Question Set B: Matrix, Drop-Down, and Bowtie
Three empty item shells drawn side by side as furniture: a matrix grid with radio cells, a cloze sentence with four drop-down chevrons, and a bowtie frame with five-box wings around a single center box.
Item 7 · MATRIX. A 61-year-old client is receiving prednisone, a corticosteroid, and enalapril, an angiotensin-converting enzyme inhibitor. Classify each finding. Scored per row.
| Finding | Expected | Unexpected | Requires immediate follow-up |
|---|---|---|---|
| a. Fasting blood glucose 148, up from 96 on admission | ☐ | ☐ | ☐ |
| b. New dry, nonproductive cough | ☐ | ☐ | ☐ |
| c. Increased appetite and difficulty sleeping | ☐ | ☐ | ☐ |
| d. White patches on the tongue and buccal mucosa | ☐ | ☐ | ☐ |
| e. Serum creatinine 1.5, up from 0.9 seven days ago | ☐ | ☐ | ☐ |
| f. Swelling of the lips and tongue with a muffled voice | ☐ | ☐ | ☐ |
| g. Potassium 6.1 with tall peaked T waves on the monitor | ☐ | ☐ | ☐ |
| h. Black, tarry stool | ☐ | ☐ | ☐ |
Item 8 · DROP-DOWN CLOZE. Complete the passage. Delafloxacin, a fluoroquinolone, kills bacteria by inhibiting [8a]. Because the class carries a boxed warning for [8b], the nurse teaches the client to [8c], and to separate each dose from [8d]. 8a 1. bacterial cell wall cross-linking · 2. bacterial DNA gyrase and topoisomerase IV · 3. the 30S ribosomal subunit · 4. bacterial folate synthesis 8b 1. tendinitis and tendon rupture · 2. lactic acidosis · 3. severe liver injury · 4. pulmonary fibrosis 8c 1. stop the drug and call the prescriber for new heel or shoulder pain · 2. massage the painful area and finish the course · 3. take an over-the-counter anti-inflammatory for the pain · 4. take two doses together after a missed dose 8d 1. high-protein meals · 2. antacids and iron or calcium supplements · 3. all fluids for 2 hours · 4. acidic fruit juices
Item 9 · BOWTIE. A 74-year-old client who takes warfarin for atrial fibrillation fell 2 days ago. The client now has a severe headache, new left-sided weakness, and a blood pressure of 176/94. The international normalized ratio is 5.8.
Center · the condition the client is most likely experiencing: intracranial bleeding in the setting of excessive anticoagulation.
Left wing · select 2 actions to take:
- Hold all anticoagulant doses and notify the prescriber immediately
- Administer phytonadione and prepare for four-factor prothrombin complex concentrate as ordered
- Ambulate the client in the hallway to evaluate the weakness
- Give the scheduled warfarin dose and document the headache
- Apply ice to the head and reassess in 4 hours
Right wing · select 2 parameters to monitor:
- Level of consciousness and pupil response
- Serial international normalized ratio and hemoglobin
- Daily weight
- Bowel sounds every shift
- Capillary blood glucose before meals
Item 7 — Answers: a Expected, b Expected, c Expected, d Unexpected, e Unexpected, f Immediate, g Immediate, h Immediate Why a is expected: corticosteroids raise blood glucose by design of their metabolic action. Why b is expected: bradykinin accumulation on an angiotensin-converting enzyme inhibitor produces a dry cough. Why c is expected: appetite increase and insomnia are common early corticosteroid effects. Why d is unexpected: oral candidiasis reflects immunosuppression and needs treatment, but is not an emergency. Why e is unexpected: a creatinine rise on the class must be reported and the drug reviewed, without emergency intervention. Why f requires immediate follow-up: angioedema on this class is airway compromise. Why g requires immediate follow-up: hyperkalemia with peaked T waves is a rhythm emergency. Why h requires immediate follow-up: melena signals gastrointestinal bleeding, and corticosteroids raise that risk. The rule: airway, rhythm, and bleeding outrank everything metabolic on the same page.
Item 8 — Answers: 8a-2, 8b-1, 8c-1, 8d-2 Why 8a option 2 is right: fluoroquinolones block DNA gyrase and topoisomerase IV. Option 1 is a cephalosporin or penicillin mechanism, option 3 a tetracycline or aminoglycoside mechanism, option 4 a sulfonamide mechanism. Why 8b option 1 is right: the current label carries tendinitis and tendon rupture. Option 2 belongs to metformin, option 3 to propylthiouracil, option 4 to amiodarone. Why 8c option 1 is right: the labeled instruction is to stop the drug and contact the prescriber at the first sign of tendon pain. Option 2 continues the injury, option 3 masks it, option 4 is unsafe dosing practice for any drug. Why 8d option 2 is right: fluoroquinolones chelate divalent and trivalent cations. Option 1 does not affect absorption meaningfully, option 3 is unnecessary and unsafe, option 4 is not a labeled interaction. The rule: distractors on a cloze are pulled from neighboring classes, so the class you wrote down first is the answer key.
Item 9 — Answers: left wing 1 and 2, right wing 1 and 2 Why left 1 is right: continuing an anticoagulant during active intracranial bleeding worsens the bleed. Why left 2 is right: phytonadione plus four-factor prothrombin complex concentrate is the warfarin reversal pathway for major bleeding. Why left 3 is wrong: ambulating a client with suspected intracranial bleeding risks injury and delays reversal. Why left 4 is wrong: it administers more of the causative agent. Why left 5 is wrong: ice and a 4-hour delay treat a bruise, not a bleed. Why right 1 is right: neurologic deterioration is the earliest sign the bleed is expanding. Why right 2 is right: they measure whether reversal worked and whether blood loss continues. Why right 3 is wrong: weight tracks fluid, not bleeding. Why right 4 is wrong: bowel sounds are not the monitoring priority here. Why right 5 is wrong: glucose is unrelated to this scenario. The rule: in a bowtie, the wings must match the center; every action and every parameter answers to the condition in the middle.
Scoring logic. The matrix scores per row, so a single wrong cell costs one row and not the item. The cloze scores per blank. The bowtie scores per selected box, so leaving a wing incomplete guarantees lost points.
Margin notepartial credit means never leave a row blank. Tick boxes: matrix · cloze · bowtie. Reading a next-generation case → BOOK 01 · P60.
TakeawayNext-generation items score by cell, so a derived answer in every cell beats a confident guess in one.