Strategies for Mastering Exam Questions

What are the steps you should aim to incorporate into your approach to dealing with PANCE questions? They need to be generic enough to work with different kinds of questions. These steps also need to protect you from making mistakes that could hurt you. Let’s look at the approach to questions used by many good test takers and focus on why it works.

The Basic Steps

1. Read the question carefully to locate the important clues.

2. Make sure you fully understand what’s being asked.

3. Before looking at any answer choices, put the clues together with what you are being asked and allow your mind to form an answer.

4. Look at the choices offered, and if one of them fits your anticipated answer, mark it.

5. If no choice is a good fit, use general knowledge, larger concepts, and logic to eliminate as many choices as you can.

6. Select an answer from the remaining choices.

Not all of these steps will necessarily be used with every question. For example, if a question asked which bacterial organism is most commonly responsible for neonatal pneumonia and you remembered it, then the process would stop at Step 4. However, in most standardized examinations, many questions will ask you to assess specifics that you won’t be able to recall. It is in dealing with these questions that good test takers have a real advantage over those who are less adept. So, just what methods are used to get more correct answers?


 Often there is more than one right answer, but the question is asking for the best answer. Read all answer choices before jumping to a conclusion.

The Methods

The arsenal of test strategies is hinted at in Step 5 above, which directs the use of general knowledge, larger concepts, and logic. Unconfident test takers are prone to an either/or mindset when they encounter questions. If, after reading the question, they aren’t sure of an answer based on what they recall, they quickly give up and guess. Good test takers use information presented in the question itself or more of their general knowledge to chip away at the question. By persevering and exploiting whatever they can to eliminate choices, they more frequently end up with correct answers. But frankly, just talking about what’s involved in abstract terms isn’t likely to make you a better test taker. To accomplish that goal, you will have to see test strategies in action.

Strategies really can’t be taught out of context. To give you a sense of how to use strategies, we are going to illustrate them with examples, followed by a discussion of how applying a strategy narrows the possible answers and, in many cases, allows a test taker to obtain correct answers by knowing something about the topic of the question but not enough to mark an answer using only recalled information.

Eliminate distractors by applying basic principles

A neonate has a flat, dark-pigmented area of skin over the sacral region. The area is roughly oval, has a clearly defined border, and differs from surrounding skin only in color. Which of the following is the most likely diagnosis?

A. Diastematomyelia

B. Mongolian spot

C. Nevus flammeus

D. Pilonidal cyst

E. Spina bifida

StrategyThe use of strategies never guarantees a correct answer; however, they allow you to extrapolate from what you do recall and relate that knowledge to the specifics of a given question. In this item, if you didn’t know the answer (choice B), you could still eliminate choice E because the patient’s findings would be more severe for spina bifida. You might also reason that it wouldn’t be a cyst (choice D) because the stem of the question states that the area differs only in color, whereas with a cyst, you would expect a palpable mass. Knowing some word etymology might help you eliminate choice C (“flammeus” [flame] suggests either redness or heat, which is not mentioned in the description). This leaves choices A or B to choose from. Now you have a 50%—instead of a 20%—chance of getting the question right.

In the two oxygen-hemoglobin dissociation curves shown below, normal findings are represented by the solid line and abnormal findings are represented by the dotted line, indicating a situation in which the curve has been shifted. Shifts such as this can occur under which of the following circumstances?

A. Carbon monoxide poisoning

B. Decreased pH

C. Increased 2,3-diphosphoglycerate (2,3-DPG)

D. Increased pCO2

E. Increased temperature

StrategyIf you recall that a left shift causes oxygen to load and a right shift causes oxygen to unload, then you can figure out the answer to this item without strategies. If you don’t recall, however, you can analyze the choices, seeking interrelationships. Look at choices B, C, D, and E, which would all occur when a person exercises. With exercise, more oxygen is needed, so you would want the body to react with a right shift. By elimination, the factor causing a left shift must be choice A, carbon monoxide poisoning, because it is the only effect not likely resulting from the oxygen demands being increased due to vigorous exercise.

Recognizing a question in disguise: What is really being asked?

A 16-year-old girl comes from a very religious family and denies any sexual activity. She has severe acne unresponsive to previous treatment of conventional therapy. Which of the following laboratory studies should be performed prior to prescribing isotretinoin?

A. Lipid profile

B. Liver function studies

C. Measurement of serum urea nitrogen (BUN)

D. Complete blood count (CBC)

E. Measurement of urine β-hCG

StrategyFirst, make sure you understand what is actually being asked. You’re dealing with someone who is potentially sexually active (any young woman of reproductive age should be assessed for pregnancy); therefore, it is always necessary to check for pregnancy before prescribing a drug that could affect a developing embryo. Knowing this, you could correctly answer this item (choice E) without knowing much, if anything, about the properties of the specific drug isotretinoin.

A 4-year-old boy is admitted with respiratory difficulty. He has had several previous admissions for pneumonia. History is significant for the failure to pass meconium at birth. Temperature is 101.1°F, and respirations are 35/min. Physical examination reveals a thin, malnourished boy <5th percentile for height and weight. Rales are heard over the left lower lobe, and percussion over the region is dull. Sputum culture grows Pseudomonas aeruginosa. Which test would confirm the diagnosis?

A. Bronchoscopy

B. Chloride sweat test

C. CT scan of the thorax

D. D-xylose absorption test

E. Pulmonary function tests

StrategyThis item illustrates the policy of portraying diseases in their most classic presentations on entry-level licensure examinations. The boy’s history and symptoms are textbook indications of cystic fibrosis, so the correct answer is B. Notice that examinees don’t receive credit for knowing what disease the boy has, only for reaching a correct diagnosis and then using that knowledge to answer the question posed (i.e., which test would confirm that diagnosis).

Recognizing a question in disguise: Red Herrings

A 52-year-old physician whom you know socially has taken secobarbital, 2 g daily, for 7 years, despite several attempts to stop using the drug. He has been abstinent from alcohol for 10 years. The patient weighs 72 kg (158 lb). Examination shows no abnormalities. Which of the following is the most appropriate next course of action?

A. Detoxification as an outpatient and referral for group treatment

B. Discontinuation of secobarbital and prescription for a benzodiazepine in equivalent doses

C. Hospitalization for detoxification

D. Psychotherapy

E. Suggest that he gradually reduce the dosage of secobarbital

StrategyWatch out for the item-writing tactic displayed in this question. The stem clearly states that this man has a history of addictive behavior (alcohol, drugs). But by making the patient a physician, the test writer is trying to confuse the strength of your convictions. Are you willing to hospitalize him, even though this might be a difficult step for you to take? Because the patient has responsibility for the well-being of others, it is even more important to take the tough but appropriate action so that his addiction won’t negatively affect patients’ welfare. Therefore, he should be hospitalized for detoxification (choice C).

A patient in chronic renal failure has five relatives as potential donors. A one- way mixed lymphocyte reaction is performed, isolating lymphocytes from each relative and treating the cells with mitomycin-C to prevent DNA replication. The cells are incubated with the patient’s untreated lymphocytes in the presence of titrated thymidine for 2 days. The DNA is isolated, and the radioactive counts (CPM) are measured. Based on the assays, who is the best potential donor?

A. Father (lymphocytes 24,000 CPM)

B. Mother (lymphocytes 18,000 CPM)

C. Grandfather (lymphocytes 30,000 CPM)

D. Brother (lymphocytes 1,500 CPM)

E. Sister (lymphocytes 6,000 CPM)

StrategyItem writers love to make questions look complex! A question like this becomes straightforward when you realize that rejection is the big worry in all transplants. When potential donor and recipient cells are mixed together, you would want the smallest number of lymphocytes, as it would indicate the least interaction between the cells. Therefore, the correct choice is D.

Visualize the correct situation

A convenience store clerk is hit in the face multiple times with a baseball bat during a robbery. Upon arrival at the emergency department, the patient is cyanotic and stridulous, with copious amounts of blood in his mouth. He has a markedly displaced mandible and midface, and clear fluid is draining from hi  nose. Two attempts at orotracheal intubation fail. Which of the following is the most appropriate next step in management?

A. Administer a high concentration of oxygen delivered through a tight-fitting face mask

B. Administer humidified oxygen and bronchodilator treatment

C. Intubate with a fiberoptic scope

D. Perform an emergency cricothyroidotomy

E. Perform a nasotracheal intubation

StrategyVisualization of stem information is critically important to getting more items correct. If you picture what this patient’s face must look like and what’s already been tried, then choices A, B, C, and even E all seem unlikely to be successful. The only way to establish an airway with any certainty of success, thus keeping your patient alive for his other injuries to be treated, is choice D, which is the correct answer.

A 27-year-old man is brought to the emergency department by paramedics after being thrown from the back of a pickup truck at high speed. He received 2 liters of intravenous (IV) fluid in transit. His pulse on arrival is 120/min and BP is 60/40 mm Hg. He is awake and without focal neurologic signs. He has a distended tender abdomen and a stable pelvis, with no deformities of the lower extremities. Portable chest x-ray results are normal. Which of the following is the most appropriate next step in management?

A. CT scan of the abdomen and head

B. Diagnostic peritoneal lavage and fluid administration while awaiting cell counts on lavage fluid

C. Dopamine infusion to improve BP, followed by observation

D. Exploratory laparotomy and administration of blood products

E. Spine films to rule out vertebral fracture

StrategyIf you visualize this patient’s injuries, it should be rather obvious that he is bleeding into the abdominal area because his blood pressure is still low (despite the IV) and his abdomen is tender and distended. This must be dealt with immediately or a rupture could kill him; there is no time for scheduling diagnostic tests (which rules out choices A and E). Choice C is clearly wrong because waiting and observing won’t stop his bleeding. You would then guess either choice B or D. In considering these final two, it would probably be smarter to pick choice D (the correct answer) because choice B also mentions waiting for cell counts.

Don’t let sharp turns confuse you

In recent years, most HMOs have instituted plans involving patient copayments. A local HMO has just raised copayments by $15 in an attempt to reduce costs. Studies have shown that the effect of increasing patient copayments in the United States has been which of the following?

A. Decreased utilization in direct proportion to the required copayment

B. Decreased utilization of unnecessary services only

C. Decreased use of tertiary services, but increased use of primary services

D. Increased utilization in a nonlinear fashion

E. Increased utilization in a linear fashion

StrategyThis is a good example of what might be called a bait-and-switch question. The item writer is hoping that you’ll assume the medical professionals’ viewpoint so that you’ll get slightly thrown off when the focus of the question is switched to the impact, not the intent, of increasing copayments. The correct answer is choice A, not choice B, because the typical citizen lacks the medical knowledge to know what is necessary and what isn’t necessary. So he or she will tend to use less of all kinds of services.

Malpractice insurance rates have continued to soar in recent years, adding to the overall cost of healthcare in the United States. It is recommended that physicians become more knowledgeable about this issue to exert peer influence on their medical colleagues. In this context, which of the following cases represents the best grounds for malpractice?

A. A 19-year-old model undergoes breast augmentation and is left with breasts of slightly unequal size.

B. A 27-year-old man dies from penicillin allergy after he receives a shot for strep throat in the emergency room.

C. A 51-year-old woman is diagnosed with breast cancer metastatic to her lungs. One month earlier, her mammogram was read as normal.

D. A 55-year-old businessman suffers peritonitis when operative sponges were not removed during his appendectomy.

E. A 77-year-old woman falls out of bed in the hospital and suffers a hip fracture.

StrategyThis is another example of the bait-and-switch in the point of view. It tries to trap the test taker into evaluating the choices from the medical practitioner’s viewpoint when in actuality, the question is asked from a malpractice attorney’s viewpoint. Choice D is the correct answer because it’s the only one that mentions any concrete physical evidence for the attorney to show a jury (the sponge). This makes it the easiest case to prove legally. Recognizing the point of view saves time and leads to fewer incorrect answers in questions like these.

When in doubt, be open and empathetic

A 13-year-old boy with poor impulse control is brought to the office for an evaluation. During the interview, the boy expresses concern at his inability to control his temper, but he subsequently becomes enraged. With clenched fists and in a trembling voice, he tells the physician to “Stop bugging me or I’ll hit you!” Which of the following would be the physician’s best response?

A. “You should never hit people.”

B. “Do you think you are really going to hit me?”

C. “It must be frightening to be that angry.”

D. “I don’t believe that you really want to hit me.”

E. Sit quietly, watching the patient attentively but doing nothing.

StrategyOnly choice C shows empathy with the boy’s feelings. By not judging his behavior, the clinician encourages the boy to confide more information and avoids provoking him into further negative emotions. When encountering questions dealing with communication skills, always search for the answer that is most likely to lead to the patient saying more. This will usually be the most open-ended, nonjudgmental question or statement on the part of the clinician. Similarly, if the question deals with an ethical situation, it makes sense to search for the choice that is most relevant or consistent with the ethical principle involved in the situation, such as patient confidentiality or patient autonomy.

Be wary of suspicion

A 52-year-old man with a 10-year history of hypertension complains of abdominal and back pain for the past 6 months, a 10-lb weight loss, and greasy, foul- smelling stools. He smokes 2 packs of cigarettes and drinks a pint of whiskey/ day. On physical examination, he is afebrile with mild epigastric tenderness but no guarding, rigidity, or distension. Bowel sounds are present, and rectal exam is normal. Laboratory tests reveal the following:

Sodium141 mEq/L
Potassium3.9 mEq/L
Glucose148 mg/dL
ALT, AST16, 24, respectively
Albumin4.7 g/dL
Prothrombin time11 Seconds

Chest x-ray is normal, and abdominal plain film shows pancreatic calcifications. Which of the following is most likely responsible for his weight loss?

A. Alcoholic hepatitis

B. Duodenal ulcer

C. Gastric ulcer

D. Pancreatic insufficiency

E. Thiamin deficiency

StrategyPeople who have struggled to do well on multiple-choice exams often carry around strong negative emotions about having to take these kinds of tests. Sometimes they feel that the items are expressly designed to trick them into choosing wrong answers. Such feelings in this case could easily lead the examinee toward avoiding answer D. The question stem lists “pancreatic calcifications”; therefore, a suspicious test taker might reason that the pancreatic calcifications clue was just to lure him or her into making a mistake. Wary test takers therefore choose another answer, the wrong one. Notice also how the wrong answers each agree with at least part of the patient’s findings. The patient drinks heavily, so choices A and E relate to this fact. The patient has abdominal symptoms, so choices B and C relate to those symptoms. In a well-written test, nearly every incorrect choice fits at least some part of the stem information, but only the correct answer fits all of the clues given in the stem.

Strategy Summary

• Rely more on general recall and concepts.

• Familiarity and life experience have validity.

• Consider what’s common versus what’s rare.

• Visualize what question stems describe.

• Use homeostasis as a guide to what the body would try to do to keep a healthy balance.

• Know important definitions.

• Rule out extreme or unrelated choices.

• Use decision rules to manage time use.

• In items with tables, seek patterns.

• In items with graphs, seek trends and anchor points.

• Always seek relationships.

• Use the whiteboard and marker to sketch or calculate.

• Use logical analysis based on concepts and information given in the question.

• Watch for hinge words in questions.

• Develop a mindset to reject choices.

• Look for the best fit with clues in the stem and with what you feel is the point of the question.