, Question 1
A community health nurse is comparing two screening strategies for a
low-prevalence condition. Which change would most increase the positive
predictive value of a screening program without altering the test's sensitivity or
specificity?
A. Lowering the screening cutoff to capture more subclinical cases
B. Restricting screening to a higher-prevalence, higher-risk subgroup
C. Increasing the screening interval to reduce cumulative false positives
D. Reporting results using a two-stage confirmatory testing protocol
Correct Answer: B - Restricting screening to a higher-prevalence,
higher-risk subgroup
RATIONALE
PPV rises as disease prevalence in the screened population increases,
so targeting a higher-risk subgroup is the only option that changes
prevalence. Lowering the cutoff alters sensitivity/specificity,
lengthening the interval does not change prevalence, and serial testing
changes post-test probability rather than the intrinsic
prevalence-driven PPV of the first test.
Question 2
During a community health assessment, a nurse uses the
PRECEDE-PROCEED framework. Which activity best exemplifies a Phase 4
(educational and ecological) diagnosis?
A. Ranking leading causes of hospitalization in the catchment area
B. Identifying predisposing, enabling, and reinforcing factors for a target
behavior
C. Mapping the policy environment that funds the proposed program
D. Measuring quality-of-life indicators among residents
Correct Answer: B - Identifying predisposing, enabling, and
reinforcing factors for a target behavior
Page 2
, RATIONALE
Phase 4 of PRECEDE-PROCEED is educational/ecological diagnosis,
which classifies predisposing, enabling, and reinforcing factors.
Epidemiologic data belong to Phase 2, policy analysis to Phase 3
(behavioral/environmental), and quality-of-life assessment to Phase 1
(social diagnosis).
Question 3
A community coalition proposes a sugar-sweetened beverage tax. Which
outcome measure best reflects a distal, policy-level evaluation indicator rather
than an intermediate or proximal measure?
A. Change in self-reported weekly soda consumption among adults
B. Retail price increase per ounce of taxed beverages
C. Reduction in age-adjusted obesity prevalence over 5-10 years
D. Number of beverage industry lobbyist contacts with legislators
Correct Answer: C - Reduction in age-adjusted obesity
prevalence over 5-10 years
RATIONALE
Distal outcomes reflect long-term health status changes, such as
population obesity prevalence. Price change is an intermediate policy
output, consumption is a proximal behavioral outcome, and lobbying
activity is a process measure, not a health outcome.
Question 4
A nurse is interpreting an epidemiologic study in which the crude mortality
rate for a community is high, but the age-adjusted rate is near the state average.
What is the most valid inference?
A. The community has a genuinely elevated risk of death compared with
the state.
B. The high crude rate is likely driven by an older population age
Page 3
, structure.
C. Age adjustment has masked a true excess mortality signal.
D. The state average is unreliable because it includes the community.
Correct Answer: B - The high crude rate is likely driven by an
older population age structure.
RATIONALE
Age adjustment removes the effect of differing age distributions; when
the adjusted rate is near average, the crude elevation is largely
explained by an older population. The other options misstate the
purpose of adjustment or the validity of the comparison.
Question 5
A local health department must allocate limited influenza vaccine during a
shortage. Which framework is most defensible for prioritizing populations
under current public health ethics guidance?
A. First-come, first-served at mass vaccination sites
B. Highest income tier to ensure program revenue
C. Risk-based allocation targeting those at greatest risk of severe
outcomes and essential workers
D. Random lottery excluding health care personnel
Correct Answer: C - Risk-based allocation targeting those at
greatest risk of severe outcomes and essential workers
RATIONALE
Scarce vaccine allocation follows ethical frameworks prioritizing risk
of severe outcomes, occupational exposure, and equity. First-come
and income-based approaches violate equity and utility, and excluding
health care personnel undermines health system capacity.
Page 4
A community health nurse is comparing two screening strategies for a
low-prevalence condition. Which change would most increase the positive
predictive value of a screening program without altering the test's sensitivity or
specificity?
A. Lowering the screening cutoff to capture more subclinical cases
B. Restricting screening to a higher-prevalence, higher-risk subgroup
C. Increasing the screening interval to reduce cumulative false positives
D. Reporting results using a two-stage confirmatory testing protocol
Correct Answer: B - Restricting screening to a higher-prevalence,
higher-risk subgroup
RATIONALE
PPV rises as disease prevalence in the screened population increases,
so targeting a higher-risk subgroup is the only option that changes
prevalence. Lowering the cutoff alters sensitivity/specificity,
lengthening the interval does not change prevalence, and serial testing
changes post-test probability rather than the intrinsic
prevalence-driven PPV of the first test.
Question 2
During a community health assessment, a nurse uses the
PRECEDE-PROCEED framework. Which activity best exemplifies a Phase 4
(educational and ecological) diagnosis?
A. Ranking leading causes of hospitalization in the catchment area
B. Identifying predisposing, enabling, and reinforcing factors for a target
behavior
C. Mapping the policy environment that funds the proposed program
D. Measuring quality-of-life indicators among residents
Correct Answer: B - Identifying predisposing, enabling, and
reinforcing factors for a target behavior
Page 2
, RATIONALE
Phase 4 of PRECEDE-PROCEED is educational/ecological diagnosis,
which classifies predisposing, enabling, and reinforcing factors.
Epidemiologic data belong to Phase 2, policy analysis to Phase 3
(behavioral/environmental), and quality-of-life assessment to Phase 1
(social diagnosis).
Question 3
A community coalition proposes a sugar-sweetened beverage tax. Which
outcome measure best reflects a distal, policy-level evaluation indicator rather
than an intermediate or proximal measure?
A. Change in self-reported weekly soda consumption among adults
B. Retail price increase per ounce of taxed beverages
C. Reduction in age-adjusted obesity prevalence over 5-10 years
D. Number of beverage industry lobbyist contacts with legislators
Correct Answer: C - Reduction in age-adjusted obesity
prevalence over 5-10 years
RATIONALE
Distal outcomes reflect long-term health status changes, such as
population obesity prevalence. Price change is an intermediate policy
output, consumption is a proximal behavioral outcome, and lobbying
activity is a process measure, not a health outcome.
Question 4
A nurse is interpreting an epidemiologic study in which the crude mortality
rate for a community is high, but the age-adjusted rate is near the state average.
What is the most valid inference?
A. The community has a genuinely elevated risk of death compared with
the state.
B. The high crude rate is likely driven by an older population age
Page 3
, structure.
C. Age adjustment has masked a true excess mortality signal.
D. The state average is unreliable because it includes the community.
Correct Answer: B - The high crude rate is likely driven by an
older population age structure.
RATIONALE
Age adjustment removes the effect of differing age distributions; when
the adjusted rate is near average, the crude elevation is largely
explained by an older population. The other options misstate the
purpose of adjustment or the validity of the comparison.
Question 5
A local health department must allocate limited influenza vaccine during a
shortage. Which framework is most defensible for prioritizing populations
under current public health ethics guidance?
A. First-come, first-served at mass vaccination sites
B. Highest income tier to ensure program revenue
C. Risk-based allocation targeting those at greatest risk of severe
outcomes and essential workers
D. Random lottery excluding health care personnel
Correct Answer: C - Risk-based allocation targeting those at
greatest risk of severe outcomes and essential workers
RATIONALE
Scarce vaccine allocation follows ethical frameworks prioritizing risk
of severe outcomes, occupational exposure, and equity. First-come
and income-based approaches violate equity and utility, and excluding
health care personnel undermines health system capacity.
Page 4
