NZREX Clinical Examination — Questions and Answers

Question 1: A 25-year-old presents with acute severe asthma. SpO2 is 90%, PEFR is 30% predicted. Which of the following is most appropriate?

Discharge with inhaler and written action plan
Continuous nebulised salbutamol, IV magnesium sulphate, high-flow oxygen, senior review (Correct answer)
Oral antibiotics and bronchodilator
Oral prednisolone and reassess in 1 hour

Correct answer: Continuous nebulised salbutamol, IV magnesium sulphate, high-flow oxygen, senior review

A PEFR <33% predicted indicates life-threatening asthma requiring hospital admission. Management includes continuous nebulised salbutamol, IV corticosteroids, IV magnesium, high-flow oxygen, and immediate senior/ICU review.

Question 2: In NZ, what is a Coroner's case and when must a doctor report a death to the Coroner?

All deaths in hospital must be reported to the Coroner
Only deaths caused by criminal activity must be reported
Coroner reporting is voluntary in NZ
Deaths that are sudden, unexplained, unnatural, or where the doctor did not treat the person during their last illness must be reported to the Coroner (Correct answer)

Correct answer: Deaths that are sudden, unexplained, unnatural, or where the doctor did not treat the person during their last illness must be reported to the Coroner

Under the Coroners Act 2006, NZ doctors must report deaths that are: violent or unnatural, sudden and unexplained, where the cause of death is unknown, where the person was not attended by a medical practitioner in their last illness, or deaths in official custody.

Question 3: Which antibiotic is the first-line treatment for community-acquired pneumonia in a previously healthy adult managed in the community in New Zealand?

Ceftriaxone
Doxycycline
Amoxicillin (Correct answer)
Azithromycin

Correct answer: Amoxicillin

New Zealand guidelines recommend amoxicillin as first-line for community-acquired pneumonia (CAP) in previously healthy adults managed in the community, as Streptococcus pneumoniae remains the most common causative organism.

Question 4: Which radiological finding on a plain chest X-ray is characteristic of pulmonary oedema?

Bilateral perihilar ('bat wing') shadowing with upper lobe venous diversion (Correct answer)
Apical consolidation with hilar lymphadenopathy
Hyperinflation with flattened hemidiaphragms
Unilateral homogeneous opacification with tracheal deviation

Correct answer: Bilateral perihilar ('bat wing') shadowing with upper lobe venous diversion

Pulmonary oedema produces bilateral perihilar ('bat wing' or 'butterfly') shadowing, upper lobe blood diversion (cephalisation), Kerley B lines, and pleural effusions, reflecting elevated left atrial pressure.

Question 5: Which of the following best describes 'therapeutic privilege' and its standing in NZ?

The right to prescribe off-label medications without consent
Prescribing placebo without disclosure
A doctor's right to treat without consent in an emergency
Withholding information believed harmful to the patient — this is not accepted under the NZ Code, which requires full disclosure (Correct answer)

Correct answer: Withholding information believed harmful to the patient — this is not accepted under the NZ Code, which requires full disclosure

Therapeutic privilege (withholding information to prevent distress) is not accepted under the NZ Code of Rights. Right 5 guarantees patients the information they need to make decisions. Information should be delivered sensitively, not withheld paternalistically.

Question 6: When eliciting the history of presenting illness, what does the 'ICE' framework stand for?

Information, Communication, Examination
Ideas, Concerns, Expectations (Correct answer)
Investigation, Clinical findings, Evidence
Illness, Cause, Experience

Correct answer: Ideas, Concerns, Expectations

ICE stands for Ideas (what the patient thinks is wrong), Concerns (what worries them most), and Expectations (what they hope the consultation will achieve). It ensures patient-centred history-taking.

Question 7: In NZ, what is the initial management of a tension pneumothorax?

Chest X-ray first to confirm the diagnosis
Immediate needle decompression in the 2nd intercostal space, midclavicular line (or 4th/5th ICS, anterior axillary line), followed by chest drain insertion (Correct answer)
CT scan of the chest before any intervention
Oral antibiotics and observation

Correct answer: Immediate needle decompression in the 2nd intercostal space, midclavicular line (or 4th/5th ICS, anterior axillary line), followed by chest drain insertion

Tension pneumothorax is a clinical diagnosis requiring immediate treatment. Needle decompression should be performed urgently (2nd ICS, midclavicular line, or 4th/5th ICS, anterior axillary line) followed by definitive management with a chest drain (intercostal catheter).

Question 8: In the NZREX examination, what communication framework is recommended for breaking bad news?

Write the diagnosis on paper and hand it to the patient
Simply state the diagnosis directly without any preamble
The SPIKES framework: Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary (Correct answer)
Ask the nurse to deliver the bad news instead

Correct answer: The SPIKES framework: Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary

The SPIKES framework is widely used in NZ medical practice for breaking bad news: Set up the interview (privacy, sit down), assess the patient's Perception, obtain Invitation (how much they want to know), give Knowledge/information, address Emotions with empathy, and provide Strategy/summary.

Question 9: When taking a psychiatric history, which component specifically explores the patient's understanding of their illness?

Thought content
Affect
Cognitive assessment
Insight (Correct answer)

Correct answer: Insight

Insight in psychiatric assessment refers to the patient's awareness and understanding that they have a mental illness and that their experiences may be symptoms of that illness. It informs treatment planning and capacity assessment.

Question 10: A Māori patient is dying in hospital. The whānau requests that the patient not be left alone and that karakia (prayer/incantation) be performed. What is the most appropriate response?

Decline as it may upset other patients
Allow only one visitor at a time as per standard policy
Accommodate these requests as much as possible and involve the Māori health team or kaiāwhina (Correct answer)
Explain that hospital rules prevent this

Correct answer: Accommodate these requests as much as possible and involve the Māori health team or kaiāwhina

Cultural safety requires accommodating the spiritual and cultural practices of dying patients and their whānau. Karakia and the need for whānau presence are important tikanga practices around death (mate). Flexible visiting and spiritual support are expected in culturally safe hospitals.

Question 11: When documenting ethnicity in a NZ clinical consultation, which approach is recommended?

Ask the patient to self-identify their ethnicity using the Statistics NZ priority coding — do not assume (Correct answer)
Only document ethnicity for Māori and Pacific patients
Record ethnicity based on the clinician's observation of appearance
Leave the field blank if unsure

Correct answer: Ask the patient to self-identify their ethnicity using the Statistics NZ priority coding — do not assume

Self-identified ethnicity (using Statistics NZ categories) is the standard for NZ health data. Ethnicity should be asked directly and sensitively, not assumed by appearance. Accurate data is essential for monitoring health equity and allocating services.

Question 12: When explaining a diagnosis of cancer to a patient, which communication approach is recommended?

Use clear language, pause frequently, check understanding, allow silence, and invite questions (Correct answer)
Avoid telling the patient and inform family first
Deliver all information at once to be efficient
Use medical jargon to appear competent

Correct answer: Use clear language, pause frequently, check understanding, allow silence, and invite questions

Breaking serious news (SPIKES protocol) involves a structured approach: check what the patient knows, ask how much they want to know, give information in clear chunks, explore emotions, summarise, and plan. Patient-centred communication improves coping and trust.

Question 13: Which organisation is responsible for registering and regulating health practitioners in New Zealand?

Ministry of Health
The relevant Responsible Authority under the HPCA Act 2003 (e.g., Medical Council of NZ) (Correct answer)
Health and Disability Commissioner
Health New Zealand (Te Whatu Ora)

Correct answer: The relevant Responsible Authority under the HPCA Act 2003 (e.g., Medical Council of NZ)

The Health Practitioners Competence Assurance (HPCA) Act 2003 established Responsible Authorities (e.g., Medical Council of NZ, Nursing Council of NZ) to register practitioners, set competence standards, and manage fitness to practise.

Question 14: A patient is found unresponsive. After ensuring scene safety, what is the correct first step in BLS?

Start chest compressions immediately
Check for responsiveness by calling out and tapping the shoulders (Correct answer)
Open the airway with head-tilt chin-lift
Call for help first before approaching

Correct answer: Check for responsiveness by calling out and tapping the shoulders

The BLS sequence (per Resuscitation Council NZ) begins with: check scene safety → check responsiveness → call for help → open airway → check breathing → start CPR if no normal breathing. Responsiveness is checked before airway manoeuvres.

Question 15: Which of the following is the most appropriate first step when approaching a systemically unwell patient?

ABCDE assessment (Correct answer)
Full history and examination
Calling the senior doctor
Ordering blood tests

Correct answer: ABCDE assessment

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is the internationally recognised framework for assessing and managing the acutely unwell patient in a structured, prioritised manner.

Question 16: Which of the following is NOT a red flag for low back pain requiring urgent investigation?

Pain that improves with rest and worsens with activity (Correct answer)
Unexplained weight loss
Saddle anaesthesia with urinary retention
History of malignancy

Correct answer: Pain that improves with rest and worsens with activity

Mechanical low back pain typically improves with rest and worsens with activity — this is a benign pattern and does not represent a red flag. Red flags (cauda equina syndrome, cancer, infection, fracture) require urgent investigation.

Question 17: What does the acronym 'Te Aka Whai Ora' refer to in the NZ health system?

The national Māori mental health service
The Māori primary health organisation network
Māori Health Authority established by the Pae Ora Act 2022 (Correct answer)
The Māori language name for Health New Zealand

Correct answer: Māori Health Authority established by the Pae Ora Act 2022

Te Aka Whai Ora (the Māori Health Authority) was established by the Pae Ora Act 2022 as a co-equal agency alongside Health New Zealand (Te Whatu Ora), with a mandate to improve Māori health outcomes and commission Māori health services.

Question 18: When taking a sexual health history, which approach is most appropriate in the context of the NZREX consultation?

Defer to a specialist for sexual health questions
Only ask about sexual history if the patient raises it
Use open, non-judgmental language and normalise questions by explaining they are routine (Correct answer)
Assume heterosexuality unless the patient states otherwise

Correct answer: Use open, non-judgmental language and normalise questions by explaining they are routine

A non-judgmental, normalising approach (e.g., 'I ask all my patients these questions') is essential for sexual health history-taking, enabling accurate disclosure and appropriate testing, including STI screening.

Question 19: In a patient with suspected deep vein thrombosis (DVT), which clinical scoring system is used to estimate pre-test probability?

Wells score (Correct answer)
CHADS2 score
CURB-65 score
Glasgow Coma Scale

Correct answer: Wells score

The Wells DVT score estimates pre-test probability of DVT based on clinical features such as calf swelling, tenderness, immobilisation, and active cancer, guiding the decision to request D-dimer or duplex ultrasound.

Question 20: In the NZREX, when examining a patient with suspected peripheral vascular disease, what clinical test assesses arterial insufficiency in the lower limbs?

Buerger's test — elevate the leg to 45 degrees and observe for pallor, then hang the leg over the bed and observe for reactive hyperaemia (Correct answer)
McMurray's test
Trendelenburg test only
Straight leg raise test

Correct answer: Buerger's test — elevate the leg to 45 degrees and observe for pallor, then hang the leg over the bed and observe for reactive hyperaemia

Buerger's test assesses arterial insufficiency: the leg is elevated to 45 degrees (pallor indicates poor arterial supply), then hung over the bed edge (delayed reactive hyperaemia — a dusky red colour — confirms arterial insufficiency).

Question 21: When performing a focused musculoskeletal examination of the knee, which test specifically assesses the anterior cruciate ligament?

Valgus stress test
McMurray test
Lachman test (Correct answer)
Patellar tap

Correct answer: Lachman test

The Lachman test assesses anterior cruciate ligament (ACL) integrity by applying an anterior force to the tibia with the knee at 20–30° flexion. It is more sensitive than the anterior drawer test.

Question 22: A 16-year-old presents alone requesting contraception. She appears to understand the information provided. What is the legal position regarding consent in New Zealand?

She must have a social worker present
She requires parental consent for any medical treatment
A 16-year-old can consent to medical treatment independently under the Care of Children Act 2004 (Correct answer)
She can only receive emergency treatment without parental consent

Correct answer: A 16-year-old can consent to medical treatment independently under the Care of Children Act 2004

Under the Care of Children Act 2004, a person aged 16 or over can consent to medical, surgical, or dental procedures as if they were an adult. Under 16, the Gillick/Fraser competence principles apply — the child may consent if they understand the information.

Question 23: Which of the following best describes 'institutional racism' in the NZ health system?

Māori patients choosing not to engage with the health system
Funding shortfalls unrelated to ethnicity
Policies and practices within health organisations that produce inequitable outcomes for Māori without necessarily involving individual racist intent (Correct answer)
Individual prejudiced attitudes of specific health workers

Correct answer: Policies and practices within health organisations that produce inequitable outcomes for Māori without necessarily involving individual racist intent

Institutional racism refers to systemic policies, practices, and norms within organisations that result in worse outcomes for racialised groups — often without individual prejudice. In NZ health, this manifests as inequitable access, quality, and outcomes for Māori.

Question 24: What is the NZ approach to managing a child with suspected non-accidental injury (NAI)?

Report to police but not to child protection services
Confront the parents immediately about the suspected abuse
Document findings carefully, obtain a thorough history, perform a skeletal survey and relevant investigations, report to Oranga Tamariki (child protection), and ensure the child's safety (Correct answer)
Discharge the child with a follow-up appointment only

Correct answer: Document findings carefully, obtain a thorough history, perform a skeletal survey and relevant investigations, report to Oranga Tamariki (child protection), and ensure the child's safety

NZ management of suspected NAI includes: careful documentation of injuries (photographs, body map), thorough history from all caregivers, appropriate investigations (skeletal survey, bloods, ophthalmology review), mandatory report to Oranga Tamariki (Ministry for Children), and ensuring the child's immediate safety.

Question 25: A NZ patient presents with symptoms of hypothyroidism. What investigations should be ordered?

No investigation needed — diagnose based on clinical symptoms alone
Free T3 and free T4 only — TSH is not useful
TSH (thyroid-stimulating hormone) as the initial screening test, followed by free T4 if TSH is abnormal (Correct answer)
Thyroid ultrasound as the first investigation

Correct answer: TSH (thyroid-stimulating hormone) as the initial screening test, followed by free T4 if TSH is abnormal

In NZ, TSH is the most sensitive initial screening test for thyroid dysfunction. An elevated TSH suggests hypothyroidism, which should be followed up with a free T4 level. Thyroid antibodies (anti-TPO) may be checked to determine the cause (e.g., Hashimoto's thyroiditis).

Question 26: When prescribing a long-term NSAID for an elderly patient with osteoarthritis in New Zealand, which co-prescription is most strongly recommended to reduce gastrointestinal risk?

A statin
A proton pump inhibitor (PPI) (Correct answer)
A beta-blocker
An antihistamine

Correct answer: A proton pump inhibitor (PPI)

Proton pump inhibitors (PPIs) are co-prescribed with NSAIDs in high-risk patients (elderly, history of peptic ulcer) to protect the gastric mucosa from NSAID-induced injury.

Question 27: In NZ, what is the recommended first-line treatment for Helicobacter pylori eradication?

No treatment — H. pylori is harmless
Triple therapy: proton pump inhibitor, amoxicillin, and clarithromycin for 14 days (Correct answer)
Proton pump inhibitor alone for 8 weeks
A single dose of metronidazole

Correct answer: Triple therapy: proton pump inhibitor, amoxicillin, and clarithromycin for 14 days

NZ guidelines recommend triple therapy for H. pylori eradication: a proton pump inhibitor (e.g., omeprazole), amoxicillin, and clarithromycin for 14 days. If penicillin-allergic, metronidazole replaces amoxicillin. Eradication should be confirmed by re-testing.

Question 28: In the context of Māori health, what does 'taha wairua' refer to and why is it clinically relevant?

Family health — relevant to social history only
Physical health — relevant to medication management
Spiritual health — relevant because spiritual wellbeing affects overall health and may influence treatment decisions and recovery (Correct answer)
Mental health — relevant to psychiatric assessment only

Correct answer: Spiritual health — relevant because spiritual wellbeing affects overall health and may influence treatment decisions and recovery

Taha wairua (spiritual health) is one of the four walls of Te Whare Tapa Whā. For many Māori patients, spiritual wellbeing is integral to overall health. Ignoring this dimension results in incomplete, culturally unsafe care.

Question 29: Which of the following is the most appropriate management for a patient with iron deficiency anaemia confirmed on blood tests?

Start IV iron without investigating the cause
Identify and treat the underlying cause while starting oral iron supplementation (Correct answer)
Blood transfusion as first-line
Erythropoietin injections

Correct answer: Identify and treat the underlying cause while starting oral iron supplementation

The underlying cause of iron deficiency (e.g., GI blood loss, poor intake, malabsorption) must be identified and treated. Oral iron supplementation repletes stores. Blood transfusion is reserved for symptomatic severe anaemia.

Question 30: What does the term 'tikanga Māori' mean in the context of healthcare?

A Māori health assessment tool
The Māori language term for a clinical guideline
Māori customary values and practices that guide appropriate and respectful behaviour (Correct answer)
A specific Māori health programme

Correct answer: Māori customary values and practices that guide appropriate and respectful behaviour

Tikanga Māori refers to the customary values, protocols, and practices of Māori society. In healthcare, understanding tikanga guides culturally safe interactions, for example around death and dying, tapu/noa, and whānau involvement.

Question 31: A patient with type 2 diabetes presents with a 3-month history of tingling and numbness in both feet in a 'glove and stocking' distribution. Which type of neuropathy does this suggest?

Radiculopathy
Mononeuritis multiplex
Distal symmetrical sensory polyneuropathy (Correct answer)
Autonomic neuropathy

Correct answer: Distal symmetrical sensory polyneuropathy

Distal symmetrical sensory polyneuropathy is the most common form of diabetic neuropathy, presenting with 'glove and stocking' distribution of sensory symptoms due to length-dependent axonal damage.

Question 32: Which of the following is the most appropriate empirical antibiotic regimen for bacterial meningitis in an adult in New Zealand?

IM benzylpenicillin as the only agent
Oral amoxicillin alone
IV vancomycin monotherapy
IV ceftriaxone 2 g 12-hourly plus IV dexamethasone (Correct answer)

Correct answer: IV ceftriaxone 2 g 12-hourly plus IV dexamethasone

Empirical treatment for bacterial meningitis includes a third-generation cephalosporin (ceftriaxone) for broad coverage, plus IV dexamethasone to reduce inflammation and improve neurological outcomes. Do not delay antibiotics for imaging.

Question 33: When using an interpreter for a patient who does not speak English, which approach is most appropriate?

Use a trained professional interpreter, ideally not a family member (Correct answer)
Use a family member as it is more convenient and culturally appropriate
Speak directly to the interpreter, not the patient
Use online translation tools for clinical consultations

Correct answer: Use a trained professional interpreter, ideally not a family member

Professional interpreters ensure accuracy, confidentiality, and neutrality. Family members (especially children) should not interpret as they may filter information, lack medical vocabulary, and compromise confidentiality or create conflict of interest.

Question 34: What is the NZ approach to prescribing for Māori and Pacific patients that NZREX candidates should understand?

Prescribe standard treatments without cultural consideration
Consider cultural factors affecting medication adherence, involve whānau/family in education, and ensure prescribing information is culturally and linguistically appropriate (Correct answer)
Only prescribe traditional medicines to Māori patients
Cultural factors are irrelevant to prescribing decisions

Correct answer: Consider cultural factors affecting medication adherence, involve whānau/family in education, and ensure prescribing information is culturally and linguistically appropriate

NZ prescribers should consider cultural factors that may affect medication understanding, acceptance, and adherence. This includes involving whānau/family in medication education, ensuring information is linguistically appropriate, and respecting cultural health beliefs alongside evidence-based medicine.

Question 35: A patient with schizophrenia refuses antipsychotic medication during a voluntary admission. What is the most appropriate initial response?

Immediately apply the Mental Health Act for compulsory treatment
Explore the reasons for refusal, address concerns, and attempt to negotiate — do not impose medication without legal authority (Correct answer)
Discharge the patient from hospital
Administer medication covertly in food

Correct answer: Explore the reasons for refusal, address concerns, and attempt to negotiate — do not impose medication without legal authority

A voluntary patient retains the right to refuse treatment. The clinician should explore reasons for refusal (e.g., side effects, insight, fears), attempt therapeutic negotiation, and only consider the Mental Health Act if the patient meets criteria for compulsory assessment.

Question 36: Which prescribing resource is specifically developed for New Zealand healthcare professionals and provides evidence-based, NZ-contextualised prescribing guidance free of charge?

British National Formulary (BNF)
Australian Medicines Handbook (AMH)
New Zealand Formulary (NZF) (Correct answer)
MIMS New Zealand

Correct answer: New Zealand Formulary (NZF)

The New Zealand Formulary (NZF) is the primary NZ-specific prescribing reference, providing evidence-based guidance tailored to NZ medicines, PHARMAC funding, and regulatory context.

Question 37: What is the NZ screening test for gestational diabetes mellitus (GDM)?

No screening is performed for GDM in NZ
Random blood glucose test at the first antenatal visit only
A polycose (glucose challenge) screening test at 24-28 weeks gestation, followed by a 75g oral glucose tolerance test (OGTT) if positive (Correct answer)
HbA1c at 36 weeks gestation

Correct answer: A polycose (glucose challenge) screening test at 24-28 weeks gestation, followed by a 75g oral glucose tolerance test (OGTT) if positive

In NZ, gestational diabetes screening involves a polycose (50g glucose challenge test) at 24-28 weeks gestation. If the result is elevated (≥7.8 mmol/L at 1 hour), a confirmatory 75g OGTT is performed. Women with risk factors may be screened earlier.

Question 38: A 22-year-old woman presents with dysuria and vaginal discharge. High vaginal swab grows Neisseria gonorrhoeae. Which treatment regimen is most appropriate per New Zealand guidelines?

IM ceftriaxone 500 mg stat plus azithromycin 1 g orally stat (Correct answer)
IM penicillin G alone
Oral doxycycline 100 mg twice daily for 7 days
Oral ciprofloxacin 500 mg stat

Correct answer: IM ceftriaxone 500 mg stat plus azithromycin 1 g orally stat

New Zealand guidelines recommend dual therapy for gonorrhoea: IM ceftriaxone (to address increasing fluoroquinolone resistance) plus azithromycin (to provide additional coverage and reduce resistance development). Contact tracing is mandatory.

Question 39: What is the appropriate management when a competent patient refuses a recommended treatment?

Override the refusal if you believe the treatment is in the patient's best interest
Discontinue care entirely
Seek a guardianship order
Document the discussion and refusal thoroughly, ensure the patient understands the consequences, and respect the decision (Correct answer)

Correct answer: Document the discussion and refusal thoroughly, ensure the patient understands the consequences, and respect the decision

A competent patient's refusal of treatment is legally and ethically binding in NZ. The doctor's obligations are: ensure decision-making capacity, provide clear information about consequences, document thoroughly, and continue providing care within the patient's wishes.

Question 40: What does the concept of 'whanaungatanga' mean and how is it relevant to clinical care?

The concept of spiritual wellbeing in Māori health
A Māori health assessment tool
A traditional Māori healing ceremony
Relationships and kinship — relevant because Māori patients often prefer whānau involvement in health decisions (Correct answer)

Correct answer: Relationships and kinship — relevant because Māori patients often prefer whānau involvement in health decisions

Whanaungatanga refers to relationships, kinship, and a sense of connection. In clinical care, it means recognising the central role of whānau in Māori patients' wellbeing and decision-making, and actively facilitating whānau involvement.

Question 41: A doctor is asked by a pharmaceutical company to speak at a conference and will receive a payment. What is the most ethical approach?

Accept without disclosure as it is a common practice
Ask a junior colleague to present instead
Disclose the conflict of interest to the audience and ensure the content is evidence-based and independent (Correct answer)
Decline all such invitations automatically

Correct answer: Disclose the conflict of interest to the audience and ensure the content is evidence-based and independent

Conflicts of interest (COI) in medicine must be disclosed transparently. Receiving payment from industry creates a potential COI that can bias clinical recommendations. Disclosure does not eliminate bias but allows the audience to judge the information critically.

Question 42: Which article of Te Tiriti o Waitangi affirms Māori rangatiratanga (chieftainship) over their lands, villages, and taonga?

Article 3 (Ōritetanga)
Article 1 (Kāwanatanga)
Article 4 (Wairua)
Article 2 (Tino Rangatiratanga) (Correct answer)

Correct answer: Article 2 (Tino Rangatiratanga)

Article 2 of Te Tiriti guarantees Māori tino rangatiratanga — full chiefly authority — over their lands, estates, forests, fisheries, and other taonga (treasures). In health, this underpins Māori self-determination in health decision-making.

Question 43: Which finding on auscultation is most consistent with a pleural effusion?

Bronchial breathing with coarse crackles
Wheeze with prolonged expiration
Stony dull percussion with reduced breath sounds (Correct answer)
Hyper-resonance with absent breath sounds

Correct answer: Stony dull percussion with reduced breath sounds

A pleural effusion produces stony dull percussion note and reduced or absent breath sounds over the effusion due to fluid accumulation in the pleural space.

Question 44: A 55-year-old smoker presents with haemoptysis, weight loss, and a new right hilar mass on chest X-ray. What is the most important next investigation?

Sputum cytology only
Bronchoscopy alone
CT chest with contrast (Correct answer)
V/Q scan

Correct answer: CT chest with contrast

CT chest with contrast is the most appropriate next investigation to characterise the hilar mass, assess extent of disease, identify mediastinal involvement, and guide bronchoscopy or biopsy for tissue diagnosis.

Question 45: Which clinical sign is elicited by asking the patient to hold their arms outstretched with wrists dorsiflexed, and is associated with hepatic encephalopathy?

Intention tremor
Myoclonus
Asterixis (flapping tremor) (Correct answer)
Cogwheel rigidity

Correct answer: Asterixis (flapping tremor)

Asterixis (flapping tremor or liver flap) is elicited with arms outstretched and wrists extended. It represents inability to maintain posture due to brief lapses in muscle contraction, classically seen in hepatic encephalopathy.

Question 46: In the NZREX, how should a candidate handle a situation where they do not know the answer to a clinical question?

Change the subject to something they know more about
Guess an answer to appear confident
Honestly acknowledge the limits of their knowledge, state what they do know, and explain how they would seek the information (guidelines, senior colleague, specialist referral) (Correct answer)
Remain silent until the examiner moves on

Correct answer: Honestly acknowledge the limits of their knowledge, state what they do know, and explain how they would seek the information (guidelines, senior colleague, specialist referral)

The NZREX values honesty and safety. Candidates should acknowledge when they don't know something, demonstrate what they do know, and show they would seek appropriate help — this reflects safe clinical practice in NZ.

Question 47: A patient presents with a tremor. Which feature best distinguishes an essential tremor from a Parkinsonian tremor?

Essential tremor is faster in frequency than Parkinsonian tremor
Essential tremor affects the legs; Parkinsonian tremor affects the hands only
Essential tremor occurs with action; Parkinsonian tremor is a resting tremor (Correct answer)
Essential tremor is unilateral; Parkinsonian tremor is bilateral

Correct answer: Essential tremor occurs with action; Parkinsonian tremor is a resting tremor

Essential tremor is an action/postural tremor that worsens with movement, whereas Parkinsonian tremor is a resting tremor (pill-rolling) that improves with voluntary movement.

Question 48: A patient presents with ptosis, miosis, and anhidrosis on the right side of the face. Which syndrome does this describe?

Argyll Robertson syndrome
Marcus Gunn phenomenon
Holmes-Adie syndrome
Horner syndrome (Correct answer)

Correct answer: Horner syndrome

Horner syndrome results from disruption of the sympathetic pathway and presents with ipsilateral ptosis, miosis (pupil constriction), and anhidrosis (loss of sweating) on the affected side.

Question 49: A 45-year-old man has a fasting blood glucose of 7.2 mmol/L and HbA1c of 52 mmol/mol (6.9%). What is the most appropriate initial management?

Start metformin immediately
Repeat HbA1c in 3 years with no intervention
Lifestyle modification (diet, exercise, weight loss) (Correct answer)
Start insulin

Correct answer: Lifestyle modification (diet, exercise, weight loss)

An HbA1c of 48–53 mmol/mol (6.5–7.0%) meets diagnostic criteria for type 2 diabetes. For newly diagnosed T2DM with these levels, lifestyle modification is the recommended first-line intervention before adding pharmacotherapy.

Question 50: A 45-year-old presents with gradual onset dyspnoea and bilateral pitting oedema to the knees. Which examination finding would most support a diagnosis of congestive heart failure?

Barrel chest with pursed-lip breathing
Tracheal deviation to the right
Elevated JVP with S3 gallop (Correct answer)
Dullness at the right base only

Correct answer: Elevated JVP with S3 gallop

Elevated JVP and S3 gallop are classic signs of congestive heart failure, reflecting increased venous pressure and a dilated, poorly compliant ventricle.

Question 51: Who developed the concept of cultural safety (kawa whakaruruhau) in New Zealand nursing?

Mason Durie
Irihapeti Ramsden (Correct answer)
Rangi Matamua
Sir Tipene O'Regan

Correct answer: Irihapeti Ramsden

Irihapeti Ramsden (Māori nurse and academic) developed the concept of kawa whakaruruhau (cultural safety) in the 1980s–90s in NZ, emphasising that safety is defined by the patient, not the provider, and that power imbalances in healthcare must be examined.

Question 52: A patient in a NZ ED presents with diabetic ketoacidosis (DKA). What are the key management priorities?

Subcutaneous insulin bolus only
IV fluid resuscitation, IV insulin infusion, potassium replacement, and monitoring of blood glucose, ketones, and electrolytes (Correct answer)
Dietary modification and discharge home
Oral hypoglycaemics and a sugary drink

Correct answer: IV fluid resuscitation, IV insulin infusion, potassium replacement, and monitoring of blood glucose, ketones, and electrolytes

DKA management in NZ involves aggressive IV fluid resuscitation (0.9% saline initially), IV insulin infusion (fixed rate), careful potassium replacement (as insulin drives K+ intracellularly), and regular monitoring of blood glucose, ketones, electrolytes, and acid-base status.

Question 53: Under the NZ Crimes Act, which of the following could constitute criminal conduct by a doctor?

Providing a second opinion at the patient's request
Reporting a mandatory notifiable disease without patient consent
Performing a procedure on a patient without consent (assault) or negligently causing serious harm (Correct answer)
Sharing records within the treating team on a need-to-know basis

Correct answer: Performing a procedure on a patient without consent (assault) or negligently causing serious harm

Operating on a patient without valid consent may constitute assault under the Crimes Act 1961. Gross negligence causing death or serious harm may constitute a criminal offence. Professional and civil accountability also applies through the HDC and Medical Council.

Question 54: Under the Pae Ora Act 2022, what is the primary function of Health New Zealand (Te Whatu Ora)?

Regulate health practitioners and set clinical standards
Fund and commission Māori health services exclusively
Manage ACC claims and injury rehabilitation
Commission and deliver health services nationally, replacing the 20 DHBs (Correct answer)

Correct answer: Commission and deliver health services nationally, replacing the 20 DHBs

Health New Zealand (Te Whatu Ora) was established to plan, fund, and deliver health services nationally, replacing the 20 District Health Boards. It operates through regional and locality planning structures.

Question 55: Which of the following health disparities is most accurately documented for Māori compared to non-Māori in New Zealand?

Māori have higher vaccination rates than non-Māori
Māori have better mental health outcomes but worse cardiovascular outcomes only
Māori have significantly lower life expectancy, higher rates of chronic disease, and poorer access to primary care (Correct answer)
Health outcomes for Māori are now equivalent to non-Māori

Correct answer: Māori have significantly lower life expectancy, higher rates of chronic disease, and poorer access to primary care

Persistent and significant health inequities exist for Māori across most indicators: lower life expectancy (~7 years), higher rates of diabetes, CVD, respiratory disease, cancer, and mental illness, and reduced access to timely primary care.

Question 56: When assessing a patient's gait, which pattern is characterised by the foot being lifted high and slapping down due to foot drop?

Antalgic gait
Trendelenburg gait
Steppage gait (Correct answer)
Scissor gait

Correct answer: Steppage gait

Steppage gait results from foot drop (weakness of ankle dorsiflexion), causing the patient to lift the knee excessively to clear the foot, which then slaps down. It indicates a common peroneal nerve or L4/L5 lesion.

Question 57: On fundoscopy, which finding is most characteristic of hypertensive retinopathy grade III?

Papilloedema with no haemorrhages
Arteriovenous nipping only
Silver wiring with no other changes
Flame haemorrhages and cotton wool spots (Correct answer)

Correct answer: Flame haemorrhages and cotton wool spots

Grade III hypertensive retinopathy includes flame-shaped haemorrhages and cotton wool spots (soft exudates), reflecting retinal ischaemia. Grade IV adds papilloedema.

Question 58: A patient has asymmetric reflexes with brisk reflexes on the right and absent reflexes on the left arm. Which type of lesion would cause absent reflexes?

Upper motor neurone lesion
Lower motor neurone lesion (Correct answer)
Basal ganglia lesion
Cerebellar lesion

Correct answer: Lower motor neurone lesion

Absent or reduced reflexes indicate a lower motor neurone lesion affecting the reflex arc (anterior horn cell, nerve root, peripheral nerve, neuromuscular junction, or muscle). UMN lesions cause brisk/exaggerated reflexes.

Question 59: In NZ, what is open disclosure and when should it be used?

A technique for opening difficult conversations about billing
A method for disclosing financial information about the hospital
An honest, transparent discussion with patients and whānau when an adverse event or error has occurred during their care (Correct answer)
Publishing all patient records online for transparency

Correct answer: An honest, transparent discussion with patients and whānau when an adverse event or error has occurred during their care

Open disclosure is the NZ standard requiring honest, transparent communication with patients and their whānau/family when an adverse event, near miss, or error occurs during care. It includes an apology, explanation of what happened, and steps to prevent recurrence.

Question 60: Which of the following most accurately describes the management of stable angina?

IV thrombolysis
Short-acting nitrate PRN, regular antiplatelet, statin, and beta-blocker or calcium channel blocker (Correct answer)
Immediate PCI
Anticoagulation with warfarin

Correct answer: Short-acting nitrate PRN, regular antiplatelet, statin, and beta-blocker or calcium channel blocker

Stable angina is managed with sublingual GTN for acute episodes, aspirin, a statin, and an anti-anginal agent (beta-blocker first-line, or calcium channel blocker). Revascularisation is considered if symptoms are not controlled.

Question 61: A patient with type 2 diabetes has a new eGFR of 25 mL/min/1.73m². What change should be made to their metformin therapy?

Cease metformin as it is contraindicated at this eGFR (Correct answer)
Reduce the metformin dose by 50% and monitor closely
Continue metformin at the same dose with routine monitoring
Switch to intravenous metformin for reliability

Correct answer: Cease metformin as it is contraindicated at this eGFR

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to impaired renal excretion leading to drug accumulation and the risk of potentially fatal lactic acidosis.

Question 62: In NZ, what is the appropriate response when a patient's family requests that you do not tell the patient their diagnosis?

Ask the hospital administrator to decide
Explore the family's concerns, but explain that the patient has the right to be informed under the Code of Rights, and work to find a culturally appropriate way to share the information (Correct answer)
Tell the patient immediately without speaking to the family
Agree to the family's request and withhold the diagnosis from the patient

Correct answer: Explore the family's concerns, but explain that the patient has the right to be informed under the Code of Rights, and work to find a culturally appropriate way to share the information

Under Right 6 of the NZ Code of Rights, patients have the right to be fully informed. While the family's concerns should be explored with sensitivity and cultural awareness, the patient's right to information generally takes precedence. A culturally appropriate approach should be negotiated.

Question 63: Which of the following is the recommended first-line antihypertensive for a 50-year-old Māori man with hypertension and no other comorbidities?

ACE inhibitor or angiotensin receptor blocker (Correct answer)
Beta-blocker
Aldosterone antagonist
Thiazide diuretic alone

Correct answer: ACE inhibitor or angiotensin receptor blocker

ACE inhibitors or ARBs are recommended as first-line antihypertensives for adults under 55 (or those with diabetes, CKD, or heart failure). They also provide renal protection. In Māori patients, cardiovascular risk is assessed using the NZ CVD risk calculator.

Question 64: Which of the following is the correct technique for assessing capillary refill time?

Assess colour return after occlusion of the radial artery for 10 seconds
Apply pressure to the sternum for 5 seconds and assess return of colour
Apply pressure to a fingernail for 5 seconds, release, and count seconds until colour returns; normal is under 2 seconds (Correct answer)
Measure time for venous filling after leg elevation

Correct answer: Apply pressure to a fingernail for 5 seconds, release, and count seconds until colour returns; normal is under 2 seconds

Capillary refill time (CRT) is measured by applying firm pressure to a fingernail for 5 seconds at heart level, then counting seconds until normal colour returns. Normal CRT is less than 2 seconds; prolonged CRT suggests poor perfusion.

Question 65: In NZ, what is the correct approach when a patient asks you to provide a medical certificate for time off work?

Always provide a certificate if the patient asks, regardless of clinical assessment
Only provide certificates for conditions lasting more than one week
Assess the patient clinically, document your findings, and provide a certificate that is honest and accurate — you must believe the patient has a genuine medical reason (Correct answer)
Refuse all medical certificate requests as they are not a medical responsibility

Correct answer: Assess the patient clinically, document your findings, and provide a certificate that is honest and accurate — you must believe the patient has a genuine medical reason

NZ doctors should clinically assess the patient, document their findings, and issue a medical certificate only if they genuinely believe the patient has a medical condition justifying time off work. The certificate should be honest, accurate, and describe the functional impact.

Question 66: Which of the following is the most appropriate technique for auscultating the mitral valve?

Bell at the left lower sternal border with breath held in expiration
Diaphragm at the right upper sternal border with the patient sitting forward
Bell of the stethoscope at the apex with the patient in the left lateral decubitus position (Correct answer)
Diaphragm at the apex with the patient supine

Correct answer: Bell of the stethoscope at the apex with the patient in the left lateral decubitus position

The mitral area is the apex of the heart. The bell (low-frequency sounds) in the left lateral position brings the apex closer to the chest wall, enhancing detection of the low-pitched mitral stenosis murmur.

Question 67: A patient reports productive cough, fever, and right-sided pleuritic chest pain. On examination there is dullness to percussion and bronchial breathing at the right base. What is the most likely diagnosis?

Pulmonary embolism
Right lower lobe pneumonia (Correct answer)
Right-sided pleural effusion
Spontaneous pneumothorax

Correct answer: Right lower lobe pneumonia

Dullness to percussion with bronchial breathing indicates consolidation, consistent with lobar pneumonia. A pleural effusion would cause absent (not bronchial) breath sounds and stony dullness.

Question 68: What is the primary care model through which most New Zealanders access general practice services?

Hospital-based outpatient GP clinics
Community Health Centres as the sole provider
Primary Health Organisation (PHO) model with enrolled patients (Correct answer)
Fee-for-service without enrolment

Correct answer: Primary Health Organisation (PHO) model with enrolled patients

NZ's primary care is delivered through PHOs, which are networks of GP practices. Patients enrol with a practice/PHO to access subsidised services. Capitation funding is provided based on enrolled patient numbers and demographics.

Question 69: What is the Health and Disability Commissioner's role in NZ and why is it important for NZREX candidates to understand?

An administrator who manages hospital waiting lists
An independent officer who investigates complaints about health services and holds providers accountable under the Code of Rights (Correct answer)
A politician who funds health services
A medical researcher who publishes clinical guidelines

Correct answer: An independent officer who investigates complaints about health services and holds providers accountable under the Code of Rights

The Health and Disability Commissioner investigates complaints about health providers under the Code of Health and Disability Services Consumers' Rights. NZREX candidates must understand the Code because it defines patient rights that doctors must uphold in NZ practice.

Question 70: In NZ, what is the recommended approach to managing a patient with suspected acute appendicitis?

Ultrasound only — CT is never used for appendicitis in NZ
Clinical assessment (including McBurney's point tenderness, Rovsing's sign), blood tests (WCC, CRP), CT scan if diagnosis uncertain, and surgical referral for appendicectomy (Correct answer)
Prescribe antibiotics and review in one week
Immediate surgery without any investigations

Correct answer: Clinical assessment (including McBurney's point tenderness, Rovsing's sign), blood tests (WCC, CRP), CT scan if diagnosis uncertain, and surgical referral for appendicectomy

In NZ, suspected appendicitis involves clinical assessment (McBurney's point tenderness, rebound tenderness, Rovsing's sign), blood tests (raised WCC and CRP support diagnosis), CT abdomen/pelvis if diagnosis is uncertain, and referral for surgical management (appendicectomy).

Question 71: A patient with rheumatoid arthritis is commenced on weekly oral methotrexate. Which supplement must be co-prescribed to reduce the risk of mucositis and haematological side effects?

Folic acid (Correct answer)
Vitamin B12
Vitamin D
Iron

Correct answer: Folic acid

Folic acid supplementation is co-prescribed with methotrexate because methotrexate inhibits dihydrofolate reductase; folic acid reduces mucositis, bone marrow suppression, and hepatotoxicity without significantly impairing efficacy.

Question 72: Under the New Zealand Medicines Act 1981, which of the following is correctly classified as a Prescription Medicine requiring a valid prescription?

Ibuprofen 200mg tablets (pharmacy-only)
Paracetamol 500mg tablets (available over-the-counter)
Chlorphenamine antihistamine syrup (pharmacy-only)
Metoprolol 50mg tablets (Correct answer)

Correct answer: Metoprolol 50mg tablets

Metoprolol is a prescription-only medicine in New Zealand, classified as a Schedule 1 prescription medicine under the Medicines Act 1981, requiring authorisation from a registered prescriber.

Question 73: In NZ emergency medicine, what is the ABCDE approach to assessing a critically unwell patient?

Awareness, Balance, Coordination, Dexterity, Endurance
Antibiotics, Blood tests, CT scan, Diagnosis, Examination
Assess, Bandage, Compress, Defibrillate, Evacuate
Airway, Breathing, Circulation, Disability (neurological), Exposure — a systematic priority-based assessment (Correct answer)

Correct answer: Airway, Breathing, Circulation, Disability (neurological), Exposure — a systematic priority-based assessment

The ABCDE approach used in NZ emergency medicine is: Airway (with cervical spine protection if trauma), Breathing (rate, oxygen saturation, chest examination), Circulation (pulse, blood pressure, perfusion), Disability (GCS, pupils, blood glucose), and Exposure (full examination, temperature).

Question 74: What is the ISBAR communication tool used in NZ healthcare, and when is it used?

Introduction, Situation, Background, Assessment, Recommendation — used for clinical handover, escalation, and referral between healthcare professionals (Correct answer)
A patient satisfaction survey tool
A medication dosage calculator
A hospital billing system

Correct answer: Introduction, Situation, Background, Assessment, Recommendation — used for clinical handover, escalation, and referral between healthcare professionals

ISBAR is the standard structured communication framework used across NZ healthcare for clinical handover, escalation of deteriorating patients, and referrals. It ensures critical clinical information is communicated clearly and completely.

Question 75: Which examination finding is most specific for meningism?

Babinski's sign
Romberg's sign
Kernig's sign (Correct answer)
Lhermitte's sign

Correct answer: Kernig's sign

Kernig's sign (inability to extend the knee when the hip is flexed to 90°) is a specific sign of meningeal irritation, seen in meningitis and subarachnoid haemorrhage.

Question 76: In NZ resuscitation guidelines, what is the recommended compression-to-ventilation ratio for adult CPR?

Continuous compressions with no ventilations
30 compressions to 2 ventilations (Correct answer)
5 compressions to 1 ventilation
15 compressions to 2 ventilations

Correct answer: 30 compressions to 2 ventilations

NZ follows the ANZCOR (Australian and New Zealand Committee on Resuscitation) guidelines recommending 30 chest compressions to 2 ventilations for adult CPR. Compressions should be at a rate of 100-120 per minute with a depth of approximately 5 cm.

Question 77: Which auscultatory finding is characteristic of aortic stenosis?

Mid-diastolic murmur loudest at the apex with the patient in the left lateral position
Early diastolic murmur at the left lower sternal border
Ejection systolic murmur loudest at the right upper sternal border radiating to the carotids (Correct answer)
Pan-systolic murmur loudest at the apex radiating to the axilla

Correct answer: Ejection systolic murmur loudest at the right upper sternal border radiating to the carotids

Aortic stenosis produces an ejection systolic (crescendo-decrescendo) murmur heard best at the right upper sternal border (aortic area) that radiates to the carotid arteries due to turbulent flow across the stenotic valve.

Question 78: A patient presents with sudden severe 'thunderclap' headache. What is the most important diagnosis to exclude?

Cluster headache
Migraine with aura
Subarachnoid haemorrhage (Correct answer)
Tension headache

Correct answer: Subarachnoid haemorrhage

A thunderclap headache (sudden onset, maximal at onset, 'worst headache of my life') must be investigated urgently to exclude subarachnoid haemorrhage (SAH), as delayed diagnosis significantly worsens outcomes.

Question 79: In NZ medical practice, what is the doctor's obligation when they make a clinical error?

Disclose the error to the patient (open disclosure), report it through the incident reporting system, and participate in a review to prevent recurrence (Correct answer)
Hide the error to avoid legal consequences
Report it anonymously and avoid discussing it with the patient
Only disclose if the error caused visible harm

Correct answer: Disclose the error to the patient (open disclosure), report it through the incident reporting system, and participate in a review to prevent recurrence

NZ medical practice requires open disclosure of clinical errors to the patient/whānau, reporting through the incident management system, and participation in reviews aimed at learning and preventing recurrence. NZ's ACC system removes the adversarial litigation element.

Question 80: A 35-year-old woman presents with acute severe asthma not responding to initial bronchodilators. Her SpO2 is 88% despite oxygen. What is the next most appropriate intervention?

Discharge with oral steroids
Oral prednisolone 40 mg
Repeat salbutamol nebuliser only
IV magnesium sulphate 2 g over 20 minutes (Correct answer)

Correct answer: IV magnesium sulphate 2 g over 20 minutes

IV magnesium sulphate is recommended for acute severe asthma not responding to initial bronchodilators, as it causes bronchial smooth muscle relaxation. This should be given alongside IV corticosteroids, continuous salbutamol, and senior review.

Question 81: A 55-year-old with known cirrhosis presents with confusion, asterixis, and fetor hepaticus. Ammonia is elevated. What is the most appropriate immediate management?

Lactulose orally or via nasogastric tube (Correct answer)
Rifaximin IV loading dose
IV thiamine followed by dextrose
Sodium bicarbonate infusion

Correct answer: Lactulose orally or via nasogastric tube

Lactulose reduces ammonia absorption from the gut by acidifying colonic contents and promoting ammonia excretion. It is first-line for hepatic encephalopathy. Rifaximin is used as adjunct or maintenance.

Question 82: A patient in NZ presents with sudden onset severe headache — the 'worst headache of my life'. What is the most important diagnosis to exclude?

Migraine — treat with triptans
Sinusitis — prescribe nasal decongestants
Tension headache — treat with paracetamol
Subarachnoid haemorrhage (SAH) — investigate with CT brain (within 6 hours) and lumbar puncture if CT is normal (Correct answer)

Correct answer: Subarachnoid haemorrhage (SAH) — investigate with CT brain (within 6 hours) and lumbar puncture if CT is normal

A sudden-onset, severe headache (thunderclap headache) must be investigated urgently to exclude subarachnoid haemorrhage. In NZ, the standard approach is CT brain (highly sensitive within 6 hours of onset). If CT is negative and clinical suspicion remains, a lumbar puncture should be performed.

Question 83: A medical student is asked by a consultant to perform an intimate examination on an anaesthetised patient purely for teaching purposes without the patient's prior consent. What should the student do?

Perform the examination as the consultant has authority
Perform the examination but document it did not occur
Ask another student to perform it instead
Decline and raise the concern with a senior or the medical school — this is unethical without consent (Correct answer)

Correct answer: Decline and raise the concern with a senior or the medical school — this is unethical without consent

Performing intimate examinations on anaesthetised patients without prior consent is unethical and potentially unlawful, regardless of seniority or teaching value. Students must feel empowered to decline and escalate such requests.

Question 84: What is the primary purpose of the 'systems review' component of a clinical history?

To document the patient's surgical history
To identify symptoms not covered in the presenting complaint that may be relevant (Correct answer)
To repeat the presenting complaint in organ-specific terms
To record current medications

Correct answer: To identify symptoms not covered in the presenting complaint that may be relevant

The systems review (or review of systems) systematically screens for symptoms in each organ system that the patient may not have volunteered, ensuring no relevant information is missed.

Question 85: When documenting a skin lesion, which descriptor refers to a solid raised lesion less than 1 cm in diameter?

Vesicle
Papule (Correct answer)
Macule
Plaque

Correct answer: Papule

A papule is a solid, raised skin lesion less than 1 cm in diameter. A macule is flat, a vesicle is fluid-filled, and a plaque is a raised flat-topped lesion greater than 1 cm.

Question 86: What is the NZ approach to managing acute upper gastrointestinal bleeding?

Oral antacids and review in one week
Barium swallow investigation first
Observation only if the patient is haemodynamically stable
ABCDE assessment, IV access with fluid resuscitation, blood transfusion if needed, IV proton pump inhibitor, and urgent endoscopy within 24 hours (Correct answer)

Correct answer: ABCDE assessment, IV access with fluid resuscitation, blood transfusion if needed, IV proton pump inhibitor, and urgent endoscopy within 24 hours

NZ management of acute upper GI bleeding includes ABCDE assessment, establishing IV access (two large-bore cannulae), fluid resuscitation, blood transfusion if haemoglobin is critically low, IV proton pump inhibitor (pantoprazole/omeprazole), and urgent endoscopy within 24 hours.

Question 87: Which of the following best defines 'cultural safety' in the NZ health context?

An environment where patients feel respected and safe to share their culture, as determined by the patient (Correct answer)
Asking every patient about their ethnicity at triage
The same as cultural competence — knowing facts about different cultures
Providing culturally themed decorations in clinical settings

Correct answer: An environment where patients feel respected and safe to share their culture, as determined by the patient

Cultural safety is about the patient's experience of feeling safe. It requires health professionals to reflect on their own identity, attitudes, and biases. Safety is assessed by the recipient of care — not the provider. This distinguishes it from cultural awareness or competence.

Question 88: Which of the following best reflects a culturally responsive approach to prescribing for Māori patients in New Zealand, consistent with Te Tiriti o Waitangi principles?

Referring all Māori patients to a specialist before prescribing any new medication
Addressing potential barriers to adherence including cost, access, health literacy, and cultural beliefs (Correct answer)
Prescribing higher doses of medications routinely as Māori patients metabolise drugs more rapidly
Avoiding discussion of rongoā Māori (traditional medicine) as it is not clinically relevant

Correct answer: Addressing potential barriers to adherence including cost, access, health literacy, and cultural beliefs

Culturally responsive prescribing for Māori acknowledges systemic barriers to access and adherence, incorporates patient values and whānau context, and is aligned with Te Tiriti principles of equity, partnership, and active protection.

Question 89: Which clinical sign is used to assess for hepatomegaly during abdominal examination?

Begin percussion in the right iliac fossa and move superiorly until dullness is detected (Correct answer)
Auscultate over the right upper quadrant for a bruit
Palpate deeply in the left hypochondrium
Percuss from the left iliac fossa toward the right upper quadrant

Correct answer: Begin percussion in the right iliac fossa and move superiorly until dullness is detected

Hepatomegaly is assessed by starting percussion in the right iliac fossa (where the liver is absent) and moving upward to detect the superior border of liver dullness, then palpating to confirm the inferior border.

Question 90: In NZ medical practice, what is the correct approach when a patient requests a treatment you believe is not in their best interest?

Report the patient to the Medical Council
Explain your clinical reasoning, discuss the evidence, explore the patient's perspective, but ultimately respect their autonomy while documenting the discussion (Correct answer)
Agree to the request to avoid conflict
Refuse the request without explanation

Correct answer: Explain your clinical reasoning, discuss the evidence, explore the patient's perspective, but ultimately respect their autonomy while documenting the discussion

NZ medical ethics requires doctors to provide clear clinical reasoning and evidence, explore the patient's values and concerns, and ultimately respect patient autonomy. The discussion, including any disagreement, should be thoroughly documented.

Question 91: Which rights under the Code of Health and Disability Services Consumers' Rights are most relevant when obtaining informed consent?

Right 1 (right to be treated with respect) and Right 3 (right to dignity)
Right 5 (information) and Right 7 (informed consent) (Correct answer)
Right 2 (fair treatment) and Right 4 (services of appropriate standard)
Right 6 (support) and Right 9 (teaching and research)

Correct answer: Right 5 (information) and Right 7 (informed consent)

Right 5 ensures patients receive sufficient information about their condition and treatment options; Right 7 ensures services are provided only with free and informed consent. Together they underpin the consent process.

Question 92: What is the NZ approach to managing disagreements between healthcare team members regarding patient care?

Report all disagreements to the Medical Council
Discuss concerns openly and respectfully, use evidence to support clinical positions, escalate through appropriate channels if unresolved, and always prioritise patient safety (Correct answer)
The most senior person's opinion always prevails without discussion
Avoid raising disagreements to maintain team harmony

Correct answer: Discuss concerns openly and respectfully, use evidence to support clinical positions, escalate through appropriate channels if unresolved, and always prioritise patient safety

NZ healthcare promotes a culture where all team members can raise concerns about patient care, discuss them openly and respectfully using evidence, and escalate through appropriate channels if needed. Patient safety always takes priority over hierarchy or interpersonal dynamics.

Question 93: In NZ, what professional standards apply to a doctor's use of social media?

Social media use is completely prohibited for doctors in NZ
Doctors may share patient cases publicly if they remove the patient's name
There are no professional standards regarding social media use
Doctors must maintain confidentiality, professional boundaries, and should not post identifiable patient information or bring the profession into disrepute (Correct answer)

Correct answer: Doctors must maintain confidentiality, professional boundaries, and should not post identifiable patient information or bring the profession into disrepute

The MCNZ requires doctors to maintain patient confidentiality on social media (no identifiable information), uphold professional boundaries (avoid patient friend requests), and not post content that could bring the medical profession into disrepute or undermine public trust.

Question 94: What is the primary legislation that established the current NZ health system structure replacing DHBs in 2022?

New Zealand Public Health and Disability Act 2000
Pae Ora (Healthy Futures) Act 2022 (Correct answer)
Health and Disability Commissioner Act 1994
Health Practitioners Competence Assurance Act 2003

Correct answer: Pae Ora (Healthy Futures) Act 2022

The Pae Ora (Healthy Futures) Act 2022 abolished the 20 DHBs and established Health New Zealand (Te Whatu Ora), the Māori Health Authority (Te Aka Whai Ora), and Public Health Agency as the new national health entities.

Question 95: A 28-year-old woman presents with amenorrhoea for 10 weeks. On examination the uterus is palpable at the umbilicus. What gestational age does this most likely correspond to?

10 weeks
20 weeks (Correct answer)
28 weeks
14 weeks

Correct answer: 20 weeks

The fundal height in centimetres approximately equals gestational age in weeks from 20 weeks onward. At 20 weeks, the fundus reaches the umbilicus. At 10 weeks the uterus is not yet abdominally palpable.

Question 96: The principle of 'equity' in Te Tiriti o Waitangi is associated with which article?

Article 1 — Crown governance
Article 3 — equal rights and citizenship for all New Zealanders (Correct answer)
Article 4 — freedom of religion
Article 2 — Māori rangatiratanga

Correct answer: Article 3 — equal rights and citizenship for all New Zealanders

Article 3 of Te Tiriti guarantees Māori the same rights and privileges as all New Zealand citizens (ōritetanga/equity). In health, this underpins the obligation to ensure Māori achieve health outcomes equivalent to non-Māori.

Question 97: When performing a respiratory examination, which finding indicates tracheal deviation and what does it signify?

Trachea always deviates toward the side of dullness
Trachea displaced away from the affected side in tension pneumothorax; toward the affected side in collapse (Correct answer)
Trachea displaced toward the affected side in tension pneumothorax; away in collapse
Trachea deviation is not clinically significant

Correct answer: Trachea displaced away from the affected side in tension pneumothorax; toward the affected side in collapse

In tension pneumothorax, mediastinal structures including the trachea are pushed away from the affected side. In lung collapse (atelectasis), the trachea is pulled toward the affected side due to reduced lung volume.

Question 98: Which of the following best describes Trousseau's sign in hypocalcaemia?

Carpal spasm induced by inflating a blood pressure cuff above systolic pressure for 3 minutes (Correct answer)
Facial muscle contraction elicited by tapping over the facial nerve
Tetany induced by hyperventilation alone
Positive Babinski response with hypocalcaemia

Correct answer: Carpal spasm induced by inflating a blood pressure cuff above systolic pressure for 3 minutes

Trousseau's sign is carpal spasm (main d'accoucheur position) induced by occluding arterial flow with a blood pressure cuff above systolic for 3 minutes, indicating latent tetany due to hypocalcaemia.

Question 99: A patient asks for a copy of their medical records. Under the Privacy Act 2020, what is the general obligation of the health provider?

Refuse if the information may distress the patient
Provide access to records within a reasonable time, subject to limited exceptions (Correct answer)
Charge a substantial fee before releasing any records
Only allow access in the presence of a health professional

Correct answer: Provide access to records within a reasonable time, subject to limited exceptions

Under the Privacy Act 2020 (Information Privacy Principle 6), individuals have a right to access information about themselves. Health providers must respond within 20 working days and provide access subject only to limited grounds for refusal.

Question 100: When examining cranial nerve VII (facial nerve), which movement tests the upper motor neurone versus lower motor neurone?

Corneal reflex (UMN) versus blink reflex (LMN)
Forehead sparing (UMN) versus forehead involvement (LMN) (Correct answer)
Taste on anterior tongue (LMN) versus posterior tongue (UMN)
Eye closure (UMN) versus mouth movement (LMN)

Correct answer: Forehead sparing (UMN) versus forehead involvement (LMN)

In upper motor neurone facial palsy (e.g., stroke), the forehead is spared due to bilateral cortical representation. In lower motor neurone palsy (e.g., Bell's palsy), the entire ipsilateral face including the forehead is affected.

Question 101: When performing a cardiovascular examination in the NZREX, what clinical signs should you specifically check in the hands?

Capillary refill time only
Temperature of the skin only
Grip strength and finger dexterity only
Clubbing, splinter haemorrhages, Janeway lesions, Osler's nodes, and peripheral cyanosis (Correct answer)

Correct answer: Clubbing, splinter haemorrhages, Janeway lesions, Osler's nodes, and peripheral cyanosis

In a cardiovascular examination, the hands may reveal important signs: clubbing (cyanotic heart disease), splinter haemorrhages (endocarditis), Janeway lesions (painless, endocarditis), Osler's nodes (painful, endocarditis), and peripheral cyanosis.

Question 102: Which symptom in a patient with haematuria most increases concern for bladder cancer?

Haematuria with flank pain and fever
Microscopic haematuria with urinary tract infection symptoms
Haematuria at the end of the urinary stream
Painless macroscopic haematuria (Correct answer)

Correct answer: Painless macroscopic haematuria

Painless macroscopic (visible) haematuria in adults is a red flag symptom for urothelial malignancy (bladder or kidney cancer) until proven otherwise, and requires urgent investigation with urine cytology and cystoscopy.

Question 103: Which of the following best describes a 'collateral history' and when it is most important?

History obtained from a third party; most important when the patient cannot reliably self-report (Correct answer)
History focused solely on medications from the pharmacy
A second history taken after initial management
History of previous hospital admissions obtained from notes

Correct answer: History obtained from a third party; most important when the patient cannot reliably self-report

A collateral history is obtained from someone who knows the patient (family, carer, witnesses) and is critical when the patient has impaired cognition, is unconscious, or has psychiatric conditions affecting insight.

Question 104: A patient describes waking at night with arm pain and paraesthesia that is relieved by shaking the hand. Which nerve is most likely affected?

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

Correct answer: Median nerve

Nocturnal paraesthesia relieved by shaking (the 'flick sign') is characteristic of carpal tunnel syndrome, which involves compression of the median nerve at the wrist.

Question 105: In NZ, what is the recommended immunisation schedule milestone at 6 weeks of age?

MMR vaccine is given at 6 weeks
First doses of rotavirus, DTaP-IPV-HepB/Hib, and pneumococcal conjugate vaccines (Correct answer)
Only BCG vaccine is given at 6 weeks
No immunisations are given until 3 months in NZ

Correct answer: First doses of rotavirus, DTaP-IPV-HepB/Hib, and pneumococcal conjugate vaccines

The NZ National Immunisation Schedule starts at 6 weeks with the first doses of rotavirus (oral), DTaP-IPV-HepB/Hib (hexavalent), and PCV13 (pneumococcal conjugate). This is a key milestone that NZREX candidates should know.

Question 106: A 35-year-old woman presents with a 6-month history of weight loss, heat intolerance, palpitations, and a smooth goitre. TSH is suppressed with elevated free T4. What is the most likely diagnosis?

Hashimoto's thyroiditis
De Quervain's thyroiditis
Toxic multinodular goitre
Graves' disease (Correct answer)

Correct answer: Graves' disease

Graves' disease is the most common cause of hyperthyroidism in young women, caused by TSH receptor antibodies. It presents with a diffusely smooth goitre, ophthalmopathy, and hyperthyroid symptoms.

Question 107: When examining peripheral pulses, which pulse site is most appropriate for assessing perfusion in a shocked patient?

Dorsalis pedis pulse
Radial pulse
Carotid pulse (Correct answer)
Femoral pulse

Correct answer: Carotid pulse

In severe shock, peripheral pulses (radial, pedal) may be absent. The carotid pulse is a central pulse that persists until cardiac arrest is imminent, making it the most reliable for assessing perfusion in shock.

Question 108: What is ACC (Accident Compensation Corporation) and how does it affect medical practice in NZ?

A no-fault personal injury insurance scheme covering all NZ residents — it replaces the right to sue for personal injury in most cases (Correct answer)
A government fund for hospital building projects
A private health insurance company
An association of NZ medical colleges

Correct answer: A no-fault personal injury insurance scheme covering all NZ residents — it replaces the right to sue for personal injury in most cases

ACC is NZ's unique no-fault personal injury compensation scheme. It covers treatment costs, income replacement, and rehabilitation for any personal injury. In exchange, the right to sue for personal injury is largely removed (except for exemplary damages).

Question 109: Which of the following is NOT a valid reason to override a patient's right to confidentiality?

The patient's partner requests information about their diagnosis (Correct answer)
Statutory requirement (e.g., notifiable disease reporting)
Risk of serious harm to an identifiable third party
Direct patient care within a treating team

Correct answer: The patient's partner requests information about their diagnosis

Confidentiality cannot be overridden simply because a partner or family member requests information. Valid exceptions include disclosure to prevent serious harm to others, statutory obligations, and sharing within the treating team on a need-to-know basis.

Question 110: When examining the abdomen, what is the correct order of examination steps?

Palpation, percussion, auscultation, inspection
Inspection, auscultation, percussion, palpation (Correct answer)
Auscultation, inspection, palpation, percussion
Inspection, percussion, palpation, auscultation

Correct answer: Inspection, auscultation, percussion, palpation

The abdomen is examined in the order: inspection, auscultation, percussion, then palpation. Auscultation precedes percussion and palpation to avoid artificially altering bowel sounds.

Question 111: In NZ, what is the management of neonatal jaundice?

Assess total serum bilirubin, plot against treatment thresholds based on gestational age and hours of life, and treat with phototherapy if above the threshold (Correct answer)
Jaundice in newborns is always pathological and requires antibiotics
No treatment is ever needed — neonatal jaundice always resolves spontaneously
All jaundiced babies require exchange transfusion

Correct answer: Assess total serum bilirubin, plot against treatment thresholds based on gestational age and hours of life, and treat with phototherapy if above the threshold

NZ neonatal jaundice management involves: measuring total serum bilirubin (TSB), plotting it on a gestational age-specific treatment threshold chart, and initiating phototherapy if the TSB is above the treatment line. Exchange transfusion is reserved for very high levels or treatment failure.

Question 112: A Māori patient presents with chronic pain. Which approach is most consistent with culturally safe practice?

Treat the physical pain only and avoid raising cultural topics
Explore the patient's own understanding of the pain including any spiritual or cultural dimensions, and involve whānau if appropriate (Correct answer)
Refer immediately to a Māori health provider without assessment
Assume the patient prefers traditional Māori healing over Western medicine

Correct answer: Explore the patient's own understanding of the pain including any spiritual or cultural dimensions, and involve whānau if appropriate

Culturally safe practice involves exploring the patient's own health beliefs, including spiritual dimensions, and integrating this with biomedical care. Whānau involvement and the patient's preferences should guide the approach.

Question 113: Which of the following is most consistent with a diagnosis of irritable bowel syndrome (IBS)?

Nocturnal diarrhoea with weight loss
Rectal bleeding with altered bowel habit in a 55-year-old
Abdominal pain relieved by defecation, altered stool form, no red flag symptoms (Correct answer)
Macrocytic anaemia with abdominal bloating

Correct answer: Abdominal pain relieved by defecation, altered stool form, no red flag symptoms

IBS is a functional gut disorder characterised by abdominal pain related to defecation, altered stool frequency and form, without red flag features (bleeding, weight loss, nocturnal symptoms, anaemia). Organic causes must be excluded first.

Question 114: Which of the following best describes the 'shifting dullness' sign in abdominal examination?

Fixed dullness in the flanks regardless of position
Tympany that becomes dull after percussion of the right iliac fossa
Dullness in the epigastrium that shifts to the left
Dullness that moves to the dependent side when the patient is rolled (Correct answer)

Correct answer: Dullness that moves to the dependent side when the patient is rolled

Shifting dullness is elicited by percussing the flanks and then rolling the patient; if ascites is present, the dull area shifts to the dependent side as fluid moves with gravity.

Question 115: What is the NZ approach to managing type 2 diabetes, including the first-line pharmacological treatment?

Dietary changes only with no medication for the first 5 years
Insulin injections from diagnosis
Sulfonylureas as first-line treatment in NZ
Lifestyle modification (diet, exercise, weight management) plus metformin as first-line pharmacotherapy, with HbA1c monitoring every 3-6 months (Correct answer)

Correct answer: Lifestyle modification (diet, exercise, weight management) plus metformin as first-line pharmacotherapy, with HbA1c monitoring every 3-6 months

NZ management of type 2 diabetes starts with lifestyle modification (healthy diet, regular exercise, weight management) and metformin as first-line pharmacotherapy. HbA1c targets are individualised (generally <53 mmol/mol), with monitoring every 3-6 months and treatment escalation as needed.

Question 116: A patient has capacity but refuses a blood transfusion that the doctor believes is life-saving. What is the correct action?

Seek a court order to override the decision
Contact next of kin to give consent instead
Respect the refusal, document it thoroughly, and explore the patient's reasons and wishes (Correct answer)
Proceed with transfusion as duty of care overrides refusal

Correct answer: Respect the refusal, document it thoroughly, and explore the patient's reasons and wishes

A competent adult has an absolute right to refuse medical treatment, even if the refusal is unwise or life-threatening. The doctor must respect this, document carefully, ensure the patient understands consequences, and continue to provide care within the patient's wishes.

Question 117: A patient presents to a NZ emergency department with chest pain. What is the first-line investigation to rule out an acute myocardial infarction?

CT coronary angiography
Echocardiogram
12-lead ECG — should be performed within 10 minutes of arrival (Correct answer)
Chest X-ray

Correct answer: 12-lead ECG — should be performed within 10 minutes of arrival

A 12-lead ECG should be performed within 10 minutes of arrival for any patient presenting with chest pain to a NZ ED. This is the first-line investigation to identify ST-elevation myocardial infarction (STEMI) requiring urgent intervention.

Question 118: When taking a history from a patient presenting with chest pain, which mnemonic is most useful for characterising the pain?

SOCRATES (Correct answer)
ABCDE
OLDCARTS
SAMPLE

Correct answer: SOCRATES

SOCRATES (Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/relieving factors, Severity) is the standard mnemonic for characterising pain in clinical history-taking.

Question 119: A 70-year-old patient presents with confusion. Which validated tool is most appropriate for brief cognitive assessment in the acute setting?

Mini-Mental State Examination (MMSE)
Clock Drawing Test alone
Montreal Cognitive Assessment (MoCA)
Abbreviated Mental Test Score (AMTS) (Correct answer)

Correct answer: Abbreviated Mental Test Score (AMTS)

The AMTS (10 questions, score 0–10) is rapid and validated for use in acute settings to screen for cognitive impairment. The MMSE and MoCA are more detailed and better suited to outpatient cognitive assessment.

Question 120: A child presents to a NZ ED with croup. What is the initial management?

Steam inhalation only
Oral dexamethasone (single dose 0.15-0.6 mg/kg) and nebulised adrenaline if severe stridor at rest (Correct answer)
Immediate intubation for all cases
Antibiotics as first-line treatment

Correct answer: Oral dexamethasone (single dose 0.15-0.6 mg/kg) and nebulised adrenaline if severe stridor at rest

NZ management of croup follows a severity-based approach: oral dexamethasone is given to all presentations (mild to severe), and nebulised adrenaline (1:1000, 5 ml) is added for severe cases with stridor at rest. Antibiotics are not indicated as croup is viral.

NZREX Clinical Examination

The New Zealand Registration Examination (NZREX Clinical) is an OSCE-format exam administered by the Medical Council of New Zealand (MCNZ) that assesses international medical graduates across seven clinical domains including history taking, physical examination, investigations, clinical reasoning, management, communication, professionalism, and cultural safety.

120

Questions

180 min

Time Limit

65%

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