Davis's PA Exam Review for the PANCE and PANRE Morton Diamond

Engineering and Reverse-Engineering Test Questions

A skilled test-item writer carefully “engineers” construction of the stem of a question.

The construction has specific goals:

Firstly, the item writer must be confident that test-taker clearly understands what is being asked in the question.

Secondly, there must be sufficient information that leads the test-taker to the correct diagnosis or away from incorrect diagnoses.

Thirdly, when the question asks for the preferred therapy, there must be appropriate information, for example, renal function values, or a co-existing condition, for example, pregnancy, that leads the test-taker to the correct response.

The skilled test-taker should engage in what I call “reverse engineering” when reading the question. Reverse engineering means that the test-taker is adroitly “getting into the mind” of the test-item writer. This is not difficult.

As he or she reads each phrase in the stem, the test-taker must be thinking.

Here are examples:

1. If the stem begins with the phrase: “Medicine X” therapy is initiated in therapy of (disease)…

The test taker should immediately focus that the question is asking specifically about the medicine:
• Contraindications
• Adverse effects
• What lab values to be monitored
• Counseling to the patient: Example: “Do not drink alcohol while taking this medicine”

2. If the stem starts with a symptom, the test-taker immediately focuses on causes of that symptom.

“A 77-year-old man has weakness”. The test taker focuses: weakness commonly is related to systolic heart failure, adrenal insufficiency, anemia.

The test taker now continues reading the stem looking for information that points to the cardiovascular system, or to the endocrine system, or to the blood.

3. Read the vital signs carefully:

• Increased pulse pressure means high cardiac output—from anemia, fever, but, for test purposes, more likely, hyperthyroidism or arteriovenous fistula

• Increased pulse pressure in a healthy, elderly patient means isolated systolic hypertension

• Increased pulse pressure with a diastolic murmur means aortic valve regurgitation

More about “reverse engineering” in a following blog.


Dr. Morton A. Diamond (AKA, The Professor), is Professor and Medical Director of the physician assistant program at Nova Southeastern University in Fort Lauderdale, Florida. He is the author of the F.A. Davis title, Davis’s PA Exam Review: Focused Review for the PANCE and PANRE, and also of Medical Insights: From Classroom To Patient, a Jones & Bartlett publication. He has written tens of thousands of test items over his career and was a leading item writer for the National Commission on Certification of Physician Assistants. He also has forgotten more words than you and I have ever known and enjoys stumping his publisher with them as often as possible.

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