, inspection, palpation, and percussion e. Inspection, auscultation, percussion, and palpation f. Palpation, inspection, auscultation, and percussion

A 29-year-old waiter comes to the clinic for a 2-month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest?

a. Barrel chest b. Flail chest c. Pectus excavatum d. Pigeon chest e. Thoracic kyphoscoliosis

A 25-year-old construction worker is complaining of a swishing noise in both ears that never goes away and has occurred for about 6 months. He is otherwise healthy, is able to work on his job (operating large, vibrating machinery) without problems, and is not taking any medications. A complete examination reveals an abnormality. Which of the following abnormality is most often associated with tinnitus?

a. Bilateral earache b. Wax in both ears c. Headache d. Vertigo e. Mild tremor

A 55-year-old air traffic control agent reports his home blood pressure log to clinic after he was diagnosed with hypertension at a prior visit. He notes that he consistently measures within the normal range at home, but seems to fall outside the normal range every time he comes to the clinic. Which of the following blood pressure measurements is considered to be most accurate (i.e., reflecting the patient's "true" blood pressure)?

a. Blood pressure recorded in three positions in the health practitioner's office b. Three separate blood pressure measurements recorded by a medical technician within 90 minutes of awakening in the morning in an office setting using an automated device c. Blood pressure recorded in three positions in the health practitioner's office after resting for a 10-minute period in a supine position d. Regular ambulatory monitoring recorded outside of the office setting e. A total of six blood pressures averaged over three visits to a health practitioner's office over a 3-month period

A 70-year-old patient has suspected chronic obstructive pulmonary disease. The clinician instructs the patient to take a deep breath in, and then with his mouth open, breathe out as fast and completely as he can. For what is the clinician checking?

a. Bronchophony b. Egophony c. Tactile fremitus d. Forced expiratory time e. Whispered pectoriloquy

A 72-year-old woman presents with concerns about several ruby-red spots on her chest and abdomen. She reports that these are growing in both size and number over time. On examination, the provider notes a number of cherry angiomas at the locations indicated by the patient. No other abnormalities are noted. Which of the following best describes the clinical characteristics and significance of a cherry angioma?

a. Cherry angiomas never show blanching under pressure. b. Cherry angiomas are associated with liver disease and B vitamin deficiencies. c. Cherry angiomas are benign and may increase in size and number with aging. d. Cherry angiomas rarely occur on the trunk and are most often noted on the legs near veins. e. Cherry angiomas are a marker for underlying pathology that requires additional evaluation.

A 17-year-old woman presents with her parents to her primary care provider. She desires to utilize a tanning facility ahead of an upcoming event. Her parents have heard that this is a dangerous practice, although the tanning facility insists it is safe without risk of skin cancer in the future after tanning. Which of the following is true regarding ultraviolet (UV) light exposure and subsequent risk of skin cancer?

a. Chronic sun exposure confers greater risk for skin cancer than intermittent intensive exposure. b. Tanning beds and sunlamps do not increase risks of skin cancer as they utilize UV wavelengths that are not carcinogenic. c. Water-resistant sunscreens confer no advantage over water-soluble products. d. Targeted messaging and practitioner reinforcement in primary care amplify sun-protective behaviors. e. Sunscreen with a sun protective factor (SPF) of 15 blocks ~50% of UV-B light.

A 45-year-old forklift driver presents to the clinic at 4 o'clock in the afternoon complaining of intense substernal chest pain and nausea. He appears pale and sweaty. At work that day, he filled in for an absent co-worker and was asked to perform heavy lifting not normally a part of his job. The physician assistant (PA) questions the patient in detail about his nausea, eating habits, and digestive history. Which of the following steps of clinical reasoning has the PA failed to follow?

a. Elicit information about the patient's gastrointestinal (GI) system b. Localize findings anatomically c. Match findings against conditions that could cause them d. Give special consideration to potential life-threatening problems e. Elicit information about the patient's family history of digestive disorders

A 19-year-old carwash attendant sustained a laceration to the ulnar aspect of his mid-forearm while at work last week. He did not have it evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the clinician expect to find the first signs of lymphadenopathy?

a. Epitrochlear nodes b. Lateral axillary nodes c. Central axillary nodes d. Infraclavicular nodes e. Cervical chain nodes

A 39-year-old architect comes to the clinic for a 2-day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say "ee," it sounds like "A." Which of the following would most likely be found on percussion of his lungs?

a. Flatness b. Hyperresonance c. Stridor d. Tympany e. Dullness

A 42-year-old female mathematician presents for follow-up care regarding a new diagnosis of systemic lupus erythematosus 6 months ago after a lengthy diagnostic process during which she was debilitated with fatigue and joint pain. Since her diagnosis, she has been minimally compliant with medications and has switched her rheumatology provider twice. She continues to feel ill, and, in explanation for her lack of adherence to the prescribed treatment, she simply says, "I don't like it." At this initial visit with her third rheumatology provider, the clinician elects to explore the issues behind her noncompliance before engaging in diagnostics and treatment using the FIFE model. Which of the following best defines the elements of the FIFE model?

a. Focus, intensity, function, and evaluation b. Facts, intensity, focus, and evidence c. Feelings, ideas, function, and expectations d. Feelings, impression, fantasy, and emotion e. Facts, intelligence, fortuity, and eventuality

A 34-year-old male with a history of complex social and medical needs (including current substance abuse) presents to a primary care teaching clinic. The patient has experienced a number of adversarial relationships with prior clinicians, including voluntarily leaving two practices within the previous year and being asked to leave care at a third clinic due to misbehavior. The attending physician desires to utilize the approaches to this patient that are most likely lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the attending physician to use?

a. Focusing on the need for immediate diagnostic certainty over personal connection b. Taking charge of the interaction to meet the clinician's desire to acquire diagnostic information c. Following the patient's lead to understand their thoughts, ideas, concerns, and requests d. Deferring respect, empathy, humility, and sensitivity in favor of the acquisition of concrete details about the patient's condition e. Taking a symptom-focused approach to reduce the involvement of the patient's emotional difficulties

A 42-year-old architect presents with widespread pain complaints, including headaches almost daily, pain at the site of an old motor vehicle accident injury, and generalized achiness and hypersensitivity throughout the body. He recounts that his first episodes of ongoing pain occurred in his early 20s, and he has been to many practitioners over several years seeking a firm diagnosis and adequate treatment of his complaints. Which of the following statements is true regarding chronic pain?

a. Following assessment and evaluation, ~80% of patients with non-cancer-related pain report control of their symptoms. b. Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months. c. Chronic pain is defined as focused pain lasting >8 months following acute injury or illness. d. In primary care practices, non-cancer-related chronic pain is seen in <10% of patients. e. Pain that recurs at intervals of months or years is never considered to be "chronic pain."

A theoretical laboratory test for infection with HIV is known to have high sensitivity. This means that the test has which of the following?

a. Good ability to rule in HIV in those who do have HIV b. Good ability to rule out HIV in those who do not have HIV c. High intraobserver reliability d. High interobserver reliability e. Good ability to diagnose AIDS

An 82-year-old gentleman seems to be speaking loudly during an examination, suggesting that he may not be hearing well. What is a good question to ask him to help identify whether or not he has hearing loss?

a. Has he been listening to loud music? b. How well does he understand people in a noisy environment such as a restaurant? c. Does he have vertigo? d. Has he been having an earache? e. Does he have discharge from his ear?

A 16-year-old boy is brought to the Emergency Department (ED) after a motor vehicle accident for shortness of breath for 1 hour. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fourth intercostal space. How does he determine where the fourth intercostal space is?

a. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib. b. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space. c. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space. d. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space. e. He finds the angle of Louis and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.

A 17-year-old male presents to a sexually transmitted disease clinic at the behest of his brother, who convinced the patient to attend the clinic after he disclosed that he prefers homosexual partners but is afraid that his last partner may have given him an infection. The patient expresses to the intake nurse that he is unashamed of his sexual orientation and will not stay through the visit if he feels that he is dismissed or discriminated against because of it. The nurse practitioner receives this communication prior to entering the examination room and decides to employ active listening to best connect with the patient at this critical juncture in his care with the clinic. Which of the following is an example of an active listening technique?

a. Ignoring visual cues to focus on the patient's exact words b. Setting aside the patient's emotional state to focus on his medical needs c. Paring down the patient's concerns to concrete medical needs d. Using nonverbal communication to encourage the patient to expand their narrative e. Considering a differential diagnosis while the patient is speaking to maximize the patient's time with the provider

A 24-year-old veteran returns from his second tour of duty in the Middle East. He was witness to a number of violent military encounters and experienced the death of several of his closest friends. He describes a number of problems including nightmares, poor sleep pattern, and mild panic attacks. In persons with trauma- and stress-related disorders as well as other disorders that may be associated with hallucinations and illusions, which of the following statements is true that distinguishes these two entities from each other?

a. Illusions occur only when awake, whereas hallucinations can occur both while awake and while sleeping. b. Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. c. Illusions involve an irrational fear or perceptions, whereas hallucinations are a misinterpretation of real external stimuli. d. Hallucinations may be visual or auditory, causing an alteration of the real external world, whereas illusions are entirely imaginary. e. Hallucinations by definition never include somatic perceptions, whereas illusions always involve at least some component of a somatic complaint.

Concerning a patient that may demonstrate a diagnosis of aphasia, which of the following statements is true?

a. It involves a loss of the voice or a slurring or hoarseness of speech secondary to pathology of the larynx or its nerve supply. b. It is best characterized by slurred speech with an associated defect in language control. c. It is best characterized by involuntary, rhythmic, repetitive movements involving the tongue and jaws making speech difficult to comprehend. d. The ability to write a full correct sentence does not rule out the presence of aphasia in a patient. e. It is defined as an inability to produce or understand language.

A 20-year-old college student is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding?

a. Left bundle branch block b. Pulmonic stenosis c. Right bundle branch block d. Atrial septal defect e. Tricuspid stenosis

A mother brings her 8-year-old daughter to the clinic because she found a tick in the girl's hair and would like her daughter to be tested for Lyme disease. The nurse practitioner (NP) explains that the enzyme-linked immunosorbent assay (ELISA), an early test for Lyme disease, is effective in finding early cases of Lyme disease but can also give positive results in some people who do not have the disease, making additional testing necessary. This means that the ELISA test has which of the following?

a. Low sensitivity, high specificity b. High sensitivity, high specificity c. High sensitivity, low specificity d. Low sensitivity, low specificity e. Undetermined sensitivity and specificity

A 59-year-old unemployed man complains of almost always feeling tired and hungry, despite getting sufficient rest and having a good appetite and access to sufficient food. The patient is obese and, despite the warm weather outside, wearing thermal socks with his sandals. He says this is because his feet are always cold and "feel funny." With which body system should the clinician begin the examination?

a. Lower extremities b. Head and neck c. Posterior thorax d. Abdomen e. Nervous system

A 28-year-old male business executive presents to a primary care provider with concerns about hair loss. He is otherwise healthy without chronic medical conditions or current medications. He has a chart history of allergy to sulfa medications, although this happened when he was a young child, and he does not recall the incident or the reaction. He is unsure at what age his father went bald, as he never remembers his father having hair. He remarks jokingly that he is losing more hair than his dogs at home, who shed frequently but are otherwise healthy. On examination, he has a single uniform oval patch of hair loss over the left temporal area without any scaling, inflammation, or other skin changes where the hair is missing. Which of the following is the most likely explanation for his hair loss?

a. Male pattern baldness, as evidenced by his father's baldness at a young age b. Tinea capitis, as evidenced by his exposure to animals that may carry this pathogen c. Trichotillomania, as evidenced by his anxiety and need to diffuse uncomfortable situations with inappropriate humor d. Alopecia areata, as evidenced by patchy hair loss without associated skin changes e. Drug rash, as evidenced by his allergy to sulfa drugs

A 14-year-old high school student comes to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy's history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma?

a. Mediastinal crunch b. Pleural rub c. Rhonchi d. Wheezes e. Stridor

A 19-year-old student of art history presents to clinic after a syncopal (fainting) episode at school. He is notably thin; on a thorough review of his medical history, he admits that he eats only minimally to maintain a very low body weight that he feels is ideal. He is embarrassed that his issues were discussed by peers after this episode, especially because he believes that this is a problem that is only faced by girls and women. Concerning the two most common eating disorders (anorexia nervosa and bulimia nervosa), which of the following statements is true?

a. Men and women are both afflicted, but with a female:male prevalence ratio estimated at ~2:1. b. Both of these eating disorders are associated with a body mass index (BMI) of <17.5. c. Both of these eating disorders are associated with a real or imagined fear of appearing fat. d. Persons with eating disorders are generally easily identified by their appearance. e. The prognosis is similar regardless of whether individuals are diagnosed and treated in the early or late stage of these disorders.

A 42-year-old fair-skinned woman of Irish origin presents with an abnormal skin growth that was first noted 7 years ago. On examination, a 2 × 3-cm lesion is noted over her left bicep. Which of the following historical elements most increases the suspicion that the lesion is malignant?

a. No evolution in size since onset, but mild intermittent pruritus over the last 2 years b. No evolution in size since onset, but uniformly darkly pigmented color c. Minimal but discernible increase in size over the past 6 months d. Presence of similar pinkish tan lesions on the sun-exposed areas including the face and hands e. Proximal location, that is, over the bicep rather than the distal arm

A concerned mother brings her 9-year-old daughter to the clinic with several days of a diffuse rash on the trunk. The child was previously healthy and is current on her vaccinations. The mother relates a history of decreased appetite, easy fatigue, and low-grade subjective fevers. On examination, temperature is recorded at 100.5ºF, the rash is confirmed as described by the mother, and additional physical findings of a strawberry tongue and erythema of the palms and soles are noted. Nonpainful peeling of the skin of the child's fingertips is noted incidentally. Based on the history and physical findings, which is the most likely diagnosis and course of action?

a. Nonspecific viral exanthem, for which observant management is advised b. Contact dermatitis, for which antihistamines are indicated c. Measles, for which review of the vaccination history is critical d. Kawasaki disease, for which close monitoring and possibly hospitalization might be required e. Strep throat, for which amoxicillin is indicated

A 47-year-old fitness trainer visits the physician assistant (PA) because of skin dryness, night sweats, and irregular menstrual periods. It is the PA's first contact with this patient. The patient notes that "My sex life has really gone downhill lately" and says that she is considering divorcing her husband of 20 years, stating that "He's not a bad guy. I just think that I can do better." In which of the following ways should the clinician proceed?

a. Obtain a menstrual history for the previous 6 months. b. Help the patient review the pros and cons of divorce. c. Inform the patient that menopause is a normal part of aging. d. Conduct a breast examination. e. Determine the patient's out-of-country travel history.

A 32-year-old office worker reports excessive stress at work and pain in the right lower quadrant. She states that last night she vomited twice. Her blood pressure is 120/75, heart rate 93 bpm. The patient looks pale and is sweating lightly. Which of the following is an objective finding?

a. Pain in the right lower quadrant b. History of vomiting c. Pale appearance d. High stress level e. Accelerated heart rate

A 39-year-old nurse who is a well-established patient complains of irregular menstrual periods and pelvic pain. She says that she is having trouble sleeping and asks whether she could be given a "sleeping pill." The patient also says she is thinking of leaving her job. What is the best "next step" in caring for this patient?

a. Perform a pelvic examination. b. Obtain a urine sample for testing. c. Obtain a more complete description of problems. d. Obtain blood for testing. e. Ask about recent travel destinations.

A 68-year-old retired administrative assistant complains of a 3-month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid-calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following?

a. Peripheral arterial disease (PAD) b. Venous stasis c. Acute arterial occlusion d. Neurogenic claudication e. Abdominal aortic aneurysm

A 51-year-old moderately overweight college professor visits the clinic with a complaint of chest pain after tennis matches. He jokes that his tennis partner "is in a lot better shape than I am" but says that he is trying to keep up. Later in the day, a 28-year-old female student at the same college reports that "my chest often feels hot and tight." She also feels stressed on the evening before mid-term exams. The clinician recommends an immediate evaluation for coronary artery disease (CAD) for the professor, but not for the student. Why?

a. Positive predictive value of an observation is higher in a group with a higher prevalence of disease. b. Positive predictive value of an observation is lower in a group with a higher prevalence of disease. c. Negative predictive value of an observation is lower in a group with a higher prevalence of disease. d. Negative predictive value of an observation is higher in a group with a higher prevalence of disease. e. Positive predictive value of an observation is greater in older people than in younger people.

A 21-year-old college student experiences tachycardia following a night of heavy drinking. She is advised to undergo a stress electrocardiogram (ECG). As she exercises, the recently calibrated pulse oximeter records a heart rate ranging from 25 beats per minute (bpm) at rest to 50 bpm while jogging. The test is stopped and re-started twice, and each time the pulse oximeter yields a resting heart rate of 25 and a jogging heart rate of 50. Which aspect of this instrument does the ECG technician question?

a. Prevalence b. Validity c. Sensitivity d. Specificity e. Predictive value

A 63-year-old male presents to establish care at a new primary care clinic to discuss issues with pain and fatigue. The clinician conducting the visit begins with general historical questions but quickly becomes suspicious that the patient is suffering from decompensated heart failure. When the patient mentions that he has had vague chest pain since last night, the clinician feels that the focus must be redirected to this potentially emergent condition. Which of the following interview techniques is the most appropriate to effectively manage this visit?

a. Providing serial reassurances such as, "Don't worry, you're going to be fine." b. Asking a series of negative questions such as, "You don't have any swelling in your feet, do you?" c. Nonverbally cuing the patient to focus on his narrative regarding a motor vehicle accident d. (MVA) that led to back pain e. Asking leading questions that focus on the presumed diagnosis of chest pain f. Moving from open-ended to focused questions

A 55-year-old truck driver with obstructive sleep apnea has diastolic heart failure. An echocardiogram demonstrates significant biatrial enlargement. What portion of his electrocardiogram would likely be abnormal?

a. QRS complex b. R wave c. S wave d. P wave e. T wave

Disparities in pain treatment have been well described in numerous studies comparing Caucasian patients to those of African American and Hispanic origin. Which of the following statements is true concerning this issue?

a. Racial and ethnic biases are only relevant in geographic areas that have a history of racial and ethnic discrimination. b. Racial and ethnic biases never involve two persons of the same race or ethnic group. c. Language barriers do not contribute to the problem of racial and ethnic biases. d. Biases of the treating clinician are associated with overtreatment of pain in minority patients and non-English speakers. e. Biases of the treating clinician are associated with under-treatment of pain in minority patients and non-English speakers.

A 74-year-old man is being seen because of a 1-day history of a painful right eye. He also mentions that he has blurred vision in that eye. He thought something had blown into his eye, but after flushing it out, the pain and blurred vision remains. What is the best course of action?

a. Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed). b. Perform a vision examination. c. Perform a complete neurological examination. d. Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma. e. Check his blood pressure.

A 70-year-old retired business executive presents to the Emergency Department with progressive shortness of breath and two-pillow orthopnea. On physical examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other murmurs or thrills are auscultated on physical exam. Which of the following interventions is to most likely to improve the patient's symptoms?

a. Removal of intravascular volume with diuresis b. Replacement of the mitral valve c. Replacement of the aortic valve d. Decrease in blood pressure e. Repair of a ventricular septal defect

A 52-year-old male presents for an annual examination. He discloses on review of family history that his father has died of skin cancer since his last visit. He personally has had two actinic keratoses frozen and has further lesions that require evaluation today. He is very concerned about his personal and family history and would like to know more about the potential for skin cancer to spread and become a dangerous condition. Which of the following skin lesions is the least likely to metastasize?

a. Squamous cell carcinoma (SCC) b. Actinic keratosis c. Melanoma d. Seborrheic keratosis e. Basal cell carcinoma (BCC)

A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if they sound hyperresonant. Which of the following is an example of good technique for percussion?

a. Strike using the tip of the third finger. b. The proximal interphalangeal joint is the joint that is struck. c. Put the third and fourth fingers next to each other on the chest. d. Strike using the finger pad of the fourth finger. e. The wrist is kept still during percussion. Submit

A 29-year-old female professional athlete presents to a new primary care provider with chronic menstrual complaints. She remarks to the nursing staff that, in the past, she has experienced a dismissal of her complaints because of her high level of physical fitness and conditioning. She is seeking a care provider who will explore the issue in more detail and work with her particular concerns. Which of the following is the description of the patient-centered care this individual seeks?

a. Structured and clinician-centered with open-ended questions b. Validating and empathetic with open-ended questions c. Dismissive and concrete with open-ended questions d. Affirming and reassuring with close-ended questions e. Factual and structured with active listening

A 38-year-old accountant presents to the office with a series of generalized complaints. He relates that he feels a loss of pleasure in daily activities, has difficulty sleeping, and is experiencing problems making decisions. Which of the following best explains the patient's presentation?

a. Substance abuse with anhedonia b. Bipolar disorder in the early pre-excitatory phase c. Histrionic personality d. Depression e. Antisocial personality

A 58-year-old carpenter presents for his annual physical examination. The physician assistant notes a systolic murmur on auscultation of the aorta. However, she does not immediately conclude that this patient has aortic stenosis. Which of the following is the reason that she seeks additional information?

a. Systolic murmurs have high sensitivity and high specificity for aortic stenosis. b. Systolic murmurs have low sensitivity and low specificity for aortic stenosis. c. Systolic murmurs have low sensitivity but high specificity for aortic stenosis. d. Systolic murmurs have high sensitivity but low specificity for aortic stenosis. e. Systolic murmurs are unrelated to aortic stenosis.

A 54-year-old diplomat working at the United Nations reports occasional chest pain and a sense of tightness in his chest when particularly stressed over work deadlines. The patient is 6 feet 4 inches tall. He has a temperature of 98.6ºF and blood pressure of 140/78. He has a cut over one eye that he says is "from shaving." Which of the following represents subjective information about this patient?

a. Temperature of 98.6ºF b. Blood pressure of 140/78 c. Employment at the United Nations d. Cut over eye from shaving e. Height of 6 feet 4 inches

A 62-year-old manual laborer presents to an annual physical examination with concerns about skin cancer screening. He does not have any lesions of concern but was recently told by a friend that he should have his skin checked by a doctor yearly. What is the best advice for this patient according to the U.S. Preventive Services Task Force (USPSTF) recommendations on skin cancer screening from 2015?

a. The USPSTF recommends that all individual age >50 years be screened yearly for skin cancer regardless of risk factors. b. The USPSTF recommendations mirror those of the American Cancer Society (ACS) and American Academy of Dermatologists (AAD) in recommending and annual skin cancer screening for patients age >50 years. c. The USPSTF recommends skin cancer screening only in sun-exposed areas of fair-skinned individuals every 6 months. d. The USPSTF recommends focused screening of individuals with a history of dysplastic nevus syndrome. e. The USPSTF recommends against routine screening for skin cancer due to lack of evidence for this intervention across the general population.

A 62-year-old former tennis pro obtained a home blood pressure cuff after an office measurement revealed that his blood pressure fell in the hypertensive range. At a follow-up visit, he questions the accuracy of the clinician's blood pressure cuff and the veracity of his diagnosis of hypertension. Which of the following is true regarding blood pressures recorded in a practitioner's office versus values obtained in the ambulatory setting?

a. The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements. b. Masked hypertension is a phenomenon whereby ambulatory blood pressure is measured in the normal range but measurement in the office is elevated. c. The accepted normal values for blood pressure are the same for ambulatory measurements compared with office measurements. d. Both systolic and diastolic measurements must be in the hypertensive range to confer cardiovascular risk on the patient. e. The American Heart Association (AHA) has issued consensus statements regarding the number and timeframe for blood pressure measurement to guide practitioners in diagnosing hypertension.

A 72-year-old retired woman presents to a primary care provider for evaluation of a suspicious mole. She noticed this lesion 3 weeks ago on her right flank in an area where she had previously seen no abnormality. She is very concerned about melanoma and asks if this could be a possible diagnosis and also wonders if this should have been noticed at her annual examination 7 months ago. Concerning the initial recognition of melanoma, which of the following is true?

a. The majority of melanomas are recognized during an annual physical examination. b. Approximately 50% of melanomas are initially noticed by patients then brought to the attention of a practitioner. c. General screening programs conducted by medical facilities identify ~75% of melanomas. d. Most melanomas are initially identified in individuals with positive family histories by DNA analysis for causative genes. e. Asymmetry of a mole is rarely associated with melanoma.

A first-semester physician assistant student reports to his supervisor that he has trouble determining the diastolic blood pressure. On manual blood pressure, which of the following provides the best estimate of the true diastolic blood pressure?

a. The point at which Korotkoff sounds first muffle after systolic blood pressure is discerned. b. The average between the highest and lowest points of the auscultatory gap. c. The recommencement of Korotkoff sounds following the lower point of the auscultatory gap. d. The disappearance of Korotkoff sounds following initial muffling. e. The average reading between the onset of the auscultatory gap and the resumption of Korotkoff sounds.

A 72-year-old retiree presents to the cardiology clinic with palpitations after several months of symptoms. An electrocardiogram (ECG) shows a tachyarrhythmia, which the cardiologist diagnoses as atrial fibrillation. In measuring the blood pressure of a patient with chronic atrial fibrillation, which of the following statements is true?

a. The precise blood pressure is measured by taking the average of three pressures in both arms over a span of 20 minutes. b. Single automated measurement in the office setting provides a reliable value for the true blood pressure. c. Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures. d. Measuring blood pressure in patients with atrial fibrillation is no different than measuring blood pressure in patients with normal cardiac rhythms. e. Because atrial fibrillation is an uncommon arrhythmia, blood pressure management of these patients does not have widespread significance in office or ambulatory practice.

Which of the following statements is true concerning mental health disorders in primary care?

a. The prevalence for mental disorders is estimated to be ~10%, of which only 25% are not diagnosed. b. Anxiety disorders are the most prevalent of all diagnoses in this setting. c. Somatic symptom disorder (DSM-5) is distinctly uncommon in this setting and constitutes less than 5% of these disorders. d. Mood disorders make up ~25% of all diagnoses. e. Alcohol and substance abuse are not considered mental health disorders.

A 23-year-old farm worker submits urine for testing. Three test strips from Container A show abnormally low pH levels in the urine. However, three test strips from Container B, purchased more recently, consistently indicate that the pH of this patient's urine is normal. Which of the following is a true statement about the test strips?

a. The test strips demonstratehigh interobserver reliability. b. The test strips demonstratelow intraobserver reliability. c. The test strips demonstrate high intraobserver reliability. d. The test strips demonstrate high sensitivity. e. The test strips demonstrate high specificity.

Concerning hallucinations, an abnormal perception experienced by a patient, which of the following statements is true about this abnormality?

a. They include false perceptions associated with dreaming and occurring with falling asleep and awakening. b. Objective testing can be performed by a trained neuropsychologist to ascertain the correct diagnosis associated with this complaint. c. Although alcoholism may be associated with abnormalities of perception, it is not considered a cause of hallucinations as this finding is due to its direct toxic effects. d. It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. e. By definition, hallucinations are confined to those abnormal perceptions that are either auditory or visual in nature.

A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is most likely to be affected?

a. Tricuspid valve b. Pulmonic valve c. Mitral valve d. Pyloric valve e. Eustachian valve

A patient with cystic fibrosis (CF) has been complaining of fullness in his left nasal cavity. Examination of his nose using an otoscope and a speculum reveals a normal nasal septum, but a pale, saclike growth of inflamed tissue that is obstructing a large part of the nasal cavity. What is the most likely diagnosis?

a. Ulcer b. Viral rhinitis c. Allergic rhinitis d. Deviated nasal septum e. Nasal polyp

A 65-year-old overweight male presents at the clinic with hoarseness which has lasted for around 2 months. He thinks it began along with a cold. He is not feeling badly other than frequent heartburn, and he has continued to work as a bartender (for the past 30 years), but he is having difficulty being heard and understood because of his hoarse voice. A diagnosis that is on the differential list includes which of the following?

a. Voice strain from bartending and talking amidst loud ambient noise b. Viral infection c. Acid reflux d. Inhalation of fumes e. Environmental allergies