NZREX Clinical Examination — Questions and Answers

Question 1: A patient asks for a copy of their medical records. Under the Privacy Act 2020, what is the general obligation of the health provider?

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

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

Only disclose if the error caused visible harm
Hide the error to avoid legal consequences
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)
Report it anonymously and avoid discussing it with the patient

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

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

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 4: 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
Diaphragm at the apex with the patient supine
Bell of the stethoscope at the apex with the patient in the left lateral decubitus position (Correct answer)

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

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

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

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

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

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

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

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

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

Coroner reporting is voluntary in NZ
Only deaths caused by criminal activity must be reported
All deaths in hospital must be reported to the Coroner
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 10: 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?

Basal ganglia lesion
Upper motor neurone lesion
Lower motor neurone lesion (Correct answer)
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 11: A 60-year-old man presents with sudden onset crushing central chest pain radiating to the left arm, diaphoresis, and nausea. His ECG shows ST elevation in leads II, III, and aVF. Which artery is most likely occluded?

Left anterior descending artery
Left circumflex artery
Right coronary artery (Correct answer)
Left main coronary artery

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates inferior STEMI, which is most commonly caused by occlusion of the right coronary artery (RCA), which supplies the inferior wall of the left ventricle in most patients.

Question 12: 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
Asterixis (flapping tremor) (Correct answer)
Cogwheel rigidity
Myoclonus

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

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
Māori have higher vaccination rates than 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 14: Which antibiotic class is generally contraindicated in children under 12 years due to the risk of arthropathy and potential damage to developing cartilage?

Penicillins (e.g., amoxicillin)
Cephalosporins (e.g., cefalexin)
Fluoroquinolones (e.g., ciprofloxacin) (Correct answer)
Macrolides (e.g., azithromycin)

Correct answer: Fluoroquinolones (e.g., ciprofloxacin)

Fluoroquinolones are contraindicated in children under 12 (and generally under 18 in most guidelines) due to evidence of arthropathy and cartilage toxicity demonstrated in animal studies and paediatric case reports.

Question 15: When examining cranial nerve VII (facial nerve), which movement tests the upper motor neurone versus lower motor neurone?

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

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

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

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

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

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 18: A nurse practitioner in NZ wishes to use a standing order to supply a medicine to patients without an individual prescription. Which legislation primarily governs the use of standing orders?

Health and Disability Commissioner Act 1994
New Zealand Public Health and Disability Act 2000
Misuse of Drugs Act 1975
Medicines Act 1981 and the Medicines (Standing Order) Regulations 2002 (Correct answer)

Correct answer: Medicines Act 1981 and the Medicines (Standing Order) Regulations 2002

Standing orders in New Zealand are governed by the Medicines Act 1981 and the Medicines (Standing Order) Regulations 2002, which specify who can issue them, their scope, and required documentation.

Question 19: 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 is unilateral; Parkinsonian tremor is bilateral
Essential tremor occurs with action; Parkinsonian tremor is a resting tremor (Correct answer)

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 20: Under NZ employment law, what are the key considerations for overseas-trained doctors regarding their working conditions?

Employment conditions are entirely at the discretion of the employer
Overseas doctors have no employment rights until they gain permanent residency
NZ employment law provides for minimum employment standards, including leave entitlements, rest breaks, and protection against unfair dismissal (Correct answer)
NZ does not have specific employment protections for health workers

Correct answer: NZ employment law provides for minimum employment standards, including leave entitlements, rest breaks, and protection against unfair dismissal

NZ employment law (Employment Relations Act 2000) provides minimum standards for all workers including overseas-trained doctors: rest and meal breaks, annual leave (4 weeks), sick leave (10 days/year), public holidays, and protection against unjustified dismissal.

Question 21: Which antibiotic is the first-line treatment for community-acquired pneumonia in a previously healthy adult managed in the community in New Zealand?

Doxycycline
Ceftriaxone
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 22: Which of the following best describes 'therapeutic privilege' and its standing in NZ?

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

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 23: Which ethical framework best describes the view that the right action is the one that produces the greatest good for the greatest number?

Utilitarianism (Correct answer)
Principlism
Virtue ethics
Deontology

Correct answer: Utilitarianism

Utilitarianism (consequentialism) judges actions by their outcomes — the right action maximises overall welfare or utility. In healthcare, this may justify resource allocation decisions that benefit more people even at the expense of individuals.

Question 24: 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?

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

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

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

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

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

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 27: 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?

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
She requires parental consent for any medical treatment
She must have a social worker present

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

No treatment is ever needed — neonatal jaundice always resolves spontaneously
All jaundiced babies require exchange transfusion
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

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

Subarachnoid haemorrhage (Correct answer)
Migraine with aura
Cluster headache
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 30: 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 of previous hospital admissions obtained from notes
History focused solely on medications from the pharmacy
A second history taken after initial management

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.

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.

Questions

35 min

Time Limit

65%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds