All practice questions

A 28-year-old woman, G1P0 at 28 weeks gestation, is brought to the emergency department following a high-speed motor vehicle collision. She is comatose with a Glasgow Coma Scale score of 6 and exhibits signs of severe intra-abdominal hemorrhage. Her blood pressure is 70/40 mm Hg, and her pulse is 140/min. Fetal heart rate monitoring shows a baseline of 150/min with moderate variability and no decelerations. The trauma surgery team determines that an emergent exploratory laparotomy is required to save her life. Emergency medical personnel provide the patient's wallet, which contains a signed, witnessed, and legally valid advance directive explicitly refusing the administration of all whole blood and blood components under any circumstances. A medical alert bracelet on her wrist also states "NO BLOOD PRODUCTS." Her husband arrives shortly after and confirms she is a devout Jehovah's Witness. He states, "She would rather die than receive a blood transfusion. You must not give her blood." The surgeon is highly concerned that the patient will not survive the laparotomy without blood product support.

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

A 78-year-old woman is evaluated in the emergency department after a mechanical fall at home. Radiographs reveal a displaced left femoral neck fracture, and orthopedic surgery recommends urgent operative repair. The patient's medical history is significant for early-stage Alzheimer dementia and hypertension. When the physician discusses the procedure, the patient states, "I do not want any operations. Hospitals are where people go to die. I just want to go home and sleep in my own bed." When asked to explain her diagnosis and the potential consequences of declining surgery, she replies, "My leg is just a little bruised. I will be walking normally by tomorrow." The patient is oriented to person, but not to place or time. Her daughter, who provides documentation establishing herself as the legally designated healthcare proxy, is at the bedside and states, "She is just confused and terrified. She was living independently before this fall. Please proceed with the surgery." Which of the following is the most appropriate next step in management?

A 54-year-old woman is evaluated in the emergency department for severe headache, photophobia, and nausea. She has a past medical history of poorly controlled asthma. The emergency physician evaluates the patient and decides to prescribe a nonselective beta-blocker for a suspected migraine abortive therapy. Before the medication is dispensed or administered, the clinical pharmacist alerts the physician that the medication is strongly contraindicated due to the patient's asthma history. The physician immediately cancels the order and prescribes a different, safe alternative agent. The patient experiences no harm and her headache improves. Which of the following best classifies this incident?

A 26-year-old medical intern sustains a deep percutaneous needlestick injury with a hollow-bore needle immediately after drawing blood from a patient. The source patient's laboratory evaluation reveals a positive hepatitis B surface antigen (HBsAg), positive hepatitis B e antigen (HBeAg), positive anti-HCV antibodies, and a positive HIV-1/2 antigen/antibody combination assay. The source patient's HIV viral load is reported as undetectable on their current antiretroviral regimen. The intern completed the standard 3-dose hepatitis B vaccination series 2 years ago, and an anti-HBs titer drawn one month after the final dose was $45 \text{ mIU/mL}$ (normal: $>10 \text{ mIU/mL}$). Which of the following is the most appropriate post-exposure management for this intern?

A 40-year-old general surgeon is preparing for his next case in an ambulatory surgery center. While walking into the staff lounge, he observes the assigned 55-year-old anesthesiologist injecting himself with a syringe of what appears to be a clear medication. The anesthesiologist quickly hides the syringe in his pocket, appears diaphoretic, and has noticeably pinpoint pupils. The next patient is already in the operating room, awake and awaiting anesthesia induction. Which of the following is the most appropriate initial action by the general surgeon?

A 55-year-old male patient is admitted to the intensive care unit with septic shock secondary to a perforated appendix. The medical team decides to insert a central venous catheter for the administration of targeted vasopressor therapy and hemodynamic monitoring. The resident physician prepares to perform the procedure at the right subclavian vein site. To minimize the risk of a central line-associated bloodstream infection (CLABSI), the resident adheres to the hospital's standardized infection control bundle. The resident performs surgical hand antisepsis and dons a surgical cap, a mask covering the nose and mouth, a sterile gown, and sterile gloves. The skin at the insertion site is thoroughly prepped with a 2% chlorhexidine and 70% isopropyl alcohol solution and allowed to dry completely. Which of the following is the most appropriate additional intervention required to minimize the risk of a central line-associated bloodstream infection in this patient?

An 82-year-old male nursing home resident with severe global ischemia following a prolonged cardiac arrest is evaluated in the medical ward. He remains ventilator-dependent with no evidence of meaningful neurologic recovery after three weeks. The critical care and neurology teams conclude that continued mechanical ventilation is medically non-beneficial and only prolongs the dying process. The patient's daughter, acting as his durable power of attorney for healthcare, vehemently disagrees and demands that full life support be maintained indefinitely, hoping for a miracle. Arrange the following steps in the recognized consensus pathway for resolving an intractable physician-surrogate dispute regarding potentially inappropriate life-sustaining therapy.

A 78-year-old woman with moderate Alzheimer dementia is brought to the clinic by her son, who is her primary caregiver and legally designated healthcare proxy. During the physical examination, the physician notes multiple cluster bruises on the patient's bilateral upper arms. The son states, "She has been falling out of bed frequently." When the son briefly leaves the examination room, the patient becomes tearful and whispers, "He squeezes my arms when he loses his temper. Please do not tell anyone; he is all I have." When the son returns, he requests a full printed copy of today's clinical notes to keep for his records. Which of the following actions are legally and ethically appropriate for the physician? (Select all that apply)

An attending physician and a resident are managing a 65-year-old man admitted to the inpatient medical service for a 3-month history of fatigue, involuntary weight loss, and diffuse lymphadenopathy. Two weeks prior, the attending physician cared for a patient with a nearly identical clinical presentation who was ultimately diagnosed with aggressive diffuse large B-cell lymphoma. Suspecting the same diagnosis in the current patient, the attending immediately orders an excisional lymph node biopsy and bone marrow evaluation.

The preliminary biopsy pathology report returns showing extensive non-caseating granulomas with no visual evidence of malignant lymphocytes. The resident suggests pivoting the diagnostic workup to evaluate for sarcoidosis, histoplasmosis, or tuberculosis. The attending physician disagrees, stating, "While rare, prominent peritumoral sarcoid-like granulomatous reactions can occur in the lymph nodes draining a lymphoma. Let us hold off on the infectious workup and wait for the specialized flow cytometry and molecular rearrangement studies to prove this is a malignancy."

Which of the following cognitive errors is most directly responsible for the physician's interpretation of the preliminary biopsy results?

A $58$-year-old woman presents to the outpatient clinic reporting a $2$-month history of worsening fatigue, diffuse joint pain, and a new rash on her lower legs. She has a past medical history of hypertension and underwent a cholecystectomy in $1989$ that required a blood transfusion. Her current medications include amlodipine. Vital signs show a temperature of $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure of $148/92\text{ mmHg}$, pulse of $84\text{/min}$, and respiratory rate of $14\text{/min}$. Physical examination reveals non-blanching, palpable purpuric lesions across her bilateral distal lower extremities. The metacarpophalangeal joints are mildly swollen and tender bilaterally.

Laboratory evaluation reveals the following:

Urinalysis demonstrates $3+$ protein, $25-30$ red blood cells/hpf, and the presence of red blood cell casts.

Which of the following is the most likely diagnosis?

A 28-year-old male is brought to the emergency department by paramedics following a high-speed motorcycle collision. He was found approximately 30 feet from his vehicle. On arrival, he is unresponsive to verbal stimuli and only groans to deep pain, yielding a Glasgow Coma Scale score of 7. His blood pressure is 68/40 mmHg, heart rate is 142/min, and respiratory rate is 8/min with shallow effort. Physical examination reveals a partially amputated right lower extremity at the level of the distal femur. The field dressings applied by emergency medical services are completely soaked through, and there is active, pulsatile bleeding from the wound. Breath sounds are clear and equal bilaterally. Arrange the following initial management steps in the most appropriate sequential order.

A 26-year-old woman presents to the emergency department with a 24-hour history of severe right lower quadrant abdominal pain and light vaginal spotting. In the last hour, she noticed that the pain has started to radiate to her right shoulder. She reports that her last menstrual period was 6 weeks ago, and her past medical history is significant for a prior *Neisseria gonorrhoeae* infection. Vital signs are temperature 37.1 C (98.8 F), blood pressure 118/76 mm Hg, and heart rate 94/min. Abdominal examination demonstrates focal tenderness in the right lower quadrant with voluntary guarding, but no rebound rigidity. Pelvic examination reveals significant right adnexal tenderness without a palpable mass.

Which of the following are the most appropriate initial diagnostic tests to order concurrently to establish the diagnosis? (Select exactly 2)

A 42-year-old man is admitted to the intensive care unit (ICU) following a severe traumatic brain injury sustained from a 15-foot fall off scaffolding at his construction job. He is currently intubated, deeply sedated, and lacks decision-making capacity. His wife is designated as his legal healthcare proxy and is actively making care decisions. Routine admission laboratory testing is performed. The patient is found to have a positive fourth-generation HIV antigen/antibody test, which is confirmed by a differentiation assay. Additionally, a clinical urine toxicology screen is positive for amphetamines. Over the next 24 hours, the primary care team receives several requests for information regarding the patient's condition and laboratory results.

Which of the following actions regarding the disclosure of this patient's protected health information are legally and ethically permissible WITHOUT explicit patient or surrogate authorization? (Select all that apply)

A 4-month-old infant in the pediatric intensive care unit requires a continuous intravenous heparin infusion. Due to a stocking error in the automated dispensing cabinet, a highly concentrated adult preparation of heparin is inadvertently retrieved and administered. The infant develops significant bleeding but is successfully stabilized following the administration of protamine and supportive care. The hospital's risk management department determines that this sentinel event requires a formal investigation. As the chief resident involved in quality improvement, you are tasked with outlining the standard investigative process. Arrange the following steps of the formal root cause analysis in the correct chronological sequence.

A $78$-year-old man with end-stage idiopathic pulmonary fibrosis is admitted to an inpatient palliative care unit. He is transitioning to comfort-focused care and has a do-not-resuscitate/do-not-intubate (DNR/DNI) order. He develops severe, distressing dyspnea at rest. Non-pharmacological measures, including optimal upright positioning, a bedside fan directed at his face, and supplemental oxygen, have been maximized but fail to provide relief. His respiratory rate is $36 \text{ breaths per minute}$, and he is utilizing accessory muscles. The patient appears extremely anxious and frightened by his inability to catch his breath. Arrange the following clinical steps in the most appropriate chronological sequence for the management of this patient's escalating terminal dyspnea, progressing from the initial pharmacological intervention to the management of truly refractory suffering.

A primary care physician in an outpatient clinic is visited by a pharmaceutical representative who wishes to discuss a newly approved medication for the management of hypertension. The representative requests 30 minutes of the physician's time and offers various options to facilitate the meeting. The physician is committed to maintaining professional boundaries and avoiding any conflicts of interest that could compromise patient care. According to the American Medical Association (AMA) ethical guidelines regarding relationships with industry, which of the following is the most appropriate action for the physician?

A 45-year-old man undergoes an uncomplicated outpatient laparoscopic cholecystectomy. Upon discharge, the surgeon uses the electronic health record (EHR) to prescribe oral hydromorphone for pain management. However, the EHR interface defaults to a continuous intravenous infusion order set for this medication. The surgeon overrides a generic warning alert without reading it, assuming it to be a routine nuisance alarm. The outpatient pharmacy receives the order, assumes it is meant to be a concentrated liquid formulation, and dispenses it to the patient with oral dosing instructions. The patient subsequently suffers a massive overdose, resulting in respiratory arrest at home that requires emergency intubation. A multidisciplinary patient safety committee is convened to review the incident. The committee identifies the EHR default setting and the surgeon's alert fatigue as primary contributing factors. Which of the following is the most appropriate next step for the committee to recommend?

A first-year resident is placing a central venous catheter in a 62-year-old patient in the intensive care unit. The critical care nurse assisting with the procedure notices that the resident has contaminated the sterile field by brushing their gown against a non-sterile bedside table. The nurse informs the resident of the contamination, but the resident dismisses the concern, stating, "It barely touched, and we need to get this line in quickly." The nurse remains concerned about the high risk of a central line-associated bloodstream infection. Which of the following is the most appropriate immediate action for the nurse to take?

A hospital quality improvement committee is reviewing a cluster of near-miss events in the pediatric intensive care unit (PICU). In these incidents, nurses almost administered look-alike, sound-alike (LASA) high-alert medications to the wrong patients. A root cause analysis reveals that frequent environmental interruptions and reliance on memory during busy shift changes were the primary contributing factors. The committee is tasked with implementing interventions based on the human factors engineering hierarchy of effectiveness. Which of the following strategies represent strong or intermediate system-level interventions to mitigate this recurring error? (Select 2 options)

A 31-year-old man is evaluated in the emergency department for a fractured zygomatic arch sustained during a fistfight outside a local tavern. He is awake, alert, and oriented to person, place, and time. His vital signs are stable, and he is currently awaiting discharge instructions. A police officer arrives at the emergency department and states that the patient is a suspect in an aggravated assault investigation. The officer asks the physician for the patient's blood alcohol concentration and urine drug screen results to include in the official police report. The officer does not have a warrant, court order, or administrative subpoena. Which of the following is the most appropriate action by the physician?