Deck 2: Behavioral Sciences

Question 1

A 45-year-old lady with type 2 diabetes, obesity, and hypertension visits the doctor for a regular check-up. A sulfonylurea and an ACE inhibitor are among her meds. The patient attributes his weight reduction of 2.3 kg (5 lb) to a new energy and weight loss supplement. She bought the supplement via the Internet on the advice of a friend and claims it includes caffeine and numerous herbs that aid in weight reduction. The supplement has been well tolerated by the patient. The blood pressure is 140/90 mm Hg, and the pulse rate is 88 beats per minute. Which of the following is the most suitable medical response?

A)Advise the patient to avoid the supplement and engage in other forms of weight loss
B)Advise the patient to limit the use of other caffeine-containing products
C)Explain that weight loss due to dietary supplements is unlikely to be sustainable
D)Offer to review the ingredients with the patient and discuss the potential risks of supplements
E)Respect the patient's decision and follow her closely

Answer 1

Offer to review the ingredients with the patient and discuss the potential risks of supplements

Question 2

A 33-year-old man arrives at the clinic for normal health maintenance. The patient expresses concern about his health after his father suffered a myocardial infarction a few months earlier at the age of 61. He has been eating well and exercising three to four times a week. The patient's medical history is irrelevant, and he or she is not taking any drugs. His aunt is a herbalist, and she recently gave him a supplement that is said to help prevent cardiovascular disease. The patient inquires whether it is safe to begin taking the supplement and produces a list of the contents, which includes plants unknown to the doctor. Which of the following responses is the most appropriate?

A)"I suggest not starting the supplement because you're already taking steps to maintain cardiovascular health by eating healthy and exercising."
B)"I'll need to read more about this combination of herbs, so I'll do some research and let you know what I find."
C)"I'm not familiar with these herbs, but studies have shown that herbs don't have significant effects on preventing cardiovascular disease."
D)"This supplement probably won't prevent cardiovascular disease, but it's likely safe for you to take if you want to."
E)"Unfortunately, I don't know enough information about these herbs, so I can't make a recommendation."

Answer 2

"I'll need to read more about this combination of herbs, so I'll do some research and let you know what I find."

Question 3

A buddy approaches a doctor and asks for a prescription for depressive medicine. The doctor has known this person since college and is aware that she has been treated for depression in the past. The buddy claims that she is merely "a little sad" as a result of work stress and relationship troubles, and that she would want to begin taking sertraline, which she had previously taken. She has a doctor, but she wants to avoid visiting him or her since it is tough to make an appointment and she has a hectic schedule. Which of the following responses is the most appropriate?

A)"I can write a prescription so that you have enough medication until you're able to get an appointment with your doctor."
B)"I wish I could help you, but your psychiatric history is too complex for me to feel comfortable prescribing medication for you."
C)"Let's schedule a time for you to come in for a full evaluation so that I can make sure sertraline is the most appropriate option."
D)"Unfortunately, I'm unable to prescribe medication for you since our relationship prevents me from providing objective treatment."
E)"Your doctor should be able to prescribe a refill without an appointment since you've taken this medication before."

Answer 3

"Unfortunately, I'm unable to prescribe medication for you since our relationship prevents me from providing objective treatment."

Question 4

A 65-year-old man from the Dominican Republic has been admitted to the hospital for surgery. He has multiple myeloma and a pathologic right humerus fracture. The operation went off without a hitch. Following that, the patient is aware and focused, but grimaces regularly and seems uneasy. He is given pain relief but respectfully rejects. When asked if he is in agony, the patient says, "It hurts a lot, but I can handle it and don't want to be a burden." Which of the following is the most suitable medical response?

A)"If you are sure you don't want pain medication, we will honor your request."
B)"I'm concerned that you feel like a burden.  Have you had feelings of low self-esteem lately?"
C)"It's not necessary to bear the pain.  Medication will help you feel better."
D)"Pain following surgery can be very severe.  My goal is to help you be more comfortable."
E)"Speaking to our pain medicine care team can help you feel more comfortable about pain treatment."

Question 5

In the middle of the night, an 82-year-old man is admitted to the hospital. He is noncommunicative and suffers from a number of comorbidities, including end-stage lung cancer. The patient does not have a power of attorney or an advance directive on file. His long-term wife, who is with him in the hospital, has a lengthy talk with the physician in charge of his treatment. During the chat, she claims that the patient repeatedly told her not to resuscitate him if he was near death because he did not want to live "connected to machines or brain dead." She claims he simply want to die in peace when the time comes. What would be the most appropriate course of action if the patient enters ventricular fibrillation?

A)Attend to the patient's comfort and allow his family to be present with him as he is dying
B)Begin full resuscitation because the patient's wife has no official documentation of her husband's wishes
C)Inform the nursing staff that the patient is "do not resuscitate" and suspend all treatment
D)Obtain a court order to confirm the patient's wishes and have legal documentation
E)Perform resuscitation without using a defibrillator but use only cardiac medications

Question 6

A 56-year-old lady with a history of schizophrenia is admitted to the hospital with right upper quadrant stomach discomfort and is later diagnosed with cholecystitis. She is being treated with antibiotics first, then a cholecystectomy is scheduled. The patient reported feeling significantly better on day two of her stay. The patient does not want surgery and would rather take oral antibiotics at home. "I believe God is on my side and will take care of me," she adds. The patient lives in a group home and attends a day treatment program where she receives risperidone on a regular basis. During the examination, the patient is attentive and aware of person, place, and time. She claims to have heard voices many times a day for many years, but they no longer affect her as much as they once did. The patient has no suicidal ideation.  Which of the following is the best next step in management of this patient?

A)Administer a higher dose of risperidone and reassess the patient
B)Assess the patient's understanding of the risks of going home
C)Keep the patient hospitalized on involuntary status due to schizophrenia
D)Obtain consent for surgery from the patient's next of kin
E)Respect the patient's wishes and schedule a follow-up in a week

Question 7

Her son brings an 86-year-old woman with Alzheimer's disease to the emergency department with a worsening cough and exhaustion; she is diagnosed with pneumonia. The doctor describes the diagnosis and treatment plan, which includes hospitalization for intravenous antibiotics. The patient responds: "I'd rather go. I feel more at ease at home." She requests that she be released with oral antibiotics. The doctor says that intravenous antibiotics are preferable and that the dangers of infection increasing include sepsis and death. The patient understands the dangers and states, "I will return to the hospital if I feel worse; I simply don't enjoy staying in the hospital." The patient is widowed and lives with her son, who insists that she stay in the hospital for treatment.  He reports that his mother has been increasingly forgetful and has gotten lost several times while walking in the neighborhood.  On mental status examination, the patient is alert and oriented.  Mini-Mental State Examination score is 24, indicating mild cognitive impairment.  Which of the following is the most appropriate next step in the managment of this patient?

A)Consult the hospital ethics committee to help mediate the discussion
B)Follow the son's wishes because he is acting in the patient's best interest
C)Follow the son's wishes because he is the next of kin surrogate decision maker
D)Obtain a second physician opinion to determine the patient's decision-making capacity
E)Respect the patient's wishes because she has capacity to make her own decisions

Question 8

After vomiting during a party, a 25-year-old man is rushed to the emergency department by his wife. The patient admits to having four glasses of wine and a shot of vodka and claims to be feeling better today. The temperature is 37.8 degrees Celsius (100 degrees Fahrenheit), the blood pressure is 100/50 mm Hg, the pulse rate is 106 bpm, and the respirations rate is 14 /minute. The physical exam reveals blood-tinged vomitus on the patient's shirt and shoes. On palpation, abdominal examination indicates epigastric discomfort. The patient is aware, cooperative, and completely oriented during the mental status evaluation. The blood alcohol concentration is 70 mg/dL. (0.07 percent blood alcohol content). The doctor suggests that a full blood count, comprehensive metabolic panel, amylase, and lipase be performed. The patient argues that he is OK and wishes to be discharged. Which of the following is the most appropriate course of action?

A)Ask the patient's wife for consent to proceed with laboratory evaluation
B)Discharge the patient with instructions to return to the hospital as needed
C)Do not allow the patient to leave the hospital due to elevated blood alcohol content
D)Explain the potential risks of leaving the hospital without further evaluation
E)Hold patient involuntarily due to imminent medical harm and elevated blood alcohol content

Question 9

A 3-year-old kid is sent to the emergency room with a fever and stiff neck. The youngster is admitted to the hospital with bacterial meningitis and begins therapy with intravenous antibiotics. On the second day of hospitalization, the mother asks to take the kid home and tells that she plans to cure him with homeopathic medicines. She also has four more children who have "never required immunizations or drugs" and are "strong and healthy." The doctor describes the dangers of meningitis, which include brain damage and death. After a lengthy conversation, the mother states that she recognizes the dangers but feels that homeopathic medications would enough for therapy and is not persuaded that hospitalization is necessary. Which of the following is the most appropriate course of action?

A)Arrange for a psychiatric evaluation to assess the mother's decision-making capacity
B)Arrange for a visiting nurse to administer intravenous antibiotics at home
C)Contact child protective services while continuing intravenous antibiotics
D)Discharge against medical advice with instructions to return if the child's condition deteriorates
E)Discharge the patient on oral antibiotics with daily in-home check ups

Question 10

A friend brings a 65-year-old man to the emergency department after discovering him bewildered at his residence. Chronic obstructive pulmonary disease, hypertension, coronary artery disease, and cigarette use are all part of the patient's medical history. He is single and unmarried. According to the buddy, the patient has a sister who lives nearby but is unclear of when they last spoke. The patient's companion has known him for 5 years and describes them as "excellent mates." He informs the doctor that they have talked about death and that he feels the patient would like to "die gently" and would refuse any heroic measures, including "being hooked up to a ventilator." The temperature is 39 ° Celsius (102.2 degrees F), the blood pressure is 120/80 mm Hg, the pulse rate is 105 beats per minute, and the respirations rate is 24 /minute. On room air, oxygen saturation is 88 percent, and on 2 L of oxygen, it is 93 percent. The patient is drowsy and unable to respond to queries. Bilateral wheeze and reduced breath sounds are seen in the lungs. A right lower lobe infiltration is shown on a chest x-ray. Bronchodilator and antibiotic therapy are started as needed. If the patient does not respond to the initial therapy within the following 2-3 hours, the doctor is concerned about the necessity for intubation. Which of the following is the best course of action?

A)Attempt to contact the patient's sister for consent to intubate
B)Consult the hospital ethics committee
C)Do not intubate based on the friend's report of the patient's wishes
D)Plan to proceed with intubation when the need arises
E)Wait to see if the patient's condition improves on therapy and he can sign consent

Question 11

Due to changed mental condition, a 67-year-old man is sent to the emergency room via ambulance. He was eating supper with his daughter when he grew disoriented and collapsed over. The patient has a history of atrial fibrillation and is taking an anticoagulant. He is a widower living with his daughter. The blood pressure is 208/113 mm Hg, the pulse is 64 beats per minute and irregular, and the respirations are 15/minute. On room air, oxygen saturation is 88 percent. The patient is dazed and unable to respond to directions. Pupils are medium in size and do not react to light. The physician concludes that intubation is required at this time to preserve the patient's airway and obtains approval from the patient's daughter and elder son who are present at the bedside. They tell the physician that the patient does not have an advance directive and they are unsure how to proceed.  Which of the following is the most appropriate next step in decision-making for this patient?

A)Ask the daughter to make a decision based on what she thinks is the best for the patient because he lives with her
B)Ask the son to make a decision based on what he thinks is the best for the patient because he is older and has legal authority
C)Ask them both to make a decision based on what they think is in the best interest of the patient
D)Ask them both to make a decision based on what they think the patient would have wanted if he was able to make the decision
E)Offer to make the decision on the patient's behalf based on the physician's best medical judgment

Question 12

An 80-year-old woman is brought to the office for hypertension monitoring. The patient is given lisinopril, but she hasn't taken it in two weeks since she ran out. She attempted to contact her son to arrange for a refill but was unable to reach him. After her house was sold, the patient moved in with her son two months ago. She claims he spends the week at his girlfriend's house, therefore she has to locate neighbors who can take her about. A cerebrovascular accident with modest residual weakness on the left side is mentioned in the medical history. The temperature is 37 ° Celsius (98.6 ° Fahrenheit), the blood pressure is 156/88 mm Hg, and the pulse rate is 80 bpm. 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?

A)Arrange for home healthcare services
B)Contact the patient's son to review treatment recommendations
C)Notify Adult Protective Services
D)Recommend an in-home social work assessment
E)Suggest moving into an assisted living facility

Question 13

A 17-year-old girl visits the office for an assessment of developing vaginal discomfort and discharge. In the last several months, she has had several sexual partners. The patient takes oral contraceptives and uses condoms seldom. She has no previous medical issues and does not use any other drugs. Urine pregnancy testing is negative, but gonorrhea testing is positive. The patient does not want her parents to know she is having sex and wonders whether the doctor would inform her parents about her visit today. Which of the following is the best way to deal with this patient?

A)"Because gonorrhea is a reportable illness, I am obligated to report it to the health authorities and to your parents."
B)"I don't need to inform your parents that you are sexually active, but I will need their consent to prescribe antibiotic treatment."
C)"I recommend that you tell your parents about today's visit in case your symptoms become more serious."
D)"I will not notify your parents because you can consent to testing and treatment for sexually transmitted infections on your own."
E)"You can consent to treatment of gonorrhea, but because you are a minor, I am obligated to notify your parents."

Question 14

A 78-year-old man with end-stage esophageal cancer is admitted to the hospital because he is very malnourished and failing to thrive. According to the patient's caregiver, he has been unable to eat or drink for the past three weeks. During that time, his weight plummeted from 72.6 kg (160 lb) to 63.5 kg (140 lb). His cancer has progressed to his lungs and liver. The patient does not want any further cancer therapy and states that he does not want any heroic measures or interventions to keep him alive. His doctor is thinking of referring him to hospice care. Which of the following is not a prerequisite for sending a patient to hospice care?

A)Patient has a diagnosis of end-stage cancer
B)Patient has a do-not-resuscitate order
C)Patient has decision-making capacity
D)Patient has a prognosis of < 6 months
E)Patient has a prognosis of < 3 months

Question 15

A primary care physician has been asked to speak to a local company. He works for a huge multi-specialty medical firm that he joined less than a year ago after finishing residency. The physician highlights the many medical specializations offered within the group, as well as the breadth of ancillary services accessible at the group's facilities, throughout the presentation. During the subsequent conversation, the physician discovers that the employer has been experiencing financial troubles. The firm desires to continue providing health care coverage to its employees but must cut costs. As a result, the employer wishes to arrange a contract in which the medical group provides treatment to all of the company's employees in exchange for a fixed monthly cost per employee. What payment method best reflects this sort of health care financing arrangement?

A)Capitation
B)Discounted fee-for-service
C)Global payment
D)Patient-centered medical home
E)Point-of-service

Question 16

A 38-year-old recently homeless woman and her 35-year-old boyfriend visit a neighborhood clinic for prenatal care at 27 weeks. She also sends her 19-year-old son, who has cerebral palsy and has received inconsistent medical attention. The patient informs the social worker that her family was just evicted from their flat due to nonpayment of rent after her partner lost his job. Which of these people is a candidate for Medicare?

A)The woman
B)The woman's boyfriend
C)The woman's child when it is born
D)The woman's disabled son
E)The woman, her boyfriend, and her son

Question 17

A 25-year-old lady visits the office for a check-up on her type 1 diabetes mellitus. She is on long- and short-acting insulin, has adequate glycemic control, and no diabetic problems. She also has a history of hypothyroidism and takes levothyroxine for it. The patient has been covered by her parents' medical insurance for several years, but she recently began working full-time for a firm that offers a wide range of employee insurance options. She seeks assistance in selecting a health insurance plan. The patient is not disabled and states that her major concern is low monthly payments. Which of the following insurance plans would be best for this patient?

A)Health maintenance organization
B)Medicaid
C)Medicare
D)Point-of-service plan
E)Preferred provider organization

Question 18

A 49-year-old man arrives to the office complaining of dysuria and hematuria. The vital signs are normal, and the physical examination is uneventful; the urinalysis reveals extensive hematuria but is otherwise normal. The doctor outlines the possible causes and the need for a cystoscopy. The patient is informed about the surgery and provided written information as well as a referral list with directions on how to make an appointment with a urologist. He looks at the documents anxiously, claiming he will arrange an appointment soon. The physician had been notified by office personnel that the patient was unable to follow the guidelines on the sign-in page and refused to complete out paperwork. Which of the following physician replies is the best at this time?

A)"I'd like to ask you some questions about your background; could you tell me how far you got in school?"
B)"I'm concerned about your ability to read and fill out forms; have you always had trouble with this?"
C)"Sometimes patients have difficulty making appointments; could you please read the instructions out loud?"
D)"The forms you get before an appointment help me do a thorough evaluation; could you fill them out next time?"
E)"We've discussed a lot of information today; how confident are you with scheduling an appointment for yourself?"

Question 19

A 30-year-old woman visits the gynecologist's clinic for her annual checkup. The patient is in good health and has no complaints. She says she's been researching tubal ligation and would want to have it done since she's weary of using oral contraceptives and doesn't want to have children. She has experienced no negative side effects from oral contraceptives. The patient has been married for ten years and considers his marriage as "extremely secure." Which of the following responses to the patient's desire for tubal ligation is most appropriate?

A)"I appreciate your reasoning for wanting a more permanent solution; have you talked about this decision with your spouse?"
B)"I can see you've thought about this procedure; let's talk about the risks and benefits of tubal ligation."
C)"I'm glad you haven't had adverse effects with oral contraceptives; what do you find to be most bothersome about taking the pill?"
D)"It is difficult to take a pill every day, but there are other long-term birth control options we could discuss."
E)"This procedure is very difficult to reverse; let's discuss why it is not recommended for women your age."

Question 20

A 55-year-old woman with advanced metastatic breast cancer arrives at the emergency room with dyspnea and tachycardia. After evaluating the patient, the resident orders an echocardiography, which confirms the existence of a pericardial effusion. The surgical team is called in, and the surgical attending informs the patient that a pericardiocentesis is required. After receiving an urgent page, the attending surgeon instructs the resident to acquire informed permission for the treatment. Although the surgical resident has never seen or done a pericardiocentesis, he has recently read an article regarding malignant pericardial effusions. Which of the following is the best plan of action for the resident?

A)Ask an attending in the emergency department to assist with the informed consent discussion
B)Ask the attending surgeon to obtain informed consent for the procedure
C)Give the patient time to carefully read the consent form and return with a witness to obtain her signature
D)Obtain the patient's signature and assure her the surgeon can answer questions before the procedure
E)Research the procedure thoroughly and then obtain informed consent for the procedure

Question 21

A 26-year-old woman, gravida 1 para 0, is admitted to the hospital in active labor at 38 weeks gestation. Twelve hours after admission, she had a spontaneous vaginal birth of a newborn boy weighing 3.8 kg (8.4 lb) and receiving Apgar ratings of 8 and 9, respectively, at 1 and 5 minutes. The patient received no normal prenatal care. She does not have any chronic medical issues or drug allergies. Following birth, the patient is advised that erythromycin ointment will be required to avoid an eye infection and potential blindness caused by untreated gonorrhea. The patient claims that her son does not require therapy because she has never been exposed to a sexually transmitted virus. A)"Although you're refusing what is recommended, I respect your decision to decline treatment and will document it in your chart."
B)"Giving medication to a healthy baby may seem unusual and unnecessary; let's talk about why this treatment is recommended for all newborns."
C)"I'm not assuming you have a sexually transmitted infection, but in case you do, this treatment could prevent serious eye conditions."
D)"Refusing treatment puts your baby at risk for lifelong consequences from an otherwise preventable condition; let's discuss the potential risks of your decision."
E)"Sometimes people can have gonorrhea without obvious symptoms, which is why I'm required to give this medication to all newborns."

Question 22

A 4-year-old girl is sent to the emergency room by her day care facility because she has a fever, right ear ache, and is vomiting often. A bulging, hazy tympanic membrane is seen on examination, along with erythema, edema, and pain over the right mastoid. A CT scan demonstrates mastoid air cell opacification and bone septal damage. When the patient's parents arrive, they report that the patient has been suffering from recurring episodes of otitis media. The parents, however, refuse antibiotic therapy, arguing that "in our family, we think that natural healing approaches are superior than injecting up our children with drugs." Which of the following responses to the parents' remark is most appropriate?

A)"Can you please tell me what you currently understand about your child's infection?"
B)"Help me understand what natural treatments you are willing to allow."
C)"I understand your concerns about medication side effects, but antibiotic treatment is necessary."
D)"If we don't give your child antibiotics, she could get a brain abscess and die."
E)"We can try natural techniques briefly, but if she doesn't get better, we will have to use antibiotics."

Question 23

A 60-year-old man comes in for a surgical consultation for multivessel coronary artery disease. Following a comprehensive assessment and review of earlier records, the surgeon explains the suggestion for a coronary artery bypass graft, detailing the rationale for the procedure and offering a summary of the surgery, including risks and advantages. The surgeon next goes over what the patient may expect during his or her recuperation. Which of the following additional disclosures is required as part of the surgeon's informed consent discussion?

A)Cost of surgery and estimated coverage by insurance
B)Mortality rate of coronary artery bypass grafts performed by the surgeon
C)Option for patient to obtain a second opinion
D)Probable outcomes if surgery is not performed
E)Risks of anesthetic agents that will be used during the procedure

Question 24

A 57-year-old man with amyotrophic lateral sclerosis (ALS) is taking part in a clinical study to test a new treatment. For the first appointment, the patient is joined by his wife. The research coordinator describes the trial and assures the wife that he believes the medicine will benefit people like her husband. He then informs her that additional volunteers are required for the study's success and asks if she would want to participate as a healthy control. Which of the following principles is at danger of being broken by the study coordinator in getting consent for the wife's participation?

A)Beneficence
B)Confidentiality
C)Nonmaleficence
D)Veracity
E)Voluntariness

Question 25

A 55-year-old man is set to undergo electrode implantation surgery to treat severe Parkinson's disease. Three days before the procedure, the surgeon goes through the specifics of the procedure, including the risks and advantages, as well as alternative treatment choices. The patient signs the permission form after expressing understanding of the talk. However, on the day of the surgery, in the preoperative room, he feels apprehensive and anxiously confesses, "I'm afraid I can't do it, doctor. I apologize. I no longer want to get the procedure." Which of the following is the best course of action?

A)Acknowledge the patient's concern and offer a sedative to alleviate anxiety
B)Ask the patient what has changed since he signed the consent form
C)Cancel and reschedule the operation for another time
D)Review the benefits of the procedure and explain that his motor symptoms will worsen without it
E)Tell the patient that his anxiety is normal and he will feel better after the procedure

Question 26

A 28-year-old lady, gravida 2 para 1, arrives at the emergency center with vaginal bleeding. For the previous 24 hours, the patient has experienced vivid red spotting but no contractions or fluid leaking. She is 31 weeks pregnant as of her last menstrual cycle and has not had prenatal care this pregnancy. Her first pregnancy concluded in a simple spontaneous vaginal birth at term. The fetal heart rate and vital signs are normal. Physical examination reveals a nontender uterus that is the same size as at 31 weeks gestation. A full placenta previa is shown via a pelvic ultrasound. The findings are addressed with the patient, who expresses her desire for a vaginal birth.The physician says, "Unfortunately, the only safe option for delivery is a cesarean delivery."  The physician's statement is an example of which of the following ethical principles?

A)Assisted decision-making
B)Directive counseling
C)Informed refusal
D)Shared decision-making
E)Substituted judgment

Question 27

In a tertiary care hospital, a 66-year-old lady with rheumatoid arthritis and atrial fibrillation is scheduled for an elective right total knee arthroplasty. The patient largely speaks Spanish and understands just a little English. Using a qualified interpreter, informed permission is acquired during a preoperative clinic visit. The operating room is running behind schedule on the day of the surgery, and the patient's procedure is delayed by 3 hours. The trained interpreter is in the emergency department dealing with another patient and will be unavailable for an hour when the surgeon and circulation nurse visit the patient to confirm the site and side of the surgery. The patient speaks quickly and has a number of questions for the staff. The surgeon has completed a three-week course in medical Spanish, and the nurse can communicate in brief words in Spanish. The surgeon speaks to the patient in a combination of Spanish and English. As the surgeon speaks, the patient frequently nods. Which of the following best defines this encounter's patient-provider communication?

A)Communication should be verified by asking the patient to describe what she has understood
B)The surgeon is acting appropriately as he is trained in medical Spanish terminology
C)The surgeon is acting appropriately as this interaction does not require additional informed consent
D)The surgeon's actions are inappropriate as the nurse has greater fluency and should speak to the patient
E)The surgeon's actions are inappropriate as they potentially violate the patient's rights

Question 28

A 62-year-old man and his wife visit the office for an examination of periodic chest discomfort. The doctor introduces herself to the patient and his wife and affirms that he is comfortable and not in any discomfort at the moment. "He brought a list of his prescriptions for you to check," the patient's wife says, "but I'm not sure he takes all of them on a regular basis." Which of the following is the most acceptable method for the physician to begin the medical interview after thanking them for bringing the list?

A)"Have you had trouble remembering to take your medications?"
B)"How will your pain improve if you don't take your medications?"
C)"May I ask your wife to leave for this part of the evaluation?"
D)"What do your episodes of chest pain feel like?"
E)"Why do you think you have difficulties taking your medications regularly?"

Question 29

A 26-year-old lady is taken by her boyfriend to the emergency department for treatment of a fractured nose. She tells to her partner that she slipped and fell in the bathroom, striking her face on the countertop. When questioned if she feels insecure with her lover in private, the patient responds, "No, nothing is wrong. He merely gets irritated when he drinks too much." When asked how she got her nasal fracture, she responds, "He pushed me and I fell, but I'm confident it won't happen again." Which of the following medical comments is most suitable after analyzing the degree of the injuries?

A)"How do you know your boyfriend won't hurt you again the next time he drinks too much?"
B)"I can give you a list of domestic violence programs, but you have to decide if you want to get help."
C)"This relationship seems unsafe to me; can you help me understand why you remain in it?"
D)"You deserve to be safe; where could you go if you felt unsafe?"
E)"Your injury is concerning; do you understand why I am worried about your safety?"

Question 30

A 23-year-old lady, 8 weeks pregnant, arrives at the office for her first prenatal checkup. There is no vaginal bleeding or pelvic discomfort in the patient. On inspection, bruising in various stages of healing can be visible on the chest and belly. When questioned about the marks, the woman claims that her lover used to punch her during disagreements and was originally enraged by the pregnancy. He has been more helpful in the last three weeks, purchasing pregnancy vitamins and providing massages. An ultrasound reveals an 8-week intrauterine pregnancy and a normal fetal heart rate. Which of the following is the most suitable next step in this patient's care?

A)Advise the patient to stay with a relative for the duration of the pregnancy
B)Provide information about a domestic violence program
C)Recommend the patient file a restraining order against her boyfriend
D)Refer the patient and her boyfriend to couples' counseling
E)Suggest the patient bring her boyfriend to the next appointment

Question 31

A 49-year-old woman visits the clinic because her hot flashes and nocturnal sweats have been worse over the last year. The patient's menstrual cycles have been inconsistent for the previous two years, with her most recent cycle occurring a year ago. She has no chronic medical issues and has never had surgery. The BMI is 23 kg/m2². Vital indicators are typical. The neck is flexible and free of thyromegaly. The remainder of the exam is routine. The sufferer declares, "This is terrible. I become hot and sweaty at work meetings and have to leave to cool down. I'm curious whether hormones may assist." Which of the following is the best way to deal with this patient?

A)"Although menopause can be uncomfortable, it is a natural process; let's try making some simple lifestyle changes first."
B)"Hot flashes and sweating are very normal in menopause; for most women, they subside on their own in 1-2 years without treatment."
C)"I can see these symptoms have been affecting your day-to-day life; hormonal therapy can be an effective option, although there are some risks."
D)"I don't recommend taking hormonal therapy because your symptoms are not that severe; the risks would likely outweigh the benefits."
E)"Menopause can be very stressful; perhaps talking about how to cope with the emotional effects would be helpful."

Question 32

An 18-year-old man returns to the office for a check-up. He was treated in the emergency room three months ago for panic episodes caused by cocaine usage. Following that, the patient quit taking cocaine and has had no recurring anxiety problems. He finished high school, got a new job, and is thinking about applying to community college. At today's appointment, the patient recalls having taken cocaine at a friend's residence over the weekend. He claims, "I really screwed up. I'm feeling defeated." The patient has no medical history. He is not in any bodily pain. Which of the following statements by the physician is the most suitable at this time?

A)"Do you think using cocaine again could have a negative impact on your job and going to college?"
B)"It's hard to quit.  Let's go over the health effects of cocaine to help motivate you to stay sober."
C)"Quitting is difficult, so don't be so hard on yourself.  Let's move forward from here."
D)"Socializing with your friend probably contributed to your relapse.  Let's look at strategies to deal with peer pressure."
E)"You've been making real progress in quitting.  What can we learn from this temporary setback?"

Question 33

A 45-year-old lady walks in for a normal check-up. The patient is doing OK generally, but she adds that climbing the last flight of steps to her third-floor apartment has become more difficult. "Sometimes I have to pause at the landing to regain my breath," she admits. Medical history includes a cocaine use disorder that has been in remission for the past four years; otherwise, it is normal. The patient does not drink alcohol or use illegal substances. She has a 25-pack-year smoking history and has previously been advised to quit smoking. The patient declares, "I've tried countless times to quit. I can reduce down to a few smokes or half a pack for a day or two, but it becomes too tough after that." Which of the following is the most appropriate response by the physician regarding this patient's smoking?

A)"I'm concerned that continuing to smoke is contributing to your breathing problems."
B)"Quitting on your own is difficult and medication can help.  Would you consider this?"
C)"Since you stopped using cocaine, I'm hopeful that you can eventually stop smoking cigarettes."
D)"Stopping smoking will likely improve your breathing and decrease your risk for other conditions."
E)"You were successful in stopping cocaine.  How might your experience help you to quit smoking?"

Question 34

A 24-year-old man arrives to the office due to mood swings. For the past two months, he has been melancholy, irritated, and nervous virtually every day. The patient struggles to get out of bed in the mornings and to stay focused at work. He has no medical issues and does not use any drugs. The patient consumes 3 to 4 beers every day, with more on weekends. The doctor educates the patient on the relationship between drinking and mood disturbances. The patient says, "But it truly helps me unwind and relax after a hard day at work, and it makes falling asleep easier. It's also how I spend my weekends with my buddies. I don't see me quitting." Which of the following statements by the physician is the most suitable at this time?

A)"Alcohol is likely making your depression worse.  It will be harder to treat your depression without addressing alcohol."
B)"Although you feel alcohol helps you to relax, I am concerned that you are using it to self-medicate your depression."
C)"I can understand your reasons for using alcohol.  What are the downsides to drinking from your perspective?"
D)"I get it, but there are other, healthier ways to relax.  Would you be willing to discuss those?"
E)"I understand your reasons and see that you are not ready to make a change.  I am here to help when you feel ready."

Question 35

A 59-year-old man visits the office for a check-up. A month ago, the patient suffered an acute myocardial infarction, and a drug-eluting stent was effectively implanted. He has no indications of cardiovascular disease, but he does have hypertension and hyperlipidemia, as well as a 40-pack-year smoking history. The blood pressure is 132/86 mm Hg, and the pulse rate is 68 beats per minute. 30.8 kg/m² is the BMI. The physical exam is ordinary. The patient declares, "I can't wait to get back to work, but I'm worried about having another heart attack. I have a demanding work, yet I need to find time to exercise. In addition, I know I should quit smoking and drop at least 20 pounds." Which of the following is the physician's most suitable reaction at this time?

A)"Having a heart attack was frightening.  It's great that you've decided to stop smoking, lose weight, and start exercising."
B)"I suggest we prioritize quitting smoking first.  That will decrease your risk significantly and make it easier to exercise."
C)"Those are excellent goals.  Let's make a comprehensive list of all the health changes you want to make."
D)"You've been through a tough time.  Would you consider working fewer hours for the time being so you can focus on your health?"
E)"You've brought up important issues.  What are one or two small changes you feel most ready to tackle now?"

Question 36

A 54-year-old woman comes in for her annual preventative checkup. She has no particular concerns. The blood pressure is 144/95 mm Hg, and the pulse rate is 86 beats per minute. 50 kg/m² is the BMI. The examination reveals extreme obesity but else is ordinary. The fasting glucose level is 128 mg/dL. When asked about her weight, the patient responds, "My family simply enjoys eating. My mother, father, and children are all overweight. It's pointless to try to reduce weight right now." Which of the following responses to this patient's remark is most appropriate?

A)"Bariatric surgery might be a good option for you to consider."
B)"Even with your family history, simple changes in your diet can lower your blood pressure."
C)"Tell me how you think your weight might relate to your blood pressure and glucose."
D)"You can still eat whatever you want as long as you don't eat so much of it."
E)"You don't have to lose all the weight at once.  A little at a time will eventually make a difference."

Question 37

A 27-year-old man comes to the office for follow-up regarding a herniated disc.  He first injured the disc 3 months ago while at work.  Nonsurgical treatment options, including physical therapy and as-needed NSAIDs and tramadol, were recommended.  The patient has completed physical therapy, and follow-up MRI indicates that the herniated disc has regressed.  He reports a significant amount of ongoing pain and asks for a dose increase and refill of his pain medication.  In the past month, the patient has been to the emergency department on 2 occasions to request pain medication due to running out before his next scheduled refill.  Vital signs are within normal limits, and physical examination is unremarkable.  Which of the following statements by the physician would be most appropriate at this time?

A)"Given your recent refill requests and interest in increasing your dose, I am concerned that you may be dependent on pain medication."
B)"It doesn't seem like medication is effective anymore; let's talk about alternate ways to treat your pain."
C)"Sometimes patients take pain medications to help with other types of symptoms; how has your mood been recently?"
D)"You're still experiencing a lot of pain, and it has not been easy managing it; let's discuss how you have been taking the medication."
E)"Your pain symptoms do not seem to be improving with additional medication, so a dose increase is unlikely to help you."

Question 38

A 22-year-old woman is brought to the emergency department for bizarre behavior over the past week.  Her parents state that she has been "talking nonsense" nonstop, laughing for no reason, and has not slept for several days.  During triage, the patient attempted to hit a staff member, resulting in administration of haloperidol.  While awaiting further evaluation, the parents alert the nurse that the patient is starting to "make weird faces" while sticking out her tongue.  Medical history is noncontributory, and the patient takes no medications.  Urine drug screen is positive for cannabis and opiates.   Which of the following is the most likely explanation for this patient's motor symptoms?

A)Catatonia
B)Conversion disorder
C)Medication reaction
D)Opioid withdrawal
E)Psychotic agitation

Question 39

A 65-year-old man is brought to a busy community hospital's inpatient ward for worsening shortness of breath during the previous several days. He smoked for 40 years and was first diagnosed with chronic obstructive pulmonary disease exacerbation and treated as such. On admission, a chest x-ray reveals a substantial hilar opacity, and a CT scan confirms the existence of a 4-cm mass in the right hilum. During the informed consent procedure for bronchoscopy with biopsy, the patient asks, "Doc, please don't tell me what they discover, because if it's cancer, I don't want to know." Which of the following responses to this patient's request is most appropriate?

A)"Hearing you have a lung mass is upsetting; perhaps take some time to think about whether you really want to undergo this procedure."
B)"I can't imagine how stressful this is for you, but if the results do show cancer, it would be important for you to make a decision about treatment."
C)"I won't share the results of the procedure if that is your preference, although I would like to understand how you came to that decision."
D)"It's normal to try and avoid hearing bad news; however, the uncertainty of not knowing your diagnosis can cause even more anxiety."
E)"You can choose to not hear your results, but you should appoint someone in your family to make decisions on your behalf."

Question 40

After being pushed into early retirement owing to poor job performance, a 55-year-old formerly healthy man is taken to the workplace by his wife. The patient used to be a financial planner, but he started missing critical deadlines and mismanaging his clients' money 6 months ago. During this period, he got increasingly angry and began to curse and disrespect his employees when they voiced worry about his performance. The patient has also become verbally aggressive toward his wife, although he appears oblivious to the pain he is causing. She has had to take charge of the money as well as the grocery shopping. She continues, "My spouse has developed a significant sweet tooth. He now consumes nearly two cartons of cookies every day." The physical exam is ordinary. This patient is most likely to have which of the following neuropathologic findings?

A)Aggregations of phosphorylated tau protein
B)Cytoplasm inclusions with alpha synuclein
C)Cytosolic vacuolation of neurons and glia with prion inclusions
D)Extracellular deposition of beta-amyloid
E)Intracellular deposition of presenilin

Question 41

Due to significant shortness of breath, an 80-year-old man is rushed to the emergency room by his son. The patient has a persistent cough and has lost 13.6 kg (30 lb) in the last 6 months. A chest x-ray reveals a big tumor in the right lung and a pleural effusion. The patient is admitted to the hospital and undergoes bronchoscopy with biopsy; the pathology report reveals bronchogenic cancer. When the doctor suggests a private chat regarding the biopsy results, the patient responds, "I'd rather not be told anything. You are free to discuss anything with my kid. I have faith in his judgment." The patient is intellectually sound and shows no indications of mental disease. Which of the following is the most suitable medical response?

A)"Could you tell me why you decided to get a bronchoscopy done if you did not wish to know the results?"
B)"Hearing about test results can be stressful.  Would you like to speak to the chaplain before making a decision?"
C)"I appreciate why you would not want to hear the results, but you could make informed decisions about your health if you knew."
D)"I understand that you would not like to be told the results of the biopsy.  I will share them with your son."
E)"Not knowing your results may also cause anxiety; let's discuss this with your son and see what he thinks."

Question 42

A 5-year-old girl is brought to the office by her mother, who is anxious after watching her daughter repeatedly speaking to an empty chair in her room. The girl's medical history is relevant for preterm delivery at 36 weeks gestation but noncontributory in other ways. Her maternal grandparents suffered from a cerebrovascular accident and depression, while her father suffered from schizoaffective disorder. When questioned, the patient claims she sees her grandma at night and talks to her before going to bed. The grandma, who had resided in the family home for two months, died two months ago. For a few weeks after her grandmother's death, the youngster would cry and ask her parents when she would see her again.   Which of the following is the most likely diagnosis in this patient?

A)Acute stress disorder
B)Brief psychotic disorder
C)Major depression with psychotic features
D)Normal behavior
E)Post-traumatic stress disorder
F)Schizophreniform disorder

Question 43

A 46-year-old man arrives at the emergency room complaining of chest discomfort that began 30 minutes earlier. The discomfort is described as a tight, squeezing sensation that radiates to the left arm by the patient. He is also experiencing excessive perspiration and nausea. The ECG reveals multi-lead ST-segment elevation, as well as elevated cardiac troponin levels. The patient has a history of substance misuse, but no history of heart problems. He had an emergency heart catheterization and is doing well in the postanesthetic care unit. A concerned woman approaches the doctor, claiming to be the patient's wife and inquiring about his status. "I am really anxious; please tell me whether my spouse is okay," she begs. Which of the following is the best course of action?

A)Discuss the patient's medical information with the woman due to the seriousness of his condition
B)Discuss the patient's status with the woman only if she has appropriate identification
C)Explain to the woman that no information can be disclosed without the patient's permission
D)Explain to the woman that the patient's status cannot be disclosed as there is no way to be sure she is his spouse
E)Tell the woman that the patient is stable, but that further details will have to wait until the patient can give permission

Question 44

A 62-year-old woman arrives at the office for a routine exam. Her spouse perished in a bicycle accident that she observed five months ago. She has a low appetite, which has resulted in a weight reduction of 3.17 kg (7 lb), and she usually wakes up two hours before her alarm clock goes off. "My spouse always took care of the bills so I wouldn't have to worry," the patient says of having to manage the home finances. She no longer cycles, a habit she enjoyed with her husband, but she still volunteers at a children's hospital. There are no nightmares or suicidal thoughts in the patient. During the meeting, she sheds a few tears but grins while recalling a trip she spent with her spouse. Which of the following is the best explanation for this patient's condition?

A)Dependent personality disorder
B)Major depressive disorder
C)Normal grief
D)Persistent complex bereavement disorder
E)Persistent depressive disorder
F)Post-traumatic stress disorder

Question 45

A 28-year-old woman arrives at the office for a routine pregnancy checkup. Her pregnancy has been progressing well, and the patient is overjoyed to be having a baby after years of trying to conceive. Her and her husband's marriage suffered greatly as they went through many failed reproductive procedures. During the visit, the doctor requests blood testing and administers a 1-hour glucose challenge test. When this is disclosed, the patient feels concerned and begins to inquire about the aim of the tests. When questioned about her worries, she reveals that the fetus is not her husband's kid.   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?

A)I am obligated to tell him as he is my patient and it is in his best interest to know.
B)I will not inform your husband, but please consider telling him the truth.
C)I will not tell him, but I am obligated to inform the biological father.
D)I will not tell him, but keeping this from your husband will have many negative effects.
E)I will not tell your husband.

Question 46

A woman brings her 11-month-old son to the office for a well-child visit. When other people approach him, he screams and cries, according to his mother. She is concerned since it has been happening for a few months and appears to be getting worse. She states, "He used to like being held by everyone, but now he only wants to be with me. He won't even let his grandmother hold him." The sufferer is crawling and can only stand with help. He babbles but does not speak well and communicates through hand gestures. Growth curves are tracking well. During the physical examination, the patient clings to his mother and begins to weep, turning his head away from the physician when he tries to connect with him. Which of the following explanations is most likely for this patient's behavior?

A)Adjustment disorder with anxiety
B)Autism spectrum disorder
C)Normal development
D)Reactive attachment disorder
E)Separation anxiety disorder

Question 47

A physician is having dinner with a colleague when he observes one of his patients seated at a nearby table with her spouse. When the patient leaves the restaurant, he approaches the table and exchanges a few pleasantries with the physician's colleague. She then gives the physician a short nod but says nothing to him. The doctor smiles as he accepts the gift. Following that, the physician's colleague inquires, "Is she one of your patients? She is a family member who has recently been diagnosed with breast cancer. I've been worried about her and have been wondering how she's doing." Which of the following is the physician's most suitable reaction to his colleague?

A)No, she is not my patient.
B)She is my patient, but unfortunately I am unable to discuss her treatment due to patient confidentiality.
C)Sorry, I cannot say whether or not she is my patient.
D)Yes, and it would be helpful to hear any feedback she may give you about my care.
E)Yes, she is doing much better, but I trust you will keep that information confidential.
F)Yes, she's doing better medically; do you know how she is doing emotionally?

Question 48

A 44-year-old man arrives at the office complaining of weariness for the previous six months. He claims, "I've fallen asleep at work a few times, and I had to force myself to focus. I'm having trouble sleeping as well since I keep waking up." The patient feels bad about spending less time with his children because he is fatigued, and he reports that his mood has been poor for the previous week. He is concerned that his wife is irritated with him since he has not been contributing as much to home tasks and keeps her up at night owing to his snoring. The patient consumes three or four beers each week and does not use cigarettes or illegal substances. Medical history is noncontributory.  Blood pressure is 146/94 mm Hg and pulse is 78/min and regular.  BMI is 32 kg/m².  Which of the following is the most likely diagnosis?

A)Major depressive disorder
B)Narcolepsy
C)Obstructive sleep apnea
D)Primary insomnia
E)Somatic symptom disorder

Question 49

After her overnight shift, a resident physician enters an elevator jammed with nurses and other hospital staff members on her way to morning signout. The team's medical student boards the elevator and inquires about the resident's shift. Throughout the interview, the student avoids mentioning the patient's name, instead asking, "Did the patient in Room 232 obtain her CT scan?" Which of the following responses to the student is the most appropriate?

A)"Discussing patient information in a public setting is against hospital policy."
B)"I have the brain scan results and can discuss them with you later."
C)"Let me pull up the results on my phone."
D)"Let's wait until morning signout to discuss all of the patients."
E)"The scan is normal."
F)"The scan was read, but ask the daytime resident about the results."

Question 50

A 24-year-old man arrives at the office for opioid use disorder therapy. The patient has a 6-year history of heroin usage that he claims has cost him the majority of his funds. His employer has spoken to him about his volatile emotions and unreliable work performance, and he is now facing dismissal. The patient requests assistance, claiming, "I tried all I could to do this on my own. My parents have spent a significant amount of money on counseling. It works for a time, but I quickly return to using. They've had enough of me and refuse to see me any more. I don't want to use, yet the desire is overwhelming." The physician refers the patient to an opioid treatment program where he is started on maintenance therapy with methadone.  During the next followup appointment, he reports a marked reduction in his cravings.  Which of the following properties of the administered drug is most likely responsible for the improvement in this patient's condition?

A)Long half-life
B)Low potency
C)Low risk of dependence
D)Low risk of respiratory depression
E)Low risk of withdrawal
F)Partial agonist activity

Question 51

A 40-year-old woman arrives at the clinic with new-onset genital lesions. She is discovered to have many genital warts in her vaginal region upon inspection. Otherwise, testing for sexually transmitted infections is negative. The patient admits to having an adulterous affair while on business. The physician receives a phone call the following week from the patient's spouse, who is not a patient at the office. He is aware that his wife has lately been examined and would like information about her health since he is concerned about his bodily issues. Which of the following is the most suitable medical response?

A)"Can I speak with your wife to obtain a verbal release of information?"
B)"I will need proof of your identity prior to disclosing information."
C)"If your spouse is a patient here, she would have to provide a release of information."
D)"Is your wife aware that you are calling for her health information?"
E)"What kind of symptoms are you experiencing?"

Question 52

More incidents of expired drugs not being renewed are expected in the coming months. Finally, a woman receiving intravenous dobutamine for decompensated heart failure does not get the drug for 6 hours, causing her condition to deteriorate and ultimately in hypotensive shock. The hospital management forms a committee to investigate this occurrence. Which of the following is the best next step in resolving this issue?

A)Create an alert system in the electronic medical record to notify physicians when orders expire
B)Have a second pharmacist double-check expired orders
C)Increase the hospital's risk management staffing
D)Interview pharmacy, nursing, and medical staff on the units where this occurred
E)Interview the patients who experienced adverse outcomes from these medication errors

Question 53

A 35-year-old man is taken to the hospital after suffering multiple injuries in a car collision. He had surgery to repair an open tibial fracture and a spiral humerus fracture. The tibial repair is effective, but the surgeon performs the procedure on the incorrect arm. Which of the following techniques is most likely to prevent a similar error?

A)Confirm the correct site with the patient
B)Have the anesthesiologist and surgeon verify the surgical site together
C)Have the head nurse verify the surgical site
D)Have the nurse and surgeon verify the surgical site independently
E)Have the operating physician verify the surgical site

Question 54

A 19-year-old Hispanic lady arrives at the clinic complaining of nausea and stomach pain. She has difficulty describing her pain and usually gestures to her lower abdomen. When asked if she is pregnant or sexually active, the patient nods her head no. When asked when she had her last menstrual cycle, she nods and responds "now." She is a single woman who moved to the United States a few months ago. The physical examination reveals mild abdominal discomfort with no rebound or guarding and stable vital signs. The patient is sent home after being diagnosed with food poisoning. She is rushed to the emergency department by ambulance later that day after having significant stomach pain and 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?

A)Asking the patient whether she feels comfortable discussing sexual issues
B)Assessing the patient's cultural health beliefs
C)Assessing the patient's current social situation
D)Calling family members to obtain additional history
E)Determining whether the patient needs language assistance

Question 55

A 46-year-old man has been admitted to the hospital with diabetic ketoacidosis. He is given intravenous fluids and an insulin drip, and lab tests are scheduled. The on-call physician transfers the patient to the day shift physician in the morning, who comes an hour late owing to an emergency at his overnight moonlighting job. The patient's state and instructions to monitor electrolytes and compute his anion gap are included in the handoff information. The doctor does inpatient rounds and then his typical clinic outpatients in the afternoon, but he forgets to check the patient's anion gap. The patient's acidity worsens, necessitating intubation for respiratory distress. Which of the following is the most likely reason for this unfortunate outcome?

A)Deficiency of knowledge
B)Excessive patient caseload
C)Inadequate patient handoff
D)Judgment error
E)Physician burnout
F)Physician fatigue

Question 56

A 19-year-old man is hospitalized for hallucinations, delusions, and disordered conduct. He is diagnosed with schizophrenia, and the doctor issues an order for him to start taking aripiprazole "2.0" mg. The patient is given 20 mg of aripiprazole instead of 2 mg. This order is missed via the pharmacy review procedure, and the nurse fails to query it before giving the patient aripiprazole. Which of the following interventions is the most successful in reducing this sort of error?

A)Confirm dosage with the patient prior to administration
B)Educate physicians to avoid use of trailing zeros
C)Employ computerized systems to flag inappropriate medication orders
D)Remind physicians to be careful with decimal point placement
E)Require 2 nurses to check medication orders
F)Require 2 pharmacists to check all orders

Question 57

A physician on a rehabilitation unit notices that a patient is having an adverse response to a drug. The doctor requests nursing aid. When the nurse comes, the doctor directs her to provide "25 mg of diphenhydramine IV push." Which of the following nurse replies reduces the likelihood of communication errors?

A)"Preparing 25 mg of diphenhydramine for IV push."
B)"I will give 25 mg of diphenhydramine stat."
C)"Okay."
D)"Order received and completed."
E)"Yes, doctor."

Question 58

A 75-year-old lady is admitted to the hospital with a bowel blockage caused by adhesions from earlier uterine cancer surgery and radiation. She has had hypertension, atrial fibrillation, and peripheral vascular disease in the past. She is discharged on many drugs, including a greater dose of her warfarin, after a lengthy hospital stay complicated by a pulmonary embolus. The patient has appointments with her internist, gynecologist, cardiologist, and gastroenterologist. She lives on her own and has previously managed her care requirements satisfactorily. Her adult daughter is helpful, although she lives out of state. Which of the following strategies would be most successful in increasing her outpatient treatment adherence?

A)Emphasize the importance of adherence to treatment during the discharge process
B)Ensure that the discharge summary is sent to all outpatient specialists
C)Provide the patient with a detailed copy of her hospital course
D)Provide the patient with a checklist to keep track of her medications and follow-up appointments
E)Review discharge instructions with the patient's daughter

Question 59

A 82-year-old lady is admitted to a tertiary care hospital with a fever and shortness of breath. The patient has had chronic obstructive pulmonary disease in the past. The admitting physician diagnoses her with pneumonia and begins her on empiric antibiotic treatment overnight. The patient's health worsens after several days of therapy, and she is moved to the critical care unit. On admission, sputum cultures were taken, but the findings were not examined by the daytime staff, causing a delay in commencing more precise antibiotic therapy. Which of the following interventions is most likely to avoid this sort of medical error?

A)Decrease the required patient caseload for physicians
B)Increase frequency of team meetings to discuss critically ill patients
C)Obtain infectious disease consultation
D)Require more detailed sign-out notes
E)Use standardized patient handoffs

Question 60

A 46-year-old lady is admitted to the hospital owing to acute sadness and exhaustion. She does not have any other medical issues. Routine laboratory testing are conducted, and depression medication is prescribed. Her depression improves marginally after a week, and she is released home to continue with outpatient therapy. However, the patient is still extremely tired and unable to return to work, requiring her to seek a leave of absence. At her follow-up appointment two weeks later, the outpatient physician reviews the hospital record and discovers a TSH level of 15.2 U/mL that was never addressed by the inpatient physician. Following an assessment and therapy with thyroid hormone, her sadness and exhaustion improve quickly. Which of the following is the appropriate categorization for this type of medical error?

A)Malpractice
B)Near miss
C)Non-preventable adverse event
D)Preventable adverse event
E)Sentinel event

Question 61

An intern attends a neighborhood dinner party and recognizes a colleague who works in another department at the same hospital. Throughout the evening, she notices her colleague responding to a number of routine medical calls from the hospital and drinking many alcoholic beverages. Later that evening, the physician discovers that her colleague is delivering pharmaceutical prescriptions over the phone while slurring her voice. The physician approaches her colleague, requesting that on-call responsibilities be transferred for the benefit of patient care. He argues that he is alright, that he is not inebriated, and that his responsibilities finish in 30 minutes. Which of the following is the best course of action?

A)Contact the colleague's on-call supervisor to report the problem now
B)Do not intervene as the colleague has already been confronted and the shift ends soon
C)Do not intervene as there is no clear evidence of patient harm
D)Do not intervene as this is the first instance of witnessing impaired behavior
E)Report the incident to the hospital's physician health program
F)Report the physician to the state medical board

Question 62

A 40-year-old jobless man with persistent back pain arrives at the office for a consultation with a new doctor. Years ago, the patient damaged his back in a job accident and has not worked since. He acknowledges that he takes marijuana everyday to "calm the agony" and that a percentage of his earnings go toward its purchase. The patient claims that nothing has changed and requests that the doctor sign a disability form so that he can continue to receive disability benefits. When the doctor inquires about his condition and previous treatment, he responds furiously, "I wouldn't be here re-applying for disability if anything had worked," slamming the disability form down on the table. The patient walks normally with no apparent discomfort or limitations.  Which of the following is the most appropriate response by the physician?

A)"I am unable to sign the form due to my concern about your drug use."
B)"I am unable to sign the form due to my concern about inappropriate use of disability benefits."
C)"I can see you are suffering from a painful condition and will sign the form."
D)"I can sign the form because I see that you were previously approved and nothing has changed."
E)"I cannot consider your request until you are able to control your anger."
F)"I cannot sign the form without further history and assessment."

Question 63

A 13-year-old kid is brought to the doctor by his mother for a standard medical examination and type 1 diabetes mellitus follow-up. "Here's the doctor; he's going to tell you how terribly you've been doing," his mother exclaims at the start of the appointment. Laboratory tests reveal a random blood glucose of 350 mg/dL and a hemoglobin A1c of 9% (normal: 6%-7%). When the doctor asks how the patient is doing with his insulin, his mother interrupts and exclaims, "He never remembers to use it!" When asked about the boy's diet, his mother puts her hands on her hips, glares at him, and exclaims, "Pizza, soda, and sweets!" After addressing the mother's worries about diabetes management, which of the following is the most appropriate course of action?

A)Ask the mother if she has any concerns about the patient's mood
B)Ask the patient if he agrees with his mother's responses
C)Ask the patient if he has felt irritable most days of the week
D)Explain to the mother that her critical tone may discourage the patient
E)Request to speak with the patient alone

Question 64

A 52-year-old lady arrives at the clinic to discuss the findings of an abdominal CT scan. The patient declares, "I'm hoping the scan will reveal why I've been losing so much weight. What does it demonstrate?" The imaging suggests pancreatic cancer, according to the doctor. When she hears this, the patient begins to scream and clutches her head in her hands. Which of the following is the most suitable medical response?

A)"I know this isn't the news you wanted to hear.  Let's talk about the results in a bit more detail."
B)"I wish I had better news to share with you.  I imagine this is very upsetting to hear."
C)"It's easy to feel lonely and isolated with news like this.  Tell me about the people who support you during difficult times."
D)"This must feel very shocking and unexpected.  Fortunately, there have been some advances in treatment recently."
E)"This news would be upsetting to anyone.  Let's set up an appointment to discuss the next steps in a few days."

Question 65

A 38-year-old woman arrives at the clinic complaining of severe dysmenorrhea and tension headaches during the last three months. "It is more difficult than I imagined; I sometimes have to stay late to catch up on paperwork and am not sleeping very well," she says of her recent promotion to school principal. The patient is married and does not have any children. She falls into tears when answering inquiries about her sexual past. When the doctor asks what is bothering her, she covers her face and confesses she was sexually molested as a youngster. Which of the following is the best way to deal with the patient?

A)"I appreciate you sharing this with me; would you consider talking to a therapist about this as well?"
B)"I can see this is upsetting for you; we can talk about this another time when you're ready."
C)"I understand how difficult this is to discuss; could you tell me more about what happened?"
D)"I'm very sorry that happened to you; do you often experience flashbacks or nightmares related to the abuse?"
E)"This must be very painful to talk about; I'm here to listen and help you through this."

Question 66

A 48-year-old deaf man arrives at the office for the first time. The patient has recently relocated to the neighborhood and is accompanied by a buddy with whom he communicates using American Sign Language. The physician is informed by the office staff that the patient has been communicating by reading lips, making gestures, and nodding his head in agreement. The buddy states at the outset of the visit that the patient has asthma and takes an inhaler as needed. The patient writes a note to the doctor saying that he would want to test a longer-acting inhaler. Which of the following is the most suitable next step in this patient's evaluation?

A)Ask the patient's friend to continue providing interpretation
B)Continue the evaluation through written communication
C)Obtain further history by having the patient fill out a detailed form
D)Speak slowly and enunciate to allow the patient to read lips
E)Use a qualified American Sign Language interpreter

Question 67

A 49-year-old lady is moved from a community hospital to a tertiary care institution for treatment of a chronic obstructive pulmonary disease exacerbation. A hospitalist cares for the patient overnight before transferring care to the teaching service in the morning. During morning rounds, the patient's new medical team meets with her for the first time. The attending physician introduces the team and informs the patient that the intern will interview him. The patient then calls the intern by his first name and says, "You are eerily similar to my kid. He's highly intelligent and looks a lot like you." Which of the following activities by the intern would be the best way to start the interview?

A)Address the patient by her first name and ask about current symptoms
B)Address the patient by her first name and ask if she is comfortable with that
C)Address the patient by her surname and ask about current symptoms
D)Greet the patient and inquire about her preferred form of address
E)Politely ask the patient to use the title of doctor and then inquire about current symptoms

Question 68

A 52-year-old man comes in for a check-up to discuss the findings of his colonoscopy. The doctor informs the patient that a malignant polyp was removed and that the resection margins show no evidence of aggressive malignancy. He is then reassured that his prognosis is favorable. As a result, the patient rants and yells furiously, "Are you saying I should be grateful you discovered cancer in the first place? You have no idea what you're doing!" Which of the following is the best way to deal with the patient?

A)"Feeling like you don't have control in your life can be difficult; I can assure you that you have received the best care."
B)"I realize it can be very upsetting to be told something unexpected about your health; what is your understanding of the results?"
C)"It's hard to process news like that, but I want to make sure you understand that the cancer was completely removed."
D)"You're allowed to feel angry, and I'm available to continue this conversation after you've calmed down."
E)"You seem very distressed with your results; would you like me to refer you to another physician for a second opinion?"

Question 69

A 54-year-old man arrives at the clinic for a first evaluation of lower back discomfort. According to the patient's medical record, he has seen multiple doctors for back pain therapy. He was provided several pain medicines and physical rehabilitation treatments, but he frequently stopped taking them too soon or did not follow through on the instructions. The patient adds at the start of the visit, "I'm sick of living with back pain, and I haven't worked in years. Nothing has helped me-I might as well quit up and go on disability at this point." Which of the following statements best describes your initial response to this patient?

A)"Although previous medications have not worked, consultation with a pain specialist may be helpful."
B)"I understand the difficulty of your situation, but applying for disability will not improve your back pain."
C)"I understand your frustration, but it is difficult to help when you think nothing will work."
D)"It must be frustrating to have chronic back pain and feel like there are no options to ease your suffering."
E)"Your chances of improving would be better if you followed recommendations and remained in treatment."

Question 70

A 34-year-old man arrives at the clinic complaining of nasal congestion and coughing for the past five days. He claims to cough up thick, yellow phlegm on occasion and is concerned about his lack of progress. The patient states that he has previously gotten antibiotics for identical symptoms and that "antibiotics always seem to make me feel better quickly." The temperature is 37.2 degrees Celsius (99 degrees Fahrenheit), the blood pressure is 120/70 mm Hg, the pulse rate is 76 beats per minute, and the respirations rate is 18 beats per minute. The physical examination reveals pharyngeal erythema; the rest of the test, including the cardiovascular evaluation, is normal. Which of the following physician replies is most appropriate?

A)"Although you've experienced improvement with antibiotics in the past, your symptoms will likely improve with over-the-counter treatment."
B)"Antibiotics can be helpful for certain infections, but I'm concerned you may have been prescribed antibiotics inappropriately in the past."
C)"Feeling sick is unpleasant; let's talk about why antibiotics are not recommended and what treatments can help you feel better."
D)"I understand why you want me to prescribe antibiotics, but this would only lead to antibiotic resistance."
E)"Many patients think antibiotics can help treat colds; unfortunately, there are no quick fixes for viral infections."

Question 71

A 65-year-old man is taken to the hospital overnight for stomach discomfort. He has a simple minor bowel blockage, which will necessitate surgery in the morning. The temperature is 37 degrees Celsius (98.6 degrees Fahrenheit), the blood pressure is 130/82 mm Hg, and the pulse rate is 90 beats per minute. To consider surgical intervention, the resident meets with the patient and his adult son, who has accompanied him to the hospital. After introducing herself, the resident discovers that the patient predominantly speaks Vietnamese and has low English competence, despite the fact that his kid speaks both Vietnamese and English. The son introduces himself as a critical care nurse and offers to translate the talk for his father. Which of the following replies to the patient's son is correct?

A)"I appreciate your offer to interpret; however, I need to get a trained medical interpreter before I start talking with your father."
B)"I'll print out the Vietnamese version of the consent form.  It would be helpful if you could interpret any questions your father may have after reading it."
C)"Thank you.  That would be very helpful, especially since you are already familiar with medical terminology."
D)"That would make things much easier; could you start by asking your father what his understanding of the situation is?"
E)"That's a kind offer, but I wouldn't be able to have a direct and objective discussion with your father if you interpret it."

Question 72

A 35-year-old man visits the office for normal health maintenance. After divorcing his wife, the patient just relocated to "make a fresh start" and begin a new work. He has no chronic medical issues and has never had surgery. The patient is sexually active and has had six lovers in her lifetime. Which of the following questions should the physician ask to complete the rest of the sexual history?

A)"What are the genders of your current and previous sexual partners?"
B)"Can you tell me about your previous romantic relationships?"
C)"Did you have other sexual partners while you were married?"
D)"Do you identify as heterosexual, homosexual, or bisexual?"
E)"Have you ever had sexual intercourse with a man?"

Question 73

A 21-year-old man arrives to the office with recurring ear leakage. His girlfriend is accompanying him. He communicates in English. On examination, the patient shows purulent otorrhea, a perforation of the tympanic membrane, and a pearly white mass behind the tympanic membrane, which is consistent with a large cholesteatoma. He is told that removing the tumor from his ear will need surgery. The patient nods momentarily but does not ask questions after hearing an explanation of the process and why it is necessary. He is also given information papers that include a written description of the treatment as well as directions on how to schedule surgery, which he promptly passes to his girlfriend, who begins reading 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?

A)Ask him to schedule a follow-up appointment and bring a family member to help him make health care decisions
B)Explain again slowly and simply what surgery entails and why it should be done
C)Gently ask the patient to read the information sheet aloud to determine his literacy
D)Use a visual aid to educate the patient about the procedure
E)Verbally review instructions on how to schedule an appointment for the procedure

Question 74

A 29-year-old man visits the urgent care clinic with a sore throat and nasal congestion. He is led to an examining room after 2 hours of waiting. The vital indicators are within normal ranges. When the doctor enters the room, the patient exclaims loudly, "I've been here for several hours and there aren't many people in the waiting room. I'm skipping work to come here." In addition to praising the patient for their patience, which of the following physician answers is most appropriate?

A)"I apologize for the delay; let's talk about the symptoms you've been experiencing."
B)"I know the waiting room appears empty; the staff is working hard to see patients efficiently."
C)"Unfortunately, the wait was so long because we triage patients based on urgency and severity."
D)"Wait times are usually shorter at outpatient offices because urgent care clinics can be unpredictable."
E)"You have a reason to be angry.  I'm also frustrated that patients have to wait this long."

Question 75

Due to cellulitis, a 38-year-old lady is taken to the hospital for the night. The next morning, the hospitalist on call presents herself to the patient and inquires as to how she is doing. The patient screams angrily, "It's already midday, and I haven't had my breakfast yet. How am I meant to improve if you're starving me?" A normal diet has been ordered for the patient. Which of the following is the most suitable medical response?

A)"Hunger can make anyone upset, so I'll come back after you've eaten."
B)"I apologize for the delay, but I'm sure your food will be here shortly."
C)"I'm sorry for the delay, but I don't control when meals are served, so please let your nurse know."
D)"Since I am here, let me examine you first and follow up on your breakfast afterward."
E)"You must be very hungry, so let me find out what happened to your meal."

Question 76

A 33-year-old man arrives at the office complaining of back discomfort. He has a 2-week history of mild lumbar discomfort that began after a hard day of yard labor. There is no temperature, muscle weakness, or urine symptoms. The patient has no history of severe trauma and a normal medical history. Lower extremity strength, sensibility, and reflexes are all normal, according to the examination. The straight-leg raising test results are negative. The patient declares, "My brother experienced comparable symptoms last year, and an MRI revealed a bulging disc. Could you please order the test for me?" The physician suggests symptomatic relief choices but advises against any imaging investigations. Which of the following is the most likely outcome of this suggestion?

A)Increased diagnostic uncertainty
B)Increased fragmentation of care
C)Increased health care disparity
D)Increased malpractice risk
E)Reduced clinical standardization
F)Reduced overutilization

Question 77

A 33-year-old woman is moved from a small community hospital to the university medical center owing to severe pyelonephritis with sepsis. She has a history of recurring urinary tract infections as a result of urine retention caused by a spinal cord injury as a youngster. The patient is febrile and sluggish when he arrives. She offers no more background, and the only information accessible is from the originating hospital's handwritten records, which are illegible. The patient is hospitalized to the critical care unit and given the antibiotics imipenem and vancomycin. The patient gets a rash and significant respiratory distress overnight, necessitating temporary artificial ventilation. The following morning, a transcribed physician note from the originating hospital arrives by fax and indicates that the patient has an allergy to multiple antibiotics, including imipenem.  When discussing events with the patient and her family, which of the following statements is associated with reduced malpractice liability for the treating clinician?

A)"As your attending physician, this mistake is my fault.  I take full responsibility."
B)"I am so sorry an error led to your allergic reaction.  I will do my best to help you through it."
C)"There are things you can do to prevent problems like this.  I recommend you get an allergy alert bracelet."
D)"Unfortunately, modern antibiotics can have serious side effects.  But I am glad to see you are doing better."
E)"Unfortunately, we did not get information about your medication allergy yesterday.  That is why you received the wrong antibiotic."

Question 78

A 73-year-old lady with congestive heart failure is being readied for hospital release. The patient has heart failure with a low ejection fraction and has been hospitalized twice in the last 60 days. The patient's medical history includes ischemic heart disease, chronic obstructive lung disease, and hypertension. Vital indicators are typical. A pulmonary examination reveals normal breathing effort, no crackles, and no peripheral edema. The patient asks to stay in the hospital for a few additional days and says, "I feel fine right now, but I am worried that if I go home, I might end up back in the hospital again." Which of the following responses to this patient's request is most appropriate?

A)"Managing heart failure at home can be difficult.  What family members are nearby who can help?"
B)"Since you are worried about going home, would you like to go to a nursing home until you feel more confident?"
C)"Some people with heart failure have problems due to too much salt intake.  Can you tell me about your diet?"
D)"What do you think are some reasons why your heart failure might be worse at home?"
E)"Your condition has now stabilized.  What benefit are you hoping to gain from a continued stay?"

Question 79

A 25-year-old lady arrives at the office for an initial assessment of her poor mood. The patient has been depressed and unable to sleep since relocating to a new apartment three weeks ago. She states, "My landlord does not let dogs in the building. I really miss my dog. I know my attitude would improve if I received a letter from you stating that my dog is welcome to live with me." The patient's dog is presently being cared for by her parents, who reside a few miles away. Which of the following physician remarks is the most appropriate?

A)"Fortunately, your dog is able to live nearby with your parents; what do you think about spending more time at their house?"
B)"Having your dog may help you feel better temporarily; let's discuss options that would allow you to develop long-term coping skills."
C)"I can see you miss your dog very much; let's start by talking about the mood symptoms you've been experiencing."
D)"It must be difficult not having your dog around; what made you decide to move into an apartment that does not allow pets?"
E)"Not having your dog live with you seems to be causing a lot of distress; I can write a letter for your dog."

Question 80

A 29-year-old lady visits the clinic for an examination of vaginal discharge and pruritus that has been bothering her for the previous week. The discharge is thick and yellow, with no odor. The patient engages in sexual activity with several partners. When asked what genders her sexual partners are, the patient responds, "What difference does it make? I'm very sure I have a yeast infection, therefore all I need is some medicine." Which of the following is the best reaction at this time?

A)"I can see you're uncomfortable talking about this.  We can discuss it at a follow-up appointment when you're ready."
B)"I routinely ask my patients about sexual partners because it helps me fully understand what their health needs are."
C)"It may be difficult to offer the most appropriate screening and treatment unless you are open about your sexual partners."
D)"This can be an uncomfortable topic for patients; tell me why you don't feel comfortable talking about your sexual partners."
E)"This is likely a yeast infection, but I need you to tell me about your sexual relationships to be sure it isn't something more serious."