All practice questions

A 68-year-old man is brought to the emergency department after a severe motor vehicle collision. He has sustained a massive traumatic brain injury and is currently comatose, lacking decision-making capacity. The trauma team determines that an emergent decompressive craniectomy is necessary to prevent impending brain herniation. An extensive search of his medical records and personal belongings reveals no advance directive, living will, or designated healthcare proxy. In the absence of a court-appointed guardian, arrange the following potential surrogate decision-makers in the standard legal hierarchy of priority (from highest priority to lowest priority) to provide informed consent for this patient's procedure.

A tertiary care hospital recently experienced a near-miss event where a patient almost received a lethal dose of concentrated potassium chloride due to an automated dispensing cabinet (ADC) stocking error. In response, the hospital administration decides to proactively evaluate the new ADC system workflow being implemented in the intensive care unit before it goes live. The quality improvement committee initiates a Failure Mode and Effects Analysis (FMEA). Arrange the following steps of the FMEA process in the correct chronological sequence.

A 48-year-old woman is admitted to the intensive care unit following a severe aneurysmal subarachnoid hemorrhage. She is currently intubated, comatose, and determined by the medical team to lack decision-making capacity. Her prognosis for meaningful neurologic recovery is exceptionally poor. The clinical team is considering transitioning to comfort-focused care, but a severe conflict arises among her visitors at the bedside. Her legally married husband, from whom she has been informally separated for three months, wishes to withdraw life support. Her 25-year-old daughter insists on continuing all aggressive medical interventions. The patient's mother is also present and requests that a tracheostomy be performed. Her older brother demands an immediate ethics committee consult to resolve the dispute. Additionally, a close friend arrives and produces a verified, signed legal document from two years ago naming the friend as the patient's designated healthcare proxy. The patient does not have a living will.

Arrange the following individuals in the correct order of their legal priority to act as the primary surrogate decision-maker for this patient, from highest (most authoritative) to lowest.

The leadership at an academic medical center is preparing to integrate a novel artificial intelligence-driven diagnostic triage software in the emergency department. To proactively identify and mitigate vulnerabilities before the software goes live, the administration initiates a Failure Mode and Effects Analysis (FMEA).

Arrange the following steps of the Failure Mode and Effects Analysis (FMEA) in the correct procedural sequence.

An elderly patient with type 2 diabetes experiences a severe hypoglycemic seizure on the medical ward after a nurse inadvertently programs an intravenous insulin pump to deliver ten times the intended hourly rate. The patient requires emergency administration of dextrose. Arrange the following actions regarding the management, disclosure, and investigation of this medical error in the most appropriate chronological sequence.

Dr. Chen, a physician in a large multispecialty clinic, observes that a peer colleague in her department consistently orders an extensive, unnecessary panel of proprietary laboratory tests for every healthy patient undergoing a routine annual physical. Dr. Chen discovers that the colleague has a financial stake in the laboratory company performing these tests, a conflict of interest that is not disclosed to the patients. Because there is no immediate medical danger to the patients, arrange the following actions in the ethically appropriate sequence Dr. Chen should take to address this professionalism breach.

A 45-year-old man is brought to the emergency department after a severe motor vehicle collision. He is intubated, comatose, and lacks decision-making capacity. The trauma surgery team determines he requires an emergent decompressive craniectomy for a rapidly expanding epidural hematoma. The patient has no written advance directives and has not legally designated a healthcare proxy. Several family members arrive at the hospital and express differing opinions on whether to proceed with the surgery. According to the standard legal hierarchy of surrogate decision-makers, arrange the following family members in order of their priority to make medical decisions on behalf of the patient, from highest priority (first) to lowest priority (last).

A hospital's quality improvement committee identifies a rising incidence of central line-associated bloodstream infections (CLABSIs) across its intensive care units over the past quarter. To address this issue, the committee decides to employ the Plan-Do-Study-Act (PDSA) quality improvement model to implement a standardized daily chlorhexidine bathing protocol.

Arrange the following steps of this quality improvement initiative in the correct chronological sequence according to the PDSA cycle.

A 71-year-old man with advanced amyotrophic lateral sclerosis and acute hypercapnic respiratory failure is admitted to the intensive care unit. He is obtunded and lacks decision-making capacity. A review of his medical records reveals no advance directives, and he has never officially designated a healthcare proxy or power of attorney. Several family members are present at the hospital and express conflicting opinions regarding whether to proceed with a tracheostomy and long-term mechanical ventilation. The medical team must determine the legally appropriate surrogate decision-maker to provide informed consent. Arrange the following individuals in the standard legal order of priority for surrogate decision-making (from highest priority to lowest priority).

A first-year internal medicine resident notices that her senior resident has slurred speech, a slight tremor, and the smell of alcohol on his breath just as he is preparing to place a central venous catheter in a patient. According to professional guidelines for managing impaired physicians, arrange the following actions and institutional responses in the correct chronological sequence.

A $68$-year-old man presents to the clinic complaining of an aching, cramping pain in his right calf that consistently occurs after walking approximately two blocks. The pain forces him to stop and is completely relieved after $5$ minutes of rest. His medical history is significant for hypertension, hyperlipidemia, and a $45$-pack-year smoking history. His blood pressure is $138/86$ mmHg and heart rate is $72$/min. Physical examination reveals diminished right dorsalis pedis and posterior tibial pulses. There are no ulcers, rest pain, or signs of critical limb ischemia.

Assuming each intervention is indicated based on the results or failure of the preceding step, arrange the following clinical actions in the most appropriate chronological sequence for the evaluation and management of this patient's condition.

A 49-year-old man is evaluated in the clinic for persistently elevated blood pressure despite adherence to a three-drug antihypertensive regimen, including a thiazide diuretic. Recent laboratory results reveal a serum potassium level of 2.9 mEq/L (spontaneous hypokalemia). The physician strongly suspects primary hyperaldosteronism. Arrange the steps of the diagnostic workup and management for this condition in the correct sequential order from initial screening to final pre-surgical evaluation.

A 68-year-old man who was intubated and mechanically ventilated 5 days ago for severe acute respiratory distress syndrome (ARDS) develops a new fever of 38.9°C (102.0°F). His oxygen requirements have increased over the past 24 hours, and thick, purulent secretions are suctioned from the endotracheal tube. A portable chest radiograph reveals a new right lower lobe consolidation. Arrange the following steps in the most appropriate chronological sequence for managing this patient's suspected ventilator-associated pneumonia (VAP).

A $62$-year-old man with a $40$-pack-year smoking history presents to the emergency department with a two-week history of progressive facial swelling, dull headache, and worsening shortness of breath. Physical examination reveals plethora of the face, engorged neck veins that do not collapse with inspiration, and dilated superficial veins over the upper anterior chest wall. His blood pressure is $135/85 \text{ mm Hg}$, heart rate is $98/\text{min}$, respiratory rate is $18/\text{min}$, and oxygen saturation is $94\%$ on room air. He is alert and oriented with no signs of stridor, respiratory distress, or airway compromise. Arrange the following steps in the most appropriate clinical sequence for evaluating and managing this patient's condition.

A 44-year-old woman presents to the emergency department on postoperative day 8 following an uncomplicated total abdominal hysterectomy for symptomatic adenomyosis. She reports a 2-day history of worsening lower abdominal pain, severe chills, and foul-smelling vaginal discharge. Her temperature is 39.2°C (102.6°F), blood pressure is 102/68 mm Hg, heart rate is 112/min, and respiratory rate is 18/min. Physical examination reveals localized lower abdominal tenderness with guarding and purulent discharge pooling at the vaginal cuff. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 32-year-old woman, gravida 1, para 0, abortus 1, presents to the clinic with an 8-month history of amenorrhea. Ten months ago, she underwent a surgical dilation and curettage for a first-trimester incomplete abortion. Over the past year, she has also been training for a marathon and runs approximately 40 miles per week. Her BMI is 18.2 kg/m². Vital signs are within normal limits. Physical examination reveals normal secondary sexual characteristics and no galactorrhea, hirsutism, or acne. Pelvic examination is unremarkable. The physician decides to initiate a comprehensive workup for secondary amenorrhea.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition.

A 9-year-old boy is brought to the emergency department via ambulance for severe difficulty breathing. His parents report that his symptoms began $12$ hours ago with a cough and wheezing, and worsened significantly over the past $6$ hours. He has a history of moderate persistent asthma and has been using his albuterol inhaler every hour for the past $6$ hours without relief. He is fully immunized. On arrival, the patient is agitated, diaphoretic, and speaking in single words. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, pulse is $148/\text{min}$, and respirations are $44/\text{min}$. Pulse oximetry shows $86\%$ on room air. Physical examination reveals marked suprasternal and subcostal retractions. Lung auscultation reveals diminished air entry bilaterally with a prolonged expiratory phase and faint, high-pitched expiratory wheezing. Arrange the following interventions in the most appropriate sequence of administration for this patient's acute management.

A 58-year-old female is admitted to the progressive care unit with worsening confusion, severe fatigue, abdominal pain, and polyuria over the past two weeks. She has a history of breast cancer treated with mastectomy and localized radiation five years ago. Vital signs show a blood pressure of 98/60 mm Hg and a heart rate of 110/min. Physical examination demonstrates dry mucous membranes and diminished skin turgor. Laboratory analysis reveals a serum calcium level of 14.8 mg/dL (normal: 8.4-10.2 mg/dL), a low parathyroid hormone level, and elevated parathyroid hormone-related peptide (PTHrP).

Arrange the following management steps in the most appropriate sequential order for this patient's acute severe hypercalcemia, from the immediate initial intervention to definitive long-term management.

A $9$-day-old female infant arrives at the emergency department presenting with worsening lethargy, recurrent vomiting, and poor feeding over the past $24$ hours. She has been exclusively breastfed since birth. Physical examination demonstrates marked scleral icterus, hypotonia, and a liver edge palpable $3$ cm below the right costal margin. Initial point-of-care blood glucose is $38$ mg/dL. A urinalysis is negative for glucose but strongly positive for reducing substances. Arrange the following management and diagnostic steps in the most appropriate sequential order for this patient.

A 7-year-old girl is brought to the emergency department experiencing an acute severe asthma exacerbation. She is visibly distressed with supraclavicular retractions, scattered wheezing, and an oxygen saturation of 89% on room air. Arrange the following interventions in the most appropriate stepwise order of priority and escalation, from the immediate first step to the appropriate step for refractory symptoms.