Critical Care

Question 1

Dimercaprol, when used as a chelation agent, can
increase the brain concentrations of which metal?
A. Lead
B. Arsenic
C. Cadmium
D. Chromium
E. Mercury

Answer 1

E. Mercury

Question 2

A patient was diagnosed with epilepsy over 30 years
ago and has been on antiepileptic medications
since diagnosis. The patient complains of a lupus-
like syndrome and progressive ataxia and is found
to have gingival hypertrophy on exam. What anti-
epileptic drug has the patient likely been taking?
A. Levetiracetam
B. Phenytoin
C. Primidone
D. Valproic acid
E. Lamotrigine

Answer 2

B. Phenytoin

Question 3

A 69-year-old man on aspirin and warfarin under-
went a craniectomy for a traumatic subdural
hematoma. Surgery was uneventful except for high-
volume blood loss, and a blood transfusion was
ordered postoperatively. Ten minutes after the
transfusion was started, the patient started having
tremors. His temperature was 102.8°F, blood pres-
sure was 130/85 mm Hg, pulse was 100 bpm, and
respiratory rate was 22 bpm. Per blood bank poli-
cies, the transfusion was stopped, and the patient
was given acetaminophen. The blood products and
a fresh type and screen sample were sent back to
the blood bank. What was the patient’s most likely
type of blood reaction?
A. Acute hemolytic
B. Delayed hemolytic
C. Febrile nonhemolytic
D. Allergic
E. Transfusion-related acute lung injury (TRALI)

Answer 3

C. Febrile nonhemolytic

Question 4

What vitamin should be coadministered with iso-
niazid to prevent neuropathy?
A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin B6
E. Vitamin E

Answer 4

D. Vitamin B6

Question 5

A 35-year-old patient admitted to the neurology
ICU following polytrauma becomes hypotensive.
What hemodynamic parameters are compatible
with hypovolemic shock?
A. Decreased right atrial pressure, decreased pul-
monary capillary wedge pressure, decreased
cardiac output, and increased systemic vascu-
lar resistance
B. Normal or increased right atrial pressure,
increased pulmonary capillary wedge pres-
sure, decreased cardiac output, and increased
systemic vascular resistance
C. Variable right atrial pressure, variable pulmo-
nary capillary wedge pressure, increased car-
diac output, and decreased systemic vascular
resistance
D. Increased right atrial pressure, normal or de-
creased pulmonary capillary wedge pressure,
decreased cardiac output, and increased sys-
temic vascular resistance
E. Increased right atrial pressure, increased pul-
monary capillary wedge pressure, decreased
cardiac output, and increased systemic vascu-
lar resistance

Answer 5

A. Decreased right atrial pressure, decreased pul-
monary capillary wedge pressure, decreased
cardiac output, and increased systemic vascu-
lar resistance

Question 6

A 10-year-old boy with von Willebrand disease
is scheduled to undergo a craniotomy for tumor
resection. Besides having blood products readily
available, what can be administered preoperatively
to ready the patient for surgery?
A. Desmopressin
B. Von Willebrand factor
C. Factor VII
D. Intravenous crystalloids
E. Factor IX

Answer 6

A. Desmopressin

Question 7

In the conjunction with absence of brainstem
­reflexes, absent motor response, and the absence of
complicating conditions (e.g., hypothermia, intoxi-
cation, etc.), what apnea test PaCO2 finding is con-
sistent with brain death?
A. PaCO2 of 40 mm Hg after 10 minutes of testing
with no spontaneous respirations
B. PaCO2 of 65 mm Hg with a 20 mm Hg rise over
the patient’s baseline after 12 minutes of test-
ing with no spontaneous respirations
C. PaCO2 of 60 mm Hg with a 10 mm Hg rise over
the patient’s baseline after 6 minutes of test-
ing with no spontaneous respirations
D. PaCO2 of 50 mm Hg after 10 minutes of testing
with no spontaneous respirations

Answer 7

B. PaCO2 of 65 mm Hg with a 20 mm Hg rise over
the patient’s baseline after 12 minutes of test-
ing with no spontaneous respirations

Question 8

What lumbar puncture cerebrospinal fluid study
profile is consistent with bacterial meningitis?
A. Opening pressure 15, 2 WBC without an abnor-
mal differential, protein 30, glucose 60
B. Opening pressure 22, 250 WBC with more
than 80% being lymphocytes, protein 500, glu-
cose 25
C. Opening pressure 30, 1,500 WBC with more
than 80% PMN, protein 400, glucose 10
D. Opening pressure 21, 110 WBC with more
than 50% lymphocytes, protein 80, glucose 50

Answer 8

C. Opening pressure 30, 1,500 WBC with more
than 80% PMN, protein 400, glucose 10

Question 9

What lumbar puncture cerebrospinal study profile
is consistent with viral meningitis?
A. Opening pressure 15, 2 WBC without an abnor-
mal differential, protein 30, glucose 60
B. Opening pressure 22, 250 WBC with more
than 80% being lymphocytes, protein 500, glu-
cose 25
C. Opening pressure 30, 1,500 WBC with more
than 80% PMN, protein 400, glucose 10
D. Opening pressure 21, 110 WBC with more
than 50% lymphocytes, protein 80, glucose 50
Abbreviations: WBC, white blood cells; PMN, poly-
morphonuclear leukocytes

Answer 9

D. Opening pressure 21, 110 WBC with more
than 50% lymphocytes, protein 80, glucose 50
Abbreviations: WBC, white blood cells; PMN, poly-
morphonuclear leukocytes

Question 10

What aspect of propofol requires the use of an ad-
ditional intravenous agent when propofol is used
as a sedative in the acute trauma setting?
A. Its lack of analgesia
B. Its lack of hypnotic effects
C. Its poor ability to lower intracranial pressure
and offer cerebral protection
D. Its poor induction properties in the setting of
rapid intubation

Answer 10

A. Its lack of analgesia

Question 11

A woman with a family history of unknown but
reportedly “significant” reactions to anesthesia is
undergoing induction of anesthesia with a halo-
genated agent. She is noted to have a sudden
increase in end-tidal PCO2 and tachycardia. The
arterial blood gas reading indicates a metabolic
acidosis. The patient had a previous surgery with-
out any complications. What is the next step in the
management of this patient?
A. Stop the anesthetic agent.
B. Administer dantrolene.
C. Hyperventilate the patient to 100% FiO2.
D. Administer calcium chloride.
E. Administer glucose and insulin.

Answer 11

A. Stop the anesthetic agent.

Question 12

What inhalational neuroanesthetic does not reduce
cerebral metabolism?
A. Halothane
B. Enflurane
C. Nitrous oxide
D. Isoflurane
E. Desflurane

Answer 12

C. Nitrous oxide

Question 13

What is a major advantage of halogenated inhala-
tional anesthetic agents?
A. They suppress EEG activity.
B. They decrease cerebral blood flow.
C. They increase cerebral metabolism.
D. They decrease intracranial pressure.
E. They are relatively nonhepatotoxic at high
doses.

Answer 13

A. They suppress EEG activity.

Question 14

Propofol has what analgesic effect?
A. Complete analgesia reversal
B. No analgesic effect
C. Strong analgesic effect
D. Blunting of the effects of other analgesics

Answer 14

B. No analgesic effect

Question 15

What is the major side effect of nitroglycerin and
nitroprusside when used for hypertension control
in neurosurgical patients?
A. Nitroglycerin and nitroprusside lower the sei-
zure threshold.
B. Nitroglycerin and nitroprusside can cause
paralysis in acute use.
C. Nitroglycerin and nitroprusside cause vaso-
constriction.
D. Nitroglycerin and nitroprusside raise intracra-
nial pressure.
E. Nitroglycerin and nitroprusside increase cere-
bral perfusion pressure.

Answer 15

D. Nitroglycerin and nitroprusside raise intracra-
nial pressure.

Question 16

A patient with various intraparenchymal hemor-
rhages following trauma has been resuscitated fully
except for a continued coagulopathy. As the coagu-
lopathy is corrected, what fluids should be avoided
for prolonged administration with regard to the
coagulopathy?
A. Nonhypertonic crystalloids (e.g., normal saline)
B. Colloids (e.g., dextran, hetastarch)
C. Hypertonic crystalloids (e.g., 3% normal saline)
D. Osmotic agents (e.g., mannitol)
E. Isotonic solutions (e.g., Isolyte)

Answer 16

B. Colloids (e.g., dextran, hetastarch)

Question 17

What is the definitive way to identify a patient at
risk for malignant hyperthermia?
A. Obtaining a muscle biopsy for in vitro testing
B. Performing genetic testing
C. Obtaining an adequate family history
D. Assessing serum potassium levels
E. Assessing serum creatine kinase levels

Answer 17

A. Obtaining a muscle biopsy for in vitro testing

Question 18

What pressor agent should be avoided in spinal shock?
A. Dopamine
B. Phenylephrine
C. Isoproterenol
D. Levophed
E. Dobutamine

Answer 18

B. Phenylephrine

Question 19

How do the steroid replacement requirements
differ between primary and secondary adrenal
insufficiency?
A. In primary adrenal insufficiency, only gluco-
corticoids need to be replaced.
B. In secondary adrenal insufficiency, only min-
eralocorticoids need to be replaced.
C. In secondary adrenal insufficiency, both gluco-
corticoids and mineralocorticoids need to be
replaced.
D. In primary adrenal insufficiency, both gluco-
corticoids and mineralocorticoids need to be
replaced.
E. In primary adrenal insufficiency, only miner-
alocorticoids need to be replaced.

Answer 19

E. In primary adrenal insufficiency, only miner-
alocorticoids need to be replaced.

Question 20

What are the side effects associated with using a
long-term, properly dosed, cortisone regimen for
a patient with panhypopituitarism secondary to a
pituitary adenoma?
A. Hypertension and hypokalemia
B. Hyperglycemia and salt wasting
C. Hyperglycemia and volume depletion through
dieresis
D. Hypertension and hyperglycemia
E. Salt wasting and volume depletion

Answer 20

A. Hypertension and hypokalemia

Question 21

What anesthetic is ideal for a patient experiencing
elevated intracranial pressure?
A. Thiopental
B. Enflurane
C. Halothane
D. Isoflurane

Answer 21

A. Thiopental

Question 22

A 45-year-old woman developed marked pallor and
a petechial rash following a craniotomy for tumor
resection. Her temperature is 101.2°F, blood pres-
sure is 105/75 mm Hg, heart rate is 90 bpm, and
respiratory rate is 18 bmp. Lab work reveals a
serum creatinine of 2, hemoglobin of 8, platelet
count of 36,000, prolonged bleeding time of 5
minutes, prothrombin time of 12.1 seconds, and
partial thromboplastin time of 30 seconds. A
peripheral blood smear shows fragmented red
blood cells. There is no elevation in the serum
d-dimer level. What is the most likely diagnosis?
A. Idiopathic thrombocytopenic purpura
B. Disseminated intravascular coagulation
C. Thrombotic thrombocytopenic purpura
D. Hemolytic uremic syndrome
E. Sepsis

Answer 22

C. Thrombotic thrombocytopenic purpura

Question 23

What is the most reliable indicator that a patient
is experiencing cerebral salt wasting and not the
syndrome of inappropriate antidiuretic hormone
secretion?
A. The patient has a high plasma volume.
B. The patient has a low serum sodium
concentration.
C. The patient has a low urine output.
D. The patient is volume depleted.
E. The patient has increasing cerebral edema.

Answer 23

D. The patient is volume depleted.

Question 24

A man with chronic alcoholism is recovering after an alcohol-induced traumatic cerebral contusion. He is neurologically intact awaiting discharge after eating several full meals when he suddenly develops quadriplegia, confusion, difficulty speaking, and
trouble swallowing. Serum sodium is 139 mEq/L. What is the most likely diagnosis?
A. Beriberi
B. Central pontine myelinolysis
C. Pseudohyponatremia
D. Cerebral edema
E. Cervical spinal cord contusion

Answer 24

B. Central pontine myelinolysis

Question 25

When/how should hyperventilation be used in
the setting of a severe head injury and with what
goals?
A. It should never be used.
B. Prophylactic hyperventilation to achieve a PaCO2
of 30 mm Hg for 48 to 72 hours is safe and
effec­tive in reducing intracranial pressure (ICP).
C. Hyperventilation to achieve a PaCO2 of 30 to 35 mm Hg is appropriate to use as a temporizing measure for patients with signs of progressive neurologic deterioration when ICP monitoring is not yet established.
D. In the case of transtentorial herniation, hyper-
ventilation to achieve a PaCO2 less than 25 mm
Hg may be more effective in reducing ICP than
achieving a PaCO2 less than 30 mm Hg.

Answer 25

C. Hyperventilation to achieve a PaCO2 of 30 to 35 mm Hg is appropriate to use as a temporizing measure for patients with signs of progressive neurologic deterioration when ICP monitoring is not yet established.

Question 26

In the event of failed maximal medical manage-
ment of increased intracranial pressure, what is the
dosing regimen for pentobarbital for instituting a
pentobarbital coma?
A. 20 mg/kg intravenous bolus followed by 100
mg every 8 hours
B. 100 mg intravenously every 4 hours
C. 20 to 75 µg/kg/min intravenous continuous
drip
D. 10 mg/kg intravenous bolus over 30 minutes
followed by a 1 mg/kg/h infusion

Answer 26

D. 10 mg/kg intravenous bolus over 30 minutes
followed by a 1 mg/kg/h infusion

Question 27

What antipsychotic medication can lead to
agranulocytosis?
A. Clozapine
B. Thioridazine
C. Chlorpromazine
D. Aripiprazole
E. Quetiapine

Answer 27

A. Clozapine

Question 28

In patients with low albumin, what equation can
be used to convert observed phenytoin levels to
equivalent/corrected phenytoin levels?
A. Equivalent level = Observed level/(0.1(Albumin
level) + 0.1)
B. Equivalent level = Observed level – 2(Albumin
level)
C. Equivalent level = Observed level/(2(Albumin
level) + 3)
D. Equivalent level = Observed level/Albumin
level
E. Equivalent level = Observed level – 3(Albumin
level)

Answer 28

A. Equivalent level = Observed level/(0.1(Albumin
level) + 0.1)

Question 29

What anesthetic agent can lead to the development
of tension pneumocephalus following surgery in
the supine position?
A. Halothane
B. Sevoflurane
C. Nitrous oxide
D. Propofol
E. Remifentanil

Answer 29

C. Nitrous oxide

Question 30

What are the two main factors that should be pres-
ent for an air embolism to occur?
A. Noncollapsible vein and negative pressure in
the vein
B. Collapsible vein and positive pressure in the
vein
C. Noncollapsible vein and positive pressure in
the vein
D. Collapsible vein and patent foramen ovale
E. Patent foramen ovale and negative pressure in
the vein

Answer 30

A. Noncollapsible vein and negative pressure in
the vein

Question 31

Following traumatic skull base fractures, if patients
are placed on empiric antibiotic coverage, what
organism should be targeted with this coverage?
A. Staphylococcus aureus
B. Staphylococcus epidermidis
C. Streptococcus pneumoniae
D. Hemophilus influenza
E. Neisseria meningitis

Answer 31

C. Streptococcus pneumoniae

Question 32

A postoperative patient has a potassium level of 6.7,
and an electrocardiogram shows peaked T waves.
What should be administered next in this patient’s
management?
A. Calcium gluconate
B. Kayexalate
C. Insulin and glucose
D. Lasix
E. Albuterol

Answer 32

A. Calcium gluconate

Question 33

What is the reversal agent for benzodiazepines?
A. Atropine
B. Physostigmine
C. Flumazenil
D. Glucagon
E. Phentolamine
F. Naloxone
G. Protamine
H. Dimercaprol

Answer 33

C. Flumazenil

Question 34

What is the reversal agent for morphine?
A. Atropine
B. Physostigmine
C. Flumazenil
D. Glucagon
E. Phentolamine
F. Naloxone
G. Protamine
H. Dimercaprol

Answer 34

F. Naloxone

Question 35

What is the antidote agent for anticholinergic
poisoning?
A. Atropine
B. Physostigmine
C. Flumazenil
D. Glucagon
E. Phentolamine
F. Naloxone
G. Protamine
H. Dimercaprol

Answer 35

B. Physostigmine

Question 36

What is the reversal agent for dopamine overdose?
A. Atropine
B. Physostigmine
C. Flumazenil
D. Glucagon
E. Phentolamine
F. Naloxone
G. Protamine
H. Dimercaprol

Answer 36

E. Phentolamine

Question 37

What is the mechanism of action of isoproterenol?
A. Selective β-adrenergic agonism
B. Nonselective β-adrenergic agonism
C. Selective β-adrenergic blockade
D. Nonselective β-adrenergic blockade
E. Trace amine–associated receptor 1 (TAAR1)
antagonism

Answer 37

B. Nonselective β-adrenergic agonism

Question 38

How does assist control ventilation work?
A. Breaths are patient- or time-triggered with a
constant tidal volume for each breath.
B. Breaths are patient- or time-triggered, flow
limited, and volume cycled; breaths taken by
patients are not assisted.
C. Breaths are patient-triggered, and inspiratory
pressure is added to patient-initiated breaths.
D. Breaths are not triggered, and continuous
pressure is applied to the ventilation circuit
throughout the breathing cycle.

Answer 38

A. Breaths are patient- or time-triggered with a
constant tidal volume for each breath.

Question 39

What pathology is represented by the following
arterial blood gas values?
pH: 7.30
PCO2: 43 mm Hg
HCO3
–: 20 mEq/L
A. Respiratory alkalosis
B. Metabolic acidosis
C. Combined respiratory and metabolic alkalosis
D. Partially compensated respiratory acidosis

Answer 39

B. Metabolic acidosis

Question 40

What pathology is represented by the following
arterial blood gas values?
pH: 7.56
PCO2: 28 mm Hg
HCO3–: 25 mEq/L
A. Respiratory alkalosis
B. Metabolic acidosis
C. Combined respiratory and metabolic alkalosis
D. Partially compensated respiratory acidosis

Answer 40

A. Respiratory alkalosis

Question 41

In an adult patient with a normal head CT follow-
ing a concussion, what risk factors increase the
likelihood for intracranial hypertension?
A. Age greater than 60 years, systolic blood pres-
sure less than 100 mm Hg, and posturing on
motor exam
B. Age greater than 40 years, systolic blood pressure less than 90 mm Hg, and posturing on motor exam
C. Age greater than 65 years, systolic blood pres-
sure less than 110 mm Hg, and posturing on
motor exam
D. Age greater than 35 years, systolic blood pres-
sure less than 80 mm Hg, and posturing on
motor exam

Answer 41

B. Age greater than 40 years, systolic blood pressure less than 90 mm Hg, and posturing on motor exam

Question 42

What is the conversion factor between mm Hg and
cm H2O?
A. 1 mm Hg = 1.36 cm H2O
B. 1 mm Hg = 1.63 cm H2O
C. 1 mm Hg = 0.735 cm H2O
D. 1 mm Hg = 0.375 cm H2O

Answer 42

A. 1 mm Hg = 1.36 cm H2O

Question 43

A 22-year-old patient with a traumatic brain
injury is admitted to the intensive care unit with a
Glasgow Coma Scale score of 7. What is the recom-
mended goal for the body temperature state for
this patient?
A. Induced hypothermia
B. Permissive hypothermia
C. Normothermia
D. Permissive hyperthermia
E. Induced hyperthermia

Answer 43

C. Normothermia

Question 44

What intravenous anesthetic may cause adrenal
insufficiency?
A. Propofol
B. Dexmedetomidine
C. Etomidate
D. Ketamine

Answer 44

C. Etomidate

Question 45

A 55-year-old woman remains comatose for 4 days
following resuscitation from a heart attack. She
is off sedation and shows absence of brainstem
­reflexes. The patient is unable to complete the
apnea test portion of the brain death examination.
Median nerve somatosensory evoked potentials
(SSEPs) are obtained. What finding would be pre-
dictive of a poor neurologic outcome?
A. Bilateral absence of the N20 waveform
B. Bilateral absence of the N9 waveform
C. Bilateral absence of the N13 waveform
D. Unilateral absence of the N13 waveform

Answer 45

A. Bilateral absence of the N20 waveform

Question 46

How does pressure support ventilation work?
A. Breaths are patient- or time-triggered with a
constant tidal volume for each breath.
B. Breaths are patient- or time-triggered, flow
limited, and volume cycled; breaths taken by
patients are not assisted.
C. Breaths are patient-triggered, and inspiratory
pressure is added to patient-initiated breaths.
D. Breaths are not triggered, and continuous
pressure is applied to the ventilation circuit
throughout the breathing cycle.

Answer 46

B. Breaths are patient- or time-triggered, flow
limited, and volume cycled; breaths taken by
patients are not assisted.

Question 47

A 35-year-old man with HIV has a multiple ring-
enhancing lesions on MRI. What is the most likely
diagnosis?
A. Tenia solium
B. Herpes simplex
C. Cryptococcus
D. Toxoplasmosis
E. West Nile virus
F. JC virus

Answer 47

D. Toxoplasmosis

Question 48

A 70-year-old woman with HIV and noncompli-
ance with HAART has 3 weeks of progressively
worsening mental status along with a left visual
field deficit and right-sided weakness. MRI reveals
nonenhancing white matter lesions without sur-
rounding edema. The lesions appear hyperintense
on T2 and hypointense on T1 sequences. What is
the most likely diagnosis?
A. Tenia solium
B. Herpes simplex
C. Cryptococcus
D. Toxoplasmosis
E. West Nile virus
F. JC virus

Answer 48

F. JC virus

Question 49

A 73-year-old woman with neck stiffness, head-
ache, left leg weakness, and fever rapidly pro-
gressed to having flaccid paralysis and areflexia.
Cerebrospinal fluid studies show a white blood cell
count over 200, a normal red blood cell count, pro-
tein of 87, and a normal glucose level. Cerebro-
spinal fluid Gram stain shows no organisms, and
the culture is negative. What is the most likely
diagnosis?
A. Tenia solium
B. Herpes simplex
C. Cryptococcus
D. Toxoplasmosis
E. West Nile virus
F. JC virus

Answer 49

E. West Nile virus

Question 50

A 65-year-old man with a history of chronic
obstructive pulmonary disease is admitted for a
lobar intracranial hemorrhage. The patient is intu-
bated and sedated. He suddenly develops pulseless
electrical activity. Auscultation of the lungs reveals
absent breath sounds on the right. The trachea is
deviated to the left. What is the best next step in
the patient’s management?
A. Chest tube placement
B. Chest radiograph
C. Needle thoracotomy
D. Ultrasound of the lungs
E. Decrease the tidal volume on the ventilator

Answer 50

C. Needle thoracotomy

Question 51

A 28-year-old man is admitted to the intensive
care unit after being hit by a car. He has a 5-mm
subdural hematoma on the right and a right femur
fracture. Two days after admission, he develops
tachypnea, tachycardia, and hypotension and be-
comes disoriented. On exam, he has new petechiae
across his chest. An electrocardiogram is obtained
and is unremarkable. A chest radiograph is normal
except for two rib fractures. What is the patient’s
most likely diagnosis?
A. Subdural hematoma expansion
B. Pulmonary embolism
C. Fat embolism
D. Cardiac contusion
E. Pulmonary contusion

Answer 51

C. Fat embolism

Question 52

What are the major potential side effects of peni-
cillin and cephalosporins?
A. Benign intracranial hypertension
B. Aseptic meningitis
C. Cerebellar ataxia
D. Cochlear and vestibular damage
E. Unpleasant taste

Answer 52

B. Aseptic meningitis

Question 53

What are the major potential side effects of am-
photericin B?
A. Benign intracranial hypertension
B. Aseptic meningitis
C. Cerebellar ataxia
D. Cochlear and vestibular damage
E. Unpleasant taste

Answer 53

A. Benign intracranial hypertension

Question 54

What are the major potential side effects of
ethambutol?
A. Benign intracranial hypertension
B. Aseptic meningitis
C. Cerebellar ataxia
D. Cochlear and vestibular damage
E. Unpleasant taste

Answer 54

C. Cerebellar ataxia

Question 55

How will the urine osmolalities of a patient with central diabetes insipidus (DI) and of a normal individual respond to the injection of DDAVP?
A. In a patient with central DI, DDAVP will cause
a 50% increase in urine osmolality, whereas it will cause an increase of 5% in a normal individual.
B. In a patient with central DI and in a normal individual, DDAVP will cause a 50% increase in urine osmolality.
C. In a patient with central DI and in a normal individual, DDAVP will cause a 25% increase in urine osmolality.
D. In a patient with central DI, DDAVP will cause
a 50% increase in urine osmolality, whereas it will cause a decrease of 5% in a normal individual.
E. In a patient with central DI, DDAVP will cause
a 25% increase in urine osmolality, whereas it will cause a decrease of 5% in a normal individual.

Answer 55

A. In a patient with central DI, DDAVP will cause a 50% increase in urine osmolality, whereas it will cause an increase of 5% in a normal individual.

Question 56

What clinical syndrome/condition is associated
with opsoclonus-myoclonus in a child?
A. Hodgkin lymphoma
B. Neuroblastoma
C. Small cell lung cancer
D. Thymoma
E. Carcinoid tumor

Answer 56

B. Neuroblastoma

Question 57

What clinical syndrome/condition is associated
with cerebellar dysfunction in an adolescent?
A. Hodgkin lymphoma
B. Neuroblastoma
C. Small cell lung cancer
D. Thymoma
E. Carcinoid tumor

Answer 57

A. Hodgkin lymphoma

Question 58

What clinical syndrome/condition is associated
with limbic encephalitis and myasthenia gravis?
A. Hodgkin lymphoma
B. Neuroblastoma
C. Small cell lung cancer
D. Thymoma
E. Carcinoid tumor

Answer 58

D. Thymoma

Question 59

What clinical syndrome/condition is associated
with Lambert-Eaton myasthenia syndrome?
A. Hodgkin lymphoma
B. Neuroblastoma
C. Small cell lung cancer
D. Thymoma
E. Carcinoid tumor

Answer 59

C. Small cell lung cancer

Question 60

During hyperventilation therapy, a PCO2 below
what level could worsen cerebral ischemia?
A. 35 mm Hg
B. 32 mm Hg
C. 28 mm Hg
D. 25 mm Hg
E. 20 mm Hg

Answer 60

C. 28 mm Hg

Question 61

What is the main anticipated outcome in proceeding with donation after cardiac death?
A. Asystole or pulselessness will occur within 1 hour of withdrawal of care.
B. The patient needs to undergo brain death ex-
amination after withdrawal of care.
C. The transplant surgeon will have to declare
the patient deceased.
D. The heart will be removed for donation.

Answer 61

A. Asystole or pulselessness will occur within 1 hour of withdrawal of care.

Question 62

What is the total blood volume of a 1-year-old boy
weighting 10 kg?
A. 200 mL
B. 400 mL
C. 800 mL
D. 1.4 L
E. 1.6 L

Answer 62

C. 800 mL

Question 63

A patient develops leukopenia after starting a
new drug therapy regimen for trigeminal neural-
gia. What medication likely is the cause of the
leukopenia?
A. Gabapentin
B. Baclofen
C. Carbamazepine
D. Levetiracetam
E. Lamotrigine

Answer 63

C. Carbamazepine

Question 64

A 45-year-old homeless man is admitted to the
hospital after being hit by a car. Thirty-six hours
after admission, he becomes agitated and starts
complaining of hearing people cursing him and
feeling people touching him. His vitals are stable.
The patient has a history of alcohol intake and
smokes one pack of cigarettes per day. He does not
use any drugs and has no significant psychiatric
history. What is his most likely diagnosis?
A. Alcoholic hallucinosis
B. Intensive care unit delirium
C. Schizophrenia
D. Brief psychotic episode
E. Delirium tremens

Answer 64

A. Alcoholic hallucinosis

Question 65

The lower limit of a normal systolic blood pressure
for a given age in children may be estimated by
what formula?
A. 70 mm Hg + 2(Age in years)
B. 70 mm Hg + 3(Age in years)
C. 50 mm Hg + 2(Age in years)
D. 40 mm Hg + 2(Age in years)
E. 40 mm Hg + 3(Age in years)

Answer 65

A. 70 mm Hg + 2(Age in years)

Question 66

Pulmonary capillary wedge pressure is reflective of:
A. Pulmonary artery pressure
B. Central venous pressure
C. Left atrial pressure
D. Right atrial pressure
E. Left ventricular pressure

Answer 66

C. Left atrial pressure

Question 67

In the setting of liver failure, an ammonia level of
greater than what value is associated with cerebral
herniation due to cerebral edema?
A. 100 µmol/L
B. 150 µmol/L
C. 200 µmol/L
D. 250 µmol/L
E. No ammonia level is predictive of cerebral
herniation

Answer 67

E. No ammonia level is predictive of cerebral
herniation

Question 68

Where does antidiuretic hormone (ADH) act in the
kidneys?
A. Glomerulus
B. Proximal renal tubule
C. Distal renal tubule
D. Loop of Henle
E. Collecting duct

Answer 68

C. Distal renal tubule

Question 69

What is the mechanism of action of ketamine when
used as an intravenous sedative?
A. GABA-A agonist
B. GABA-B agonist
C. NMDA receptor antagonist
D. Decreases the extent of gap junction cell
coupling
E. Unknown mechanism of action

Answer 69

C. NMDA receptor antagonist

Question 70

What is the crystalloid of choice to be administered along with a blood transfusion?
A. Lactated Ringer’s solution
B. 0.9% normal saline
C. D5 water
D. 0.225% normal saline

Answer 70

B. 0.9% normal saline

Question 71

A patient presents to the emergency room in status epilepticus. According to the standard treatment algorithm for status epilepticus, after securing the patient’s airway, breathing, and circulation, what medication should be given first?
A. Lorazepam 0.1 mg/kg intravenously
B. Phenytoin/fosphenytoin 20 mg/kg intravenous load
C. Phenytoin/fosphenytoin 125 mg/kg intravenous load
D. Dextrose 50 mL of D50 intravenous bolus
E. Thiamine 100 mg intravenously

Answer 71

E. Thiamine 100 mg intravenously

Question 72

Deficiency of what nutrient is associated with
ophthalmoplegia, ataxia, and confusion?
A. Cyanocobalamin
B. Thiamine
C. Pyridoxine
D. Folate
E. Niacin

Answer 72

B. Thiamine

Question 73

A patient is in coma with the respiratory pattern
shown in this image. Where is the patient’s lesion?
A. Diencephalon or bilateral cerebral hemispheres
B. Nonorganic (psychogenic origin)
C. Superior medulla or inferior pons
D. Superior pons
E. Medulla

Answer 73

E. Medulla

Question 74

A 45-year-old man with a recent diagnosis of von
Hippel–Lindau disease is admitted to the hospital
with a blood pressure of 199/110. He has been
complaining of recurrent headaches for the past
few days. What is his most likely diagnosis?
A. Pheochromocytoma
B. Hyperaldosteronism
C. Renal artery stenosis
D. Renal cell carcinoma
E. Primary hypertension

Answer 74

A. Pheochromocytoma

Question 75

Following resection of a brain tumor, a patient is
maintained on minimal intravenous fluids. The
next morning, he has an elevated creatinine. A
fractional excretion of sodium (FENa) is obtained
and is 0.7. What is the most likely etiology of his
elevated creatinine?
A. Dehydration
B. Acute kidney injury
C. Kidney stones
D. Drug toxicity

Answer 75

A. Dehydration

Question 76

What is the most sensitive monitoring method to
detect a venous air embolism during surgery?
A. Right atrial central venous pressure catheter
B. Transesophageal echocardiogram
C. Precordial Doppler probe
D. Radial arterial line
E. End-tidal PCO2 detector

Answer 76

B. Transesophageal echocardiogram

Question 77

A 78-year-old man develops a pulmonary embolus
on day 3 following tumor resection. He is not
started on anticoagulation and is scheduled for an
inferior vena cava filter placement. While waiting
for filter placement, he develops acute abdominal
pain with bloody diarrhea. His abdomen is soft.
What is the next best step in his management?
A. Clostridium difficile studies
B. Stool parasitic studies
C. Stool for fecal occult blood testing
D. Emergent vascular consultation and abdominal CT angiogram
E. Abdominal ultrasound

Answer 77

D. Emergent vascular consultation and abdominal CT angiogram

Question 78

The rapid shallow breathing index (RSBI) is a wean-
ing assessment tool measured during 1 minute of
spontaneous breathing. A value of more than 105
determines a poor chance of ventilator weaning
success. How is the RSBI calculated?
A. RSBI = Breath frequency/Tidal volume
B. RSBI = Tidal volume/Breath frequency
C. RSBI = PaO2/Breath frequency
D. RSBI = PCO2/Tidal volume
E. RSBI = Tidal volume/PaO2

Answer 78

A. RSBI = Breath frequency/Tidal volume

Question 79

Although controversial, a negative inspiratory force
(NIF) of –25 or less is considered a criterion for
readiness for extubation. What is the NIF?
A. Pressure generated by a patient during forced
expiration
B. Pressure generated by a patient during forced
inspiration
C. Pressure generated by a patient during regular
expiration
D. Volume circulated by a patient during one
breath
E. Volume circulated by a patient during 1 min-
ute of spontaneous ventilation

Answer 79

B. Pressure generated by a patient during forced
inspiration

Question 80

A 78-year-old man is admitted to the intensive
care unit with an intracranial hemorrhage. His sys-
tolic blood pressure is 190 mm Hg. What are the
current guidelines regarding acute blood pressure
lowering in the setting of intracranial hemorrhage
for a patient with a presentation systolic blood
pressure between 150 and 220 mm Hg?
A. Acute lowering of the systolic blood pressure
to 140 mm Hg is safe and can be effective in improving functional outcome.
B. Acute lowering of the systolic blood pressure
to 140 mm Hg is dangerous and should be
avoided.
C. Acute lowering of the systolic blood pressure
to 170 mm Hg is safe and can be effective in
reducing mortality.
D. Acute lowering of the systolic blood pressure
to two thirds of the presentation blood pres-
sure is safe and can be effective in improving
functional outcome.
E. Acute lowering of systolic BP to 120 mm Hg is
probably safe.

Answer 80

A. Acute lowering of the systolic blood pressure
to 140 mm Hg is safe and can be effective in improving functional outcome.

Question 81

Emergency administration of what medication
is indicated in the setting of symptomatic acute
alcohol withdrawal with ataxia and confusion?
A. Glucose
B. Magnesium
C. Beta-blockers
D. Nicotine
E. Thiamine

Answer 81

E. Thiamine

Question 82

How does polymyositis compare with dermatomy-
ositis regarding associations with malignancy and
B- and T-cell infiltration?
A. Polymyositis more often is associated with
malignancy and T-cell infiltration more than B-cell infiltration.
B. Polymyositis more often is associated with
malignancy and B-cell infiltration more than
T-cell infiltration.
C. Polymyositis more often is associated with
malignancy and T-cell infiltration more than
B-cell infiltration.
D. Polymyositis more often is associated with
malignancy and B-cell infiltration more than
T-cell infiltration.
E. Polymyositis and dermatomyositis are associ-
ated equally with malignancy and B- and
T-cell infiltration.

Answer 82

A. Polymyositis more often is associated with
malignancy and T-cell infiltration more than B-cell infiltration.

Question 83

While doing a myelogram, the radiology resident
realizes that he just injected an ionic contrast agent
intrathecally. What is the best next step in management of the patient?
A. Do nothing, as this should not be a problem.
B. Withdraw fluid through a myelogram needle.
C. Start intravenous steroids.
D. Start antiepileptic drugs.
E. Administer antihistamines

Answer 83

B. Withdraw fluid through a myelogram needle.

Question 84

What is the effect of nimodipine on a patient with
an aneurysmal subarachnoid hemorrhage?
A. Decreases the risk of vasospasm and mortality
rate
B. Decreases the risk of vasospasm but not the
mortality rate
C. Increases the risk of vasospasm and mortality
rate
D. Does not affect the risk of vasospasm but decreases the mortality rate
E. Increases the risk of vasospasm but decreases
the mortality rate

Answer 84

D. Does not affect the risk of vasospasm but decreases the mortality rate

Question 85

A man has an allergic reaction to receiving a blood
transfusion. A direct Coombs test is negative, no
free hemoglobin was found in the blood, and the
urinalysis was normal. The allergic reaction stopped
spontaneously during the workup of its cause. What
could have been done to prevent the described
reaction?
A. Warming the transfused blood products
B. Transfusing whole blood
C. Administering better clerical training
D. Premedication with acetaminophen
E. Washing the transfused cells

Answer 85

E. Washing the transfused cells

Question 86

A 26-year-old patient with a history of a selective
IgA-deficiency syndrome requires a blood transfu-
sion following a traumatic injury. What is the major
risk of transfusing regular packed red blood cells to
this patient?
A. Anaphylactic transfusion reaction
B. Rejection of donor blood due to incompatibility
C. Sepsis
D. Chemical meningitis
E. Disseminated intravascular coagulation

Answer 86

A. Anaphylactic transfusion reaction

Question 87

A 60-year-old man with a glomerular filtration rate
of 30 mL/min secondary to chronic diabetes melli-
tus type 2 is being evaluated for a newly discov-
ered brain mass. Three days after he is discharged
from the hospital, he develops large areas of indu-
rated skin with fibrotic nodules and plaques. What
might have prevented the development of his
symptoms?
A. Avoiding contrasted MRI studies
B. Stopping metformin during hospitalization
C. Immediate dialysis following contrast-
enhanced CT head scans
D. Better management of the blood glucose during
hospitalization
E. Antihistamine use prior to contrast-enhanced
studies

Answer 87

A. Avoiding contrasted MRI studies

Question 88

A 22-year-old man admitted with a traumatic brain
injury develops a pulmonary embolism 4 days fol-
lowing a craniectomy. What is the most sensitive
clinical sign for detecting a pulmonary embolism?
A. Tachycardia
B. Hypotension
C. Tachypnea
D. Oxygen desaturation
E. Low-grade fever

Answer 88

A. Tachycardia