All practice questions

A married 40-year-old man presents to an urgent care center complaining of a widespread rash on his trunk, palms, and soles that has been present for two weeks. Rapid plasma reagin and treponemal-specific testing confirm a diagnosis of secondary syphilis. The physician administers intramuscular benzathine penicillin G and initiates counseling regarding the critical necessity of partner testing and treatment. The patient becomes highly agitated and states, 'My wife is 16 weeks pregnant. If she finds out about my infidelity, she will divorce me immediately. I give you my word that I will sleep in the guest room and not have any physical contact with her until I am completely cured, but you cannot report this or tell her.' Which of the following is the most appropriate next step for the physician?

A 68-year-old woman is evaluated in the clinic after a biopsy confirms localized breast cancer. The recommended standard of care is surgical resection. The patient refuses the surgery, stating, "I understand that without surgery the cancer will spread and likely shorten my life, but I value my current comfort and do not want to go through an operation or its recovery." She consistently repeats this choice, demonstrates a clear understanding of her diagnosis and the risks of refusing treatment, and applies this information logically to her own values. Her daughter is highly distressed by this decision and demands that the physician declare the patient "incompetent" so the daughter can authorize the surgery on her mother's behalf. Which of the following is the most accurate statement regarding the evaluation of this patient's decision-making ability?

A 45-year-old male is brought to the intensive care unit intubated and sedated following a severe motor vehicle collision. He requires urgent surgical intervention for a complex fracture, and informed consent must be obtained. The patient currently lacks decision-making capacity. Hospital records and immediate inquiries confirm he does not have an advance directive or a designated durable power of attorney for healthcare. Several individuals arrive at the hospital, all expressing willingness to make medical decisions on his behalf. According to standard US medical jurisprudence, arrange the following individuals in the correct legal hierarchy to act as the default surrogate decision-maker, from highest priority (first) to lowest priority (last).

A 32-year-old man comes to the primary care clinic for a routine follow-up of well-controlled essential hypertension. During the visit, he makes several overtly sexually suggestive remarks toward the physician and comments inappropriately on her physical appearance. The physician feels uncomfortable but notes that the patient is medically stable and in no acute distress. Which of the following are appropriate professional actions for the physician to take regarding this patient? (Select all that apply)

A 68-year-old man with a history of severe obstructive sleep apnea is admitted to the surgical ward following an elective laparoscopic inguinal hernia repair. During evening sign-out, the primary surgical team informs the cross-covering night resident that the patient is hemodynamically stable and recovering well. Later that night, the patient complains of moderate incisional pain. The cross-covering resident, who has not reviewed the patient's full preoperative anesthesia assessment, orders a standard dose of intravenous hydromorphone. A floor nurse administers the medication. Two hours later, the patient is found unarousable with a respiratory rate of 6/min and an oxygen saturation of 82% on room air. A rapid response code is initiated, naloxone is administered, and the patient is transferred to the intensive care unit, where he subsequently makes a full recovery. The hospital's patient safety committee is tasked with evaluating this sentinel event.

Which of the following is the most appropriate initial step in the formal investigation of this incident?

A 78-year-old man is brought to the emergency department with altered mental status and is found to lack decision-making capacity. He requires medical intervention that necessitates surrogate consent. According to the standard ethical and legal hierarchy in most US jurisdictions, arrange the following potential surrogate decision-makers in the correct order of priority, from highest (first to be consulted) to lowest.

A 62-year-old man with a documented history of severe asthma is admitted to the telemetry unit. During a shift change, the cross-covering night physician receives a page regarding the patient's new-onset tachycardia (heart rate of 135/min). While simultaneously managing two other unstable patients, the physician quickly enters an order for intravenous propranolol. A pop-up alert appears in the electronic medical record (EMR) warning of a medication-disease interaction. Experiencing alert fatigue from numerous daily low-priority warnings, the physician clicks 'override' without reading the text. The night nurse, assuming the physician evaluated the risk, administers the medication. The patient subsequently develops severe bronchospasm, requiring transfer to the intensive care unit for mechanical ventilation.

A multidisciplinary committee is convened to investigate this sentinel event.

Which of the following committee recommendations represents the most effective systems-based intervention to prevent a recurrence of this specific error?

An outpatient internal medicine physician is seeing a 48-year-old male patient for a routine wellness examination and management of well-controlled asthma. The patient and physician have maintained a positive therapeutic relationship for the past four years. The patient works as a certified public accountant. Toward the end of the encounter, the physician mentions feeling stressed about the upcoming tax season and the complexities of filing taxes for a new private practice. The patient enthusiastically offers to prepare the physician's tax returns this year free of charge. He states, "It is the least I can do to show my gratitude for your excellent care over the years." Which of the following statements is the most appropriate response by the physician?

A 75-year-old woman with metastatic pancreatic cancer is admitted to the intensive care unit with urosepsis and acute respiratory distress syndrome. She is intubated and mechanically ventilated. She is currently deeply sedated and lacks decisional capacity. Five years ago, she executed a living will stating she would not want life-sustaining treatments, including mechanical ventilation or dialysis, if she developed a terminal illness. At that time, she also appointed her eldest son as her healthcare proxy (durable power of attorney for healthcare).

The patient develops severe oliguria, and the nephrology service recommends continuous renal replacement therapy. The attending physician meets with the son to discuss transitioning to comfort measures only, referencing the living will. The son insists on starting renal replacement therapy. He explains, "I know what the document says, but three weeks ago, after she learned her daughter was pregnant with her first grandchild, she explicitly told me that she had changed her mind. She said she wants everything medically possible done so she can survive to see the baby born."

There is no other family present, and the nursing staff notes that the son has been a consistently devoted caregiver. Which of the following is the most appropriate next step in management?

A 34-year-old woman at 38 weeks gestation is admitted to the labor and delivery unit. During the planned placement of an epidural catheter, the anesthesiologist inadvertently administers an intravenous test dose of bupivacaine. This leads to transient maternal hypotension and fetal bradycardia. The anesthesiologist recognizes the medication error immediately.

Arrange the following actions in the most appropriate chronological sequence for managing this medical error and its aftermath.

A $28$-year-old woman presents to the clinic with a persistent cough, night sweats, and weight loss. Sputum analysis confirms an active *Mycobacterium tuberculosis* infection. The patient is employed as a childcare worker at a local daycare center. Upon hearing the diagnosis, she becomes extremely agitated and explicitly forbids the physician from sharing her medical information with anyone, stating she intends to continue working while taking her medications. Furthermore, in her distressed state, she reveals a specific, detailed, and imminent plan to shoot a named coworker whom she blames for her current stress. She confirms she has a firearm at home.

Which of the following disclosures of information are legally and ethically appropriate without the patient's consent? (Select all that apply)

A 52-year-old man is hospitalized in the step-down unit for management of acute decompensated heart failure. During the night shift, the cross-covering physician is notified by the laboratory that the patient's serum potassium level is 2.7 mEq/L. The physician gives a verbal order over the telephone to the nurse to administer "40 milliequivalents of intravenous potassium chloride." Due to background noise, the nurse mishears the dose as "400 milliequivalents." Standard floor stock limits premixed intravenous potassium bags to a maximum of 40 mEq. However, because of a recent pharmacy inventory change, highly concentrated multidose potassium vials were temporarily placed in the unit's automated dispensing cabinet. The nurse withdraws the massive dose and begins administration. Shortly thereafter, the patient develops ventricular fibrillation, requiring immediate cardiopulmonary resuscitation, defibrillation, and transfer to the intensive care unit. The hospital administration is notified of this sentinel event. Which of the following is the most appropriate initial method to investigate the system failures that led to this adverse outcome?

An attending physician in a rural primary care clinic is evaluating a 32-year-old patient for a follow-up of poorly controlled asthma. The physician has managed this patient for three years. Toward the end of the visit, the patient hands the physician an expensive designer watch and a handwritten letter containing explicit romantic propositions. The patient steps closer to the physician and states, "I have felt this connection for a long time, and I know you feel it too." The patient is currently experiencing mild wheezing, and their asthma action plan requires immediate adjustment. Which of the following actions are appropriate for the physician to take in managing this situation? (Select all that apply)

An emergency medicine attending physician is working a busy weekend shift. A triage nurse approaches the attending and expresses concern about another staff physician, who has just arrived for their shift. The nurse reports that the arriving physician is slurring their words and stumbling. The attending physician approaches their colleague and immediately notes a strong odor of alcohol. The impaired physician is currently logging into a computer to pick up the first patient's chart. Which of the following is the most appropriate next step for the attending physician?

A 54-year-old woman is admitted to the general medical ward for community-acquired pneumonia. On hospital day 2, she develops acute agitation, diaphoresis, and tachycardia (120/min). The cross-cover night physician receives a page from the nurse stating, "The patient in room 412 is getting restless and her heart rate is up." The physician quickly reviews the electronic health record, notes a prominent "Alcohol Use Disorder" entry in her past medical history, and immediately concludes the patient is in alcohol withdrawal. Without performing a bedside evaluation or reviewing the recent vital signs (which showed a new fever of 39.2°C and blood pressure of 85/50 mmHg), the physician orders high-dose intravenous lorazepam. Two hours later, the patient requires transfer to the intensive care unit for septic shock secondary to an expanding empyema.

During the subsequent morbidity and mortality conference, a root cause analysis is performed to identify the cognitive errors made and to propose durable, system-level human factors engineering solutions.

Which of the following statements correctly pair a cognitive error demonstrated in this case with an effective, strong system-level mitigation strategy? (Select the 2 correct answers)

A 35-year-old man is admitted to the medical ward for intravenous antibiotic treatment of uncomplicated cellulitis of the left lower extremity. On the second day of admission, he informs the care team that he plans to leave the hospital immediately to attend an urgent financial meeting for his business. The patient accurately describes his diagnosis, explicitly acknowledges the risk of worsening infection and sepsis if he leaves, and states that saving his business is currently his highest priority. A medical student on the team expresses concern and suggests that the patient's legal competence must be established before he can sign out against medical advice. Which of the following is the most appropriate next step in managing this patient's request?

A 32-year-old primigravida at 38 weeks gestation is admitted to the labor and delivery unit for induction of labor due to preeclampsia with severe features. A continuous intravenous magnesium sulfate infusion is initiated for seizure prophylaxis. During the evening shift change, the departing nurse is urgently called to assist with a fetal deceleration in an adjacent room before completing a standardized bedside handoff. The incoming nurse assumes the patient's baseline deep tendon reflexes (DTRs) were recently checked and documented. Three hours later, the patient develops profound bradypnea and absent DTRs. Prompt administration of intravenous calcium gluconate reverses the patient's symptoms. A subsequent safety investigation reveals two key findings: the smart infusion pump library was inadvertently patched with a default loading dose rate instead of a maintenance rate, and the electronic health record (EHR) features a mandatory alert to check DTRs every 2 hours that only appears on the interface of the clinician who initially scanned the medication barcode.

Which of the following best classifies the EHR alert design flaw in this patient's care sequence?

Match each clinical boundary dilemma (left) with the most appropriate physician response or ethical rationale (right).

Match each clinical scenario describing a patient encountering a medical decision with the underlying ethical or legal principle regarding decision-making capacity that it best illustrates.

A 58-year-old man is brought to the emergency department after sustaining a severe traumatic brain injury in a fall from a roof. He is intubated, comatose, and lacks medical decision-making capacity. The trauma surgery team determines he requires an urgent, but non-emergent, decompressive craniectomy to manage rising intracranial pressure. The patient is unable to provide informed consent. Several individuals arrive at the hospital, all expressing differing opinions on whether the surgery should proceed.

According to the standard legal hierarchy of surrogate decision-makers recognized in the majority of United States jurisdictions, arrange the following individuals in order of their priority to provide informed consent on behalf of the patient, from HIGHEST priority (first) to LOWEST priority (last).