Physician Assistant National Certifying Exam (PANCE) — Questions and Answers

Question 1: During a cardiovascular exam, you note that a patient's JVP is elevated at 45° with hepatojugular reflux present. These findings suggest:

Dehydration
Normal variant in obese patients
Tamponade as the only diagnosis
Right heart failure or elevated central venous pressure (Correct answer)

Correct answer: Right heart failure or elevated central venous pressure

Elevated JVP with a positive hepatojugular reflux (sustained rise with abdominal compression) indicates elevated right-sided filling pressures consistent with right heart failure.

Question 2: Phenomenon in which one or more fingers or toes are completely or partially joined, either naturally (as in web-footed animals) or as a deformity.

homograft (allograft)
sydactyl (Correct answer)
inframammary
partial colectomy

Correct answer: sydactyl

Syndactyly is the condition in which fingers or toes are fully or partially fused, either naturally or as a deformity (the prefix 'syn-' means together). Homograft refers to a tissue graft, inframammary means below the breast, and partial colectomy is bowel surgery—none describe fused digits.

Question 3: Who was involved in developing the first NP program?

Karen Bass
Dr Stead and Thelma Ingles
Dr Silver and Loretta Ford (Correct answer)
Dr Johnson and Henry Treadwell

Correct answer: Dr Silver and Loretta Ford

Dr. Loretta Ford and Dr. Henry Silver together created the first Nurse Practitioner (NP) program in the mid-1960s at the University of Colorado.

Question 4: Which finding is MOST characteristic of constrictive pericarditis on physical exam?

Kussmaul's sign (JVD increasing with inspiration) (Correct answer)
Friction rub that disappears with leaning forward
Pulsus alternans
Loud S1 heart sound

Correct answer: Kussmaul's sign (JVD increasing with inspiration)

Kussmaul's sign — paradoxical rise in JVP during inspiration — is a classic finding in constrictive pericarditis.

Question 5: Which of the following lung diseases is marked by dyspnea, pursed lips during breathing, a thin, wasted appearance, a hardly audible cough, and diminished breathing sounds?

Emphysema (Correct answer)
Asthma
Atelectasis
Chronic bronchitis

Correct answer: Emphysema

Emphysema is a form of chronic obstructive pulmonary disease (COPD) characterized by the destruction of alveolar walls and loss of lung elasticity. Patients with emphysema often present as 'pink puffers' – appearing thin and wasted, experiencing dyspnea, using pursed-lip breathing, and having a quiet chest with diminished breath sounds due to poor air movement and hyperinflation.

Question 6: A patient's ECG shows a prolonged PR interval, but all P waves are conducted. What rhythm is this?

Second-degree AV block Mobitz II
First-degree AV block (Correct answer)
Second-degree AV block Mobitz I
Third-degree AV block

Correct answer: First-degree AV block

First-degree AV block is defined by a PR interval >200 ms with all P waves conducted to the ventricles.

Question 7: A patient with Type 2 DM on metformin develops lactic acidosis after a hospitalization for cardiac catheterization with contrast. Which medication is most likely responsible?

Glipizide
Pioglitazone
Sitagliptin
Metformin (Correct answer)

Correct answer: Metformin

Metformin can cause lactic acidosis, especially when combined with IV contrast, renal impairment, or hypoxic states; it should be held before contrast procedures.

Question 8: A child presents with failure to thrive, foul-smelling greasy stools, and recurrent respiratory infections. Sweat chloride testing confirms the diagnosis. Which nutritional supplement is most critical for this patient?

Fat-soluble vitamins (A, D, E, K) (Correct answer)
Water-soluble vitamins
Iron supplementation
Calcium only

Correct answer: Fat-soluble vitamins (A, D, E, K)

Cystic fibrosis causes pancreatic exocrine insufficiency with fat malabsorption, making fat-soluble vitamin supplementation essential.

Question 9: A 45-year-old patient is diagnosed with hypertrophic cardiomyopathy (HCM). Which of the following should be strongly advised against for this patient?

Treatment with beta-blockers for symptomatic relief
Participation in competitive, high-intensity sports (Correct answer)
Annual screening with echocardiography
Genetic counseling for first-degree relatives

Correct answer: Participation in competitive, high-intensity sports

Hypertrophic cardiomyopathy is a leading cause of sudden cardiac death in young athletes. The dynamic left ventricular outflow tract obstruction can worsen with intense physical exertion and dehydration. Therefore, patients with HCM are typically restricted from competitive, high-intensity sports to reduce this risk. Beta-blockers are a first-line treatment, and regular screening and genetic counseling are standard parts of management.

Question 10: Which statistical test is most appropriate for comparing means between three or more independent groups?

Chi-square test
Student's t-test
Pearson correlation
One-way ANOVA (Correct answer)

Correct answer: One-way ANOVA

One-way ANOVA compares means across three or more independent groups while controlling the type I error rate that would inflate with multiple t-tests.

Question 11: An intubated patient's capnography waveform shows a gradually rising plateau phase (shark-fin pattern) instead of the normal flat plateau. What does this indicate?

Cardiac output compromise
Esophageal intubation
Obstructive airway disease with uneven emptying (Correct answer)
Hypoventilation with CO2 retention

Correct answer: Obstructive airway disease with uneven emptying

The shark-fin or sloped plateau (phase III) on capnography indicates uneven alveolar emptying due to airflow obstruction, as seen in asthma or COPD.

Question 12: A 62-year-old man with a history of MI presents with palpitations. ECG shows a wide complex tachycardia at 160 bpm. What is the most important initial step?

Synchronized cardioversion only if unstable
Adenosine 6 mg IV push
Assume VT and treat accordingly until proven otherwise (Correct answer)
Verapamil IV

Correct answer: Assume VT and treat accordingly until proven otherwise

Wide complex tachycardia in a patient with structural heart disease should be presumed ventricular tachycardia until proven otherwise.

Question 13: A 60-year-old woman is incidentally found to have calcium of 11.2 mg/dL, low phosphate, and PTH three times the upper limit of normal. She is largely asymptomatic. What is the most likely diagnosis?

Vitamin D toxicity
Malignancy-associated hypercalcemia
Hypoparathyroidism
Primary hyperparathyroidism (Correct answer)

Correct answer: Primary hyperparathyroidism

Primary hyperparathyroidism is characterized by hypercalcemia, hypophosphatemia, and elevated PTH, most commonly from a parathyroid adenoma.

Question 14: Which cell type produces surfactant in the lung?

Type II pneumocytes (Correct answer)
Type I pneumocytes
Goblet cells
Clara cells

Correct answer: Type II pneumocytes

Type II pneumocytes synthesize and secrete pulmonary surfactant, which reduces alveolar surface tension and prevents collapse.

Question 15: A patient is prescribed doxycycline for Lyme disease. Which counseling point is most important?

Avoid prolonged sun exposure due to photosensitivity (Correct answer)
Take with a full glass of milk
Avoid all exercise during therapy
Take at bedtime only

Correct answer: Avoid prolonged sun exposure due to photosensitivity

Tetracyclines including doxycycline cause photosensitivity reactions; patients should use sunscreen and avoid prolonged UV exposure.

Question 16: A 67-year-old woman with rheumatoid arthritis presents with acute monoarthritis of the right knee. Which diagnosis must be excluded emergently?

Osteoarthritis exacerbation
Gout flare
Reactive arthritis
Septic arthritis (Correct answer)

Correct answer: Septic arthritis

Septic arthritis is a joint-destroying emergency that must be excluded by synovial fluid analysis whenever acute monoarthritis is present, especially in immunocompromised patients.

Question 17: A 28-year-old woman with known Crohn's disease presents with perianal fistulas and abscesses that have not responded to antibiotics. Which biologic agent is most appropriate?

Infliximab (Correct answer)
Certolizumab pegol
Ustekinumab
Vedolizumab

Correct answer: Infliximab

Infliximab (anti-TNF-α) is FDA-approved specifically for fistulizing Crohn's disease and has demonstrated efficacy in closing perianal fistulas.

Question 18: A 60-year-old with COPD and FEV1 of 35% predicted has multiple hospitalizations yearly. Which long-acting bronchodilator combination has the strongest evidence for reducing exacerbations?

Long-acting beta-agonist plus inhaled corticosteroid plus long-acting muscarinic antagonist (triple therapy) (Correct answer)
Long-acting beta-agonist alone
Inhaled corticosteroid alone
Short-acting beta-agonist plus short-acting muscarinic antagonist

Correct answer: Long-acting beta-agonist plus inhaled corticosteroid plus long-acting muscarinic antagonist (triple therapy)

Triple therapy (LABA + LAMA + ICS) reduces exacerbation rates more than dual therapy in severe COPD patients with frequent exacerbations, per the IMPACT trial.

Question 19: A 45-year-old man with kidney stones, bone pain, and depression has calcium of 11.9 mg/dL and PTH four times normal. What is the definitive treatment?

High-dose vitamin D supplementation
IV bisphosphonate therapy
Cinacalcet (calcimimetic agent)
Parathyroidectomy (Correct answer)

Correct answer: Parathyroidectomy

Parathyroidectomy is the definitive treatment for symptomatic primary hyperparathyroidism, providing a surgical cure.

Question 20: Which of the following is a contraindication to IV tPA in acute ischemic stroke?

Ischemic stroke or head trauma within the past 3 months (Correct answer)
Atrial fibrillation
Age over 65
Blood pressure of 150/90 mmHg

Correct answer: Ischemic stroke or head trauma within the past 3 months

Recent ischemic stroke or serious head trauma within the prior 3 months is an absolute contraindication to IV tPA due to the risk of hemorrhagic transformation.

Question 21: A patient on warfarin for AF has an INR of 8.5 with active major bleeding. What is the most appropriate immediate treatment?

4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K (Correct answer)
Vitamin K 10 mg IV only
Hold warfarin and recheck INR tomorrow
Fresh frozen plasma alone

Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K

Life-threatening warfarin-related bleeding requires rapid reversal with 4F-PCC for immediate effect plus IV vitamin K for sustained reversal.

Question 22: According to the 2021 United States Preventive Services Task Force (USPSTF) recommendations, which of the following patients is the most appropriate candidate for annual low-dose computed tomography (LDCT) screening for lung cancer?

A 70-year-old who quit smoking 20 years ago but had a 30 pack-year history.
An 82-year-old former smoker with a 40 pack-year history who quit 10 years ago.
A 45-year-old current smoker with a 25 pack-year history.
A 65-year-old current smoker with a 25 pack-year history. (Correct answer)

Correct answer: A 65-year-old current smoker with a 25 pack-year history.

The 2021 USPSTF guidelines recommend annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. The 65-year-old patient meets all three criteria (age, pack-year history, and current smoking status). The 70-year-old is ineligible because they quit more than 15 years ago. The 45-year-old is too young, and the 82-year-old is too old.

Question 23: A 68-year-old with a 6 cm solitary pulmonary nodule has a PET scan showing high SUV uptake. CT-guided biopsy reveals adenocarcinoma. Which staging workup is MOST critical before surgical planning?

Echocardiography and stress test
Bronchoscopy with BAL
Brain MRI and mediastinoscopy (Correct answer)
Bone scan and liver biopsy

Correct answer: Brain MRI and mediastinoscopy

Brain MRI detects occult CNS metastases and mediastinoscopy evaluates mediastinal lymph node involvement, both critical for determining resectability in NSCLC.

Question 24: Which type of PA practice agreement or document outlines the specific clinical duties and prescribing authority of a PA at a given practice site?

National Provider Agreement
Medicare Enrollment Form 855I
HIPAA Business Associate Agreement
Delegation of Services Agreement (DSA) (Correct answer)

Correct answer: Delegation of Services Agreement (DSA)

A Delegation of Services Agreement (also called a practice agreement or scope of practice document) defines the PA's authorized clinical activities and prescriptive authority at a specific site.

Question 25: A 55-year-old male with a history of poorly controlled hypertension presents with a headache and confusion. His blood pressure is measured at 220/130 mmHg. Fundoscopic examination reveals papilledema. Which of the following is the most appropriate immediate step in management?

Admit to the ICU and initiate an intravenous antihypertensive infusion (Correct answer)
Prescribe a high-dose oral diuretic and recheck blood pressure in 24 hours
Administer oral clonidine and discharge home with follow-up
Schedule an outpatient cardiology consultation for the following week

Correct answer: Admit to the ICU and initiate an intravenous antihypertensive infusion

This patient is presenting with a hypertensive emergency, defined as severely elevated blood pressure (typically >180/120 mmHg) with evidence of end-organ damage (in this case, papilledema indicating hypertensive encephalopathy). The standard of care is immediate admission to an ICU for continuous monitoring and a controlled reduction of blood pressure using an intravenous antihypertensive agent like nicardipine or labetalol.

Question 26: A patient with myasthenia gravis will show which characteristic pattern on repetitive nerve stimulation?

Fibrillation potentials
Incremental response
Decremental response (Correct answer)
No change

Correct answer: Decremental response

Myasthenia gravis is characterized by a decremental response on repetitive nerve stimulation due to depletion of acetylcholine at the neuromuscular junction.

Question 27: A 45-year-old man presents with sudden severe tearing chest pain radiating to the back. BP is 180/100 in the right arm and 140/80 in the left arm. What is the most likely diagnosis?

Acute STEMI
Esophageal rupture
Aortic dissection (Correct answer)
Pulmonary embolism

Correct answer: Aortic dissection

Asymmetric blood pressures combined with tearing back pain are classic for aortic dissection.

Question 28: A beaker holds 500 mL. If 20% of the liquid evaporates and then 50 mL is added, how many mL remain?

430 mL
440 mL
450 mL (Correct answer)
420 mL

Correct answer: 450 mL

500 × 0.80 = 400 mL after evaporation; 400 + 50 = 450 mL.

Question 29: The BEST way to strengthen an argument in an academic paper is to:

Use emotional language to persuade the reader
Cite peer-reviewed evidence that directly supports the claim (Correct answer)
Present only one perspective without acknowledging counterarguments
Repeat the thesis multiple times throughout the paper

Correct answer: Cite peer-reviewed evidence that directly supports the claim

Peer-reviewed evidence provides credible, verifiable support that directly strengthens academic arguments.

Question 30: A 50-year-old woman presents with dyspnea and a loud S2 with fixed splitting. What is the most likely diagnosis?

Patent ductus arteriosus
Atrial septal defect (Correct answer)
Pulmonary stenosis
Ventricular septal defect

Correct answer: Atrial septal defect

Fixed wide splitting of S2 that does not vary with respiration is pathognomonic for an atrial septal defect.

Question 31: Which one of the following conditions is NOT a long-term side effect of essential hypertension?

Diabetes
Renal failure
Neuropathy
Asthma (Correct answer)

Correct answer: Asthma

Essential hypertension, if left unmanaged over time, can lead to severe long-term complications affecting various organ systems, including renal failure, neuropathy due to vascular damage, and an increased risk of cardiovascular disease and diabetes. Asthma, however, is a chronic inflammatory disease of the airways and is not a direct long-term side effect or complication that develops as a result of essential hypertension.

Question 32: Which of the following is the most appropriate initial imaging study for a patient with suspected osteoporosis?

MRI of the hip
CT scan of the lumbar spine
DEXA scan (Correct answer)
Plain X-ray of the spine

Correct answer: DEXA scan

DEXA (dual-energy X-ray absorptiometry) scan is the gold standard for measuring bone mineral density and diagnosing osteoporosis.

Question 33: Which of the following BEST illustrates a non sequitur in argumentation?

Studies show exercise reduces blood pressure, so patients should exercise more.
The patient's fever broke after treatment, suggesting the medication was effective.
She is an excellent surgeon, so she would make a great PA educator. (Correct answer)
All antibiotics kill bacteria; penicillin is an antibiotic; therefore penicillin kills bacteria.

Correct answer: She is an excellent surgeon, so she would make a great PA educator.

A non sequitur presents a conclusion that does not logically follow from the premise; surgical skill does not necessarily translate to teaching ability.

Question 34: What is the value of x if 3(2x − 4) = 2(x + 6)?

x = 6 (Correct answer)
x = 9
x = 3
x = 5

Correct answer: x = 6

Expanding: 6x − 12 = 2x + 12, so 4x = 24, giving x = 6.

Question 35: A 55-year-old woman with systemic lupus erythematosus develops pericarditis. Which anti-inflammatory agent is typically added to NSAIDs to reduce recurrence?

Methotrexate
Colchicine (Correct answer)
Hydroxychloroquine
Prednisone high-dose

Correct answer: Colchicine

Colchicine added to NSAIDs significantly reduces the risk of recurrent pericarditis and is now standard first-line adjunct therapy.

Question 36: A 45-year-old with idiopathic pulmonary fibrosis develops acute worsening of dyspnea over 2 weeks with new bilateral ground-glass opacities on CT superimposed on honeycombing. What is this complication called?

Hypersensitivity pneumonitis flare
Acute respiratory distress syndrome
Organizing pneumonia
Acute exacerbation of IPF (Correct answer)

Correct answer: Acute exacerbation of IPF

Acute exacerbation of IPF is defined as rapid respiratory deterioration with new bilateral ground-glass opacities without an identifiable cause in a patient with established IPF.

Question 37: Which laboratory finding is most characteristic of rheumatoid arthritis?

Elevated alkaline phosphatase
Positive ANA with anti-dsDNA
Positive rheumatoid factor and anti-CCP antibodies (Correct answer)
Elevated uric acid

Correct answer: Positive rheumatoid factor and anti-CCP antibodies

Rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) antibodies are the hallmark serologic markers of rheumatoid arthritis.

Question 38: A patient with hypertension develops a blood pressure of 210/120 mmHg with headache and papilledema. How should this be managed?

IV nitroprusside with continuous BP monitoring (Correct answer)
Sublingual nifedipine
Furosemide IV bolus only
Oral labetalol and discharge

Correct answer: IV nitroprusside with continuous BP monitoring

Hypertensive emergency with end-organ damage requires IV antihypertensives with controlled, gradual BP reduction.

Question 39: You are examining a 78-year-old man whose heart rate is between 140 and 150 beats per minute when he arrives at the emergency room. Although you can observe a narrow-complex tachycardia on the monitor, the underlying rhythm cannot be identified. When you massage the carotid arteries, the patient starts to have a typical sinus rhythm. What rhythm was probably the original?

Supraventricular tachycardia (Correct answer)
Ventricular tachycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter

Correct answer: Supraventricular tachycardia

When the patient's heart rate is between 140 and 150 beats per minute with a narrow-complex tachycardia, and the rhythm is converted to a typical sinus rhythm by carotid sinus massage, the most likely original rhythm was supraventricular tachycardia (SVT).

Question 40: A 70-year-old presents with progressive resting tremor, bradykinesia, and cogwheel rigidity. What is the most likely diagnosis?

Parkinson's disease (Correct answer)
Wilson's disease
Essential tremor
Huntington's disease

Correct answer: Parkinson's disease

Parkinson's disease presents with the classic triad of resting tremor, bradykinesia, and rigidity, typically beginning unilaterally in older adults.

Question 41: A table shows that 60 out of 400 patients developed a side effect. What percentage of patients experienced the side effect?

18%
12%
15% (Correct answer)
20%

Correct answer: 15%

60 / 400 = 0.15 = 15%.

Question 42: Which of the following distinguishes essential tremor from Parkinson's tremor?

Essential tremor is an action/postural tremor; Parkinson's is a resting tremor (Correct answer)
Essential tremor is associated with bradykinesia
Essential tremor occurs at rest; Parkinson's occurs with action
Essential tremor involves the legs primarily

Correct answer: Essential tremor is an action/postural tremor; Parkinson's is a resting tremor

Essential tremor is a postural/action tremor that occurs during movement, while Parkinson's tremor is characteristically present at rest and suppressed by movement.

Question 43: A 25-year-old male is diagnosed with moderate-to-severe ileocolonic Crohn's disease. Which of the following biologic agents is often considered a first-line therapy for inducing and maintaining remission in this patient?

Infliximab (an anti-TNF agent) (Correct answer)
Prednisone
Mesalamine (5-ASA)
Metronidazole

Correct answer: Infliximab (an anti-TNF agent)

For moderate-to-severe Crohn's disease, biologic therapies such as anti-TNF agents (e.g., infliximab, adalimumab) are recommended as a first-line treatment to both induce and maintain clinical remission. [15, 29, 45] Corticosteroids like prednisone are used for short-term induction but not maintenance, while mesalamine has limited efficacy in moderate-to-severe disease. [4, 10]

Question 44: What is the minimum degree required to sit for the PANCE as of 2020?

Doctor of Medical Science
Master's degree (Correct answer)
Associate's degree
Bachelor of Science

Correct answer: Master's degree

ARC-PA mandated that all accredited PA programs must award a master's degree by 2020, making it the minimum requirement to graduate and sit for the PANCE.

Question 45: A PA evaluates two patients with identical presentations but very different pre-test probabilities for pulmonary embolism. How does pre-test probability affect diagnostic reasoning?

A positive test result is more meaningful in a high-probability patient, raising post-test probability substantially (Correct answer)
High pre-test probability means no further testing is needed
Pre-test probability does not affect interpretation of test results
A negative test always rules out PE regardless of pre-test probability

Correct answer: A positive test result is more meaningful in a high-probability patient, raising post-test probability substantially

Pre-test probability directly influences post-test probability through Bayes' theorem; the same positive test result carries more weight when disease is more likely before testing.

Question 46: Which finding is most consistent with acute mesenteric ischemia?

Gradual onset pain with nausea only
Pain relieved by eating
Rebound tenderness with a rigid abdomen from onset
Pain out of proportion to physical examination findings (Correct answer)

Correct answer: Pain out of proportion to physical examination findings

Acute mesenteric ischemia classically presents with severe abdominal pain that is disproportionately worse than the relatively benign physical exam findings early in the course.

Question 47: What is the primary scope of practice document that guides PA practice in the United States?

Collaborating Physician Agreement
PA Practice Agreement
State Medical Practice Act (Correct answer)
AAPA Guidelines for Ethical Conduct

Correct answer: State Medical Practice Act

Each state's Medical Practice Act defines the legal scope of practice for PAs within that state.

Question 48: A 55-year-old man with Type 2 DM presents with a foot ulcer and no sensation on 10-gram monofilament testing. Which diabetic complication does this represent?

Diabetic peripheral neuropathy (Correct answer)
Diabetic nephropathy
Charcot arthropathy
Peripheral arterial disease

Correct answer: Diabetic peripheral neuropathy

Loss of protective sensation on monofilament testing is the hallmark of diabetic peripheral neuropathy, a microvascular complication of diabetes.

Question 49: A 65-year-old with COPD has a barrel chest. Which physical exam finding would you also expect?

Decreased AP diameter
Increased tactile fremitus
Elevated diaphragm on percussion
Hyperresonance to percussion (Correct answer)

Correct answer: Hyperresonance to percussion

Air trapping in COPD leads to hyperinflation, causing hyperresonance to percussion and an increased AP:lateral diameter ratio (barrel chest).

Question 50: A 29-year-old pregnant woman at 32 weeks gestation presents with acute onset pleuritic chest pain and hemoptysis. D-dimer is elevated. CT pulmonary angiography confirms PE. Which anticoagulant is preferred?

Warfarin (vitamin K antagonist)
Unfractionated heparin infusion
Low molecular weight heparin (LMWH) (Correct answer)
Rivaroxaban (direct oral anticoagulant)

Correct answer: Low molecular weight heparin (LMWH)

LMWH is the preferred anticoagulant for PE in pregnancy; warfarin is teratogenic, DOACs lack safety data in pregnancy, and LMWH does not cross the placenta.

Question 51: A patient with Alzheimer's disease has deficiency of which neurotransmitter?

Dopamine
Acetylcholine (Correct answer)
Serotonin
Norepinephrine

Correct answer: Acetylcholine

Alzheimer's disease is associated with loss of cholinergic neurons in the nucleus basalis of Meynert, leading to acetylcholine deficiency, which is the basis of cholinesterase inhibitor therapy.

Question 52: Which finding on physical examination is most consistent with a complete rotator cuff tear?

Positive apprehension sign
Inability to initiate abduction with preserved passive range of motion (Correct answer)
Painful arc between 60–120 degrees of abduction
Tenderness over the acromioclavicular joint

Correct answer: Inability to initiate abduction with preserved passive range of motion

A complete rotator cuff tear results in inability to initiate active abduction while passive range of motion remains intact due to loss of musculotendinous continuity.

Question 53: Which immunoglobulin class is the first to be produced during a primary immune response?

IgG
IgM (Correct answer)
IgE
IgA

Correct answer: IgM

IgM is the predominant antibody produced early in a primary immune response and is the most efficient complement activator.

Question 54: A 35-year-old man with a headache walks into your office and is being evaluated. His blood pressure reading during a physical examination was 240/120 mmHg. You discover papilledema during the fundoscopic examination. What is the underlying diagnosis of this person?

Hypertensive urgency
Prehypertension
Hypertensive emergency (Correct answer)
Stage III hypertension
Stage I hypertension

Correct answer: Hypertensive emergency

The patient's blood pressure reading of 240/120 mmHg is significantly elevated and falls within the range of a hypertensive emergency. Hypertensive emergency is a severe and acute elevation in blood pressure that requires immediate medical attention to prevent potential organ damage or life-threatening complications. The presence of papilledema during the fundoscopic examination indicates that the elevated blood pressure is causing increased intracranial pressure, which can be dangerous.

Question 55: Which medication is contraindicated in a patient with decompensated heart failure and an ejection fraction of 20%?

IV furosemide
Nitrates for preload reduction
Carvedilol initiated at low dose (Correct answer)
Dobutamine infusion

Correct answer: Carvedilol initiated at low dose

Beta-blockers should not be started during decompensated HF; they should only be initiated once the patient is stabilized.

Question 56: A 16-year-old female athlete presents with stress fracture, amenorrhea for 8 months, and BMI of 16.5. What is this triad called?

Female athlete triad (Correct answer)
Turner syndrome presentation
Anorexia nervosa criteria
Polycystic ovary syndrome triad

Correct answer: Female athlete triad

The female athlete triad consists of energy deficiency (often with disordered eating), menstrual dysfunction, and low bone mineral density.

Question 57: A 45-year-old woman has a positive straight leg raise (SLR) test at 40°. This finding is most consistent with:

Piriformis syndrome
Sacroiliac joint dysfunction
Hip flexor strain
L4-S1 nerve root compression (lumbar disc herniation) (Correct answer)

Correct answer: L4-S1 nerve root compression (lumbar disc herniation)

A positive SLR at less than 60° (reproduction of radicular pain, not just tightness) strongly suggests L4-S1 nerve root irritation from disc herniation.

Question 58: A 65-year-old smoker presents with hemoptysis, weight loss, and a central lung mass. Serum sodium is 120 mEq/L. Which paraneoplastic syndrome is most likely?

Eaton-Lambert syndrome
Hypercalcemia from PTHrP secretion
Cushing's syndrome from ACTH secretion
SIADH from ADH secretion (Correct answer)

Correct answer: SIADH from ADH secretion

Small cell lung cancer most commonly produces SIADH via ectopic ADH secretion, causing hyponatremia.

Question 59: A patient with newly diagnosed seizure disorder is started on phenytoin. Which finding on CBC would be a serious adverse effect requiring dose adjustment?

Polycythemia vera
Basophilia
Megaloblastic anemia (Correct answer)
Mild thrombocytosis

Correct answer: Megaloblastic anemia

Phenytoin inhibits folate absorption, leading to megaloblastic anemia; folic acid supplementation may be necessary.

Question 60: A 65-year-old woman with diabetes presents with fatigue and jaw pain during exertion but denies chest pain. Troponin is elevated. What is the most likely diagnosis?

Acute coronary syndrome (Correct answer)
Anxiety disorder
GERD
Musculoskeletal pain

Correct answer: Acute coronary syndrome

Diabetic patients often have atypical ACS presentations (jaw pain, fatigue) due to autonomic neuropathy masking classic chest pain.

Question 61: A patient with a known pulmonary embolism develops sudden worsening of hypoxemia despite anticoagulation. Which mechanism most directly causes hypoxemia in acute PE?

Right-to-left intracardiac shunting
Diffusion impairment across the alveolar-capillary membrane
Ventilation-perfusion mismatch with increased dead space (Correct answer)
Hypoventilation from respiratory muscle fatigue

Correct answer: Ventilation-perfusion mismatch with increased dead space

PE creates high V/Q areas (dead space) where ventilation occurs without perfusion, and can also cause atelectasis leading to low V/Q areas, both worsening oxygenation.

Question 62: Which sentence uses the word 'affect' correctly?

We studied the affect of exercise on mood.
The affect of the drug was well documented.
The new medication had a positive affect on blood pressure.
Stress can affect cardiovascular health significantly. (Correct answer)

Correct answer: Stress can affect cardiovascular health significantly.

'Affect' is a verb meaning to influence; 'effect' is the noun referring to the result.

Question 63: Which imaging modality is the preferred initial study for a patient presenting with acute stroke symptoms?

CT angiography
MRI brain with contrast
Carotid ultrasound
Non-contrast CT head (Correct answer)

Correct answer: Non-contrast CT head

Non-contrast CT head is the first-line imaging study in acute stroke to rapidly exclude hemorrhage before considering thrombolytic therapy.

Question 64: Which of the following pleural effusions is brought on by chronic heart failure, cirrhosis, or nephrotic syndrome?

Combined
Transudative (Correct answer)
Exudative
Mixed

Correct answer: Transudative

Transudative pleural effusions occur due to systemic factors that alter hydrostatic or oncotic pressures, leading to fluid leakage into the pleural space. Conditions like chronic heart failure (increased hydrostatic pressure), cirrhosis (decreased oncotic pressure due to low albumin), and nephrotic syndrome (protein loss leading to decreased oncotic pressure) are classic causes of transudative effusions.

Question 65: Which heart valves are shutting when the first heart sound is made?

Mitral and tricuspid valves (Correct answer)
Aortic and tricuspid valves
Aortic and mitral valves
Aortic and pulmonic valves

Correct answer: Mitral and tricuspid valves

The first heart sound, S1, commonly referred to as the 'lub' sound, marks the beginning of ventricular systole (contraction). It is produced by the simultaneous closure of the atrioventricular (AV) valves: the mitral valve, located between the left atrium and left ventricle, and the tricuspid valve, located between the right atrium and right ventricle. This closure prevents the backflow of blood into the atria as the ventricles begin to contract.

Question 66: Wolff-Parkinson-White syndrome involves which anatomical abnormality?

Hypertrophied bundle of His
Abnormal SA node automaticity
Accessory conduction pathway (Bundle of Kent) bypassing the AV node (Correct answer)
Dilated coronary sinus

Correct answer: Accessory conduction pathway (Bundle of Kent) bypassing the AV node

WPW is caused by an accessory pathway (Bundle of Kent) that bypasses the AV node, allowing pre-excitation of the ventricles.

Question 67: How many PAs are employed in general pediatrics?

2.1%
1.3%
1.9% (Correct answer)
5.6%

Correct answer: 1.9%

According to the 2020 Statistical Profile of Certified Physician Assistants, 1.8% of physician assistants (PAs) work in pediatrics, which includes both general pediatrics and pediatric subspecialties.

Question 68: A patient with Type 1 DM presents with nausea, vomiting, abdominal pain, Kussmaul respirations, and fruity breath odor. Blood glucose is 380 mg/dL. What is the most likely diagnosis?

Alcoholic ketoacidosis
Hyperosmolar hyperglycemic state
Diabetic ketoacidosis (Correct answer)
Lactic acidosis

Correct answer: Diabetic ketoacidosis

DKA presents with hyperglycemia, anion gap metabolic acidosis, Kussmaul respirations, and fruity breath due to ketone production.

Question 69: Which of the following is an example of a primary source in medical research?

An original clinical trial published in a peer-reviewed journal (Correct answer)
A textbook chapter summarizing diabetes management
A news article reporting on a new vaccine
A systematic review of hypertension trials

Correct answer: An original clinical trial published in a peer-reviewed journal

A primary source presents original, firsthand research data, such as an original clinical trial.

Question 70: Which of the following is the most common cause of primary hypothyroidism in the United States?

Iodine deficiency
Surgical thyroidectomy
Hashimoto's thyroiditis (Correct answer)
Subacute thyroiditis

Correct answer: Hashimoto's thyroiditis

Hashimoto's thyroiditis is an autoimmune condition and the most common cause of primary hypothyroidism in iodine-sufficient countries.

Question 71: A 75-year-old female is being treated for heart failure with reduced ejection fraction (HFrEF). Which of the following medication classes has been shown to improve mortality in patients with HFrEF and should be considered a cornerstone of therapy?

Calcium channel blockers
Beta-blockers (Correct answer)
Loop diuretics
Digoxin

Correct answer: Beta-blockers

Beta-blockers (e.g., carvedilol, metoprolol succinate, bisoprolol) are one of the primary classes of medications, along with ACE inhibitors/ARBs/ARNIs, that have been proven to reduce mortality and hospitalizations in patients with HFrEF. Loop diuretics manage symptoms but do not improve mortality. Digoxin can reduce hospitalizations but does not have a mortality benefit. Most calcium channel blockers are not recommended in HFrEF.

Question 72: A 45-year-old, otherwise healthy male with no comorbidities or recent antibiotic use is diagnosed with community-acquired pneumonia (CAP) in an outpatient setting. According to the most recent IDSA/ATS guidelines, which of the following is a recommended first-line empiric monotherapy?

Vancomycin
Ceftriaxone
Levofloxacin
Amoxicillin (Correct answer)

Correct answer: Amoxicillin

For healthy outpatient adults with CAP and no significant comorbidities or risk factors for resistant pathogens, the IDSA/ATS guidelines strongly recommend high-dose amoxicillin (1g three times daily) as a first-line agent. Doxycycline is another option. Levofloxacin is a respiratory fluoroquinolone typically reserved for patients with comorbidities or recent antibiotic exposure. Vancomycin is used for suspected MRSA and ceftriaxone is a parenteral antibiotic for inpatient use.

Question 73: A PA applies the principle of parsimony (Occam's Razor) in formulating a diagnosis. What does this principle suggest?

The most expensive test should be ordered first
One unifying diagnosis should explain all of the patient's findings when possible (Correct answer)
The rarest diagnosis should be prioritized
Multiple diagnoses must always be considered simultaneously

Correct answer: One unifying diagnosis should explain all of the patient's findings when possible

Occam's Razor in clinical reasoning favors a single unifying diagnosis over multiple separate diagnoses when the clinical evidence supports it.

Question 74: A patient with known HFrEF reports dizziness after starting a new medication. Potassium is 5.9 mEq/L and creatinine has risen. Which drug is most likely responsible?

Hydralazine
Digoxin
Spironolactone (Correct answer)
Metoprolol succinate

Correct answer: Spironolactone

Spironolactone, a potassium-sparing aldosterone antagonist, commonly causes hyperkalemia and can worsen renal function.

Question 75: A 30-year-old male presents with acute monoarticular arthritis of the first metatarsophalangeal joint, erythema, and severe pain. Synovial fluid analysis shows negatively birefringent needle-shaped crystals. What is the treatment of choice for an acute attack?

Methotrexate
Allopurinol
Prednisone taper over 6 weeks
Colchicine or NSAIDs (Correct answer)

Correct answer: Colchicine or NSAIDs

Colchicine and NSAIDs are first-line treatments for acute gout attacks; allopurinol is used for long-term urate-lowering therapy, not acute episodes.

Question 76: What does the term 'opt-out' mean in the context of PA Medicare billing?

The PA chooses not to accept Medicare patients
The PA delegates billing to the supervising physician
The PA bills at a reduced Medicare rate
The PA privately contracts outside Medicare reimbursement rules (Correct answer)

Correct answer: The PA privately contracts outside Medicare reimbursement rules

An opt-out provider enters private contracts with patients and cannot submit claims to Medicare for those services.

Question 77: A 62-year-old male with a 40 pack-year smoking history presents with progressive exertional dyspnea and chronic productive cough for >3 months per year over 2 consecutive years. Spirometry shows FEV1/FVC ratio of 0.62. What is the diagnosis?

Asthma
Restrictive lung disease
Chronic obstructive pulmonary disease (Correct answer)
Pulmonary fibrosis

Correct answer: Chronic obstructive pulmonary disease

COPD is defined by a post-bronchodilator FEV1/FVC ratio <0.70 with appropriate clinical history; chronic bronchitis meets the symptom criteria.

Question 78: Under Medicare, PAs are reimbursed at what percentage of the physician fee schedule when billing independently?

80%
75%
85% (Correct answer)
90%

Correct answer: 85%

Medicare reimburses PAs at 85% of the physician fee schedule when billing under their own NPI.

Question 79: A 68-year-old female with diabetes presents with a 3-day history of fever, productive cough, and new-onset confusion. On examination, her respiratory rate is 32 breaths/min, blood pressure is 88/58 mmHg, and her BUN is 25 mg/dL. Which of the following is the most appropriate action based on the CURB-65 score?

Observe in the emergency department for 4-6 hours before making a disposition decision
Admit to a general medical ward for inpatient treatment
Discharge home with oral antibiotics
Admit to the intensive care unit for management of severe pneumonia (Correct answer)

Correct answer: Admit to the intensive care unit for management of severe pneumonia

The patient scores 4 points on the CURB-65 scale: Confusion (1), Urea >20 mg/dL (1), Respiratory rate ≥30 (1), and Blood pressure <90 systolic (1). A score of 3 or more indicates severe pneumonia with a high risk of mortality, warranting urgent admission to the hospital, typically to an intensive care unit (ICU), for aggressive management.

Question 80: A patient presents with right lower quadrant pain, fever, and elevated WBC. CT shows a 9 cm appendix with periappendiceal fat stranding. Which is the most appropriate next step?

Barium enema
Colonoscopy
Urgent appendectomy (Correct answer)
IV antibiotics and discharge

Correct answer: Urgent appendectomy

CT findings of an enlarged appendix with periappendiceal fat stranding indicate acute appendicitis requiring urgent surgical intervention.

Question 81: A patient with frequent symptoms of gastroesophageal reflux disease (GERD) and evidence of erosive esophagitis on endoscopy has failed to respond to lifestyle changes. Which medication class is the most effective for providing symptom relief and promoting healing of the esophagus?

Prokinetic agents
Antacids
H2-receptor antagonists
Proton Pump Inhibitors (PPIs) (Correct answer)

Correct answer: Proton Pump Inhibitors (PPIs)

Proton Pump Inhibitors (PPIs) are the most effective class of medications for treating GERD, providing superior symptom relief and healing of erosive esophagitis compared to other options. They work by potently suppressing gastric acid production. While H2-receptor antagonists, antacids, and prokinetics can be used for GERD, they are less effective than PPIs, especially in the presence of erosive disease.

Question 82: A number increased by 15% equals 92. What was the original number (rounded to the nearest whole number)?

80 (Correct answer)
75
82
78

Correct answer: 80

92 / 1.15 ≈ 80.

Question 83: A 45-year-old woman presents with iron deficiency anemia and a positive fecal occult blood test. Which is the most appropriate next diagnostic step?

Capsule endoscopy first
Both upper endoscopy and colonoscopy (Correct answer)
Upper endoscopy only
Colonoscopy only

Correct answer: Both upper endoscopy and colonoscopy

In a patient with FOBT-positive iron deficiency anemia, bidirectional endoscopy (both upper and lower) is recommended to identify the source of occult GI bleeding.

Question 84: A 5-year-old with known asthma presents with wheezing, respiratory rate of 38, accessory muscle use, and SpO2 of 91%. After 3 albuterol treatments and ipratropium, there is minimal improvement. What is the next medication?

Theophylline IV
IV magnesium sulfate (Correct answer)
Oral montelukast
Subcutaneous terbutaline only

Correct answer: IV magnesium sulfate

IV magnesium sulfate is recommended for severe acute asthma exacerbations unresponsive to initial bronchodilator therapy due to its bronchodilatory effects.

Question 85: A 68-year-old man with a history of smoking and alcohol use presents with chronic epigastric pain radiating to the back, steatorrhea, and new-onset diabetes. CT shows pancreatic calcifications. What is the most likely diagnosis?

Acute pancreatitis
Pancreatic adenocarcinoma
Chronic pancreatitis (Correct answer)
Autoimmune pancreatitis

Correct answer: Chronic pancreatitis

Pancreatic calcifications on CT with steatorrhea (exocrine insufficiency) and diabetes (endocrine insufficiency) in a patient with chronic alcohol use is classic chronic pancreatitis.

Question 86: A 3-year-old boy presents with painless scrotal swelling that transilluminates. Ultrasound confirms fluid around the testis with no blood flow abnormality. What is the most likely diagnosis?

Epididymo-orchitis
Hydrocele (Correct answer)
Testicular torsion
Inguinal hernia

Correct answer: Hydrocele

A painless, transilluminating scrotal mass in a child is a hydrocele, caused by accumulation of fluid within the tunica vaginalis.

Question 87: A 25-year-old with asthma is awakened 4 nights per week by wheezing and uses rescue albuterol daily. Spirometry shows FEV1 of 75% predicted with 15% bronchodilator response. How is this asthma classified?

Severe persistent asthma
Mild intermittent asthma
Moderate persistent asthma (Correct answer)
Mild persistent asthma

Correct answer: Moderate persistent asthma

Daily symptoms, nighttime awakenings more than once per week, and FEV1 60-80% predicted classify asthma as moderate persistent, requiring step 3-4 therapy.

Question 88: Which sentence contains a dangling modifier?

The student ran quickly but missed the bus.
The student, running quickly, missed the bus.
Running quickly, the bus was missed by the student. (Correct answer)
Because she ran quickly, the student missed the bus.

Correct answer: Running quickly, the bus was missed by the student.

In the first option, the participial phrase 'Running quickly' incorrectly modifies 'the bus' rather than the student.

Question 89: Which medication is classified as a disease-modifying antirheumatic drug (DMARD) and is first-line for rheumatoid arthritis?

Celecoxib
Prednisone
Methotrexate (Correct answer)
Ibuprofen

Correct answer: Methotrexate

Methotrexate is the anchor DMARD and first-line agent for rheumatoid arthritis, slowing disease progression and joint damage.

Question 90: On a skin examination, a 0.5 cm, circumscribed, elevated lesion containing serous fluid is identified. How should this primary skin lesion be documented?

Papule
Vesicle (Correct answer)
Pustule
Macule

Correct answer: Vesicle

A vesicle is defined as a small (<1 cm), circumscribed, elevated lesion that contains serous fluid. A papule is a solid, elevated lesion. A pustule is similar to a vesicle but contains purulent material (pus). A macule is a flat, non-palpable change in skin color.

Question 91: A 4-month-old baby who has a tonic-clonic seizure with a 39.4°C (103°F) fever is being evaluated by you. There is no previous history of epilepsy or seizures. Lumbar punctures don't disclose anything. Which of the following is most likely to be the reason for this baby's seizures?

Meningitis
Fever (Correct answer)
Malignancy
Epilepsy
Encephalitis

Correct answer: Fever

This child is experiencing a febrile seizure (a fever fit). Meningitis and encephalitis are ruled out by a normal lumbar puncture.

Question 92: A T-score of -2.8 on DEXA scan indicates which diagnosis according to WHO criteria?

Severe osteoporosis with fracture
Normal bone density
Osteoporosis (Correct answer)
Osteopenia

Correct answer: Osteoporosis

A T-score of -2.5 or below indicates osteoporosis per WHO criteria; a T-score between -1.0 and -2.5 indicates osteopenia.

Question 93: Which of the following types of tumors originates in the mediastinum the most frequently?

Adenoma
Thymoma (Correct answer)
Fibroadenoma
Squamous cell carcinoma

Correct answer: Thymoma

The mediastinum is divided into compartments, and the anterior mediastinum is the most common site for tumors. Among these, thymomas are the most frequently occurring primary tumors, originating from the thymus gland. Other common anterior mediastinal masses include lymphomas, teratomas, and thyroid goiters.

Question 94: Which neurotransmitter is deficient in Parkinson's disease?

Dopamine (Correct answer)
Acetylcholine
GABA
Serotonin

Correct answer: Dopamine

Parkinson's disease results from degeneration of dopaminergic neurons in the substantia nigra, leading to dopamine deficiency in the nigrostriatal pathway.

Question 95: A 33-year-old with HIV (CD4 count 45 cells/μL) presents with progressive dyspnea, dry cough, and bilateral perihilar ground-glass opacities on CXR. LDH is markedly elevated. What is the diagnosis?

Pneumocystis jirovecii pneumonia (Correct answer)
Mycobacterium avium complex pulmonary disease
Pulmonary Kaposi sarcoma
CMV pneumonitis

Correct answer: Pneumocystis jirovecii pneumonia

PCP classically presents in severely immunocompromised HIV patients with bilateral perihilar ground-glass opacities, elevated LDH, and an indolent progressive course.

Question 96: A 68-year-old female with a history of autoimmune gastritis presents with progressive fatigue, paresthesias in her lower extremities, and glossitis. A complete blood count reveals a macrocytic anemia. Which of the following is the most likely underlying deficiency?

Pyridoxine (Vitamin B6)
Folate (Vitamin B9)
Iron
Cobalamin (Vitamin B12) (Correct answer)

Correct answer: Cobalamin (Vitamin B12)

The patient's presentation of macrocytic anemia combined with neurological symptoms (paresthesias) is a classic manifestation of cobalamin (Vitamin B12) deficiency. [32, 34, 36] Her history of autoimmune gastritis is a major risk factor for pernicious anemia, which is the leading cause of B12 deficiency due to a lack of intrinsic factor needed for absorption. [3, 5, 7]

Question 97: Which physical exam finding is most specific for medial meniscus tear?

Positive Lachman test
Positive McMurray test with medial joint line pain (Correct answer)
Positive valgus stress test
Positive anterior drawer test

Correct answer: Positive McMurray test with medial joint line pain

The McMurray test with clicking and medial joint line pain during knee extension from a flexed position is most specific for a medial meniscus tear.

Question 98: A patient with medullary thyroid carcinoma is found to have a RET proto-oncogene mutation. Which familial syndrome should be investigated?

Multiple Endocrine Neoplasia Type 1 (MEN1)
Von Hippel-Lindau disease
Neurofibromatosis type 1
Multiple Endocrine Neoplasia Type 2 (MEN2) (Correct answer)

Correct answer: Multiple Endocrine Neoplasia Type 2 (MEN2)

Medullary thyroid carcinoma is a component of MEN2, which is caused by RET proto-oncogene mutations and also includes pheochromocytoma.

Question 99: A 42-year-old woman presents with massive hemoptysis (>300 mL in 24 hours). She has a history of bronchiectasis from childhood tuberculosis. What is the MOST important immediate intervention?

Emergent surgical resection
Bronchoscopy with cold saline lavage
IV tranexamic acid administration
Airway protection and positioning the bleeding lung in the dependent position (Correct answer)

Correct answer: Airway protection and positioning the bleeding lung in the dependent position

The bleeding lung should be placed dependent (affected side down) to prevent aspiration of blood into the healthy lung, which is the most immediate life-threatening risk.

Question 100: A 72-year-old woman on warfarin presents with INR of 8.2 and active GI bleeding. What is the most appropriate immediate treatment?

Vitamin K 10 mg IV only
Fresh frozen plasma alone
4-factor prothrombin complex concentrate (PCC) plus vitamin K IV (Correct answer)
Hold warfarin and observe

Correct answer: 4-factor prothrombin complex concentrate (PCC) plus vitamin K IV

Life-threatening bleeding on warfarin is best managed with 4-factor PCC for rapid INR reversal plus IV vitamin K to sustain the effect.

Question 101: Carpal tunnel syndrome results from compression of which nerve?

Musculocutaneous nerve
Radial nerve
Ulnar nerve
Median nerve (Correct answer)

Correct answer: Median nerve

Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel, causing numbness and tingling in the thumb, index, middle, and radial half of the ring finger.

Question 102: Which genetic mutation pattern is associated with familial adenomatous polyposis (FAP)?

X-linked dominant mutation in BRCA2
Autosomal recessive mutation in MLH1
Trinucleotide repeat expansion in TP53
Autosomal dominant loss-of-function mutation in APC (Correct answer)

Correct answer: Autosomal dominant loss-of-function mutation in APC

FAP results from autosomal dominant loss-of-function mutations in the APC tumor suppressor gene, causing hundreds to thousands of colorectal polyps.

Question 103: Which valve disorder characteristically produces a mid-systolic click followed by a late systolic murmur?

Mitral stenosis
Aortic stenosis
Tricuspid regurgitation
Mitral valve prolapse (Correct answer)

Correct answer: Mitral valve prolapse

Mitral valve prolapse produces a mid-systolic click with a late systolic murmur heard best at the apex.

Question 104: Which of the following is the most appropriate initial management for a patient presenting with anaphylaxis?

IV diphenhydramine
Intramuscular epinephrine (Correct answer)
Nebulized albuterol
IV corticosteroids

Correct answer: Intramuscular epinephrine

Intramuscular epinephrine in the lateral thigh is the first-line treatment for anaphylaxis due to its rapid onset and ability to reverse bronchospasm, vasodilation, and urticaria.

Question 105: Which of the following negative effects of beta channel blockers is NOT one of them?

Hypotension
Hypertension (Correct answer)
Impotence
Bradycardia

Correct answer: Hypertension

Beta-blockers work by blocking beta-adrenergic receptors, which leads to a decrease in heart rate, reduced myocardial contractility, and vasodilation. These actions collectively result in a *reduction* of blood pressure, making hypotension a common side effect. Therefore, hypertension is not a negative effect; instead, beta-blockers are frequently prescribed to *treat* hypertension.

Question 106: A patient with systolic heart failure (HFrEF) is on optimal medical therapy. Which medication has shown mortality reduction and is recommended by ACC/AHA guidelines as first-line?

Furosemide
Spironolactone alone
Carvedilol (beta-blocker) (Correct answer)
Digoxin

Correct answer: Carvedilol (beta-blocker)

Beta-blockers including carvedilol, metoprolol succinate, and bisoprolol reduce mortality in stable HFrEF and are guideline-directed first-line therapy.

Question 107: Which medication class is first-line for long-term rate control in atrial fibrillation in a patient with heart failure with reduced ejection fraction?

Class IC antiarrhythmics
Beta-blockers (Correct answer)
Non-dihydropyridine calcium channel blockers
Digoxin alone

Correct answer: Beta-blockers

Beta-blockers (e.g., carvedilol, metoprolol succinate) are first-line for rate control in AF with HFrEF and provide mortality benefit.

Question 108: A 45-year-old man presents with dysphagia to solids that has progressed to liquids over 3 months, along with a 20-lb weight loss. Which diagnosis is most likely?

Achalasia
Esophageal spasm
Zenker's diverticulum
Esophageal adenocarcinoma (Correct answer)

Correct answer: Esophageal adenocarcinoma

Progressive dysphagia from solids to liquids with significant weight loss is classic for esophageal carcinoma.

Question 109: Which of the following best defines 'respondeat superior' in the context of PA practice?

The physician's right to override a PA's clinical decision
A PA's obligation to report superior officers
A PA's duty to respond to emergencies
An employer's legal liability for the negligent acts of their employee PA (Correct answer)

Correct answer: An employer's legal liability for the negligent acts of their employee PA

Respondeat superior is a legal doctrine holding employers vicariously liable for negligent acts committed by employees within the scope of their employment.

Question 110: A 48-year-old bird handler presents with fever, dry cough, and diffuse interstitial infiltrates 6 hours after cleaning the bird cage. Pulmonary function tests show a restrictive pattern. What is the most likely diagnosis?

Hypersensitivity pneumonitis (bird fancier's lung) (Correct answer)
Acute eosinophilic pneumonia
Pulmonary alveolar proteinosis
Psittacosis (Chlamydophila psittaci infection)

Correct answer: Hypersensitivity pneumonitis (bird fancier's lung)

Bird fancier's lung is a classic hypersensitivity pneumonitis triggered by avian antigens, presenting hours after exposure with fever, dyspnea, and restrictive physiology.

Question 111: Which of the following cardiovascular conditions is most often connected to exophthalmos and jugular venous distension?

Massive tricuspid regurgitation (Correct answer)
Coarctation of the aorta
Myocarditis
Thoracic aortic aneurysm

Correct answer: Massive tricuspid regurgitation

Massive tricuspid regurgitation causes a noticeably increased venous pressure, which is typically exhibited by a liver that is extremely engorged and frequently pulsing. Exophthalmoses could develop if the venous pressure is high enough.

Question 112: A 62-year-old man with alcoholic cirrhosis develops sudden onset, large-volume hematemesis. Endoscopy reveals actively bleeding esophageal varices. Which pharmacologic agent should be initiated immediately?

Nitroglycerin
Vasopressin IV bolus only
Octreotide (Correct answer)
Propranolol

Correct answer: Octreotide

Octreotide (somatostatin analogue) reduces splanchnic blood flow and portal pressure and is the preferred pharmacologic agent for acute variceal bleeding.

Question 113: Which neurotransmitter is released at the neuromuscular junction to initiate skeletal muscle contraction?

Acetylcholine (Correct answer)
Norepinephrine
Dopamine
Glutamate

Correct answer: Acetylcholine

Acetylcholine is released from motor neuron terminals and binds nicotinic receptors on the motor end plate, triggering muscle depolarization.

Question 114: Which of the following is the most common type of thyroid cancer, accounting for approximately 80% of cases?

Follicular thyroid carcinoma
Anaplastic thyroid carcinoma
Papillary thyroid carcinoma (Correct answer)
Medullary thyroid carcinoma

Correct answer: Papillary thyroid carcinoma

Papillary thyroid carcinoma is the most common thyroid cancer with the best prognosis; it spreads via lymphatics and is associated with radiation exposure.

Question 115: Every two years, log 100 hours of continuing education, and every six years, take the recertification exam.

pa's responsibilities
admissions test
to maintain national certification, PA's must (Correct answer)
average pa program runs

Correct answer: to maintain national certification, PA's must

The sentence describes the recertification requirements PAs follow to keep their national certification — logging 100 hours of continuing education every two years and passing the recert exam every six years. So the correct completion is 'to maintain national certification, PAs must.' The other phrases describe program length, job duties, or admissions, which don't match these maintenance requirements.

Question 116: Which hormone stimulates osteoclast activity, increases renal calcium reabsorption, and raises serum calcium levels?

Cortisol
Parathyroid hormone (PTH) (Correct answer)
Calcitonin
Vitamin D3 (calcitriol)

Correct answer: Parathyroid hormone (PTH)

PTH raises serum calcium by stimulating osteoclast-mediated bone resorption, increasing renal calcium reabsorption, and promoting renal 1-alpha-hydroxylase activity to activate vitamin D.

Question 117: If x² = 49, which of the following gives ALL possible values of x?

x = 7 or x = −7 (Correct answer)
x = −7
x = 7
x = 0

Correct answer: x = 7 or x = −7

A square root has both positive and negative solutions: x = ±7.

Question 118: All of the following are true with regard to the EKG findings of premature atrial contractions EXCEPT:

Extra P waves may be hidden within the QRS complex or T waves
P waves are invariably absent (Correct answer)
The QRS is usually narrow
P waves may be present

Correct answer: P waves are invariably absent

Premature atrial contractions (PACs) originate in the atria, meaning there must be an atrial depolarization event, which manifests as a P wave on an EKG. While the P wave may be abnormal in shape, hidden within other waves, or premature, its complete and invariable absence is characteristic of rhythms like atrial fibrillation, not PACs.

Question 119: According to the most recent United States Preventive Services Task Force (USPSTF) recommendations, at what age should average-risk adults begin screening for colorectal cancer?

40
45 (Correct answer)
55
50

Correct answer: 45

In May 2021, the United States Preventive Services Task Force (USPSTF) updated its guidelines, lowering the recommended age for average-risk adults to begin screening for colorectal cancer from 50 to 45. [9, 12, 16] This change was based on data showing an increasing incidence of colorectal cancer in younger adults. [12]

Question 120: A 32-year-old woman at 36 weeks gestation presents with severe headache, visual disturbances, and BP of 162/110 mmHg. Urinalysis shows 3+ proteinuria. What is the definitive treatment?

IV magnesium sulfate alone
Delivery of the fetus (Correct answer)
Corticosteroids and expectant management
Oral labetalol and outpatient monitoring

Correct answer: Delivery of the fetus

Delivery is the only definitive treatment for preeclampsia with severe features; at 36 weeks gestation, the risks of continuing the pregnancy outweigh those of delivery.

Question 121: A patient presents with sudden severe headache, nuchal rigidity, photophobia, and fever. CSF analysis shows cloudy fluid, elevated protein, low glucose, and neutrophilic pleocytosis. What is the most appropriate immediate treatment?

Await culture results before starting antibiotics
IV acyclovir only
Oral amoxicillin and close outpatient follow-up
IV ceftriaxone and dexamethasone empirically (Correct answer)

Correct answer: IV ceftriaxone and dexamethasone empirically

Bacterial meningitis is a medical emergency; empiric IV ceftriaxone and dexamethasone (to reduce inflammation) should be started immediately without waiting for culture results.

Question 122: A 6-week-old male presents with projectile non-bilious vomiting after feeds and an olive-shaped mass in the epigastrium. What is the diagnosis?

Malrotation with volvulus
Duodenal atresia
Intussusception
Pyloric stenosis (Correct answer)

Correct answer: Pyloric stenosis

Hypertrophic pyloric stenosis presents in males aged 3–6 weeks with projectile non-bilious vomiting and a palpable pyloric mass (olive), leading to hypochloremic metabolic alkalosis.

Question 123: A 40-year-old woman presents with episodic right upper quadrant pain after fatty meals, lasting 30–60 minutes. Ultrasound shows gallstones but no bile duct dilation. What is this condition called?

Acute cholecystitis
Choledocholithiasis
Biliary colic (Correct answer)
Primary sclerosing cholangitis

Correct answer: Biliary colic

Biliary colic is transient RUQ pain caused by temporary gallstone obstruction of the cystic duct, without sustained inflammation or infection.

Question 124: A patient presents with pain and swelling over the lateral epicondyle of the elbow, worsened by wrist extension and gripping. What is the most likely diagnosis?

Lateral epicondylitis (tennis elbow) (Correct answer)
Medial epicondylitis
Radial tunnel syndrome
Olecranon bursitis

Correct answer: Lateral epicondylitis (tennis elbow)

Lateral epicondylitis (tennis elbow) involves overuse of the forearm extensor muscles, causing pain at the lateral epicondyle worsened by wrist extension and gripping.

Question 125: A 40-year-old woman presents with exertional dyspnea and a mean pulmonary artery pressure of 30 mmHg on right heart catheterization. She has no left heart disease or lung disease. Which treatment is first-line for Group 1 pulmonary arterial hypertension?

High-dose calcium channel blockers for all patients
Phosphodiesterase-5 inhibitors or endothelin receptor antagonists (Correct answer)
Supplemental oxygen therapy alone
Long-term anticoagulation with warfarin

Correct answer: Phosphodiesterase-5 inhibitors or endothelin receptor antagonists

PDE-5 inhibitors (sildenafil) or endothelin receptor antagonists (bosentan, ambrisentan) are first-line for Group 1 PAH in patients without vasoreactivity on testing.

Question 126: A 70-year-old woman has a positive Romberg sign. This finding indicates dysfunction of which sensory system?

Visual acuity
Motor cortex pathways
Proprioception and vestibular input (Correct answer)
Cerebellar coordination

Correct answer: Proprioception and vestibular input

A positive Romberg sign (increased sway with eyes closed) indicates impaired proprioception or vestibular input, not cerebellar dysfunction.

Question 127: A PA is asked to perform a procedure they have not been trained to do. The most appropriate response is to:

Ask a nurse to assist and proceed
Perform the procedure with the patient's verbal consent only
Attempt the procedure to avoid inconveniencing the patient
Decline and refer the patient to a qualified provider (Correct answer)

Correct answer: Decline and refer the patient to a qualified provider

PAs are ethically and legally obligated to practice within their competency and should decline procedures they are not trained to perform, ensuring patient safety.

Question 128: Which drug used for HIV is a protease inhibitor known to cause hyperlipidemia, lipodystrophy, and hyperglycemia as metabolic side effects?

Raltegravir
Ritonavir (Correct answer)
Emtricitabine
Tenofovir

Correct answer: Ritonavir

Ritonavir and other protease inhibitors are associated with significant metabolic complications including dyslipidemia, fat redistribution, and insulin resistance.

Question 129: A 2-year-old swallows a button battery. What is the most critical concern?

Aspiration into the airway
Esophageal perforation from electrical current (Correct answer)
Heavy metal toxicity
Intestinal obstruction

Correct answer: Esophageal perforation from electrical current

Button batteries lodged in the esophagus generate an electrical current causing liquefactive necrosis and perforation within hours, requiring emergency endoscopic removal.

Question 130: A 70-year-old woman with dyspnea has an S3 gallop, bilateral crackles, and JVD. Which BNP level best supports acute decompensated heart failure?

BNP 850 pg/mL (Correct answer)
BNP 120 pg/mL
BNP 30 pg/mL
BNP 50 pg/mL

Correct answer: BNP 850 pg/mL

BNP >100 pg/mL strongly supports heart failure; levels above 400-500 pg/mL are highly specific for decompensated HF.

Question 131: Which of the following types of cyanotic congenital heart disease is most prevalent?

Truncus Arteriosus
Tetrology of Fallot (Correct answer)
Transposition of the Great Vessels
Tricuspid atresia

Correct answer: Tetrology of Fallot

Tetralogy of Fallot (TOF) is the most prevalent cyanotic congenital heart disease. It is a complex condition characterized by four distinct cardiac defects: a ventricular septal defect, pulmonary stenosis, an overriding aorta, and right ventricular hypertrophy. These defects collectively lead to reduced blood flow to the lungs and mixing of oxygenated and deoxygenated blood, resulting in cyanosis.

Question 132: A patient on rifampin for tuberculosis has a subtherapeutic oral contraceptive effect. What is the mechanism?

Competitive binding at estrogen receptors
Increased renal estrogen excretion
Inhibition of estrogen absorption in the gut
Induction of CYP3A4 increasing estrogen metabolism (Correct answer)

Correct answer: Induction of CYP3A4 increasing estrogen metabolism

Rifampin is a potent CYP3A4 inducer that accelerates estrogen and progestin metabolism, reducing plasma contraceptive concentrations.

Question 133: Which sign is used to diagnose De Quervain tenosynovitis?

Tinel sign
Finkelstein test (Correct answer)
Phalen sign
McMurray test

Correct answer: Finkelstein test

The Finkelstein test, where ulnar deviation of the wrist with the thumb enclosed in the fist reproduces pain over the radial styloid, is used to diagnose De Quervain tenosynovitis.

Question 134: A 16-year-old male presents with knee pain after a twisting injury during basketball. Exam shows a positive Lachman test and anterior drawer sign. What structure is most likely injured?

Posterior cruciate ligament
Anterior cruciate ligament (Correct answer)
Medial collateral ligament
Lateral meniscus

Correct answer: Anterior cruciate ligament

The Lachman test and anterior drawer sign both assess anterior tibial translation and are positive with anterior cruciate ligament (ACL) tears.

Question 135: Which finding on colonoscopy is most characteristic of ulcerative colitis compared to Crohn's disease?

Continuous involvement starting at the rectum (Correct answer)
Skip lesions
Cobblestoning mucosa
Transmural inflammation

Correct answer: Continuous involvement starting at the rectum

Ulcerative colitis causes continuous, contiguous mucosal inflammation that always involves the rectum and extends proximally.

Question 136: When obtaining a sexual history using the 5 P's framework, which of the following is NOT one of the 5 P's?

Practices
Protection
Partners
Prior STIs (Correct answer)
Pregnancy plans

Correct answer: Prior STIs

The 5 P's are Partners, Practices, Protection from STIs, Past history of STIs, and Pregnancy intention — 'Prior STIs' is phrased differently but the framework doesn't use that exact term as a standalone P.

Question 137: Which of the following is the most important initial intervention in the management of Diabetic Ketoacidosis (DKA)?

IV insulin bolus
Oral potassium replacement
IV fluid resuscitation with normal saline (Correct answer)
Sodium bicarbonate infusion

Correct answer: IV fluid resuscitation with normal saline

IV fluid resuscitation is the most critical initial step in DKA to correct severe dehydration before initiating insulin therapy.

Question 138: A 35-year-old man presents with coarse facial features, enlarged hands and feet, headaches, and bitemporal hemianopsia. IGF-1 is markedly elevated. What is the most likely diagnosis?

Prolactinoma
Gigantism
Cushing's disease
Acromegaly (Correct answer)

Correct answer: Acromegaly

Acromegaly is caused by excess GH after epiphyseal closure, leading to coarse acral features and elevated IGF-1; a pituitary tumor causes the visual field defect.

Question 139: In a patient with metabolic alkalosis, which compensatory mechanism would you expect?

Hyperventilation to eliminate CO2
Hypoventilation to retain CO2 (Correct answer)
Increased renal bicarbonate excretion only
Decreased aldosterone secretion

Correct answer: Hypoventilation to retain CO2

Metabolic alkalosis is compensated by hypoventilation, which retains CO2 and increases carbonic acid to buffer the elevated pH.

Question 140: A 55-year-old male presents to the emergency department with an acute onset of pleuritic chest pain and dyspnea. He returned from an international flight yesterday. His heart rate is 115 bpm, and his O2 saturation is 90% on room air. A D-dimer is elevated. According to diagnostic algorithms for suspected pulmonary embolism (PE), what is the most appropriate next step for this hemodynamically stable patient?

Chest X-ray
Lower extremity venous duplex ultrasound
CT pulmonary angiography (CTPA) (Correct answer)
Ventilation/perfusion (V/Q) scan

Correct answer: CT pulmonary angiography (CTPA)

In a patient with a high clinical pretest probability for pulmonary embolism and an elevated D-dimer, CT pulmonary angiography (CTPA) is the diagnostic imaging modality of choice. It is readily available and provides definitive visualization of the pulmonary arteries. While a chest X-ray is often obtained to rule out other pathologies, it cannot confirm a PE. A V/Q scan is an alternative if CTPA is contraindicated. A lower extremity ultrasound can diagnose a DVT but cannot rule out a PE.

Question 141: On auscultation, a mid-systolic click followed by a late systolic murmur is characteristic of:

Aortic regurgitation
Mitral valve prolapse (Correct answer)
Aortic stenosis
Ventricular septal defect

Correct answer: Mitral valve prolapse

A mid-systolic click followed by a late systolic murmur is the hallmark auscultatory finding of mitral valve prolapse.

Question 142: Which organization became a supporting organization of the National Commission on Certification of Physician Assistants in 2011?

The PA History Society (Correct answer)
American Academy of Physician Assistants
Association of Physician Assistant Programs
Duke University Medical Center

Correct answer: The PA History Society

The PA History Society became a supporting organization of the NCCPA in 2011, aligning its historical-preservation mission with the certifying body. The AAPA, Duke, and APAP play different roles and were not the supporting organization referenced here.

Question 143: A 28-year-old patient reports waking up with coughing and wheezing four nights per month. They use their albuterol inhaler approximately three times per week for symptom relief. Their FEV1 is 85% of predicted. According to the National Asthma Education and Prevention Program (NAEPP) guidelines, what is the most appropriate classification of this patient's asthma severity?

Mild persistent (Correct answer)
Intermittent
Severe persistent
Moderate persistent

Correct answer: Mild persistent

According to the NAEPP guidelines, mild persistent asthma is characterized by symptoms occurring more than two days a week (but not daily), nighttime awakenings 3-4 times a month, and SABA use more than two days a week (but not daily). This patient's symptom frequency fits squarely within the mild persistent category, guiding the initiation of appropriate daily controller therapy.

Question 144: A 4-month-old has a head circumference crossing two percentile lines upward over 2 months. The anterior fontanelle is bulging. CT scan shows enlarged ventricles. What is the diagnosis?

Subdural hematoma
Hydrocephalus (Correct answer)
Megalencephaly
Craniosynostosis

Correct answer: Hydrocephalus

Hydrocephalus presents with rapidly increasing head circumference, bulging fontanelle, sunset sign of the eyes, and ventricular enlargement on neuroimaging.

Question 145: In genetics, incomplete dominance results in which pattern of inheritance?

One allele completely masks the other
Intermediate phenotype in heterozygotes (Correct answer)
Both alleles are fully expressed simultaneously
Expression varies by sex of the offspring

Correct answer: Intermediate phenotype in heterozygotes

Incomplete dominance produces an intermediate phenotype in heterozygotes, as neither allele fully dominates the other (e.g., red × white = pink flowers).

Question 146: A 5-year-old boy is brought in with inspiratory stridor, fever, and a 'steeple sign' on anteroposterior neck X-ray. What is the most likely causative organism?

Parainfluenza virus (Correct answer)
Streptococcus pyogenes
Staphylococcus aureus
Haemophilus influenzae type b

Correct answer: Parainfluenza virus

Croup (laryngotracheobronchitis) is most commonly caused by parainfluenza virus and produces the classic steeple sign on AP neck X-ray.

Question 147: A patient with peripheral artery disease has an ABI of 0.55. What does this indicate?

Mild PAD
Non-compressible vessels (calcification)
Moderate-to-severe PAD (Correct answer)
Normal arterial perfusion

Correct answer: Moderate-to-severe PAD

An ABI of 0.41–0.70 indicates moderate-to-severe peripheral arterial disease with significant hemodynamic compromise.

Question 148: A 60-year-old woman presents with nausea, early satiety, and bloating after meals. Her blood glucose is poorly controlled. Which condition best explains her symptoms?

Gastroparesis (Correct answer)
Irritable bowel syndrome
Peptic ulcer disease
Celiac disease

Correct answer: Gastroparesis

Gastroparesis is a common complication of long-standing diabetes mellitus and causes delayed gastric emptying with these symptoms.

Question 149: A patient with mitral stenosis is most at risk for which complication?

Ventricular tachycardia
Ventricular fibrillation
Complete heart block
Atrial fibrillation and systemic embolism (Correct answer)

Correct answer: Atrial fibrillation and systemic embolism

Mitral stenosis causes left atrial enlargement, predisposing to atrial fibrillation and thrombus formation with embolic risk.

Question 150: Where are pediatric PAs employed?

Inpatient
Both patient and outpatient (Correct answer)
Outpatient

Correct answer: Both patient and outpatient

Pediatric Physician Assistants (PAs) can work in a variety of settings, including inpatient and outpatient settings. Inpatient settings may include hospitals, neonatal intensive care units (NICUs), pediatric wards, and emergency departments, where they may provide care for acutely ill children and manage complex medical conditions. Outpatient settings may include clinics, private practices, and community health centers, where they may provide preventive care, routine check-ups, and diagnosis and treatment of chronic and acute illnesses. Additionally, they may work in schools, child care centers, and other community settings to provide health education and promote healthy lifestyles for children and families.

Question 151: A 4-week-old male infant presents with a 1-week history of non-bilious, projectile vomiting immediately after feeding. The mother reports he seems hungry all the time. On physical examination, an olive-sized mass is palpated in the epigastric region. What is the most appropriate next step to confirm the diagnosis?

Barium upper GI series
Abdominal X-ray
Empiric trial of thickened feeds
Abdominal ultrasound (Correct answer)

Correct answer: Abdominal ultrasound

The history and physical exam findings are classic for hypertrophic pyloric stenosis. Abdominal ultrasound is the preferred, most sensitive, and specific imaging modality to confirm the diagnosis. [13, 23, 24] It is non-invasive, avoids radiation exposure, and allows for direct measurement of the pyloric muscle thickness and channel length. [25, 28]

Question 152: When examining the eyes, the consensual light reflex tests the integrity of which pathway?

Contralateral CN II and ipsilateral CN III
Ipsilateral CN II, optic chiasm, and contralateral CN III (Correct answer)
CN IV and CN VI bilaterally
Ipsilateral CN II and ipsilateral CN III only

Correct answer: Ipsilateral CN II, optic chiasm, and contralateral CN III

Light in one eye travels via CN II to the optic chiasm; efferent fibers cross to activate the contralateral CN III, producing the consensual pupillary response.

Question 153: A 34-year-old male complains of recurrent episodes of excruciating, unilateral pain behind his right eye, which he describes as a 'hot poker' sensation. The attacks last for 60-90 minutes and occur several times a day for weeks at a time. During these episodes, he also experiences right-sided nasal congestion and tearing from his right eye. Which of the following is the most likely diagnosis?

Tension-type headache
Cluster headache (Correct answer)
Trigeminal neuralgia
Migraine with aura

Correct answer: Cluster headache

This patient's presentation is classic for a cluster headache. Key features include the severe, unilateral, periorbital pain of relatively short duration, occurring in cyclical 'clusters'. The associated ipsilateral autonomic symptoms (lacrimation, nasal congestion) are also characteristic of this headache syndrome. [3, 16, 17] Migraines are typically throbbing and last longer. Tension headaches are bilateral and pressing. Trigeminal neuralgia involves brief, electric shock-like pains in the distribution of the trigeminal nerve.

Question 154: Feldshers in Russia received instruction in the 1650s.

8 years
4 months
2-3 months
2.5 years (Correct answer)

Correct answer: 2.5 years

Feldshers in Russia in the 1650s typically received about 2.5 years of training, including basic medical skills such as bloodletting, wound care, and childbirth.

Question 155: A 25-year-old woman presents with optic neuritis and new-onset sensory disturbances in her extremities. MRI shows periventricular white matter lesions. What is the most likely diagnosis?

CNS vasculitis
Neuromyelitis optica
Vitamin B12 deficiency
Multiple sclerosis (Correct answer)

Correct answer: Multiple sclerosis

Multiple sclerosis classically presents in young women with relapsing-remitting neurological symptoms, optic neuritis, and periventricular demyelinating lesions on MRI.

Question 156: A patient presents with thunderclap headache described as 'the worst headache of my life.' CT head is negative. What is the next most appropriate step?

Discharge with analgesics
EEG
Lumbar puncture to check for xanthochromia (Correct answer)
MRI brain without contrast

Correct answer: Lumbar puncture to check for xanthochromia

When CT is negative in a patient with thunderclap headache, lumbar puncture to detect xanthochromia is essential to rule out subarachnoid hemorrhage, which may not appear on CT after several hours.

Question 157: A 45-year-old male presents with low back pain and morning stiffness lasting more than 1 hour that improves with exercise. HLA-B27 is positive. What is the most likely diagnosis?

Osteoarthritis
Ankylosing spondylitis (Correct answer)
Reactive arthritis
Lumbar disc herniation

Correct answer: Ankylosing spondylitis

Ankylosing spondylitis is a seronegative spondyloarthropathy strongly associated with HLA-B27, presenting with inflammatory back pain, prolonged morning stiffness relieved by activity.

Question 158: A 50-year-old presents with symmetric ascending weakness and areflexia following a GI infection 3 weeks prior. CSF shows albuminocytologic dissociation. What is the most likely diagnosis?

Amyotrophic lateral sclerosis
Multiple sclerosis
Myasthenia gravis
Guillain-Barré syndrome (Correct answer)

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome presents with ascending flaccid paralysis, areflexia, and CSF albuminocytologic dissociation (elevated protein with normal cell count), often following infection.

Question 159: A patient taking an MAO inhibitor for depression eats aged cheese and develops a hypertensive crisis. What is the mechanism?

Tyramine displaces norepinephrine from nerve terminals causing massive release (Correct answer)
Tyramine blocks calcium channels
Tyramine directly activates alpha-2 adrenergic receptors
Tyramine inhibits renal dopamine clearance

Correct answer: Tyramine displaces norepinephrine from nerve terminals causing massive release

MAO normally metabolizes tyramine; when inhibited, dietary tyramine enters systemic circulation, displacing NE from storage vesicles causing a catecholamine surge.

Question 160: Which of the following is the most appropriate initial biochemical test to screen for pheochromocytoma?

Plasma free metanephrines or 24-hour urine fractionated metanephrines (Correct answer)
CT scan of the abdomen
Serum cortisol level
Clonidine suppression test

Correct answer: Plasma free metanephrines or 24-hour urine fractionated metanephrines

Plasma free metanephrines or 24-hour urine fractionated metanephrines are the preferred biochemical tests for screening pheochromocytoma due to high sensitivity.

Question 161: Which nutritional deficiency most commonly causes night blindness?

Vitamin A (Correct answer)
Vitamin D
Vitamin C
Zinc

Correct answer: Vitamin A

Vitamin A (retinol) is required for rhodopsin synthesis in rod photoreceptors; deficiency impairs dark adaptation and causes night blindness.

Question 162: A patient on amiodarone develops hypothyroidism. What is the mechanism?

Increased TSH receptor antibodies
Direct thyroid gland destruction
Inhibition of iodide uptake via Wolff-Chaikoff effect (Correct answer)
Decreased GnRH secretion

Correct answer: Inhibition of iodide uptake via Wolff-Chaikoff effect

Amiodarone contains ~37% iodine by weight; the high iodine load can trigger the Wolff-Chaikoff effect, suppressing thyroid hormone synthesis.

Question 163: Which finding on urinalysis is most specific for acute tubular necrosis (ATN)?

Muddy brown granular casts (Correct answer)
Waxy casts
Red blood cell casts
White blood cell casts

Correct answer: Muddy brown granular casts

Muddy brown granular casts are the hallmark finding of acute tubular necrosis, representing sloughed renal tubular epithelial cells.

Question 164: Which vitamin requires intrinsic factor for absorption and is deficient in pernicious anemia?

Vitamin B1 (thiamine)
Vitamin B6 (pyridoxine)
Folate
Vitamin B12 (cobalamin) (Correct answer)

Correct answer: Vitamin B12 (cobalamin)

Vitamin B12 binds intrinsic factor produced by gastric parietal cells for absorption in the terminal ileum; autoimmune destruction of parietal cells causes pernicious anemia.

Question 165: Bell's palsy involves dysfunction of which cranial nerve?

CN V (Trigeminal)
CN X (Vagus)
CN VII (Facial) (Correct answer)
CN IX (Glossopharyngeal)

Correct answer: CN VII (Facial)

Bell's palsy is idiopathic peripheral CN VII (facial nerve) palsy causing ipsilateral upper and lower facial weakness, distinguishing it from central causes which spare the forehead.

Question 166: A PA's differential diagnosis is overly influenced by a recently diagnosed patient with the same condition. Which cognitive bias is most likely operating?

Framing effect
Overconfidence bias
Availability heuristic (Correct answer)
Anchoring bias

Correct answer: Availability heuristic

The availability heuristic causes clinicians to overestimate the likelihood of diagnoses that come easily to mind, often due to recent or vivid experiences.

Question 167: Which of the following is the most common type of stroke?

Ischemic stroke (Correct answer)
Subarachnoid hemorrhage
Hemorrhagic stroke
Subdural hematoma

Correct answer: Ischemic stroke

Ischemic stroke accounts for approximately 87% of all strokes, caused by thrombotic or embolic occlusion of cerebral vessels.

Question 168: A 30-year-old pregnant woman at 28 weeks is found to have a 1-hour glucose challenge test result of 185 mg/dL. She subsequently completes a 3-hour oral glucose tolerance test. How many abnormal values are needed to diagnose gestational diabetes?

Two or more abnormal values (Correct answer)
One abnormal value
Any value above fasting threshold
Three or more abnormal values

Correct answer: Two or more abnormal values

Using the Carpenter-Coustan criteria, gestational diabetes is diagnosed when 2 or more values on the 3-hour OGTT meet or exceed threshold levels.

Question 169: Which of the following is the most significant risk factor for stroke that can be modified?

Congestive heart failure
Hypertension (Correct answer)
Hypotension
Diabetes

Correct answer: Hypertension

Hypertension is recognized as the single most significant and modifiable risk factor for stroke. Chronically elevated blood pressure damages blood vessels, promoting atherosclerosis, increasing the risk of clot formation, and weakening vessel walls, which can lead to both ischemic and hemorrhagic strokes. Effective management of hypertension is crucial for stroke prevention.

Question 170: Which of the following best describes the pathophysiology of Type 2 Diabetes Mellitus?

Autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency
Peripheral insulin resistance combined with progressive beta-cell dysfunction (Correct answer)
Downregulation of hepatic glucose transporters only
Excess glucagon secretion from alpha cells as the primary mechanism

Correct answer: Peripheral insulin resistance combined with progressive beta-cell dysfunction

Type 2 DM involves both peripheral insulin resistance and progressive pancreatic beta-cell dysfunction, leading to relative insulin deficiency over time.

Question 171: A 55-year-old develops hemoptysis, and bronchoscopy reveals a central endobronchial mass with biopsy showing small cell lung cancer. PET/CT shows hilar lymphadenopathy only. This is classified as:

Stage IIB NSCLC
Limited-stage SCLC (Correct answer)
Stage IIIB NSCLC
Extensive-stage SCLC

Correct answer: Limited-stage SCLC

Limited-stage SCLC is confined to one hemithorax and regional nodes that can be encompassed in a radiation field; this patient's disease fits within that definition.

Question 172: A 25-year-old lady who complains of palpitations is being evaluated by you. You hear a midsystolic click during inspection. Which of the following would you advise in regards to her heart condition assessment?

She may need a beta blocker if the palpitations continue.
She should be screened for rheumatic fever. (Correct answer)
Her murmur would decrease with a Valsalva maneuver.
She should be screened for major depressive disorder.
She should be screened for a bleeding diathesis.

Correct answer: She should be screened for rheumatic fever.

The presence of a midsystolic click during inspection can be indicative of mitral valve prolapse (MVP). Mitral valve prolapse is a condition where the valve between the left atrium and the left ventricle doesn't close properly during systole and bulges back into the atrium. It can sometimes produce a clicking sound. <br> <br> Mitral valve prolapse is often benign and may not require treatment in many cases. However, it can be associated with other complications, and one of them is the increased risk of infective endocarditis, especially in patients with a history of rheumatic fever. Rheumatic fever is a condition caused by an untreated or inadequately treated streptococcal infection, and it can damage the heart valves, leading to mitral valve prolapse.

Question 173: A 52-year-old with obstructive sleep apnea refuses CPAP. Which consequence of untreated OSA poses the greatest cardiovascular risk?

Nocturnal hypoventilation causing CO2 retention
Repetitive hypoxemia and sympathetic surges causing systemic hypertension (Correct answer)
Reduced cardiac output from decreased preload during apneas
Peripheral chemoreceptor desensitization to hypoxia

Correct answer: Repetitive hypoxemia and sympathetic surges causing systemic hypertension

Repetitive hypoxic episodes and arousal-associated sympathetic activation cause sustained systemic hypertension, which is the primary cardiovascular complication of OSA.

Question 174: A patient presents with pain in the heel that is worst with the first steps in the morning and improves after walking. What is the most likely diagnosis?

Calcaneal stress fracture
Plantar fasciitis (Correct answer)
Achilles tendinopathy
Tarsal tunnel syndrome

Correct answer: Plantar fasciitis

Plantar fasciitis classically presents with heel pain that is worst with the first steps after rest (post-static dyskinesia) and improves with continued ambulation.

Question 175: A patient is found to have hemoglobin of 9.2 g/dL, MCV of 72 fL, low serum ferritin, and low serum iron with elevated TIBC. What is the most likely diagnosis?

Sideroblastic anemia
Thalassemia trait
Anemia of chronic disease
Iron deficiency anemia (Correct answer)

Correct answer: Iron deficiency anemia

Iron deficiency anemia presents with microcytic anemia, low ferritin (depleted stores), low serum iron, and high TIBC (transferrin upregulation).

Question 176: Which of the following is the most common overall cause of Cushing's syndrome?

Pituitary adenoma (Cushing's disease)
Ectopic ACTH production
Exogenous corticosteroid use (Correct answer)
Adrenal adenoma

Correct answer: Exogenous corticosteroid use

Exogenous corticosteroid use is the most common cause of Cushing's syndrome overall, making it iatrogenic in most cases.

Question 177: A 68-year-old female with type 2 diabetes presents to the emergency department with altered mental status. Her family reports a week of increasing polyuria, polydipsia, and lethargy. Laboratory results show a blood glucose of 850 mg/dL, serum bicarbonate of 20 mEq/L, arterial pH of 7.35, and minimal urine ketones. Serum osmolality is calculated to be 345 mOsm/kg. Which of the following is the most likely diagnosis?

Severe hypoglycemia
Lactic acidosis
Hyperosmolar hyperglycemic state (HHS) (Correct answer)
Diabetic ketoacidosis (DKA)

Correct answer: Hyperosmolar hyperglycemic state (HHS)

This patient's presentation of profound hyperglycemia (glucose >600 mg/dL), high serum osmolality (>320 mOsm/kg), and altered mental status without significant ketosis or acidosis (pH >7.3, bicarbonate >18 mEq/L) is the hallmark of hyperosmolar hyperglycemic state (HHS). [2, 5, 10] DKA is characterized by lower glucose levels, significant ketosis, and metabolic acidosis. Severe hypoglycemia would present with low blood glucose. Lactic acidosis involves a high anion gap with elevated lactate levels, which is not the primary picture here.

Question 178: A 10-year-old presents with limping and dull hip pain for 3 weeks. X-ray shows flattening and fragmentation of the femoral head. What is the diagnosis?

Transient synovitis
Slipped capital femoral epiphysis (SCFE)
Septic arthritis
Legg-Calvé-Perthes disease (Correct answer)

Correct answer: Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children aged 4–10, presenting with insidious hip pain and radiographic femoral head fragmentation.

Question 179: Which of the following is the Rocky Mountain spotted fever-causing organism?

Corynebacterium
Bordetella pertussis
Rickettsia siberica
Rickettsia rickettsii (Correct answer)

Correct answer: Rickettsia rickettsii

Rocky Mountain spotted fever (RMSF) is a serious bacterial infection transmitted to humans through the bite of infected ticks. The specific causative agent for this disease is the bacterium *Rickettsia rickettsii*. This organism infects the endothelial cells lining blood vessels, leading to vasculitis and the characteristic rash associated with RMSF.

Question 180: A 68-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with a sudden-onset 'tearing' chest pain that radiates to his back. On examination, his blood pressure is 190/110 mmHg in the right arm and 155/90 mmHg in the left arm. A new diastolic murmur is auscultated at the right sternal border. Which of the following is the most likely diagnosis?

Pericarditis
Acute myocardial infarction
Aortic dissection (Correct answer)
Pulmonary embolism

Correct answer: Aortic dissection

The classic presentation of a sudden-onset 'tearing' or 'ripping' chest pain radiating to the interscapular area of the back, accompanied by a significant blood pressure differential between the upper extremities (>20 mmHg systolic), and a new diastolic murmur of aortic regurgitation strongly suggests an acute aortic dissection.

Question 181: A 35-year-old woman presents with weakness, fatigue, hyperpigmentation, hyponatremia, and hyperkalemia. Cortisol is low and ACTH is markedly elevated. What is the most likely diagnosis?

Primary hyperaldosteronism
Cushing's disease
Addison's disease (Correct answer)
Secondary adrenal insufficiency

Correct answer: Addison's disease

Addison's disease (primary adrenal insufficiency) features elevated ACTH causing hyperpigmentation, with low cortisol, hyponatremia, and hyperkalemia.

Question 182: When a PA documents 'patient refused treatment,' this primarily protects against which legal concern?

HIPAA violations
Fraud and abuse allegations
Claims of abandonment or negligence (Correct answer)
Unauthorized practice of medicine

Correct answer: Claims of abandonment or negligence

Documenting patient refusal protects the PA from claims of negligence or abandonment by demonstrating the patient was informed and made an autonomous decision.

Question 183: A 58-year-old man presents with exertional chest pain relieved by rest. ECG at rest is normal. What is the most appropriate next diagnostic step?

Holter monitor
Coronary angiography
Exercise stress test (Correct answer)
Echocardiogram

Correct answer: Exercise stress test

Exercise stress testing is the standard initial evaluation for stable angina when the resting ECG is normal.

Question 184: Which of the following statements regarding the assessment and treatment of lipomas is true?

They are usually painful and tender on examination
They are usually associated with a malignant condition
They usually require surgical removal to prevent further complications
They can usually be watched without surgical intervention (Correct answer)
They are associated with diabetes mellitus

Correct answer: They can usually be watched without surgical intervention

Lipomas are benign fatty tumors that are usually soft, painless, and slow-growing, so they can typically be observed without surgery. They are not malignant, not painful or tender, not linked to diabetes, and rarely require removal unless they cause symptoms or cosmetic concern.

Question 185: The Fick principle is used to calculate cardiac output. Which formula correctly represents it?

CO = MAP / SVR
CO = HR × SV
CO = (CaO2 - CvO2) / VO2
CO = VO2 / (CaO2 - CvO2) (Correct answer)

Correct answer: CO = VO2 / (CaO2 - CvO2)

The Fick principle states cardiac output equals oxygen consumption divided by the arteriovenous oxygen content difference.

Question 186: What age range do pediatric physician assistants see?

1-18
Bith-18
Birth-21 (Correct answer)
Birth-Death

Correct answer: Birth-21

Pediatric Physician Assistants (PAs) typically see patients from birth up to 21 years of age. They may work in various settings, such as hospitals, clinics, or private practices, and may provide a wide range of medical services, including physical exams, preventive care, diagnosis and treatment of acute and chronic illnesses, and management of complex medical conditions. Additionally, they may collaborate with other healthcare professionals, such as physicians, nurses, and therapists, to provide comprehensive care for children and adolescents.

Question 187: Which of the following electrocardiogram (ECG) findings is most characteristic of acute pericarditis?

Diffuse ST-segment elevation and PR-segment depression (Correct answer)
ST-segment elevation in a localized coronary distribution
Development of pathologic Q waves
Deep, symmetric T-wave inversions

Correct answer: Diffuse ST-segment elevation and PR-segment depression

The classic ECG finding in acute pericarditis is diffuse, concave-up ST-segment elevation across multiple limb and precordial leads, which does not conform to a specific coronary artery territory. This is often accompanied by PR-segment depression, particularly in lead II. Localized ST elevation and Q waves are more indicative of a myocardial infarction.

Question 188: What is the purpose of a PA's National Provider Identifier (NPI)?

To uniquely identify the PA in all healthcare transactions covered by HIPAA (Correct answer)
To assign billing rates for Medicare services
To verify a PA's DEA registration status
To track a PA's CME completion

Correct answer: To uniquely identify the PA in all healthcare transactions covered by HIPAA

The NPI is a unique 10-digit identification number used in HIPAA standard electronic transactions to identify healthcare providers.

Question 189: A neonate presents at 24 hours of life with bilious vomiting. Abdominal X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

Duodenal atresia (Correct answer)
Hirschsprung's disease
Pyloric stenosis
Meconium ileus

Correct answer: Duodenal atresia

The double bubble sign on X-ray (air in stomach and proximal duodenum) is pathognomonic for duodenal atresia.

Question 190: A 58-year-old man with diabetes presents with a painless foot ulcer. His history of peripheral neuropathy is known. Which complication should be highest on the differential?

Venous stasis ulcer
Diabetic neuropathic ulcer with possible underlying osteomyelitis (Correct answer)
Pressure ulcer
Arterial insufficiency ulcer

Correct answer: Diabetic neuropathic ulcer with possible underlying osteomyelitis

Painless foot ulcers in diabetics with neuropathy are hallmarks of diabetic neuropathic ulcers, and osteomyelitis must be excluded given its high prevalence in this context.

Question 191: Which feature distinguishes cardiac syncope from vasovagal syncope during diagnostic formulation?

Syncope triggered by prolonged standing
Syncope preceded by nausea and diaphoresis in a warm environment
Syncope occurring without prodrome during exertion or at rest (Correct answer)
Syncope with slow recovery over several minutes

Correct answer: Syncope occurring without prodrome during exertion or at rest

Syncope without prodrome during exertion or at rest suggests an arrhythmic or structural cardiac cause and requires urgent cardiac evaluation.

Question 192: A 58-year-old male presents with crushing chest pain radiating to the left arm. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left main coronary artery
Left circumflex artery
Right coronary artery (Correct answer)
Left anterior descending artery

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates an inferior wall STEMI, which is most commonly caused by right coronary artery (RCA) occlusion.

Question 193: Which test is the gold standard for diagnosing H. pylori infection in a patient who has not recently taken PPIs or antibiotics?

Urea breath test
Upper endoscopy with biopsy (Correct answer)
Stool antigen test
Serology (IgG antibody)

Correct answer: Upper endoscopy with biopsy

Upper endoscopy with biopsy allows direct visualization and multiple testing methods (urease test, culture, histology), making it the gold standard for H. pylori diagnosis.

Question 194: During a pelvic exam, the PA notes a blue-gray discoloration of the cervix and vaginal walls in a patient with amenorrhea. This is known as:

Goodell's sign
Hegar's sign
Cullen's sign
Chadwick's sign (Correct answer)

Correct answer: Chadwick's sign

Chadwick's sign is the blue-violet discoloration of the vagina and cervix due to increased vascularity, appearing in early pregnancy.

Question 195: A newborn is noted to have a continuous 'machine-like' murmur at the left upper sternal border. What is the most likely congenital heart defect?

Tetralogy of Fallot
Atrial septal defect
Patent ductus arteriosus (Correct answer)
Ventricular septal defect

Correct answer: Patent ductus arteriosus

A continuous machine-like murmur at the left upper sternal border is pathognomonic for patent ductus arteriosus (PDA).

Question 196: A 28-year-old woman with Type 1 DM is found unresponsive with fingerstick glucose of 28 mg/dL. No IV access is available. What is the most appropriate immediate treatment?

Intramuscular glucagon injection (Correct answer)
Orange juice by mouth
Dextrose 50% IV push
Oral glucose gel under the tongue

Correct answer: Intramuscular glucagon injection

IM glucagon is the correct treatment for an unconscious hypoglycemic patient without IV access, as oral agents cannot be safely administered.

Question 197: Which type of shock is characterized by low PCWP, low SVR, and high cardiac output?

Hypovolemic shock
Distributive (septic) shock (Correct answer)
Obstructive shock
Cardiogenic shock

Correct answer: Distributive (septic) shock

Distributive shock (e.g., sepsis) features vasodilation causing low SVR and compensatory high CO with low filling pressures.

Question 198: A 70-year-old male with a history of atrial fibrillation is found unresponsive with right-sided weakness. CT head shows no hemorrhage. What is the most appropriate immediate intervention?

Aspirin 325 mg
Warfarin loading dose
IV alteplase (tPA) (Correct answer)
Heparin infusion

Correct answer: IV alteplase (tPA)

In the absence of contraindications and within the therapeutic window, IV alteplase (tPA) is the standard of care for acute ischemic stroke.

Question 199: Which accrediting body oversees PA educational programs in the United States?

ARC-PA (Correct answer)
NCCPA
AAPA
LCME

Correct answer: ARC-PA

The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) accredits PA programs.

Question 200: Which statement about the management of STEMI is correct?

Fibrinolysis is preferred over PCI when door-to-balloon time is under 90 minutes
Anticoagulation is not required if PCI is performed
Primary PCI is preferred when door-to-balloon time is under 120 minutes (Correct answer)
Aspirin should be withheld until after revascularization

Correct answer: Primary PCI is preferred when door-to-balloon time is under 120 minutes

Primary PCI is the preferred reperfusion strategy for STEMI when it can be performed within 90-120 minutes of first medical contact.

Question 201: A 38-year-old woman with antiphospholipid syndrome has a right lower lobe pulmonary infarction confirmed on V/Q scan. She completes 3 months of anticoagulation. What is the recommended long-term management?

Switch to low-dose aspirin for long-term secondary prevention
Repeat 3-month course of anticoagulation if another clot occurs
Indefinite anticoagulation with a vitamin K antagonist targeting INR 2-3 (Correct answer)
Discontinue anticoagulation and monitor with periodic V/Q scans

Correct answer: Indefinite anticoagulation with a vitamin K antagonist targeting INR 2-3

Antiphospholipid syndrome with thrombosis requires indefinite anticoagulation with a VKA (warfarin) targeting INR 2-3 due to very high recurrence risk.

Question 202: A patient on amiodarone develops thyroid dysfunction. Which pattern is MOST common?

Hyperthyroidism due to iodine excess only
Thyroid storm
Hypothyroidism (Correct answer)
Euthyroid sick syndrome

Correct answer: Hypothyroidism

Amiodarone-induced hypothyroidism is the most common thyroid side effect, especially in iodine-sufficient populations.

Question 203: Which vaccine is contraindicated in a 6-month-old with a severe egg allergy?

MMR
Influenza (egg-based) (Correct answer)
DTaP
Hepatitis B

Correct answer: Influenza (egg-based)

Egg-based influenza vaccines contain egg protein and are contraindicated in severe egg allergy; cell-based alternatives should be used.

Question 204: Of the following, which one is macrocytic anemia?

Multiple myeloma
Chronic liver disease (Correct answer)
Anemia of kidney disease
Pure red cell aplasia
Myelophthisic anemia

Correct answer: Chronic liver disease

Chronic liver disease is not an example of macrocytic anemia. Macrocytic anemia is a type of anemia characterized by the presence of large red blood cells (RBCs) in the blood. This can occur due to a deficiency in vitamin B12 or folate, which are required for proper RBC production and maturation.

Question 205: Which mechanism allows viruses to evade the immune system by downregulating MHC class I expression?

Suppressing natural killer cell activity
Blocking B cell antibody production
Preventing cytotoxic T cells from recognizing infected cells (Correct answer)
Inhibiting complement activation

Correct answer: Preventing cytotoxic T cells from recognizing infected cells

Downregulation of MHC class I prevents CD8+ cytotoxic T cells from recognizing viral peptides presented on infected cells, allowing viral persistence.

Question 206: A patient on amiodarone for 18 months develops new bilateral pulmonary infiltrates and decreased DLCO. Which finding on BAL most supports amiodarone pulmonary toxicity?

Malignant cells on cytology
Foamy lipid-laden macrophages (Correct answer)
Eosinophilia >25%
Hemosiderin-laden macrophages

Correct answer: Foamy lipid-laden macrophages

Foamy macrophages containing phospholipid inclusions are characteristic of amiodarone pulmonary toxicity due to drug-induced phospholipidosis, though they are not specific.

Question 207: The PANRE (Physician Assistant National Recertifying Examination) must be taken every how many years?

10 years (Correct answer)
5 years
7 years
15 years

Correct answer: 10 years

PAs must pass the PANRE every 10 years to maintain their NCCPA certification.

Question 208: A 55-year-old obese man with a history of Barrett's esophagus undergoes surveillance endoscopy showing high-grade dysplasia. What is the most appropriate management?

Nissen fundoplication alone
H. pylori eradication
Increased PPI dose and repeat biopsy in 1 year
Endoscopic eradication therapy or esophagectomy (Correct answer)

Correct answer: Endoscopic eradication therapy or esophagectomy

High-grade dysplasia in Barrett's esophagus carries significant risk of progression to adenocarcinoma and requires endoscopic eradication or surgical resection.

Question 209: Which of the following diseases, which can be brought on by heart failure, features bouts of deep breathing interspersed with periods of no breathing?

Tachypnea
Obstructive breathing
Ataxic breathing
Kussmaul breathing (Correct answer)

Correct answer: Kussmaul breathing

Kussmaul breathing is characterized by deep, rapid, and labored breathing, which is a compensatory mechanism for severe metabolic acidosis. While typically associated with conditions like diabetic ketoacidosis, advanced heart failure can lead to poor tissue perfusion and lactic acidosis, triggering this profound breathing pattern to expel excess carbon dioxide. Although the description 'interspersed with periods of no breathing' more accurately describes Cheyne-Stokes respiration, Kussmaul breathing represents a severe, deep respiratory effort that can manifest in the context of advanced heart failure and its metabolic complications.

Question 210: A 7-year-old boy has been struggling in school, is frequently out of his seat, and interrupts others. Symptoms are present at home and school. What is the first-line pharmacotherapy?

Fluoxetine
Clonidine
Methylphenidate (Correct answer)
Atomoxetine

Correct answer: Methylphenidate

Stimulant medications such as methylphenidate are first-line pharmacotherapy for ADHD in school-age children.

Question 211: A 55-year-old male complains of a chronic, gnawing epigastric pain that improves with meals but worsens 2-3 hours later. He has no alarm symptoms. Which of the following is considered the most accurate diagnostic test for an active Helicobacter pylori infection in this patient?

Stool antigen assay
Upper endoscopy with biopsy (Correct answer)
Urea breath test
Serology testing

Correct answer: Upper endoscopy with biopsy

While the urea breath test and stool antigen assay are excellent non-invasive tests, upper endoscopy with biopsy is considered the most accurate or 'gold standard' for the diagnosis of an active H. pylori infection. [30, 39] It allows for direct histological examination, rapid urease testing, and culture. In a patient over 50 with new-onset dyspepsia, endoscopy is also indicated to rule out other pathology like malignancy.

Question 212: Which federal law prohibits PA programs from discriminating against applicants based on disability?

Rehabilitation Act of 1973
HIPAA
Both B and C (Correct answer)
Americans with Disabilities Act (ADA)

Correct answer: Both B and C

Both the ADA and the Rehabilitation Act protect individuals with disabilities from discrimination in educational programs.

Question 213: Which of the following metabolic outcomes is brought on by the release of insulin?

Causes glucose to be phosphorylated in kidney
Decreased blood sugar (Correct answer)
Increased breakdown of proteins
Increased breakdown of fats

Correct answer: Decreased blood sugar

Lowering blood sugar levels is one of insulin's main metabolic actions. Thus, diabetes mellitus is caused by a lack of insulin or a resistance to its effects.

Question 214: Which antibiotic class is most appropriate for empiric treatment of community-acquired pneumonia in an otherwise healthy outpatient with no recent antibiotic use?

Macrolide monotherapy (Correct answer)
Fluoroquinolone
Beta-lactam + macrolide
Carbapenems

Correct answer: Macrolide monotherapy

IDSA/ATS guidelines recommend macrolide monotherapy (e.g., azithromycin) for healthy outpatients with no comorbidities.

Question 215: Which medication class is contraindicated in patients with gout who are taking allopurinol and develop a skin rash?

Colchicine
NSAIDs
Corticosteroids
Ampicillin-class antibiotics (Correct answer)

Correct answer: Ampicillin-class antibiotics

Aminopenicillins (ampicillin, amoxicillin) increase the risk of severe drug reactions including Stevens-Johnson syndrome when used with allopurinol.

Question 216: A newborn presents with bilious vomiting, abdominal distension, and failure to pass meconium within 48 hours. Rectal suction biopsy shows absence of ganglion cells. What is the diagnosis?

Intussusception
Meconium ileus
Hirschsprung's disease (Correct answer)
Pyloric stenosis

Correct answer: Hirschsprung's disease

Hirschsprung's disease results from failed neural crest cell migration, causing an aganglionic segment of colon that cannot relax, leading to functional obstruction.

Question 217: A 55-year-old woman presents with bilateral knee pain worse with activity and relieved by rest. X-ray shows joint space narrowing and osteophytes. What is the most likely diagnosis?

Gout
Psoriatic arthritis
Osteoarthritis (Correct answer)
Rheumatoid arthritis

Correct answer: Osteoarthritis

Osteoarthritis is characterized by joint space narrowing, osteophytes, and pain worsened by activity, most commonly affecting weight-bearing joints.

Question 218: What is the most common cause of osteomyelitis in adults in the United States?

Streptococcus pyogenes
Pseudomonas aeruginosa
Staphylococcus aureus (Correct answer)
Escherichia coli

Correct answer: Staphylococcus aureus

Staphylococcus aureus is the most common causative organism of osteomyelitis in adults, accounting for the majority of hematogenous and contiguous cases.

Question 219: Which of the following is NOT a tetralogy of fallot feature?

Large ventricular septal defect
A left to right cardiac shunt (Correct answer)
Right ventricular hypertrophy
Right ventricular outflow obstruction

Correct answer: A left to right cardiac shunt

Tetralogy of Fallot is a complex congenital heart defect defined by four key features: a large ventricular septal defect (VSD), pulmonary stenosis (right ventricular outflow obstruction), an overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis and right ventricular hypertrophy, pressure in the right ventricle is typically higher than in the left, causing a *right-to-left* shunt of deoxygenated blood through the VSD. A left-to-right cardiac shunt is therefore not a characteristic feature of Tetralogy of Fallot.

Question 220: Which one of the following best describes the likely cause of paronychia?

A bacterial infection (Correct answer)
A prescribed medication
A viral infection
An autoimmune reaction
A fungal infection

Correct answer: A bacterial infection

Paronychia is a skin infection affecting the nail bed and surrounding tissues. Bacteria most commonly cause it, typically Staphylococcus aureus, which can invade the area through a small cut or injury to the skin around the nail. A fungal infection or other bacteria can also cause paronychia.

Question 221: A 35-year-old woman with chronic diarrhea, bloating, and a positive anti-tissue transglutaminase (anti-tTG) IgA antibody most likely has which condition?

Celiac disease (Correct answer)
Lactose intolerance
Microscopic colitis
Whipple's disease

Correct answer: Celiac disease

Elevated anti-tTG IgA is the most sensitive and specific serologic test for celiac disease.

Question 222: A 50-year-old man presents with dysphagia to solids and liquids simultaneously from onset. Barium swallow shows a 'bird-beak' appearance. What is the most likely diagnosis?

Diffuse esophageal spasm
Zenker's diverticulum
Esophageal carcinoma
Achalasia (Correct answer)

Correct answer: Achalasia

Achalasia presents with dysphagia to both solids and liquids from the start due to failure of LES relaxation, and the bird-beak appearance is classic on barium swallow.

Question 223: A 45-year-old man has resistant hypertension despite three antihypertensives and persistent hypokalemia. The aldosterone-to-renin ratio is markedly elevated. What is the most likely diagnosis?

Renovascular hypertension
Cushing's syndrome
Primary hyperaldosteronism (Conn's syndrome) (Correct answer)
Pheochromocytoma

Correct answer: Primary hyperaldosteronism (Conn's syndrome)

Primary hyperaldosteronism causes autonomous aldosterone excess, resulting in resistant hypertension, hypokalemia, and an elevated aldosterone-to-renin ratio.

Question 224: Which type of seizure is characterized by sudden loss of muscle tone causing the patient to fall?

Absence seizure
Atonic seizure (Correct answer)
Tonic-clonic seizure
Myoclonic seizure

Correct answer: Atonic seizure

Atonic (drop) seizures involve sudden loss of postural muscle tone, causing the patient to fall abruptly without warning.

Question 225: A 3-year-old has a 2-day history of bloody diarrhea after attending a petting zoo. Labs show microangiopathic hemolytic anemia, thrombocytopenia, and elevated creatinine. What organism is responsible?

Salmonella typhi
Yersinia enterocolitica
Campylobacter jejuni
Shiga toxin-producing E. coli (STEC) (Correct answer)

Correct answer: Shiga toxin-producing E. coli (STEC)

Hemolytic uremic syndrome (HUS) in children is most commonly caused by Shiga toxin-producing E. coli O157:H7, often acquired from contaminated food or animal contact.

Question 226: A mechanically ventilated ARDS patient has plateau pressure of 32 cmH2O and PEEP of 10 cmH2O. Driving pressure is 22 cmH2O. Which ventilator adjustment best reduces ventilator-induced lung injury?

Increase FiO2 to reduce PEEP requirement
Increase respiratory rate to normalize PaCO2
Switch to pressure-controlled ventilation mode
Reduce tidal volume to achieve driving pressure ≤15 cmH2O (Correct answer)

Correct answer: Reduce tidal volume to achieve driving pressure ≤15 cmH2O

Driving pressure (plateau - PEEP) >15 cmH2O is associated with increased ARDS mortality; reducing tidal volume to lower driving pressure reduces stress on remaining functional lung units.

Question 227: Which of the following best describes the collaborative practice model for PAs?

PAs must refer all cases to a physician before treatment
PAs practice under hospital administrative oversight only
PAs work under the supervision of a licensed physician (Correct answer)
PAs practice independently without physician oversight

Correct answer: PAs work under the supervision of a licensed physician

PAs practice medicine with physician supervision or collaboration, though the degree varies by state law.

Question 228: When building a problem representation, which element best distinguishes it from a simple symptom list?

A list of all abnormal lab values
A concise synthesis that highlights key epidemiological, temporal, and clinical features (Correct answer)
A verbatim transcript of the patient's chief complaint
A chronological list of every symptom the patient reports

Correct answer: A concise synthesis that highlights key epidemiological, temporal, and clinical features

A problem representation distills the case into a one-line synthesis emphasizing the most discriminating features to guide differential diagnosis.

Question 229: What is the most common cause of right heart failure in the United States?

Left heart failure (Correct answer)
Primary pulmonary hypertension
Tricuspid stenosis
Pulmonary embolism

Correct answer: Left heart failure

Left heart failure is the most common cause of right heart failure due to elevated pulmonary pressures transmitted to the right ventricle.

Question 230: A patient with sarcoidosis has bilateral hilar lymphadenopathy on CXR and an ACE level of 85 U/L. Serum calcium is 11.4 mg/dL. What is the mechanism of hypercalcemia in this condition?

Decreased renal calcium excretion from tubular dysfunction
Increased PTH secretion from parathyroid gland hyperplasia
1-alpha hydroxylation of vitamin D by activated macrophages in granulomas (Correct answer)
Bone destruction from osteolytic granulomatous lesions

Correct answer: 1-alpha hydroxylation of vitamin D by activated macrophages in granulomas

Activated macrophages within sarcoid granulomas express 1-alpha-hydroxylase, converting 25-OH vitamin D to calcitriol, which increases intestinal calcium absorption.

Question 231: A 35-year-old woman with no prior history presents with sudden onset severe headache she describes as 'the worst headache of my life.' Neck stiffness and photophobia are present. CT head is negative. What is the next best step?

Perform lumbar puncture (Correct answer)
Administer sumatriptan and observe
Obtain MRI brain with contrast
Start empiric antibiotics and discharge

Correct answer: Perform lumbar puncture

A negative CT with classic subarachnoid hemorrhage (SAH) presentation requires lumbar puncture to detect xanthochromia or blood that CT may miss.

Question 232: A PA has reasonable suspicion that a patient is being abused by a caregiver. Which of the following is the most appropriate action?

Inform the caregiver and give them a chance to explain
Discuss only with the supervising physician and take no further action
File a mandatory report with Adult Protective Services or child protective services (Correct answer)
Document the concern and revisit it at the next visit

Correct answer: File a mandatory report with Adult Protective Services or child protective services

PAs are mandatory reporters in all US states; suspected abuse must be reported to the appropriate protective services, and failure to report is a legal and ethical violation.

Question 233: Which of the following BEST describes the purpose of an abstract in a research article?

To provide detailed methods and raw data
To offer a brief summary of the study's purpose, methods, results, and conclusions (Correct answer)
To describe the researchers' qualifications
To list all references used in the study

Correct answer: To offer a brief summary of the study's purpose, methods, results, and conclusions

An abstract concisely summarizes all major sections of the research article to help readers quickly assess relevance.

Question 234: What is the primary mechanism of action of digoxin in atrial fibrillation?

Blocks potassium channels to prolong action potential
Directly cardioverts AF to sinus rhythm
Enhances vagal tone to slow AV node conduction (Correct answer)
Blocks sodium channels in atrial cells

Correct answer: Enhances vagal tone to slow AV node conduction

Digoxin slows ventricular rate in AF primarily by increasing vagal tone and decreasing AV nodal conduction.

Question 235: Which finding on echocardiography is most consistent with cardiac tamponade?

Left ventricular hypertrophy
Diastolic collapse of the right ventricle (Correct answer)
Aortic stenosis gradient
Mitral valve prolapse

Correct answer: Diastolic collapse of the right ventricle

Diastolic right ventricular collapse is the classic echocardiographic sign of cardiac tamponade due to elevated pericardial pressure.

Question 236: Which of the following best describes a measles symptom?

Impetigo
Coronary artery disease
Pneumonitis
Slapped-cheek appearance
Koplik spots (Correct answer)

Correct answer: Koplik spots

Koplik spots are a characteristic manifestation of measles, a highly contagious viral infection that primarily affects children. These spots appear as small, white, or grayish-blue spots surrounded by a red ring on the inside lining of the cheeks. They usually appear 1-2 days before the onset of the rash, which is another hallmark feature of measles.

Question 237: A 60-year-old male smoker presents with hemoptysis, weight loss, and a central lung mass on CT. Biopsy shows small blue cells. Which lung cancer type is this?

Squamous cell carcinoma
Large cell carcinoma
Small cell lung carcinoma (Correct answer)
Adenocarcinoma

Correct answer: Small cell lung carcinoma

Small cell lung carcinoma presents as a central mass with small blue cells on biopsy and is strongly associated with smoking; it often presents with paraneoplastic syndromes.

Question 238: DNA gyrase, the bacterial enzyme targeted by fluoroquinolone antibiotics, belongs to which class of enzymes?

Type II topoisomerase (Correct answer)
Type I topoisomerase
DNA helicase
DNA primase

Correct answer: Type II topoisomerase

DNA gyrase is a bacterial type II topoisomerase that introduces negative supercoils to relieve tension ahead of the replication fork; fluoroquinolones inhibit it by stabilizing the cleavage complex.

Question 239: Do you want to work as a pediatric PA?

No, not for me
Yes, I love children! (Correct answer)
No, children are icky

Correct answer: Yes, I love children!

This is a personal reflection question with no objectively right or wrong answer—'Yes, I love children!' reflects genuine interest in working with pediatric patients. The other responses simply indicate the role isn't a personal fit.

Question 240: A patient with low back pain radiating down the posterior leg to the foot has a positive straight leg raise at 45 degrees. Which nerve root is most likely involved?

L5 or S1 (Correct answer)
L3
L2
L4

Correct answer: L5 or S1

A positive straight leg raise combined with posterior leg pain radiating to the foot is classic for L5 or S1 nerve root compression, typically from a herniated disc.

Question 241: A PA documents in a patient's chart that a procedure was performed, but it was actually done by a different provider. This constitutes which type of misconduct?

Falsification of medical records (Correct answer)
Battery
Breach of confidentiality
Negligence

Correct answer: Falsification of medical records

Documenting a procedure as personally performed when it was not constitutes falsification of medical records, which is both an ethical violation and potentially illegal.

Question 242: Which of the ensuing antidotes best suits the toxicity at its core?

Ethylene glycol — ethanol (booze)
Acetaminophen — fomepizole (4-methylpyrazole) (Correct answer)
Narcotics — flumazenil (Romazicon)
High carboxyhemoglobin — methylene blue
Benzodiazepines — naloxone (Narcan)

Correct answer: Acetaminophen — fomepizole (4-methylpyrazole)

Fomepizole is the antidote for toxicity caused by ethylene glycol or methanol, not acetaminophen. It is used to treat poisoning from these substances by inhibiting the enzymes that metabolize ethylene glycol and methanol into toxic byproducts.

Question 243: A 44-year-old woman presents with transient migratory pulmonary infiltrates, peripheral eosinophilia of 18%, and wheezing. IgE is markedly elevated. Sputum contains eosinophils and fungal hyphae. What is the diagnosis?

Chronic eosinophilic pneumonia
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
Löffler syndrome from Ascaris migration
Allergic bronchopulmonary aspergillosis (ABPA) (Correct answer)

Correct answer: Allergic bronchopulmonary aspergillosis (ABPA)

ABPA presents with asthma, migratory infiltrates, peripheral eosinophilia, markedly elevated total IgE, and Aspergillus-specific IgE/IgG with central bronchiectasis.

Question 244: A PA is evaluating a 30-year-old woman with episodic hypertension, headaches, palpitations, and diaphoresis. Which secondary cause of hypertension should be included on the differential?

Renal artery stenosis
Pheochromocytoma (Correct answer)
Primary hyperaldosteronism
Cushing's syndrome

Correct answer: Pheochromocytoma

The triad of episodic hypertension, headache, and diaphoresis with palpitations is classic for pheochromocytoma, a catecholamine-secreting adrenal tumor.

Question 245: Which vaccine is contraindicated in a 26-year-old pregnant woman at 20 weeks gestation?

MMR vaccine (Correct answer)
Inactivated influenza vaccine
Tdap
COVID-19 mRNA vaccine

Correct answer: MMR vaccine

MMR is a live attenuated vaccine and is contraindicated during pregnancy due to theoretical risk of fetal infection; it should be given postpartum.

Question 246: A 30-year-old with cystic fibrosis presents with increased sputum production and worsening FEV1. Sputum culture grows Pseudomonas aeruginosa. Which antibiotic combination is most appropriate for an acute exacerbation?

Azithromycin and trimethoprim-sulfamethoxazole
Vancomycin and metronidazole
Amoxicillin-clavulanate and doxycycline
Piperacillin-tazobactam and tobramycin (Correct answer)

Correct answer: Piperacillin-tazobactam and tobramycin

Anti-pseudomonal beta-lactam plus an aminoglycoside provides synergistic coverage against Pseudomonas in CF exacerbations and helps prevent resistance.

Question 247: A PA who discloses a patient's HIV status to the patient's employer without consent has violated which principle?

Non-maleficence
Veracity
Confidentiality (Correct answer)
Autonomy

Correct answer: Confidentiality

Unauthorized disclosure of protected health information violates the ethical and legal principle of confidentiality, as well as HIPAA.

Question 248: A 1-year-old is found to have a hemoglobin of 9.2 g/dL with microcytic hypochromic anemia. The child drinks 30 oz of cow's milk daily. What is the best initial treatment?

Blood transfusion
B12 supplementation
Erythropoietin injection
Oral iron supplementation and reduce cow's milk intake (Correct answer)

Correct answer: Oral iron supplementation and reduce cow's milk intake

Iron deficiency anemia from excessive cow's milk intake (which is low in iron and impairs iron absorption) is treated with oral ferrous sulfate and limiting milk to <24 oz/day.

Question 249: A 24-year-old female presents for a routine physical exam. On cardiac auscultation, a mid-systolic click followed by a late systolic murmur is heard best at the apex. The murmur is accentuated when she stands up from a squatting position. What is the most likely valvular abnormality?

Tricuspid regurgitation
Aortic stenosis
Mitral regurgitation
Mitral valve prolapse (Correct answer)

Correct answer: Mitral valve prolapse

A mid-systolic click is the pathognomonic finding for mitral valve prolapse. The click is caused by the sudden tensing of the chordae tendineae as the valve leaflets prolapse into the left atrium during systole. Maneuvers that decrease venous return and left ventricular volume, such as standing, cause the click and murmur to occur earlier in systole and become more prominent.

Question 250: Which organism is most commonly responsible for traveler's diarrhea?

Enterotoxigenic Escherichia coli (ETEC) (Correct answer)
Giardia lamblia
Campylobacter jejuni
Salmonella typhi

Correct answer: Enterotoxigenic Escherichia coli (ETEC)

ETEC is the leading cause of traveler's diarrhea, producing heat-labile and heat-stable enterotoxins that increase intestinal fluid secretion.

Question 251: A PA is evaluating a 72-year-old with confusion, fever, and costovertebral angle tenderness. Which diagnosis best explains this triad?

Urosepsis (Correct answer)
Hypertensive encephalopathy
Bacterial meningitis
Viral encephalitis

Correct answer: Urosepsis

Confusion with fever and CVA tenderness in an elderly patient points to urosepsis—a urinary source of infection causing systemic inflammatory response.

Question 252: A 50-year-old man with chronic hypersensitivity pneumonitis from ongoing exposure develops honeycombing on HRCT. FVC is 55% predicted. He continues working as a farmer. Which intervention has the strongest evidence for slowing progression?

Antifibrotic therapy with nintedanib
High-dose inhaled corticosteroids
Complete removal from the offending antigen (Correct answer)
Long-term oral prednisone taper

Correct answer: Complete removal from the offending antigen

Antigen avoidance is the cornerstone of hypersensitivity pneumonitis management; continued exposure drives progressive fibrosis regardless of pharmacologic therapy.

Question 253: A 50-year-old woman presents with chronic watery diarrhea, episodic flushing, and wheezing. Urine 5-HIAA levels are elevated. Where is this tumor most likely located?

Appendix or terminal ileum (Correct answer)
Duodenum
Stomach
Rectum

Correct answer: Appendix or terminal ileum

Carcinoid syndrome (flushing, diarrhea, wheezing) with elevated 5-HIAA is most commonly caused by carcinoid tumors of the appendix or terminal ileum with hepatic metastases.

Question 254: Which history-taking mnemonic is used to characterize the quality of a patient's pain comprehensively?

CAGE
SOAP
OLDCARTS (Correct answer)
HEADSSS

Correct answer: OLDCARTS

OLDCARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) is used to fully characterize pain in the HPI.

Question 255: A 35-year-old patient describes a history of debilitating, unilateral, throbbing headaches occurring 2-3 times per month, accompanied by photophobia and nausea. Which of the following is the most appropriate first-line abortive medication for moderate to severe acute attacks?

Propranolol
Verapamil
Sumatriptan (Correct answer)
Amitriptyline

Correct answer: Sumatriptan

Triptans, such as sumatriptan, are serotonin 1B/1D receptor agonists and are considered first-line abortive therapy for moderate to severe migraine headaches. Propranolol and amitriptyline are used for migraine prophylaxis (prevention), not for treating an acute attack. Verapamil is more commonly used for the prophylaxis of cluster headaches.

Question 256: A 30-year-old woman at 32 weeks gestation presents with BP 160/110, 3+ proteinuria, and headache. Labs show platelets 85,000/µL, AST 180 U/L, and hemolytic anemia. What is the diagnosis?

Acute fatty liver of pregnancy
HELLP syndrome (Correct answer)
Thrombotic thrombocytopenic purpura
Severe preeclampsia

Correct answer: HELLP syndrome

HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelets, and is a severe complication of preeclampsia.

Question 257: Which finding most strongly supports a diagnosis of heart failure with preserved ejection fraction (HFpEF) over chronic obstructive pulmonary disease (COPD) in a dyspneic patient?

Barrel chest with prolonged expiratory phase
Elevated BNP with bilateral crackles and orthopnea (Correct answer)
Increased resonance on percussion
Pursed-lip breathing

Correct answer: Elevated BNP with bilateral crackles and orthopnea

Elevated BNP, bilateral crackles, and orthopnea are cardinal features of heart failure that help distinguish HFpEF from obstructive lung disease.

Question 258: What causes a hypercoagulable state the majority of the time?

Nephrotic syndrome
Antiphospholipid antibody syndrome
Antithrombin III deficiency
Factor V Leiden mutation (Correct answer)
Prothrombin gene mutation

Correct answer: Factor V Leiden mutation

The Factor V Leiden mutation is one of the most common genetic causes of a hypercoagulable state. In this genetic condition, a mutation in the Factor V gene leads to a form of the protein resistant to inactivation by activated protein C, which normally helps to prevent blood clotting. This can increase the risk of developing blood clots, especially in the veins (venous thrombosis), which can lead to deep vein thrombosis (DVT) or pulmonary embolism (PE). Other common causes of a hypercoagulable state include deficiencies in anticoagulant proteins such as protein C, protein S, and antithrombin III and acquired conditions such as cancer, pregnancy, and certain medications.

Question 259: A PA student reads: 'Patients with condition X who received treatment Y showed a 30% reduction in symptoms compared to controls.' What type of study design MOST likely produced this result?

Cross-sectional survey
Ecological study
Case report
Randomized controlled trial (Correct answer)

Correct answer: Randomized controlled trial

Comparing a treatment group to controls with measured outcomes is the hallmark of a randomized controlled trial.

Question 260: Which of the following tests is most accurate for determining whether someone has primary hypothyroidism?

Determining T4 levels
Determining thyroid stimulating hormone (TSH) levels (Correct answer)
Determining triiodothyronine levels
Determining thyroxine levels

Correct answer: Determining thyroid stimulating hormone (TSH) levels

In primary hypothyroidism, the thyroid gland itself is underactive, leading to insufficient production of thyroid hormones (T3 and T4). The pituitary gland, sensing these low hormone levels, compensates by increasing the secretion of Thyroid Stimulating Hormone (TSH) in an attempt to stimulate the thyroid. Therefore, an elevated TSH level is the most sensitive and accurate indicator of primary hypothyroidism, often rising even before T4 levels significantly drop.

Question 261: A 28-year-old female presents with malar rash, arthritis, and proteinuria. ANA is positive at 1:640. Which antibody is most specific for systemic lupus erythematosus (SLE)?

Anti-Scl-70
Anti-SSA (Ro)
Anti-histone
Anti-Smith (Sm) (Correct answer)

Correct answer: Anti-Smith (Sm)

Anti-Smith (anti-Sm) antibodies are highly specific for SLE, though not sensitive, making them useful when positive.

Question 262: Which physical exam maneuver increases the intensity of the murmur of hypertrophic obstructive cardiomyopathy?

Passive leg raise
Squatting
Valsalva maneuver (Correct answer)
Handgrip

Correct answer: Valsalva maneuver

Valsalva decreases preload and venous return, reducing LV size and worsening outflow obstruction in HOCM, increasing the murmur.

Question 263: A 6-year-old with Down syndrome (trisomy 21) presents for a well-child visit. Which screening is uniquely important in this population?

Renal ultrasound
Thyroid function tests (Correct answer)
Colonoscopy
Pulmonary function tests

Correct answer: Thyroid function tests

Children with Down syndrome have a markedly increased risk of autoimmune thyroid disease (hypothyroidism) and should have TSH screened annually.

Question 264: A 30-year-old with epilepsy presents in status epilepticus. After two doses of lorazepam, seizures persist. What is the next pharmacological treatment?

Oral phenytoin
Oral valproate
IV levetiracetam or fosphenytoin (Correct answer)
Repeat lorazepam indefinitely

Correct answer: IV levetiracetam or fosphenytoin

After benzodiazepine failure in status epilepticus, the next step is IV second-line agents such as levetiracetam, fosphenytoin, or valproate per established treatment algorithms.

Question 265: A patient with new-onset heart failure has an ejection fraction of 35%. Which combination of medications has been shown to reduce mortality?

Nitrates + hydralazine alone
Digoxin + furosemide
ACE inhibitor + beta-blocker + aldosterone antagonist (Correct answer)
ARB + calcium channel blocker

Correct answer: ACE inhibitor + beta-blocker + aldosterone antagonist

The combination of ACE inhibitor (or ARB/ARNI), beta-blocker, and aldosterone antagonist forms the evidence-based cornerstone of HFrEF therapy.

Question 266: Which of the following forms of cardiomyopathy occurs most frequently?

Dilated cardiomyopathy (Correct answer)
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy

Correct answer: Dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is the most frequently occurring form of cardiomyopathy. It is characterized by the enlargement and weakening of the heart's ventricles, leading to impaired pumping ability. While other forms exist, DCM accounts for the majority of cardiomyopathy cases, often leading to heart failure.

Question 267: A 55-year-old man with Type 2 DM, HbA1c 9.5%, BMI 34, and established cardiovascular disease is on metformin and a sulfonylurea. Which additional agent provides the most proven cardiovascular mortality benefit?

Sitagliptin (DPP-4 inhibitor)
Pioglitazone
Glargine insulin
Empagliflozin (SGLT2 inhibitor) (Correct answer)

Correct answer: Empagliflozin (SGLT2 inhibitor)

SGLT2 inhibitors such as empagliflozin have demonstrated significant cardiovascular mortality reduction in patients with established cardiovascular disease and Type 2 DM.

Question 268: How many PA programs are there right now?

282 (Correct answer)
300
212
268

Correct answer: 282

As of September 2025, there are 282 accredited PA programs in the United States.

Question 269: A 3-year-old presents with barky cough, stridor at rest, and low-grade fever. Which treatment is first-line?

Dexamethasone 0.6 mg/kg IM/PO (Correct answer)
Heliox inhalation
Nebulized racemic epinephrine
Albuterol nebulization

Correct answer: Dexamethasone 0.6 mg/kg IM/PO

Dexamethasone is the first-line treatment for croup, reducing airway edema with a single dose.

Question 270: A 28-year-old woman presents with a butterfly-shaped rash across her cheeks and nose, joint pain, and fatigue. ANA is positive. What is the most likely diagnosis?

Psoriasis
Systemic lupus erythematosus (Correct answer)
Dermatomyositis
Rosacea

Correct answer: Systemic lupus erythematosus

The malar (butterfly) rash, arthralgia, fatigue, and positive ANA are classic features of systemic lupus erythematosus.

Question 271: What is the time window for administration of IV alteplase (tPA) in acute ischemic stroke?

Within 12 hours of symptom onset
Within 6 hours of symptom onset
Within 3–4.5 hours of symptom onset (Correct answer)
Within 1 hour of symptom onset

Correct answer: Within 3–4.5 hours of symptom onset

IV alteplase is approved for administration within 3 hours of symptom onset, with select patients eligible up to 4.5 hours based on AHA/ASA guidelines.

Question 272: Which enzyme is responsible for the rate-limiting step in cholesterol biosynthesis?

Acetyl-CoA carboxylase
Squalene synthase
Lanosterol synthase
HMG-CoA reductase (Correct answer)

Correct answer: HMG-CoA reductase

HMG-CoA reductase catalyzes the conversion of HMG-CoA to mevalonate, the committed and rate-limiting step in cholesterol synthesis, and is the target of statins.

Question 273: A 14-year-old female presents with primary amenorrhea, short stature, webbed neck, and a wide carrying angle. What is the most likely karyotype?

47,XXY
46,XY
47,XX,+21
45,X (Correct answer)

Correct answer: 45,X

Turner syndrome (45,X) presents with primary amenorrhea, short stature, webbed neck, and increased carrying angle (cubitus valgus).

Question 274: A 66-year-old male with a significant smoking history presents with increased dyspnea, wheezing, and a change in sputum color from white to green over the past three days. His baseline oxygen saturation is 91% on 2L nasal cannula, but today it is 87%. According to the GOLD guidelines, which of the following is the most critical initial intervention for his acute COPD exacerbation?

Start broad-spectrum intravenous antibiotics immediately
Obtain an urgent CT angiogram of the chest
Initiate systemic corticosteroids and inhaled short-acting bronchodilators (Correct answer)
Administer high-flow oxygen to achieve an SpO2 of >95%

Correct answer: Initiate systemic corticosteroids and inhaled short-acting bronchodilators

The cornerstones of managing an acute COPD exacerbation are rapid-acting inhaled bronchodilators (beta-agonists and anticholinergics) to relieve bronchospasm and systemic glucocorticoids to reduce airway inflammation. While oxygen is necessary for hypoxemia, the target saturation is typically 88-92% to avoid suppressing the hypoxic respiratory drive. Antibiotics are indicated for increased sputum purulence (as seen here), but bronchodilators and steroids are the priority intervention. A CT angiogram would be considered if pulmonary embolism was highly suspected but is not the first-line step for a typical exacerbation.

Question 275: A 30-year-old athlete collapses during a basketball game. ECG shows asymmetric septal hypertrophy. What is the most likely diagnosis?

Hypertrophic obstructive cardiomyopathy (Correct answer)
Dilated cardiomyopathy
Myocarditis
Arrhythmogenic right ventricular cardiomyopathy

Correct answer: Hypertrophic obstructive cardiomyopathy

HOCM is the most common cause of sudden cardiac death in young athletes and presents with asymmetric septal hypertrophy.

Question 276: A patient with CKD stage 3 is started on metformin. Which creatinine clearance threshold requires discontinuation of metformin?

< 60 mL/min
< 45 mL/min
< 15 mL/min
< 30 mL/min (Correct answer)

Correct answer: < 30 mL/min

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to risk of lactic acidosis.

Question 277: A 70-year-old woman sustains a hip fracture after a minor fall. DEXA shows a T-score of -3.1. Which bisphosphonate is FDA-approved for reducing fracture risk in postmenopausal osteoporosis?

Methotrexate
Alendronate (Correct answer)
Colchicine
Raloxifene

Correct answer: Alendronate

Alendronate is a bisphosphonate FDA-approved for treating postmenopausal osteoporosis and reducing vertebral, hip, and nonvertebral fracture risk.

Question 278: A 29-year-old is diagnosed with Major Depressive Disorder (MDD) of moderate severity and has no other medical conditions. Which of the following is considered a first-line pharmacologic treatment for this patient?

Amitriptyline
Alprazolam
Lithium
Sertraline (Correct answer)

Correct answer: Sertraline

Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, are considered the first-line pharmacologic choice for Major Depressive Disorder due to their favorable balance of efficacy and tolerability. Amitriptyline is a tricyclic antidepressant (TCA) with a less favorable side-effect profile and is not a first-line agent. Alprazolam is a benzodiazepine used for anxiety and is not a primary treatment for MDD. Lithium is a mood stabilizer primarily used for bipolar disorder.

Question 279: A 55-year-old smoker presents with progressive dyspnea, barrel chest, and decreased breath sounds bilaterally. Spirometry shows FEV1/FVC of 0.58. Which pathophysiologic mechanism best explains the air trapping?

Loss of elastic recoil causing dynamic airway collapse (Correct answer)
Alveolar flooding with proteinaceous fluid
Increased surfactant production reducing surface tension
Bronchial wall thickening from eosinophilic inflammation

Correct answer: Loss of elastic recoil causing dynamic airway collapse

In emphysema, destruction of alveolar walls reduces elastic recoil, causing small airways to collapse during exhalation and trapping air distally.

Question 280: A 40-year-old male presents with episodic hypertension, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines and catecholamines. What is the next best imaging study?

CT abdomen/pelvis with contrast (Correct answer)
Nuclear medicine MIBG scan
MRI adrenals without contrast
CT chest

Correct answer: CT abdomen/pelvis with contrast

CT abdomen/pelvis with contrast is the first-line imaging for pheochromocytoma after biochemical confirmation to localize the tumor.

Question 281: A 65-year-old with stage IIIA non-small cell lung cancer (N2 disease, no distant metastases) is being evaluated for treatment. He has adequate pulmonary reserve. What is the preferred approach?

Palliative chemotherapy only
Concurrent chemoradiation followed by durvalumab (Correct answer)
Surgery alone with adjuvant chemotherapy
Stereotactic body radiation therapy (SBRT) alone

Correct answer: Concurrent chemoradiation followed by durvalumab

Unresectable stage III NSCLC is treated with concurrent platinum-based chemoradiation followed by consolidation durvalumab (anti-PD-L1), per the PACIFIC trial.

Question 282: Of the following cells, which one develops into osteoblasts, which create bone for remodeling and repair?

Osteogenic cells (Correct answer)
Osteons
Osteocytes
Osteoclasts

Correct answer: Osteogenic cells

Osteogenic cells, also known as osteoprogenitor cells, are undifferentiated stem cells found in the periosteum and endosteum of bones. These specialized cells have the unique capacity to differentiate into osteoblasts. Osteoblasts are then responsible for synthesizing and secreting the organic matrix of bone, known as osteoid, and initiating its mineralization, which is crucial for bone formation, remodeling, and repair.

Question 283: A 28-year-old presents with sudden right-sided pleuritic chest pain and dyspnea after a long flight. CXR shows a 25% right-sided pneumothorax. He is hemodynamically stable with SpO2 of 96%. What is the best initial management?

Aspiration with 14-gauge angiocatheter and discharge if successful
Chest tube thoracostomy at 5th ICS anterior axillary line
Immediate needle decompression at 2nd ICS midclavicular line
Observation with supplemental oxygen and repeat CXR in 6 hours (Correct answer)

Correct answer: Observation with supplemental oxygen and repeat CXR in 6 hours

A small-to-moderate primary spontaneous pneumothorax in a stable patient can be managed with observation and supplemental O2, which accelerates pleural air reabsorption.

Question 284: Which electrolyte abnormality is most commonly associated with prolonged nasogastric suctioning?

Hypernatremia
Hyperkalemia
Hyperchloremic metabolic acidosis
Hypokalemic hypochloremic metabolic alkalosis (Correct answer)

Correct answer: Hypokalemic hypochloremic metabolic alkalosis

Prolonged NG suctioning removes HCl and K+, leading to hypokalemic hypochloremic metabolic alkalosis.

Question 285: A patient taking lisinopril develops a dry, nonproductive cough. What is the most appropriate alternative antihypertensive?

Amlodipine
Losartan (Correct answer)
Enalapril
Hydrochlorothiazide

Correct answer: Losartan

ARBs (e.g., losartan) do not cause bradykinin accumulation and are the preferred substitute for ACE inhibitor-induced cough.

Question 286: Which pulmonary function test finding is characteristic of a fixed upper airway obstruction (e.g., tracheal stenosis)?

Flow-volume loop shows flattening of both inspiratory and expiratory limbs (Correct answer)
Flow-volume loop shows selective flattening of the inspiratory limb only
Decreased DLCO with normal spirometry
Increased RV/TLC ratio with normal FVC

Correct answer: Flow-volume loop shows flattening of both inspiratory and expiratory limbs

Fixed upper airway obstruction causes equal limitation of both inspiratory and expiratory flow, producing a characteristic plateau (flattening) on both limbs of the flow-volume loop.

Question 287: Which credential does a PA earn upon successfully passing the PANCE?

PA-C (Correct answer)
MPA
PA-BC
RPA-C

Correct answer: PA-C

Passing the PANCE awards the PA-C (Physician Assistant — Certified) credential from the NCCPA.

Question 288: A 35-year-old non-smoker presents with lower lobe-predominant emphysema and recurrent liver disease. Which deficiency should be suspected?

Alpha-1 antitrypsin deficiency (Correct answer)
IgA deficiency
Primary ciliary dyskinesia
Cystic fibrosis transmembrane conductance regulator mutation

Correct answer: Alpha-1 antitrypsin deficiency

Alpha-1 antitrypsin deficiency causes panacinar emphysema predominantly in the lower lobes and can cause liver disease from misfolded protein accumulation in hepatocytes.

Question 289: A patient presents with jaundice. Which of the following questions in the history is LEAST relevant to the initial workup?

Current immunization status (Correct answer)
Alcohol consumption history
Family history of Gilbert syndrome
Recent travel abroad

Correct answer: Current immunization status

Immunization status is least immediately relevant; alcohol use, travel history, and family history of hemolytic or hepatic conditions directly inform the differential for jaundice.

Question 290: A 30-year-old woman is diagnosed with irritable bowel syndrome (IBS) with predominant constipation. Which dietary intervention has the strongest evidence for improving her symptoms?

Low FODMAP diet (Correct answer)
Lactose-free diet alone
Gluten-free diet
High-fiber diet with insoluble fiber

Correct answer: Low FODMAP diet

The low FODMAP diet reduces fermentable carbohydrates that cause osmotic diarrhea and gas production, and has the strongest evidence for symptom relief in IBS.

Question 291: You are evaluating a 25-year-old woman who has a rash on her face. She says she might be reacting to a recently consumed meal, but she is unsure. The nasolabial fold is not spared, and the rash is reddish and macular on both cheeks. Which of the following would you now order?

Oral prednisone
Oral doxycycline (Vibramycin) (Correct answer)
Rheumatoid factor
ANA and complement levels
Oral amoxicillin (Trimox)Oral doxycycline (Vibramycin)

Correct answer: Oral doxycycline (Vibramycin)

Based on the description of the rash, the patient may be presented with a condition called "malar rash," which is a characteristic finding in systemic lupus erythematosus (SLE). Malar rash is a butterfly-shaped rash that spreads across the cheeks and bridge of the nose but does not spare the nasolabial folds. Given the possibility of SLE, ordering oral doxycycline would not be the appropriate course of action, as this medication is typically used to treat bacterial infections, such as acne or Lyme disease.

Question 292: Are there any additional requirements for a pediatric PA?

Yes, you need to pass the CAQ exam
Yes, you need to complete a fellowship
No, but it is recommended (Correct answer)

Correct answer: No, but it is recommended

While there is no additional formal training required to become a Pediatric PA, it is highly recommended to complete a pediatric-focused postgraduate residency or fellowship program after completing a PA program. These programs provide specialized training and experience in the care of pediatric patients, which can better prepare PAs for working in pediatric healthcare settings. Additionally, obtaining certification from the Pediatric Specialty Exam offered by the National Commission on Certification of Physician Assistants (NCCPA) can demonstrate a PA's expertise and competency in the field of pediatrics.

Question 293: A 60-year-old male smoker presents with ptosis, diplopia, and proximal muscle weakness that improves with exercise. Which paraneoplastic syndrome is most likely?

Dermatomyositis
Polymyositis
Myasthenia gravis
Lambert-Eaton myasthenic syndrome (Correct answer)

Correct answer: Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome is a paraneoplastic syndrome most commonly associated with small cell lung cancer, causing proximal weakness that paradoxically improves with repeated movement.

Question 294: All of the following, WITH THE EXCEPTION OF, constitute a typical duodenal ulcer.

Occasional malignancy
Affects people over 65 (Correct answer)
Primarily affects males
Can lead to weight gain

Correct answer: Affects people over 65

In most cases, duodenal ulcers develop between the ages of 30 and 50.

Question 295: A 65-year-old male presents with sudden onset right-sided facial droop, arm weakness, and aphasia that resolved completely within 45 minutes. What is the most likely diagnosis?

Transient ischemic attack (TIA) (Correct answer)
Complex migraine
Todd's paralysis
Ischemic stroke

Correct answer: Transient ischemic attack (TIA)

A transient ischemic attack (TIA) presents with stroke-like symptoms that resolve completely within 24 hours (typically minutes), with no infarction on imaging.

Question 296: A 28-year-old woman presents with palpitations, heat intolerance, weight loss, and exophthalmos. TSH is undetectable and free T4 is elevated. What is the most likely diagnosis?

Subacute thyroiditis
Toxic multinodular goiter
Graves' disease (Correct answer)
Hashimoto's thyroiditis

Correct answer: Graves' disease

Graves' disease is an autoimmune hyperthyroid condition, and exophthalmos (Graves' ophthalmopathy) is pathognomonic for this diagnosis.

Question 297: A 70-year-old man presents with painless jaundice, clay-colored stools, and dark urine. CT shows a mass in the head of the pancreas. Which additional finding would most support malignancy?

McBurney's point tenderness
Murphy's sign
Palpable, non-tender gallbladder (Courvoisier's sign) (Correct answer)
Elevated amylase

Correct answer: Palpable, non-tender gallbladder (Courvoisier's sign)

Courvoisier's sign — a palpable, non-tender gallbladder in the setting of painless jaundice — suggests malignant biliary obstruction.

Question 298: A breastfed 3-week-old has jaundice with a total bilirubin of 18 mg/dL. The infant is feeding well, gaining weight, and has a normal exam. What is the most appropriate management?

Continue breastfeeding and recheck bilirubin in 24 hours (Correct answer)
Immediate exchange transfusion
Start phenobarbital
Switch to formula permanently

Correct answer: Continue breastfeeding and recheck bilirubin in 24 hours

Breast milk jaundice is benign, peaks at 2–3 weeks, and resolves spontaneously; breastfeeding should be continued with close monitoring unless bilirubin exceeds phototherapy thresholds.

Question 299: A 40-year-old woman presents with moon facies, central obesity, purple striae, and easy bruising. 24-hour urinary free cortisol is markedly elevated. What is the most likely diagnosis?

Primary hyperaldosteronism
Acromegaly
Addison's disease
Cushing's syndrome (Correct answer)

Correct answer: Cushing's syndrome

Cushing's syndrome results from chronic excess cortisol and presents with moon facies, buffalo hump, purple striae, and central obesity.

Question 300: Which DOES NOT fall under IPC's purview?

Lower or stabilized costs (Correct answer)
Skills
Attitudes
Knowledge

Correct answer: Lower or stabilized costs

Lower or stabilized costs are not a competency of IPC.

Physician Assistant National Certifying Exam (PANCE)

The PANCE is the entry-level certification exam administered by NCCPA that assesses medical and surgical knowledge essential for physician assistants; passing it is required to practice as a PA in the United States.

300

Questions

300 min

Time Limit

65%

To Pass

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