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AANPCB A-GNP study materials
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AANPCB A-GNP practice questions

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Question 1Health Promotion and Disease Prevention

At what age should an average-risk adult with no family history of colorectal cancer begin screening?

  1. 55 years
  2. 35 years
  3. 60 years
  4. 45 years Correct answer.

Explanation

Average-risk adults should begin colorectal cancer screening at age 45. Earlier screening is reserved for people with increased risk, such as a strong family history or inherited syndrome. Starting at 55 or 60 misses the recommended window.

Question 2Health Promotion and Disease Prevention

At what age is recombinant zoster vaccine routinely recommended for healthy adults?

  1. 65 years
  2. 50 years Correct answer.
  3. 60 years
  4. 40 years

Explanation

Recombinant zoster vaccine is recommended for healthy adults beginning at age 50, regardless of prior herpes zoster history. The two-dose series helps prevent shingles and postherpetic neuralgia.

Question 3Health Promotion and Disease Prevention

Which adults should receive influenza vaccination annually?

  1. Only adults with chronic illness
  2. All adults unless contraindicated Correct answer.
  3. Only adults older than 65
  4. Only health care workers

Explanation

Annual influenza vaccination is recommended for all adults who do not have a contraindication. Age, chronic illness, and occupation affect risk but do not limit the general recommendation.

Question 4Health Promotion and Disease Prevention

At what interval should adults aged 18 and older without diagnosed hypertension be screened for hypertension?

  1. Only if symptomatic
  2. At every routine health care encounter Correct answer.
  3. Every 5 years
  4. Every 2 years

Explanation

Adults should be screened for hypertension at every routine health care encounter. Hypertension is often asymptomatic, so symptom-based screening would miss many cases. Routine measurement allows early treatment and cardiovascular risk reduction.

Question 5Health Promotion and Disease Prevention

Which counseling approach is recommended for every adult who uses tobacco?

  1. Ask, advise, and offer treatment Correct answer.
  2. Recommend e-cigarettes as first-line
  3. Advise abrupt cessation without follow-up
  4. Wait for patient to request help

Explanation

Brief tobacco counseling should include asking about use, advising cessation, and offering pharmacotherapy or referral. This approach is effective and should be repeated at routine visits. Waiting for the patient to ask misses opportunities for intervention.

Question 6Health Promotion and Disease Prevention

Which screening tool is recommended for adults to identify unhealthy alcohol use?

  1. AUDIT-C Correct answer.
  2. GAD-7
  3. MMSE
  4. PHQ-9

Explanation

The AUDIT-C is a brief validated tool for identifying unhealthy alcohol use in adults. It asks about consumption frequency, quantity, and binge drinking. Other listed tools screen for anxiety, depression, or cognition.

Question 7Health Promotion and Disease Prevention

Which woman should be screened for osteoporosis with bone densitometry?

  1. Women aged 65 and older Correct answer.
  2. Only women with back pain
  3. All women at age 40
  4. Only women with prior fracture

Explanation

Bone densitometry is recommended for women aged 65 and older and for younger postmenopausal women at increased risk. Screening before age 65 is based on risk factors rather than age alone. Prior fracture and back pain may prompt evaluation but are not the general screening criterion.

Question 8Health Promotion and Disease Prevention

At what age does the American Diabetes Association recommend beginning routine diabetes screening for asymptomatic adults with no risk factors?

  1. 25 years
  2. 30 years
  3. 35 years Correct answer.
  4. 40 years

Explanation

The American Diabetes Association recommends beginning routine diabetes screening at age 35 for asymptomatic adults without risk factors. Screening should be repeated at least every 3 years if results are normal. Earlier screening is indicated for adults with risk factors.

Question 9Health Promotion and Disease Prevention

A 52-year-old woman at average risk asks about breast cancer screening. Which recommendation is most consistent with the USPSTF?

  1. Mammography only after age 60
  2. Biennial mammography, ages 40-74 Correct answer.
  3. Annual breast MRI beginning at age 40
  4. Clinical breast exam every 5 years

Explanation

The USPSTF recommends biennial mammography for average-risk women aged 40 through 74. Breast MRI is reserved for women at high risk, such as those with BRCA mutations. Clinical breast examination alone is not recommended as a screening method.

Question 10Health Promotion and Disease Prevention

Which patient meets criteria for annual low-dose CT lung cancer screening?

  1. 50-year-old current smoker with 15 pack-years
  2. 45-year-old with 10 pack-years who quit 5 years ago
  3. 60-year-old with 30 pack-years, quit 10 years ago Correct answer.
  4. 70-year-old nonsmoker with COPD

Explanation

Lung cancer screening is recommended for adults aged 50 to 80 with at least 20 pack-years who currently smoke or quit within the past 15 years. This patient meets the age, pack-year, and quit-time criteria. The other patients do not meet the minimum age or pack-year thresholds.

Question 11Health Promotion and Disease Prevention

Which adult should receive one-time hepatitis C antibody screening?

  1. Only adults with jaundice
  2. Only adults who inject drugs currently
  3. All adults aged 18 to 79 once Correct answer.
  4. Only adults born before 1965

Explanation

Hepatitis C screening is recommended at least once for all adults aged 18 to 79. Risk-based screening should continue for people with ongoing risk. Jaundice and current injection drug use are not required for screening.

Question 12Health Promotion and Disease Prevention

Which adult should be screened for HIV at least once?

  1. Only adults with symptoms
  2. Only adults with a prior STI
  3. Only men who have sex with men
  4. All adults aged 15 to 65 Correct answer.

Explanation

HIV screening is recommended at least once for all adults aged 15 to 65. Younger and older adults should be screened if they have risk factors. Screening should not be limited to symptomatic people or those with known risk factors.

Question 13Health Promotion and Disease Prevention

A 58-year-old man has LDL 130 mg/dL, no diabetes, a 10-year ASCVD risk of 12%, and is not on a statin. What is the best action?

  1. Start high-intensity statin regardless
  2. Start moderate-intensity statin Correct answer.
  3. No statin; recheck in 5 years
  4. Start ezetimibe alone

Explanation

Adults aged 40 to 75 with a 10-year ASCVD risk of 10% or greater should usually start a moderate-intensity statin. High-intensity statin is reserved for higher-risk situations such as clinical ASCVD or diabetes with multiple risk factors. Ezetimibe is not first-line primary prevention.

Question 14Health Promotion and Disease Prevention

A 70-year-old with no history of ASCVD asks about aspirin for primary prevention. What is recommended?

  1. Start aspirin 325 mg daily
  2. Start aspirin 81 mg daily
  3. No aspirin for primary prevention Correct answer.
  4. Start aspirin only if LDL is elevated

Explanation

For adults aged 60 and older, the risk of bleeding generally outweighs the benefit of starting aspirin for primary prevention. Aspirin may be considered in selected adults aged 40 to 59 with elevated ASCVD risk and low bleeding risk. LDL level alone is not a reason to start aspirin.

Question 15Health Promotion and Disease Prevention

A 22-year-old woman has not received HPV vaccine. What is appropriate?

  1. Give one dose only
  2. Give vaccine only if HPV positive
  3. Offer catch-up HPV vaccination Correct answer.
  4. No vaccine after age 18

Explanation

HPV vaccination is recommended as catch-up for adults through age 26 if not vaccinated previously. Shared clinical decision-making applies for ages 27 to 45. A positive HPV test does not preclude vaccination.

Question 16Health Promotion and Disease Prevention

Which intervention is most appropriate for a 75-year-old with a fall in the past year?

  1. Advise avoiding all exercise
  2. Recommend bed rest
  3. Order a cane without assessment
  4. Multifactorial fall risk assessment Correct answer.

Explanation

Older adults with a recent fall are at increased risk for further falls and should receive a multifactorial fall risk assessment. Assessment addresses gait, strength, vision, medications, and home hazards. Exercise is a key component of fall prevention rather than something to avoid.

Question 17Health Promotion and Disease Prevention

Which statement best describes advance care planning for a healthy 70-year-old?

  1. Begin before a crisis occurs Correct answer.
  2. It is needed only after terminal diagnosis
  3. It requires a lawyer to be valid
  4. It should be deferred until age 85

Explanation

Advance care planning should begin while the patient can discuss goals and preferences, before a crisis occurs. It may include identifying a health care proxy and documenting preferences. A lawyer is not required for all advance care planning documents.

Question 18Health Promotion and Disease Prevention

Which screening tool is recommended for initial depression screening in adults?

  1. PHQ-2 Correct answer.
  2. AUDIT-C
  3. CAGE
  4. MMSE

Explanation

The PHQ-2 is a brief initial screen for depression and is followed by the PHQ-9 when positive. Depression screening is recommended for adults in settings where follow-up and treatment are available. MMSE, AUDIT-C, and CAGE assess cognition, alcohol use, and alcohol use, respectively.

Question 19Health Promotion and Disease Prevention

A 45-year-old has a BMI of 32 kg/m². Which is the recommended first step?

  1. Bariatric surgery referral
  2. Advise no intervention until BMI 40
  3. Prescribe phentermine without counseling
  4. Intensive behavioral counseling Correct answer.

Explanation

Adults with obesity should be offered intensive multicomponent behavioral interventions that address diet, physical activity, and behavior change. Pharmacotherapy and bariatric surgery may be considered for selected patients but are not the first step for everyone. Intervention should not be delayed until BMI reaches 40.

Question 20Health Promotion and Disease Prevention

Which approach is appropriate for cognitive impairment screening in an older adult with memory complaints?

  1. Use a validated brief tool Correct answer.
  2. Reassure without testing
  3. Order APOE genotyping
  4. Screen only if family requests

Explanation

When an older adult has memory complaints, use a validated brief cognitive screening tool such as the Mini-Cog. Screening should be paired with evaluation for reversible causes and follow-up. APOE genotyping is not a screening test for cognitive impairment.

Question 21Health Promotion and Disease Prevention

A 55-year-old man asks about prostate cancer screening. What is the most appropriate approach?

  1. Order PSA without discussion
  2. Shared decision-making about PSA Correct answer.
  3. Tell him screening is not recommended at any age
  4. Recommend routine annual PSA for all men

Explanation

For men aged 55 to 69, prostate cancer screening should be an individualized decision based on a discussion of benefits and harms. Routine PSA screening for all men is not recommended. Screening decisions should reflect patient values and preferences.

Question 22Health Promotion and Disease Prevention

A 65-year-old woman had a total hysterectomy for benign disease and has had normal cervical screening before. What is recommended?

  1. Start annual HPV testing
  2. Continue Pap every 3 years
  3. Perform Pap and HPV every 5 years
  4. Stop cervical cancer screening Correct answer.

Explanation

Cervical cancer screening can stop after total hysterectomy for benign disease if there is no history of cervical cancer or high-grade precancer and prior screening was normal. The cervix has been removed, so Pap and HPV testing are not indicated. Continued screening would provide no benefit and may cause harm.

Question 23Health Promotion and Disease Prevention

Which older adult is recommended to receive RSV vaccine?

  1. Adults aged 75 and older Correct answer.
  2. Only residents of nursing homes
  3. All adults at age 50
  4. Only those with COPD

Explanation

RSV vaccination is recommended as a single dose for all adults aged 75 and older. Adults aged 60 to 74 with increased risk, such as chronic lung disease, may also receive it. Vaccination is not limited to nursing home residents.

Question 24Health Promotion and Disease Prevention

Which woman should be referred for genetic counseling for hereditary breast and ovarian cancer?

  1. A 40-year-old with no family history
  2. A 30-year-old with no children
  3. A woman whose mother had ovarian cancer at 45 Correct answer.
  4. A 45-year-old with an aunt with breast cancer at 60

Explanation

A first-degree relative with ovarian cancer, especially at a young age, meets criteria for hereditary breast and ovarian cancer evaluation. A maternal history of ovarian cancer at 45 is a significant red flag. An aunt with breast cancer at 60 is less likely to meet referral criteria.

Question 25Health Promotion and Disease Prevention

Which adult should be screened for latent tuberculosis infection?

  1. Adult born in a high-incidence country Correct answer.
  2. A patient with a normal chest radiograph
  3. A person with a negative prior tuberculin test
  4. A 70-year-old with no risk factors

Explanation

Latent tuberculosis screening is recommended for people at increased risk, including adults born in countries with high tuberculosis incidence. A prior negative test or normal chest radiograph does not remove the need for screening when risk factors are present. Average-risk adults without risk factors do not require routine screening.

Question 26Health Promotion and Disease Prevention

A healthy 42-year-old man received a Tdap vaccine at age 32 after a laceration. He has no other immunization needs. What is the recommended tetanus and diphtheria booster schedule from now on?

  1. Annual Td booster
  2. Tdap booster every 5 years
  3. A single lifetime booster is sufficient
  4. Td or Tdap booster every 10 years Correct answer.

Explanation

Adults who have completed a primary series and received a tetanus-containing booster require Td or Tdap every 10 years, with one lifetime Tdap preferred for pertussis protection. Shorter intervals are reserved for wound management or pregnancy.

Question 27Health Promotion and Disease Prevention

A 30-year-old sedentary office worker wants to start exercising. Which activity prescription best matches national recommendations for adults?

  1. Sixty minutes of high-intensity aerobic exercise every single day of the week with no resistance training
  2. 150 minutes of moderate aerobic activity weekly plus 2 days of strength training Correct answer.
  3. Walking 20 minutes three times weekly
  4. Strength training only, three days per week

Explanation

Federal guidance for adults is at least 150 minutes of moderate-intensity (or 75 minutes vigorous) aerobic activity weekly plus muscle-strengthening activity on 2 or more days. This combination improves cardiometabolic and musculoskeletal health.

Question 28Health Promotion and Disease Prevention

A 27-year-old woman is planning a pregnancy within the next few months. Which preventive measure is recommended before conception?

  1. Iron 65 mg daily starting when pregnancy is confirmed
  2. Vitamin A 10,000 IU daily to support fetal development
  3. No supplements until a positive pregnancy test
  4. Folic acid 0.4 mg daily before conception Correct answer.

Explanation

Folic acid 0.4 mg (400 mcg) daily beginning at least 1 month before conception reduces the risk of neural tube defects, which occur in the first weeks of gestation. Women with a prior affected pregnancy generally need a higher dose.

Question 29Health Promotion and Disease Prevention

A healthy 66-year-old woman has never received a pneumococcal vaccine. Which regimen is recommended?

  1. Wait until age 75, when risk is highest
  2. No vaccine is needed unless she has a chronic condition
  3. A single dose of PCV20 Correct answer.
  4. Give PPSV23 only, since it covers more serotypes

Explanation

Adults 65 and older with no prior pneumococcal vaccination should receive a single dose of PCV20, or PCV15 followed by PPSV23. Age alone is the indication, so chronic disease is not required.

Question 30Health Promotion and Disease Prevention

A 46-year-old man at average risk for colorectal cancer has never been screened. What is the most appropriate recommendation?

  1. Wait until age 50, since he is still at low risk
  2. Schedule screening colonoscopy every 2 years beginning at age 50
  3. Begin screening now with colonoscopy or a stool-based test Correct answer.
  4. Obtain a baseline CEA level and repeat in one year

Explanation

Average-risk screening now begins at age 45, using colonoscopy every 10 years or an approved stool-based test at its recommended interval. Starting at 45 reduces incidence and mortality in younger adults.

Question 31Health Promotion and Disease Prevention

A 21-year-old sexually active woman with no symptoms asks what screening she needs. She has no history of sexually transmitted infection. Which is recommended?

  1. Annual HIV testing only
  2. Annual screening for chlamydia and gonorrhea Correct answer.
  3. Routine screening is not needed unless symptoms appear
  4. Screening for syphilis, chlamydia, and trichomonas every 6 months

Explanation

Sexually active women 24 years and younger should be screened annually for chlamydia and gonorrhea, since most infections are asymptomatic. HIV screening is recommended at least once for all adults, but chlamydia and gonorrhea screening is the age-specific need here.

Question 32Health Promotion and Disease Prevention

A 48-year-old man has blood pressure readings of 148/94 and 146/92 mm Hg at two office visits. He feels well. What is the best next step before diagnosing hypertension?

  1. Start an ACE inhibitor immediately based on these readings
  2. Confirm with home or ambulatory blood pressure monitoring Correct answer.
  3. Reassure him and recheck in one year
  4. Obtain an echocardiogram and renal artery duplex to exclude secondary causes

Explanation

Elevated office readings should be confirmed with out-of-office measurement (home or ambulatory monitoring) before a hypertension diagnosis and lifelong therapy. This identifies white-coat elevation and avoids overtreatment.

Question 33Health Promotion and Disease Prevention

A 52-year-old woman with obesity has an A1c of 6.0% and a fasting glucose of 112 mg/dL. What is the most appropriate next step?

  1. Begin basal insulin therapy now
  2. Advise weight loss only if she develops symptoms
  3. Repeat the A1c in 3 years because these values are within normal limits
  4. Refer to an intensive behavioral lifestyle program Correct answer.

Explanation

These values meet prediabetes criteria, and the cornerstone of management is referral to an intensive behavioral program modeled on the Diabetes Prevention Program: 7% weight loss and 150 minutes of activity weekly. Metformin is considered only in selected higher-risk patients after lifestyle intervention.

Question 34Health Promotion and Disease Prevention

Which zoster vaccination recommendation applies to a 55-year-old woman with no prior history of shingles?

  1. No vaccine until age 60
  2. One dose of live attenuated zoster vaccine
  3. Vaccination only if she has a documented history of chickenpox
  4. Two doses of recombinant zoster vaccine 2 to 6 months apart Correct answer.

Explanation

Recombinant zoster vaccine is recommended in two doses 2 to 6 months apart for all adults 50 and older, regardless of prior shingles or prior live vaccine. The live attenuated product is no longer recommended in the United States.

Question 35Health Promotion and Disease Prevention

A 28-year-old man who has sex with men reports multiple partners and inconsistent condom use. He asks about HIV prevention beyond condoms. What is the most appropriate recommendation?

  1. Offer daily tenofovir/emtricitabine as pre-exposure prophylaxis Correct answer.
  2. Reassure him that condom use alone is sufficient for someone his age
  3. Test for HIV annually and rely on consistent condom use
  4. Prescribe post-exposure prophylaxis to be started after each high-risk encounter

Explanation

Daily oral PrEP, combined with periodic HIV and STI testing, is recommended for adults at substantial risk of HIV acquisition. It is highly effective when adherence is good and is the appropriate addition to condom use.

Question 36Health Promotion and Disease Prevention

A 45-year-old man smokes one pack per day and is willing to use medication to quit. Which approach is most likely to succeed?

  1. Recommend nicotine gum as the only intervention
  2. Refer to a support group and defer medication until he fails counseling alone
  3. Advise him to cut down gradually without medication
  4. Combine behavioral counseling with a first-line pharmacotherapy Correct answer.

Explanation

Combining behavioral counseling with a first-line agent (varenicline, bupropion, or nicotine replacement) produces the highest quit rates. Both elements should be offered at the same visit rather than sequenced.

Question 37Health Promotion and Disease Prevention

A 35-year-old woman has had three consecutive normal Pap tests with negative HPV co-testing. What screening interval is recommended for a woman at average risk?

  1. Cytology alone every 2 years until age 65, then stop screening
  2. No further screening is needed until age 50
  3. Annual cytology alone, because co-testing is not recommended after age 30
  4. Co-testing every 5 years Correct answer.

Explanation

For women 30 to 65, co-testing with cytology plus HPV every 5 years (or cytology alone every 3 years) is acceptable. A history of prior normal co-tests supports the extended interval.

Question 38Health Promotion and Disease Prevention

A 33-year-old woman presents for a routine visit with no signs of injury. Which statement best reflects recommended practice for intimate partner violence?

  1. Defer screening unless the patient raises the topic first
  2. Screen only when injuries or inconsistent explanations are noted
  3. Screen all adults annually with a written questionnaire at intake
  4. Screen women of reproductive age using a validated tool Correct answer.

Explanation

Screening women of reproductive age for intimate partner violence and referring those who screen positive to support services is recommended. Detection cannot rely on visible injury, since most affected patients have no physical findings.

Question 39Health Promotion and Disease Prevention

Which adult should receive hepatitis B vaccination according to current recommendations?

  1. Only adults with identified risk factors such as injection drug use
  2. A healthy 40-year-old with no identified risk factors Correct answer.
  3. Adults born before 1957 who have no documentation of immunity
  4. Only adults over age 60 with diabetes

Explanation

Hepatitis B vaccination is now recommended for all adults aged 19 through 59 regardless of risk factors. Adults 60 and older without risk factors may still be vaccinated after shared decision-making.

Question 40Health Promotion and Disease Prevention

A 68-year-old asymptomatic man asks to be screened for carotid artery stenosis because his father had a stroke. He has no bruit on examination. What is the best response?

  1. Order screening only if he has hyperlipidemia
  2. Explain that screening is not recommended in asymptomatic adults Correct answer.
  3. Order carotid duplex ultrasound every 2 years
  4. Order a one-time ultrasound, since family history increases his risk substantially

Explanation

Screening for carotid artery stenosis in asymptomatic adults is recommended against because the harms of false positives, unnecessary surgery, and stroke from procedures outweigh benefits. Stroke risk in this patient is better addressed through blood pressure, lipid, smoking, and lifestyle management.

Question 41Assessment and Diagnosis

On cardiac auscultation, a murmur is readily heard, moderately loud, and not accompanied by a palpable thrill. Which grade does this represent on the Levine scale?

  1. Grade 2
  2. Grade 1
  3. Grade 4
  4. Grade 3 Correct answer.

Explanation

The Levine scale grades murmurs 1 through 6: grade 1 is barely audible, grade 2 is soft but immediately heard, grade 3 is moderately loud, grade 4 is loud with a palpable thrill, and grades 5 and 6 are audible with the stethoscope partly or fully off the chest. A murmur that is clearly heard but lacks a thrill therefore falls at grade 3.

Question 42Assessment and Diagnosis

A 62-year-old with calf claudication has an ankle-brachial index of 0.85 in the symptomatic leg. How should this value be interpreted?

  1. A falsely elevated value caused by arterial calcification
  2. Mild to moderate peripheral arterial disease Correct answer.
  3. Normal peripheral arterial flow
  4. Severe peripheral arterial disease with critical limb ischemia

Explanation

An ankle-brachial index of 0.90 or less is abnormal and confirms peripheral arterial disease. Values from roughly 0.41 to 0.90 indicate mild to moderate disease, while 0.40 or less suggests severe disease. Values above 1.30 raise concern for falsely elevated readings from medial calcinosis.

Question 43Assessment and Diagnosis

In the CAGE screening tool for unhealthy alcohol use, what does the letter "C" assess?

  1. Previous cessation attempts in the past year
  2. The typical pattern of consumption
  3. The need to cut down on drinking Correct answer.
  4. Craving for alcohol on waking

Explanation

CAGE stands for Cut down, Annoyed, Guilty, and Eye-opener. The C item asks whether the patient has ever felt the need to cut down on drinking. Two or more affirmative answers suggest a clinically significant alcohol problem.

Question 44Assessment and Diagnosis

A patient completes the PHQ-9 and scores 17. How should this score be categorized?

  1. Severe major depressive symptoms
  2. Minimal depressive symptoms
  3. Moderately severe depression Correct answer.
  4. Mild depressive symptoms

Explanation

PHQ-9 totals are stratified as 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe, and 20 to 27 severe. A score of 17 therefore falls in the moderately severe band and warrants active treatment discussion. Any positive response on item 9 also requires suicide risk assessment.

Question 45Assessment and Diagnosis

Percussion over Traube's space produces a dull note. This finding most directly suggests which abnormality?

  1. An enlarged spleen Correct answer.
  2. An enlarged right hepatic lobe
  3. A distended urinary bladder
  4. Free intraperitoneal fluid

Explanation

Traube's space is the semilunar area over the left lower anterior chest; it is normally tympanitic because of the air-filled stomach. Dullness there suggests that a solid organ, most often an enlarged spleen, has displaced the stomach. A full stomach can produce a false-positive result, so the finding is confirmed with other maneuvers.

Question 46Assessment and Diagnosis

A patient sways only after closing the eyes during the Romberg maneuver. This finding indicates dysfunction in which system?

  1. Lower extremity motor strength
  2. Cerebellar hemispheres
  3. Proprioceptive pathways of the dorsal columns Correct answer.
  4. Bilateral vestibular organs

Explanation

The Romberg test compares stance with eyes open and closed; worsening only with eye closure indicates sensory ataxia from impaired proprioception. Cerebellar lesions typically cause truncal instability with the eyes open as well. Vestibular disease usually produces vertigo and directional falling rather than isolated Romberg positivity.

Question 47Assessment and Diagnosis

Which deep tendon reflex finding is most clearly pathologic?

  1. 3+ at the brachioradialis in an anxious patient
  2. 4+ at the Achilles with sustained clonus Correct answer.
  3. 2+ at the patella
  4. 1+ at the biceps

Explanation

Reflexes are graded 0 to 4+, with 2+ considered normal. A 3+ response is hyperactive but may be seen in anxiety or normal variation. A 4+ response with sustained clonus reliably indicates upper motor neuron disease.

Question 48Assessment and Diagnosis

A new S3 gallop is heard in a 68-year-old man with progressive dyspnea and bilateral crackles. What does this finding most likely reflect?

  1. Aortic valve sclerosis
  2. Constrictive pericarditis
  3. Left ventricular hypertrophy
  4. Elevated left ventricular filling pressures Correct answer.

Explanation

An S3 in an older adult is a low-pitched early diastolic sound generated by rapid ventricular filling into a volume-overloaded, compliant ventricle, and it is a classic sign of heart failure. The finding is normal in children and young athletes but rarely normal after midlife. S4, by contrast, reflects a stiff ventricle during atrial systole.

Question 49Assessment and Diagnosis

Which technique correctly estimates jugular venous pressure?

  1. Time from the carotid upstroke to the visible venous peak
  2. Vertical height of the internal jugular pulsation above the sternal angle at 30-45 degrees Correct answer.
  3. Depth at which the external jugular vein collapses when compressed with the patient supine and the head flat
  4. Palpated carotid amplitude compared with the radial pulse

Explanation

Jugular venous pressure is estimated by positioning the patient at 30 to 45 degrees and measuring the vertical height of the right internal jugular pulsation above the sternal angle. Heights greater than about 3 to 4 cm above the sternal angle suggest elevation. The external jugular vein is a less reliable landmark because of valves and variable anatomy.

Question 50Assessment and Diagnosis

Otoscopy reveals a retracted, amber-tinged tympanic membrane with a visible air-fluid level and no bulging. Which diagnosis fits best?

  1. Acute otitis media
  2. Otitis externa
  3. Otitis media with effusion Correct answer.
  4. Tympanic membrane perforation

Explanation

Otitis media with effusion presents with a retracted or neutral membrane, an amber or dull color, and an air-fluid level or bubbles without acute inflammation. Acute otitis media, in contrast, shows a bulging, erythematous membrane with acute symptoms. Otitis externa affects the canal and usually spares the tympanic membrane.