NR 509 final exam 2022 / nrNR509 Final Questions & Answers.

1. A 44-year-old female mathematician presents to clin- ic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self-ex- amination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mam- mogram was ordered as a routine screening test at c. This patient was in compliance with the U.S. Pre- ventive Services Task Force (USP- STF) recommen- dations for her age group and risk fac- age 43 years after a brief discussion with her primary tors prior to her care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group? a. BSE is well evidenced, and all recommending agen- cies agree that it should be taught and reinforced. b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examina- tions starting at age 30 years. c. This patient was in compliance with the U.S. Pre- ventive Services Task Force (USPSTF) recommenda- tions for her age group and risk factors prior to her current complaint. d. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately. e. Breast cancer screening is extremely well stud- ied, and no controversy exists on the recommended norms for screening and follow-up. 2. A 42-year-old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mam- mography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modal- current complaint. b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of speci- ficity. ity for breast cancer in the general population? a. Breast cancer screening by MRI has been well studied in the general population. b. Sensitivity of screening for breast cancer increas- es with breast MRI at the expense of specificity. c. This patient is an ideal candidate for screening via breast MRI based on current evidence. d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI. e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI. 3. A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This dis- charge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irreg- ular periods over the last few months. On examina- tion, she is able to express a small amount of dis- charge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis? a. Mastitis b. Ductal carcinoma in situ c. Paget disease of the breast d. Occult pregnancy e. Prolactinoma 4. A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self-examination (BSE) at home. The mass is non- e. Prolactinoma b. This patient is more likely to find a fibroadeno- tender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self-detection of breast cancer? a. Most masses that women find at home and bring to a provider's attention turn out to be malignant. b. This patient is more likely to find a fibroadenoma than a cancer on self-examination. c. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis. d. Because of this patient's age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low. e. BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions. 5. A 48-year-old female psychologist presents to clin- ic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father's side in as many years to be diagnosed with breast cancer, including the patient's own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grand- parents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further infor- mation about whether this would be appropriate for her. Which of the following is true about this patient's indications for BRCA testing? ma than a can- cer on self-exami- nation. d. This patient car- ries several risk factors that togeth- er justify BRCA testing. a. Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing her risk for these genes. b. Breast cancer in a male relative does not add sig- nificant weight to the decision to test for the BRCA genes in this patient. c. The BRCAPRO calculator does not add any further clinical information to this patient's risk for carrying the BRCA gene. d. This patient carries several risk factors that togeth- er justify BRCA testing. e. Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recom- mended. 6. A 68-year-old former paleontologist presents to clin- ic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnor- mal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imag- ing (MRI) screening of this patient? a. No agency recommends breast MRI for a patient such as this one, who has moderately but not extra- ordinary risk factors for breast cancer. b. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients with such risk factors. c. Regardless of recommenda- tions, the high sensitivity of breast MRI comes at the expense of markedly de- creased specificity (i.e., the ability to rule out disease in healthy breasts). c. Regardless of recommendations, the high sensitiv- ity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out dis- ease in healthy breasts). d. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual. e. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient. 7. A 66-year-old female museum curator presents for a routine annual examination. On examination, a no- tably enlarged supraclavicular lymph node is appre- ciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized e. Metastatic breast cancer cells may spread directly into the infraclavicular and or systemic symptoms such as breast lumps, fevers, then supraclavicu- or night sweats. She has been taking conjugated es- trogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this pre- sentation of lymphadenopathy? a. Breast cancer always presents with axillary lym- phadenopathy because the lymphatics of the breast uniformly drain into the axilla. b. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up. c. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck. d. Firm, rubbery lymph nodes are generally consid- ered to be benign. e. Metastatic breast cancer cells may spread direct- ly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. 8. lar nodes without first causing no- table changes in the axillary nodes. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile, non- tender mass is palpated in the right breast as de- scribed by the patient, which is consistent with a fir- broadenoma. In describing the location of the mass, a. "Rubbery, mo- bile, nontender mass located in right breast, in the 10:30 position the examiner notes that it is 3 cm proximal to and 3 cm from the nipple" to the left of the nipple. Which of the following would be the most appropriate way to report this finding? a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple" b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant" c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant" d. "Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant" e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple" 9. A 54-year-old female dietician presents for a routine annual examination. On review of systems, she re- ports that she has had many breast findings over sev- eral years, including one biopsy with normal pathol- ogy. She feels that her breasts have become far less c. Glandular tis- sue of the breast atrophies with menopause, primarily due to lumpy since she underwent menopause 3 years ago. decrease in the Which of the following is true regarding changes in the breasts with menopause? a. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and speci- ficity of mammograms. b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause. c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. d. Breast density has no genetic component and is entirely due to estrogen dose from endogenous and number of lobules. exogenous sources over the lifetime. e. Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason. 10. An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of in- tense abdominal pain, light-headedness, and a faint- ing episode that finally prompted her to seek medical attention. She has a strong family history of gall- stones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a nor- mal bowel movement this morning. Her ²h- uman chori- onic gonadotropin (²h- CG) is positive at triage. She re- ports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely di- agnosis? a. Ruptured tubal (or ectopic) pregnancy b. Acute cholecystitis c. Ruptured appendix d. Perforated bowel wall e. Ruptured ovarian cyst 11. A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dys- lipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moder- ate elevations of aspartate aminotransferase, alanine aminotransferase, ³g- lutamyl transferase, and alkaline phosphatase as well as a mildly elevated total biliru- bin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his a. Ruptured tubal (or ectopic) preg- nancy e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration liver. Which of the following findings would be most consistent with hepatomegaly? a. Liver span of 11 cm at the midclavicular line b. Liver span of 8 cm at the midsternal line c. Dullness to percussion over a span of 11 cm at the midclavicular line d. Dullness to percussion over a span of 8 cm at the midsternal line e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration 12. A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a sev- eral month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and de- nies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxy- gen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aor- ta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? a. Female gender b. History of smoking c. Underweight d. Family history of ruptured aneurysm e. Hypertension 13. A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his pre- ventive health care. He has a positive FOBT on one b. History of smok- ing a. Do not screen routinely occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal can- cer or adenomatous polyps. What are the U.S. Preven- tive Services Task Force (USPSTF) screening recom- mendations for this patient? a. Do not screen routinely b. Continue annual FOBT screening until age 80 years c. Continue annual FOBT screening until age 85 years d. Repeat colonoscopy this year e. Sigmoidoscopy every 5 years with FOBT every 3 years 14. An otherwise healthy 31-year-old accountant pre- sents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with on- set of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a. A large, firm fecal mass in the rectum b. Decreased fecal bulk c. Functional change in bowel movement d. Spasm of the external sphincter e. Impairment of autonomic innervations 15. A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiecta- sis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes c. Functional change in bowel movement a. Tympany to per- cussion in the right upper quad- rant, dullness to that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant b. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation c. Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease d. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line e. A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration 16. An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of se- vere abdominal pain. The emergency physician sus- percussion of the left upper quad- rant b. Pressing down onto the abdomen firmly and slow- pects appendicitis and general surgery is consulted. ly and withdrawing The resident believes the patient has signs of peri- tonitis on exam. Which of the following physical exam findings supports peritonitis? a. Voluntary contraction of the abdominal wall that persists over several examinations b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c. Abdominal pain that increases with hip flexion d. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus e. Pain with internal rotation of the right hip 17. A 58-year-old man with a history of diabetes and alco- hol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, the hand quickly produces pain e. Fibrosis of the pancreas and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? a. Helicobacter pylori infection b. Inflammation of the gallbladder c. Inflammation of colonic diverticulum d. Reduced blood supply to the bowel e. Fibrosis of the pancreas 18. A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? a. Exacerbating factor includes alcohol intake b. Positive McBurney point tenderness c. Poorly localized periumbilical pain d. Vomiting of bile e. Associated right shoulder pain 19. A 67-year-old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of pro- gressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most af- fected by vascular deficiencies related to his preex- isting medical conditions and is likely contributing to his symptoms? a. Corpora cavernosa b. Ejaculatory duct e. Associated right shoulder pain a. Corpora caver- nosa c. Epididymis d. Seminal vesicle e. Vas deferens Submit 20. A 29-year-old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem? a. Androgen insufficiency b. Endocrine dysfunction c. Peyronie disease d. Psychogenic e. Sexually transmitted infection (STI) 21. Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following? a. Follicle-stimulating hormone (FSH) b. Gonadotropin-releasing hormone (GRH) c. Luteinizing hormone (LH) d. Nitric oxide (NO) and cyclic guanosine monophos- phate (cGMP) e. Testosterone 22. The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages? a. 6-9 months d. Psychogenic d. Nitric ox- ide (NO) and cyclic guano- sine monophos- phate (cGMP) d. 9-21 years b. 1-3 years c. 5-7 years d. 9-21 years e. 30-50 years 23. A 32-year-old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumi- nation is noted. What is the most likely diagnosis? a. Direct hernia b. Indirect hernia c. Spermatocele d. Testicular tumor e. Varicocele 24. A 25-year-old graduate student presents to the clinic complaining of scrotal pain, which has been increas- ing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis? a. Acute epididymitis b. Hydrocele c. Primary syphilis d. Spermatocele e. Testicular cancer 25. A 32-year-old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of aver- age height and weight and has normal secondary c. Spermatocele a. Acute epi- didymitis c. Follicle-stimu- lating hormone (FSH) sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility? a. 5±D- ihydrotestosterone b. 5±R- eductase c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH) e. Thyroid-stimulating hormone (TSH) 26. While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an ex- ternal examination of the abdominal wall or inguinal region? a. External inguinal ring b. Internal inguinal ring c. Pubic tubercle d. Anterior superior iliac spine e. Direct inguinal hernia 27. A 20-year-old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of pre- venting sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention? a. Early withdrawal b. Male condoms c. Spermicides d. Diaphragms e. Cervical caps 28. A 21-year-old college student presents to the student health clinic for a full physical examination. He is gen- erally healthy; however, he reports that he has had b. Internal inguinal ring b. Male condoms c. Explain this is a normal response sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician proceed at this point? a. Stop the examination immediately. b. Have him return to see another provider. c. Explain this is a normal response and finish the examination. d. Tell him the examination cannot proceed until the erection subsides. e. Assume that he is malingering. Submit 29. A 45-year-old driver's education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her preg- nancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding? a. Large colonic stool b. Ovarian mass c. Fibroids d. 4-Month pregnancy e. Bartholin gland enlargement 30. A 32-year-old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient and finish the ex- amination. c. Fibroids a. Prior pelvic inflammatory dis- ease (PID) relates she began her periods at age 12 and has been fairly regular ever since. She began oral contracep- tive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient's history, what is the best explanation for her infertility? a. Prior pelvic inflammatory disease (PID) b. Prior Bartholin gland infection c. Prior herpes infection d. Metabolic disorder with subsequent hormonal ir- regularities leading to anovulation e. Secondary amenorrhea 31. A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most impor- tant area to obtain cells for a Pap smear? a. Zona reticularis b. Transformation zone c. Squamous zone d. Columnar zone e. Linea nigra 32. A 35-year-old grade school teacher presents for her b. Transformation zone c. The mass dents annual exam. Her last Pap smear was 4 years ago and with digital pres- normal. She is a G1P1 with a 6-year-old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A sure speculum exam is done followed by a bimanual exam- ination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass? a. No cervical motion tenderness b. No pus from the os c. The mass dents with digital pressure d. Both adnexa are nontender e. The perineum has no lesions 33. A 21-year-old college student presents for her first c. Raised friable or annual exam. She has been sexually active for 1 year lobed lesions and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions? a. Several shallow ulcers with a red base b. Translucent nodules c. Raised friable or lobed lesions d. Bright red, soft lesion arising from the cervical canal e. Strawberry cervix (small red granular spots or pe- techiae) 34. A 23-year-old female comes to the clinic to discuss her birth control options. Although she has been sex- ually active since age 16 years, she has been with one partner for the last year. She has decided to discon- tinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex a. She is on her menses. with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam? a. She is on her menses. b. She has only one current partner and does not need STI testing. c. She had a normal Pap smear within the last 3 years. d. She should not be sexually active. e. She has been using condoms. 35. An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID? a. Cervical os b. Posterior fornix c. Anterior fornix d. Skene gland opening e. Bartholin gland opening 36. A 27-year-old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last a. Cervical os c. Withdraw the speculum slight- week. She reached menarche at age 12 years, became ly and reposition sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not it on a different slope. having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix? a. Replace the speculum with a larger one (large Graves). b. Withdraw the speculum and do a bimanual exam to find the cervix. c. Withdraw the speculum slightly and reposition it on a different slope. d. Replace the speculum with a plastic one with a better light source. e. Discontinue the speculum exam and treat empiri- cally. 37. A 63-year-old office worker comes to the clinic for her women's health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam? a. Sitting b. Supine c. Prone d. Trendelenburg e. Lithotomy 38. A 68-year-old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when e. Lithotomy a. Levatori ani she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall? a. Levatori ani b. Anal sphincter c. Pubis symphysis d. Ischiocavernosus muscle e. Bulbocavernosus muscle 39. A 49-year-old male nurse experiences fecal incon- tinence after a motor vehicle accident that left him paralyzed below the waist. He asks his rehabilitation physician about the control of this function in a per- son without his injuries. Which of the following is true regarding the muscle control of the anal sphincter? a. The internal anal sphincter is under voluntary con- trol, whereas the external anal sphincter is under involuntary control. b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. c. Both internal and external anal sphincter are under voluntary control. d. Both internal and external anal sphincter are under involuntary control. e. Control of the anal sphincters is variable between individuals. 40. A 62-year-old male who is undergoing evaluation for possible prostate cancer strongly declines a rectal examination, stating that, "Some trainee once did that and it hurt badly." Which of the following is true about the innervation of the anus and rectum that may ex- plain this patient's experience of discomfort? a. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. d. The anal canal has a rich so- matosensory in- nervation, making poorly directed ex- aminations painful in this area. nerves, making the rectum the most likely source of this patient's discomfort. b. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient's discomfort. c. Proximal to the dentate line, the lower gastrointesti- nal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patient's pain. d. The anal canal has a rich somatosensory innerva- tion, making poorly directed examinations painful in this area. e. The dentate or pectinate line does not differentiate any neurological input, making the area either prox- imal or distal to the line equally responsible for this patient's discomfort. 41. A 54-year-old male with a strong family history of breast and prostate cancer presents to his prima- ry care provider to discuss prostate screening. His father died at age 73 years from prostate cancer that was not detected on routine digital rectal exam- inations (DREs), and he would like to minimize his chance of a similar occurrence. Which of the follow- ing is true regarding the anatomy and screening of the prostate by DRE? a. All three lobes of the prostate are palpable on DRE. b. The seminal vesicles are palpable distal to the prostate on DRE. c. The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE. d. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE. e. A prostate of 5 cm diameter without palpable nodes or masses represents a normal prostate examination. c. The medi- an lobe of the prostate is located anterior to the ure- thra and is not pal- pable on DRE. 42. e. Cervix A third-year medical student rotating on the internal medicine service performs a digital rectal examina- tion (DRE) on a 56-year-old female patient. The pa- tient has been admitted for suspicion of a myocardial infarction, and confirmation that there is no blood in the stool is required before anticoagulation can be started. The student reports that the fecal occult blood test was negative but notes that he palpated a structure through the anterior rectum that he could not identify. The attending physician confirms normal anatomy and reviews with the student that the most likely identity of the structure palpable is which of the following? a. Sacrum b. Pectinate line c. Uterine fundus d. Prostate e. Cervix 43. A 45-year-old female executive reports to her prima- ry care provider that she has recently experienced a change in the patterns of her bowel movements. She expresses a great concern as her family history includes a maternal aunt who died of colon cancer at age 49 years; her mother has had colonoscopies every 3 years with numerous adenomatous polyps removed. Which of the following historical elements would be the most concerning for colon cancer in this patient? a. Long-term history of hemorrhoids b. Recent history of black, tarry stools c. Remote history of anal pruritus d. New-onset anal fissures e. Recent onset of small-caliber stools 44. A 49-year-old customer service representative pre- sents to his gastroenterologist for follow-up of his e. Recent on- set of small-cal- iber stools b. The patient should undergo long-standing inflammatory bowel disease (IBD). He was diagnosed with ulcerative colitis (UC) at age 37 years and has had irregular care for this condition since then. His sole colonoscopy was done at the time of diagnosis 12 years ago. His only relevant family history is of prostate cancer in his father; his mother and sisters are healthy. Which of the follow- ing is true about recommended screening for colon cancer in this patient? a. The patient should begin screening for colon can- cer 10 years prior to the age of onset of his father's prostate cancer. b. The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer. c. The patient is due for routine age-based colon can- cer screening by colonoscopy regardless of his risk factors. d. The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years. e. The patient's condition puts him at a high risk of bowel perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely. 45. A 49-year-old male with well-controlled HIV under- goes a proctoscopic examination as routine screen- ing for anal cancer. The patient is asymptomatic and specifically denies complaints of frequent urination (frequency), large volume of urination (polyuria), or repeated urination at night (nocturia). Under direct vi- sualization, the clinician observes a clear, circumfer- ential demarcation of proximal versus distal tissue. This demarcation was not palpable on digital rectal examination (DRE) prior to proctoscopy. What is the most likely origin of this finding? a. Pathological constriction of the anal canal b. Normal anatomy of the mucosal surface colonoscopy for his bowel condi- tion, which confers risk of colon can- cer. b. Normal anato- my of the mucosal surface c. Carcinoma d. Valve of Houston e. External anal sphincter 46. A 34-year-old female reports anal pain with defeca- tion. She notes incidentally to this complaint that she has developed episodic abdominal discomfort and sores in her mouth. Anoscopic examination reveals anal fissures that appear to be her source of pain. Which of the following underlying conditions is the clinician most likely to find? a. Inflammatory bowel disease (IBD) b. Lymphogranuloma venereum c. Human papillomavirus (HPV) d. Gonorrhea cervicitis e. Primary syphilis 47. A 53-year-old African American advertising agent presents for discussion of his prostate cancer risk and possible screening for this disease. His father was diagnosed at age 82 years with prostate cancer but died recently at age 87 years from a myocardial in- farction before the disease progressed. Family histo- ry also reveals that his mother died of ovarian cancer when he was age 10 years, and two of his maternal aunts had breast cancer. Which of the following is true about risk and screening for prostate cancer? a. The incidence of prostate cancer does not rise until age >65 years, thus this patient needs no screening at this time. b. Prostate cancer is always an aggressive neoplasm, thus the risks of overdiagnosis with screening is out- weighed by the benefits of early case-finding. c. This patient is at an elevated risk of prostate can- cer due to his family history, thus screening modal- ities should be discussed between the patient and provider. a. Inflammato- ry bowel disease (IBD) c. This patient is at an elevated risk of prostate can- cer due to his family history, thus screening modali- ties should be dis- cussed between the patient and provider. d. This patient's race is a protective factor for prostate cancer, thus reassurance is the only intervention nec- essary. e. The patient's family history in the female line is irrelevant to his own risks and can be safely ignored in discussion of his risk for prostate cancer. 48. A 64-year-old retired architect presents to his primary d. Setting nor- care provider with a magazine article about prostate cancer screening that states, "You should talk to your doctor about the ups and downs of prostate can- cer screening." The patient hands this to the clini- cian and states, "Tell me about the ups and down of prostate screening." Which of the following is true about prostate cancer screening? a. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should al- ways be ordered due to the malignant nature of the disease. b. The prostate-specific antigen (PSA) effectively dif- ferentiates aggressively malignant prostate tumors from indolent cases. c. The prostate-specific antigen (PSA) cut-off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer. d. Setting normal cut-offs for prostate-specific anti- gen (PSA) testing relies on balancing the risk of over- diagnosis with the risk of underdiagnosis. e. Most prostate cancers are palpable and sympto- matic by the time they are biopsied, reducing the need for screening as patients can report symptoms. 49. A thin, 58-year-old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign? mal cut-offs for prostate-spe- cific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of un- derdiagnosis. b. Ankylosing spondylitis a. Osteoporosis b. Ankylosing spondylitis c. Malignancy d. Infection e. Torticollis 50. During an evaluation of an athletic 30-year-old pa- tient, the clinician conducts an active range of mo- tion evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck? a. Splenius capitis b. Trapezius c. Splenius cervicis d. Sternocleidomastoid (SCM) e. Sacrospinalis Submit 51. An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine supports the body's weight? a. Vertebral arch b. Intervertebral disk c. Transverse process d. Vertebral body e. Spinous process 52. A 31-year-old day care worker presents with a wors- ening stiff, painful neck. On inspection, the patient's head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis? a. Torticollis b. Spondylolisthesis c. Osteoarthritis (OA) d. Thoracic kyphosis d. Sternocleido- mastoid (SCM) d. Vertebral body a. Torticollis e. Ankylosing spondylitis Submit 53. A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the exami- nation continues, which of the following maneuvers would confirm a likely diagnosis? a. Assess his ability to touch his toes b. Assess the lateral bending movement of his neck c. Compare the strength of his trapezia muscles d. Assess his ability to extend his back e. Check for listing of his trunk Submit 54. During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)? a. Scalenes b. Sternocleidomastoid (SCM) c. Splenius capitis d. Prevertebral muscles e. Splenius cervicis 55. During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group? a. Rotation of the spine b. Extension of the spine c. Flexion of the spine c. Compare the strength of his trapezia muscles b. Sternocleido- mastoid (SCM) b. Extension of the spine d. Lateral bending of the spine e. Rotation and lateral bending of the spine 56. The clinician is seeing a middle-aged patient who has a diagnosis of lumbar spinal stenosis. The patient's history is consistent with this diagnosis as he has e. Flexed forward posture with low- er extremity weak- pain in the back with walking that improves with rest. ness Which physical sign(s) are most consistent with his diagnosis? a. Hyperreflexia of the lower limb b. Pelvic tilt or drop c. Thoracic kyphosis d. Positive straight-leg raise e. Flexed forward posture with lower extremity weak- ness Submit 57. The clinician is seeing a 58-year-old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem? a. Osteoarthritis (OA) b. Rheumatoid arthritis (RA) c. Psoriatic arthritis d. Gout e. Polymyalgia rheumatica 58. A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What charac- teristic(s) are consistent with her diagnosis of RA? a. Stiffness follows joint activity. b. Joint distribution is asymmetrical. c. Swelling of the synovial tissue is seen in joints and tendon sheaths. d. It most frequently involves the first metatarsopha- a. Osteoarthritis (OA) c. Swelling of the synovial tissue is seen in joints and tendon sheaths. langeal joint. e. Tophi are found in the subcutaneous tissue. 59. A 55-year-old woman with a headache explains to the clinician that she has had headaches before, but c. The patient also has devel- this one is unusual because of some new symptoms. oped fever and Which of the following symptoms would prompt an immediate investigation? a. The headache is similar in nature to prior ones she has had for decades but more severe. b. The patient had a car accident and minor head trauma about 3 months ago. c. The patient also has developed fever and night sweats and thinks she lost some weight. d. The headache comes and goes. e. The patient lost her glasses. 60. In the case of a middle-aged female with a pounding headache, what is an effective question to ask the patient? a. Does the patient have any aura prior to the headaches? b. How old is the patient? c. Is she feeling stressed? d. Does she think she is losing her memory? e. Has she ever seen anyone with a stroke? 61. A 35-year-old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contra- night sweats and thinks she lost some weight. a. Does the pa- tient have any aura prior to the headaches? c. Take a fur- ther history and perform a very ceptive pills (OCPs), exercises, and has a steady job. careful neurologi- Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action? cal examination. a. Reassure her that this is a common pattern with migraines. b. Order studies to evaluate potential transient is- chemic attacks (TIAs) because she is on OCPs. c. Take a further history and perform a very careful neurological examination. d. Treat her for sinusitis. 62. An 82-year-old grandmother presents to the Emer- gency Department in the care of her extended fam- ily with new-onset speech impairment. According to family members, the patient awoke with this symp- tom as well as difficulty in understanding questions or following commands. Her past medical history is remarkable for atrial fibrillation but no other notable conditions. On examination, her speech is verbose but poorly comprehensible and lacks meaning. She is unable to follow simple commands. Which of the following best describes her speech disorder? a. Dysphonia with expressive deficit b. Dysarthria c. Wernicke aphasia d. Global aphasia e. Broca aphasia 63. A 74-year-old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial fea- tures and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recov- ery from his symptoms. The astute passenger was thanked and congratulated for recognizing the signs of acute stroke; this individual credited this recog- nition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risks and rapid recognition of suspected c. Wernicke apha- sia b. Hypertension is the leading risk factor for both is- chemic and hem- orrhagic stroke. strokes? a. Atrial fibrillation is not a risk factor for ischemic stroke in individuals age e75 years. b. Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. c. Obesity with normal glucose tolerance is not a risk factor for stroke. d. Transient ischemic attacks (TIAs) that resolve with- in in 1 hour confer a 5% risk of death from stroke within the next 12 months. e. Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours. 64. A 70-year-old male presents to the Emergency De- partment accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awoke with drooping of the right side of his mouth. He has a history of hypertension and diet-controlled diabetes, but no history of prior transient ischemic at- tacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a well-nourished, right-handed male, who has an obvious flattening of the right na- solabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The re- mainder of the neurologic examination is symmetric with intact strength and normal deep tendon reflex- es. Based on this history and physical examination, which of the following statements is true? a. The patient most likely has a central upper motor neuron lesion involving cranial nerve (CN) VII (the facial nerve). b. The patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent computed tomography (CT) scan. c. The patient most likely has had an embolic affecting d. The patient most likely has an isolated peripheral lower motor neu- ron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve. an upper motor neuron (UMN). d. The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve. e. The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) V, the trigeminal nerve. 65. In longstanding and poorly controlled hypertension, white matter tracts in the brain are subjected to ate- riolosclerotic effects. Which one of the following is most vulnerable to this process? a. Thalamus b. Basal ganglia c. Internal capsule d. Diencephalon e. Reticular activating system 66. A 14-year-old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of the photosensitivity complaint and the pupillary asymmetry? a. CN II b. CN III c. CN IV d. CN V e. CN VI 67. Parents bring in their 3-year-old toddler, stating that he has been pulling at his right ear and fussing all c. Internal capsule b. CN III b. CN IX day. Examination of the auditory canal shows a small green plastic toy piece partially obstructing the pas- sage. Which cranial nerve (CN) supplies the sensory innervation to that area and is conducting the boy's pain sensation? a. CN VII b. CN IX c. CN X d. CN XI e. CN XII 68. A new mother brings in her 6-month-old baby for not being able to keep his eyes together when looking to the left. On examination, both of his eyes appear in alignment (conjugate) when looking to the right. However, when looking to the left, the baby's left eye stays in the forward gaze position, while the right continues on with full adduction to the left. The eyes appear to be out of alignment (dysconjugate). Which cranial nerve (CN) is responsible for the dysfunction in looking left? a. Right oculomotor nerve (CN III) b. Right trochlear nerve (CN IV) c. Right abducens nerve (CN VI) d. Left oculomotor nerve (CN III) e. Left trochlear nerve (CN IV) f. Left abducens nerve (CN VI) 69. A 45-year-old physician is having increasing difficul- ty with speech for the past 6 months. She is less pre- cise in pronunciation of words (dysarthria), has found it more effortful to speak, and finds that her voice sounds more nasal than usual. On examination, her articulation is less than precise, especially with rapid repetition of single syllables, such as "ta-ta-ta-ta," "go-go-go-go," "la-la-la-la," and "ba-ba-ba." Her neu- rological examination is otherwise normal. Which f. Left abducens nerve (CN VI) b. Corticobulbar tract nervous system pathway is responsible for control of the muscles producing this symptom? a. Corticospinal tract b. Corticobulbar tract c. Spinothalamic tract d. Cerebellar system e. Posterior column system 70. A 63-year-old practicing attorney makes an appoint- ment with the office urgently for pain in his right leg for 3 days. Since working in the garden moving heavy bags of mulch for his wife this past weekend, he has had intermittent but excruciating pain shooting down the posterior aspect of his right leg. On examination, sensory loss to light touch in the right leg posteriorly, corresponding to a sacral 1 (S1) dermatome, is not- ed. Which reflex would be expected to be decreased compared to the other side? a. Right plantar (Babinski) b. Right ankle c. Right knee d. Left plantar (Babinski) e. Left ankle f. Left knee 71. An 82-year-old retired insurance broker complains of difficulty in walking, having to consciously lift up his feet so he does not trip, stumble, or fall. Both feet are affected equally; he has no sensory complaints or pain. This has been worsening over the past 3 years, and he has had to give up his beloved hiking. The symptoms are improved while wearing tall boots and worse when walking around the house with house slippers. What is the likely location of the pathology in this man? a. Frontal motor area of the cerebral cortex b. Right ankle d. Peripheral nerve b. Brainstem c. Lumbar spinal cord d. Peripheral nerve e. Distal muscle 72. A mother brings her 15-month-old toddler to the clinic for his preventive health care visit. The clinician takes the history and observes the child's interactions and behaviors and is then ready to begin the rest of the examination. Which of the following best describes the general approach to the pediatric examination of the young child? a. Always give immunizations prior to beginning the examination. b. Examine the child in the same order as for an adult patient. c. Children age <2 years do not need to be examined. d. Begin with least invasive parts of the examination first. e. Never examine a young child in the mother's lap. 73. In caring for children, physicians and other clinicians need to understand child development. Of the fol- lowing, which is a principle of normal child develop- ment? a. Child development proceeds along a predictable pathway in a healthy child. b. There is minimal variation in when children achieve milestones. c. All delays in development can be explained by one or two risk factors. d. Regression in developmental skills is not a cause for concern. e. A child's developmental level can be ignored in conducting an examination. d. Begin with least invasive parts of the examination first. a. Child devel- opment proceeds along a pre- dictable pathway in a healthy child. 74. 74. The parents of a 21-month-old child explain that their son used to speak nearly 50 words and was using 2-word phrases. In the last month or so, the child has not been using as many words and tends to echo what is being said to him rather than use language spontaneously. They want to know if this is normal. After taking a thorough developmental history, the clinician finds that the child makes poor eye contact and does not play with toys in a purposeful manner. The physical examination is normal except for the child's limited social interactions. There is a family history of autism in two first cousins. Which of the following would be the best response to the parents at this time? a. Reassure the parents that all toddlers lose skills at some point in development. b. Reassure the parents that the child is fine as long as he has not lost skills in other domains. c. Send the child to the Emergency Department (ED). d. Refer the child to a developmental and behavioral pediatrician. e. Refer the parents for mental health counseling. 75. A clinician is meeting the mother of a 5-year-old with asthma for the first time. The mother notes that the asthma has been poorly controlled and that the child has had multiple hospitalizations. The clinician inquires about family stressors and finds that the d. Refer the child to a developmen- tal and behavioral pediatrician. e. Develop a health promotion plan that includes more frequent vis- its and guidance parents are divorced, the mother recently lost her job, to assist fam- and the child spent 2 months living with her grand- parents who both smoke. Which of the following is the best example of the role of health promotion with this family? a. Plan less frequent pediatric visits because the fam- ily will take too much time. b. Delay immunizations because of the family stres- sors. ily with stres- sors and improve the child's asthma symptoms. c. Postpone vision and hearing screening because the child may not pass. d. Reassure the parent that the family stressors are not impacting the child's asthma. e. Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve the child's asthma symp- toms. 76. A clinician is reading the chart of a full-term newborn whose mother had an uneventful pregnancy in the hospital for the first time on the day of birth. In review- ing the infant's chart, the clinician notes that, in the delivery room, at 5 minutes, the infant had a heart rate >100, strong respiratory effort, was crying vigorously, moving actively, and had good color except for some acrocyanosis of the hands and feet. This infant's AP- GAR score is closest to which of the following? a. 9 b. 7 c. 5 d. 3 e. 1 77. A newborn who is floppy and limp, blue in color, with a heart rate of 60, and minimal respiratory effort has just been delivered. The infant has no grimace and only a very weak cry. What is the best immediate response to the infant in this situation? a. Discuss the infant's poor appearance with the par- ents who are both in the room. b. Suction the infant's mouth while waiting to calcu- late the 5-minute APGAR score. c. Dry the infant off and swaddle him. d. Begin neonatal resuscitation. e. Order a chest x-ray. a. 9 d. Begin neonatal resuscitation. 78. An infant is born 4 weeks preterm to a mother with a history of hypertension, severe diabetes, and alcohol abuse. The infant is noted to be small for gestational age (SGA), weighing just 1,500 g. Which of the follow- ing is the most important reason for assessing both gestational age and birth weight for any infant? a. These two factors help to anticipate certain medical and developmental problems. b. The parents should be informed of these. c. A SGA infant is at low risk for neonatal problems. d. A premature infant with a weight appropriate for gestational age has a very low risk for neonatal prob- lems. e. Full-term, appropriate-for-gestational age (AGA) in- fants having a high risk of long-term problems. 79. A clinician arrives at the hospital several hours after the birth of a full-term infant. The infant is rooming in with her parents and appears to be doing well. There were no problems with the pregnancy, labor, or delivery. The nurse asks if the baby should be taken back to the nursery for examination. What is the best response to the nurse? a. State that it will be much more efficient to conduct the examination in the nursery. b. Note that the infant already had an examination in the delivery room and does not need another exami- nation so soon. c. State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do. d. Note that the lighting is better in the newborn nurs- ery. e. Refer the parents to a good book on newborns and wheel the infant back to the newborn nursery to conduct the examination. a. These two fac- tors help to antici- pate certain med- ical and develop- mental problems. c. State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do. 80. The nurse in the newborn nursery reports that she is concerned about Baby Boy Jones, who was born full-term by cesarean section for failure to progress. The pregnancy was complicated only by a maternal urinary tract infection in the first trimester. He had APGARs of 9 and 10 at 1 and 5 minutes, respectively, and had been doing well. However, now, on the fourth day of life, the infant has developed a tremor. Which of the following factors would cause the most concern about the tremor? a. There is a history of benign tremor in elderly family members. b. The infant also has asymmetric limb movements. c. The infant's vital signs are normal. d. The tremor is brief and only present when the infant is crying vigorously. e. The infant lies in a symmetric position with limbs flexed when relaxed. 81. A mother brings her 9-month-old son to the practice for the first time, concerned that he is not yet sitting by himself. After taking a careful history, the physi- cian notes that the infant has good head control and can grasp a rattle but is unable to roll over, crawl, or pull to stand. What should the clinician explain to the mother? a. Her child is progressing normally and does not need further evaluation. b. Gross motor development proceeds from peripher- al skills, such as finger feeding, to central skills, such as sitting. c. As long as the child is babbling, delays in gross motor skills are not a concern. d. Delays in gross motor skills are usually because of lack of coordination and catch up as the child ages. e. The delay in his physical motor skills is concerning b. The infant also has asymmetric limb movements. e. The delay in his physical motor skills is concern- ing and warrants a more complete de- velopmental histo- ry and possible re- ferral for early in- tervention. and warrants a more complete developmental history and possible referral for early intervention. 82. A 42-year-old school teacher with a history of irreg- ular periods who underwent successful intrauterine insemination (IUI) on January 25th presents to the clinic for care on March 19th. Her last menstrual pe- riod (LMP) was November 11th of the previous year. Which of the following is true about the gestational age of her pregnancy? a. It is determined by her LMP. b. It is 18 weeks and 2 days. c. It is determined by date of insemination plus 2 weeks. d. It is determined by the opinion of the specialist who completed the procedure. e. It is indeterminate due to the IUI procedure. 83. A 32-year-old patient with two prior pregnancies pre- sents to clinic concerned that she may be pregnant