NCE PREP Challenge 2025

A 17-year-old adolescent is brought to the emergency department after several paroxysmal spells. During the episodes, she is unresponsive, staring straight ahead, and has loss of tone. Her eyes then close, and she has a gradual onset of shaking movements of the extremities that at times self-resolve and then resume again. The shaking is described as a back-and-forth semirhythmic fluctuating movement of the extremities, sometimes involving all 4 and sometimes only 1 of the extremities. When the extremity shaking resolves, she appears to be sleeping. 

These symptoms can wax and wane from several minutes up to several hours before resolving. Family members report that the adolescent seems confused after these episodes; she is generally not able to remember the episodes or the events preceding them. 

The adolescent is currently in 12th grade and attends nursing classes. She reports recently experiencing the death of a close friend. She is engaged in weekly cognitive behavioral therapy and grief counseling.

One month ago, the adolescent was evaluated in the emergency department for acute onset of bilateral vision loss, which self-resolved within 24 hours. Findings of magnetic resonance imaging of the brain and orbits (with and without intravenous contrast) were within normal limits.

In the emergency department today, the adolescent’s vital signs and physical examination findings are within normal limits. During the examination, she has an episode. She becomes still, closes her eyes, has some eye tearing, and begins to hyperventilate. She has thrashing movements of both arms and legs for about 10 min. She has an episode of urinary incontinence during the event. After the episode self-resolves, the girl appears confused and distressed.Of the following, this adolescent’s MOST likely diagnosis is a:

A 3-year-old child with chronic kidney disease secondary to posterior urethral valves is seen in the office for ear pain and fever of 2 days’ duration. He has no ear drainage, cough, or runny nose. His medications include sodium bicarbonate, iron sulfate, and calcitriol. The child’s physical examination shows bilateral erythematous, opacified, bulging tympanic membranes. The remainder of his physical examination findings are unremarkable. The result of a recent measurement of his estimated glomerular filtration rate is 26 mL/min/1.73 m2 (normal range, 90-120 mL/min/1.73 m2).

Of the following, the BEST recommendation regarding amoxicillin dosing for this child is to:

A 2-month-old boy is admitted to the hospital for evaluation of possible seizure activity. He has had recurrent, short episodes of jerking motions of the extremities for the past week. The boy was born at term and has otherwise been well, with no recent illness. There was a prenatal concern for a “bright spot” in his heart noted on a 20-week obstetric anatomy sonogram; no further evaluation was undertaken, and there were no other prenatal concerns. His growth and development have been appropriate. His vital signs are normal for age, and physical examination findings are only remarkable for a harsh, III/VI systolic ejection murmur along the left sternal border and 3 small hypopigmented macules on his trunk. 

Electroencephalographic monitoring demonstrates hypsarrhythmia. During the hospitalization, he has an episode of supraventricular tachycardia, which is terminated with a single dose of adenosine. 

Of the following, further evaluation of this infant is MOST likely to demonstrate:

A 10-year-old with a second relapse of high-risk B-cell acute lymphoblastic leukemia after a failed bone marrow transplant is admitted to the pediatric intensive care unit. He is receiving treatment for acute respiratory failure and presumed sepsis. The family asks about their child’s prognosis related to the cancer diagnosis. During a multidisciplinary meeting with the family, the oncology team indicates that there are no additional cancer chemotherapy options that would offer meaningful survival benefit to the child; any additional therapy would be palliative in nature. The parents present the team with printed information from a website advocating for the use of an experimental medical therapy. The treatment is not US Food and Drug Administration-approved. There are no data regarding outcomes or side effects in children. The parents inquire as to whether this therapy could be administered to their child. The consensus from the medical team is that the therapy should not be used, and they make the decision not to offer it. 

Of the following, the ethical principle that MOST justifies the medical team’s decision is:

A 2-month-old term infant is seen for a health maintenance visit. She has no significant family history. She has been growing and developing appropriately. The parents report that she appears to see and hear well.

Of the following, the MOST appropriate components of vision screening for this infant are: