COMLEX-USA Level 2-CE (Cognitive Evaluation)
Licensure Exam V1
1. A 45-year-old male presents with dull, aching low back pain after lifting boxes. Physical
exam reveals a positive seated flexion test on the right. In the prone position, the right sacral
sulcus is deeper than the left, and the left inferior lateral angle (ILA) is posterior. The
asymmetry improves when the patient rests on his elbows. Which of the following is the
most likely diagnosis?
A. Right-on-right forward torsion
B. Left-on-left forward torsion
C. Left-on-right backward torsion
D. Right-on-left backward torsion
Correct Answer: A
Explanation: The positive seated flexion test on the right indicates a sacroiliac dysfunction
on the right side. A deeper right sulcus and posterior left ILA, which improves with lumbar
extension (Sphinx test), signifies a forward (neutral) sacral torsion. In forward torsions, the
side of the deep sulcus is opposite the axis, so a deeper right sulcus with a positive right
seated flexion test means the axis is on the left; however, standard Fryette-based sacral
rules for neutral torsions dictate that the rotation and axis are on the same side, making
this a right-on-right torsion. Clinical significance involves distinguishing between neutral
and non-neutral torsions to apply the correct muscle energy or HVLA technique. Pitfalls
,include misinterpreting the Sphinx test, which improves findings in forward torsions and
worsens them in backward torsions.
2. A 68-year-old female with a history of hypertension and chronic kidney disease presents
with worsening shortness of breath and pedal edema. Physical exam reveals bibasilar
crackles and an S3 gallop. An echocardiogram shows an ejection fraction of 35%. Which of the
following medications is most likely to provide a mortality benefit for this patient?
A. Furosemide
B. Lisinopril
C. Digoxin
D. Amlodipine
Correct Answer: B
Explanation: Lisinopril is an ACE inhibitor, which is a cornerstone of therapy for heart
failure with reduced ejection fraction (HFrEF) because it reduces afterload and inhibits
remodeling, thus providing a mortality benefit. Furosemide is highly effective for
symptomatic relief of fluid overload but has not been shown to reduce mortality in HFrEF.
Digoxin may reduce hospitalizations but does not improve survival rates. A common pitfall
is assuming all heart failure medications improve survival, whereas only specific classes
like ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists are
proven to do so.
,3. A 28-year-old primigravida at 38 weeks gestation presents with a blood pressure of
165/110 mmHg and a severe headache. Urinalysis shows 3+ protein. While being evaluated,
she has a generalized tonic-clonic seizure. After ensuring her airway is protected, which of the
following is the most appropriate next step in pharmacologic management?
A. Phenytoin
B. Diazepam
C. Valproic acid
D. Magnesium sulfate
Correct Answer: D
Explanation: Magnesium sulfate is the treatment of choice for preventing recurrent
seizures in eclampsia and is superior to standard anticonvulsants like phenytoin or
diazepam in this clinical setting. The clinical significance of this management is to prevent
further maternal morbidity and stabilize the patient before delivery, which is the definitive
treatment for eclampsia. Pitfalls include delaying magnesium therapy to obtain imaging or
attempting to treat with benzodiazepines alone, which are less effective at preventing
recurrence in the setting of preeclampsia/eclampsia.
4. A 4-week-old male infant is brought to the pediatrician for non-bilious, projectile vomiting
after every feeding. On physical exam, the infant appears dehydrated and a small, firm,
mobile mass is palpated in the right upper quadrant. Which of the following metabolic
abnormalities is most likely to be found on his lab results?
A. Hyperchloremic metabolic acidosis
, B. Hypochloremic, hyperkalemic metabolic alkalosis
C. Hypochloremic, hypokalemic metabolic alkalosis
D. Hyperchloremic metabolic alkalosis
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis leads to the loss of hydrochloric acid and
potassium from the stomach through vomiting, resulting in a characteristic metabolic
profile of hypochloremic, hypokalemic metabolic alkalosis. This condition is a surgical
emergency that requires fluid resuscitation and electrolyte correction before
pyloromyotomy. A common pitfall on exams is confusing this with the bilious vomiting
seen in duodenal atresia or malrotation, which would not typically cause this specific
alkalotic state.
5. A 55-year-old female presents with acute onset right upper quadrant pain that radiates to
her right shoulder. She also reports nausea and fever. Physical exam reveals tenderness and
guarding in the right upper quadrant, and inspiration is inhibited upon deep palpation of the
area. Which of the following is the most sensitive initial imaging study for this condition?
A. Ultrasound of the right upper quadrant
B. CT scan of the abdomen
C. Abdominal X-ray
D. HIDA scan
Correct Answer: A
Licensure Exam V1
1. A 45-year-old male presents with dull, aching low back pain after lifting boxes. Physical
exam reveals a positive seated flexion test on the right. In the prone position, the right sacral
sulcus is deeper than the left, and the left inferior lateral angle (ILA) is posterior. The
asymmetry improves when the patient rests on his elbows. Which of the following is the
most likely diagnosis?
A. Right-on-right forward torsion
B. Left-on-left forward torsion
C. Left-on-right backward torsion
D. Right-on-left backward torsion
Correct Answer: A
Explanation: The positive seated flexion test on the right indicates a sacroiliac dysfunction
on the right side. A deeper right sulcus and posterior left ILA, which improves with lumbar
extension (Sphinx test), signifies a forward (neutral) sacral torsion. In forward torsions, the
side of the deep sulcus is opposite the axis, so a deeper right sulcus with a positive right
seated flexion test means the axis is on the left; however, standard Fryette-based sacral
rules for neutral torsions dictate that the rotation and axis are on the same side, making
this a right-on-right torsion. Clinical significance involves distinguishing between neutral
and non-neutral torsions to apply the correct muscle energy or HVLA technique. Pitfalls
,include misinterpreting the Sphinx test, which improves findings in forward torsions and
worsens them in backward torsions.
2. A 68-year-old female with a history of hypertension and chronic kidney disease presents
with worsening shortness of breath and pedal edema. Physical exam reveals bibasilar
crackles and an S3 gallop. An echocardiogram shows an ejection fraction of 35%. Which of the
following medications is most likely to provide a mortality benefit for this patient?
A. Furosemide
B. Lisinopril
C. Digoxin
D. Amlodipine
Correct Answer: B
Explanation: Lisinopril is an ACE inhibitor, which is a cornerstone of therapy for heart
failure with reduced ejection fraction (HFrEF) because it reduces afterload and inhibits
remodeling, thus providing a mortality benefit. Furosemide is highly effective for
symptomatic relief of fluid overload but has not been shown to reduce mortality in HFrEF.
Digoxin may reduce hospitalizations but does not improve survival rates. A common pitfall
is assuming all heart failure medications improve survival, whereas only specific classes
like ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists are
proven to do so.
,3. A 28-year-old primigravida at 38 weeks gestation presents with a blood pressure of
165/110 mmHg and a severe headache. Urinalysis shows 3+ protein. While being evaluated,
she has a generalized tonic-clonic seizure. After ensuring her airway is protected, which of the
following is the most appropriate next step in pharmacologic management?
A. Phenytoin
B. Diazepam
C. Valproic acid
D. Magnesium sulfate
Correct Answer: D
Explanation: Magnesium sulfate is the treatment of choice for preventing recurrent
seizures in eclampsia and is superior to standard anticonvulsants like phenytoin or
diazepam in this clinical setting. The clinical significance of this management is to prevent
further maternal morbidity and stabilize the patient before delivery, which is the definitive
treatment for eclampsia. Pitfalls include delaying magnesium therapy to obtain imaging or
attempting to treat with benzodiazepines alone, which are less effective at preventing
recurrence in the setting of preeclampsia/eclampsia.
4. A 4-week-old male infant is brought to the pediatrician for non-bilious, projectile vomiting
after every feeding. On physical exam, the infant appears dehydrated and a small, firm,
mobile mass is palpated in the right upper quadrant. Which of the following metabolic
abnormalities is most likely to be found on his lab results?
A. Hyperchloremic metabolic acidosis
, B. Hypochloremic, hyperkalemic metabolic alkalosis
C. Hypochloremic, hypokalemic metabolic alkalosis
D. Hyperchloremic metabolic alkalosis
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis leads to the loss of hydrochloric acid and
potassium from the stomach through vomiting, resulting in a characteristic metabolic
profile of hypochloremic, hypokalemic metabolic alkalosis. This condition is a surgical
emergency that requires fluid resuscitation and electrolyte correction before
pyloromyotomy. A common pitfall on exams is confusing this with the bilious vomiting
seen in duodenal atresia or malrotation, which would not typically cause this specific
alkalotic state.
5. A 55-year-old female presents with acute onset right upper quadrant pain that radiates to
her right shoulder. She also reports nausea and fever. Physical exam reveals tenderness and
guarding in the right upper quadrant, and inspiration is inhibited upon deep palpation of the
area. Which of the following is the most sensitive initial imaging study for this condition?
A. Ultrasound of the right upper quadrant
B. CT scan of the abdomen
C. Abdominal X-ray
D. HIDA scan
Correct Answer: A
