All practice questions

A 16-year-old girl comes to the outpatient clinic unaccompanied for a health evaluation. She reveals that she is sexually active and requests screening for sexually transmitted infections. Laboratory testing confirms active infection with *Neisseria gonorrhoeae* and *Chlamydia trachomatis*. During the consultation, she tearfully confides that her 19-year-old boyfriend frequently hits her when he is angry. Physical examination reveals multiple healing ecchymoses on her upper arms and back. She explicitly begs the physician not to tell her parents about her sexual activity, her infections, or the physical abuse, fearing they will force her to leave home.

Which of the following actions involving disclosure of this patient's health information are legally required or permissible without her consent? (Select all that apply)

A 34-year-old woman is rushed to the operating room for a ruptured ectopic pregnancy with severe hemorrhagic shock. During the massive transfusion protocol, the circulating nurse bypasses the manual surgical count to expedite abdominal packing. A hospital supply chain decision three months prior had placed visually identical laparotomy sponges and standard absorbent towels in the same trauma cart. Postoperatively, the attending surgeon attributes the patient's persistent tachycardia entirely to expected recovery from hypovolemia, delaying the diagnosis of a retained item. A month later, the patient is readmitted with an intra-abdominal abscess secondary to a retained laparotomy sponge.

Following the event, a Root Cause Analysis (RCA) panel proposes two distinct interventions: implementing surgical instrument trays that physically lock and cannot be closed if an RFID-tagged sponge is missing from the sterile field, and updating the departmental policy manual to mandate mandatory staff retraining on surgical counts.

Match each specific element of this event or proposed intervention to its correct patient safety and error science classification.

A patient in the emergency department experiences a severe anaphylactic reaction after receiving a dose of intravenous penicillin, despite having a clearly documented penicillin allergy in the electronic health record. The patient is successfully resuscitated. The hospital safety committee decides to initiate a formal Root Cause Analysis (RCA) to investigate the incident and prevent future occurrences.

Arrange the following steps of the formal Root Cause Analysis process in the correct chronological sequence, from the initial step to the final step.

A 68-year-old woman with advanced amyotrophic lateral sclerosis is evaluated in the emergency department for severe dyspnea and fever. She is entirely dependent on others for activities of daily living and uses noninvasive positive pressure ventilation 24 hours a day for chronic respiratory failure. She communicates effectively via an eye-tracking speech-generating device. Today, she is diagnosed with severe aspiration pneumonia and acute respiratory distress syndrome. The critical care physician informs her that her respiratory status is rapidly declining and that without endotracheal intubation and invasive mechanical ventilation, she will likely die within hours.

Through her device, the patient clearly states, "I do not want a breathing tube. I want to die peacefully. Please give me medicine to make me sleep."

Her husband, who holds her legally executed durable power of attorney for healthcare, is extremely distressed. He states, "She is legally incompetent right now because her brain isn't getting enough oxygen. I am her proxy, and I authorize you to intubate her immediately."

Arterial blood gas analysis on her current noninvasive ventilation settings reveals a pH of $7.22$, $PaCO_2$ of $78$ mm Hg, and $PaO_2$ of $58$ mm Hg. Despite the severe hypercapnia, the physician's evaluation reveals the patient is fully alert, correctly answers questions about her medical condition, logically explains her rationale for refusing the breathing tube, and accurately describes the fatal consequences of her decision.

Which of the following is the most appropriate next step in management?

A 29-year-old woman comes to the outpatient clinic for a routine follow-up to discuss the results of a recent sexually transmitted infection screening. The nucleic acid amplification test is positive for *Chlamydia trachomatis*. When the physician discusses the results, the patient becomes visibly distressed. She confides that she had a single unprotected sexual encounter with a coworker during a business trip three weeks ago. She states, "You absolutely cannot tell my husband. If he finds out I cheated on him, or worse, gave him a disease, he will kill me." She reports a history of severe physical abuse by her husband, including an incident two years ago that resulted in a fractured orbital floor requiring surgical repair. The physician confirms the patient currently feels safe returning home as long as her husband remains unaware of the diagnosis. The patient is prescribed a 7-day course of doxycycline. Which of the following is the most appropriate next step in management?

A 42-year-old primary care physician is approached at home by his 16-year-old daughter. She tells him that she recently became sexually active and asks him to prescribe oral contraceptive pills for her. She expresses anxiety about discussing this with her regular pediatrician, whom she has known since childhood, and asks her father to keep the request confidential from her mother. Which of the following are appropriate responses or actions by the physician? (Select all that apply.)

An outpatient oncology clinic is transitioning to a new electronic prescribing system for high-risk chemotherapeutic agents. To ensure patient safety, the medical director convenes a multidisciplinary team to systematically map out the new prescribing workflow. The goal is to proactively identify potential points of failure, evaluate the severity and likelihood of potential harm, and implement preventive safeguards before the new system goes live next month. Which of the following quality improvement methodologies is the most appropriate to achieve this goal?

Match each clinical scenario describing a medical error or decision-making misstep to the most appropriate underlying cognitive bias.

A 65-year-old man with metastatic pancreatic cancer is admitted to the hospital with severe pneumonia. He is awake, alert, and oriented to person, place, and time. The attending physician explains that his respiratory status is rapidly declining and that without endotracheal intubation and mechanical ventilation, he will likely die within a few days. The patient demonstrates a clear understanding of his prognosis, the proposed intervention, and the consequences of his decision. He explicitly states that he does not want to be intubated and wishes to receive comfort measures only. Shortly after this conversation, his adult daughter, who is his legally designated healthcare proxy, arrives at the hospital. She is extremely distressed and demands that the medical team intubate her father immediately to save his life. Which of the following is the most appropriate next step in management?

Following an acute hemolytic transfusion reaction caused by the administration of mislabeled packed red blood cells during an orthopedic surgery, a hospital initiates a sentinel event investigation. The patient survived but required emergent stabilization and prolonged intensive care. The chief medical officer mandates a comprehensive systems evaluation to prevent recurrence. Arrange the following formal Root Cause Analysis (RCA) steps in the correct chronological sequence to appropriately investigate and address this event.

A 68-year-old man is admitted to the hospital for evaluation of progressive jaundice, pruritus, and a 10-kg (22-lb) weight loss over the past 3 months. He has a history of major depressive disorder, which is currently well-controlled on sertraline. A CT scan of the abdomen reveals a large mass in the head of the pancreas with multiple liver lesions. A subsequent image-guided biopsy confirms metastatic pancreatic adenocarcinoma. The patient is alert, fully oriented, and engages appropriately in conversation. As the physician prepares to enter the patient's room to discuss the biopsy results, the patient's daughter pulls the physician aside. She tearfully states, "Please do not tell my father he has cancer. He has been so depressed lately, and watching his brother die of the same disease last year traumatized him. If you tell him it is cancer, he will give up all hope. I am his designated healthcare proxy, and I forbid you from telling him." Which of the following is the most appropriate next step in management?

A $72$-year-old woman with end-stage renal disease on hemodialysis is brought to the emergency department by her son after missing her last two dialysis sessions. She reports generalized weakness and fatigue. Her vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $110/70\text{ mm Hg}$, pulse $55/\text{min}$, and respirations $16/\text{min}$. An electrocardiogram shows peaked T waves, and laboratory studies reveal a serum potassium level of $7.4\text{ mEq/L}$. The emergency physician informs the patient that she requires immediate medical treatment and emergent hemodialysis to prevent a fatal cardiac arrhythmia. The patient, who is fully alert, oriented, and cognitively intact, calmly states, "I am exhausted from living on a machine. I know that refusing treatment means I will have a heart attack and die, but I am ready to go. I do not want any medications or dialysis." Her son, who is her legally designated healthcare proxy, becomes distraught and insists, "You have to treat her! She is just having a bad day and doesn't know what she's saying. I authorize the dialysis." Which of the following is the most appropriate next step in management?

You are a first-year anesthesiology attending assisting the Chief of Anesthesiology during a complex coronary artery bypass grafting procedure. As the patient is being weaned from cardiopulmonary bypass, you observe the Chief slurring his words, exhibiting pinpoint pupils, and repeatedly nodding off. The patient's mean arterial pressure precipitously drops to 45 mm Hg, but the Chief fails to recognize the severe hypotension or administer appropriate vasopressors. You also notice an unlogged, empty fentanyl syringe near his workstation. Arrange the following actions in the most appropriate ethical and legal sequence.

An 82-year-old woman is evaluated on the postoperative ward on hospital day 4 following an open reduction and internal fixation of a left femoral neck fracture. She has a history of type 2 diabetes mellitus and hypertension. An indwelling urethral catheter, placed prior to surgery, remains in situ. The patient reports minimal incisional pain and states she feels well enough to go home. She has no dysuria, suprapubic pain, or flank tenderness. Vital signs are temperature 37.1°C (98.8°F), blood pressure 138/82 mmHg, pulse 76/min, and respirations 14/min. Physical examination is unremarkable.

A basic metabolic panel and a urinalysis were ordered this morning by the surgical intern. The urinalysis shows:

A reflex urine culture is pending. Based on principles of antimicrobial stewardship and infection control, which of the following is the most appropriate next step in the management of this patient?

A 74-year-old man is admitted to the intensive care unit with severe septic shock secondary to pneumonia. He is intubated, sedated, and lacks decision-making capacity. The critical care team determines that he requires initiation of continuous renal replacement therapy due to worsening acute kidney injury. A review of the medical record reveals no advance directive or designated healthcare power of attorney. Several family members and individuals close to the patient are present in the waiting room and have conflicting opinions regarding his care. The physician must obtain informed consent from the appropriate legally authorized representative. According to the standard legal hierarchy for surrogate decision-makers in most jurisdictions, arrange the following individuals from highest priority (first) to lowest priority (last) to provide informed consent.

A 65-year-old woman is brought to the emergency department unconscious following a massive ischemic stroke. Clinical findings include a Glasgow Coma Scale score of 4, with fixed pupils and an absent gag reflex. The neurosurgery team determines she requires an emergent decompressive craniectomy, but she cannot provide informed consent. The patient does not have an advance directive or a designated healthcare proxy. Several family members have arrived at the hospital and are discussing her care. According to standard US medical ethics and jurisprudence, arrange the following family members in the correct hierarchical order of priority to act as the legally authorized surrogate decision-maker, from highest priority (first) to lowest priority (last).

A 42-year-old woman is brought to the emergency department by her husband due to worsening confusion, unsteadiness, and a prominent tremor over the past three days. Her past medical history is significant for bipolar disorder, which has been well-controlled on lithium carbonate for several years, and chronic migraines. Two weeks ago, she sustained a minor ankle sprain while hiking. Her vital signs are temperature 37.1°C (98.8°F), blood pressure 122/78 mmHg, heart rate 84/min, and respiratory rate 14/min. Physical examination is notable for a coarse resting tremor, bilateral horizontal nystagmus, and an ataxic gait. Eliciting which of the following specific historical details is the most critical next step to establish the etiology of this patient's current presentation?

Paramedics bring an 82-year-old resident from a skilled nursing facility to the emergency room following a sudden episode of intractable abdominal cramping. The patient has a documented medical history of persistent atrial fibrillation and currently takes metoprolol, but receives no anticoagulant therapy due to a prior severe gastrointestinal bleed. Vital signs demonstrate an irregular heart rate of 118 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 105/65 mm Hg. On clinical evaluation, the abdomen is remarkably soft, non-distended, and lacks rebound tenderness, despite the patient writhing in agony. Initial laboratory analysis reveals a serum lactate level of 4.2 mmol/L (normal: 0.5-2.2 mmol/L). Which of the following is the most appropriate initial imaging modality to establish the diagnosis?

A 32-year-old woman is evaluated in the neurology clinic for a three-month history of intermittent double vision and bilateral drooping of her eyelids. She notes that her symptoms are typically absent upon awakening but progressively worsen throughout the day, particularly after prolonged reading. Recently, she has also experienced transient difficulty chewing tough foods during the evening. Her past medical history is unremarkable, and she takes no medications. Vital signs are within normal limits. Neurologic examination reveals bilateral ptosis that worsens after sustained upward gaze for two minutes. Extraocular movements are restricted in multiple directions without a clear single cranial nerve pattern. Pupillary responses are brisk and symmetric. Muscle strength in the extremities is 5/5, and deep tendon reflexes are 2+ throughout. Which of the following is the most appropriate next step in the diagnostic workup?

Match each patient's clinical presentation with the most appropriate diagnostic laboratory test to order to confirm the suspected underlying hematologic condition.