Free Part II Patient Assessment and Management (PAM) Practice Questions

Sample Practice Questions

Try these 10 sample questions from the Part II Patient Assessment and Management (PAM) practice bank. Each includes the answer and explanation. Continue with the interactive practice above to review the full question set.

1. 1A 52-year-old emmetrope must now hold reading material farther away than a year ago, while distance acuity is unchanged at 20/20. Which change in the crystalline lens accounts for this finding?

   1. A. The lens becomes harder and less flexible with age
   2. B. The lens becomes thinner and flatter with age
   3. C. The lens becomes steeper and more powerful with age
   4. D. The lens becomes clearer and less dense with age

   Answer: A

   Explanation: The National Eye Institute states: "As you age, the lens in your eye gets harder and less flexible, and it stops focusing light correctly on the retina." Loss of lens flexibility reduces the accommodative change in shape that is needed for near focus, which is why the patient must increase the working distance while distance acuity is preserved. A lens that became flatter would shift refraction hyperopically at distance, a lens that became steeper would shift it myopically, and increasing lens clarity is not a change that occurs with age.

   Reference: Presbyopia | National Eye Institute — Presbyopia, 'What causes presbyopia?' section

2. 2A 12-year-old reports that the classroom board looks blurry while reading at near is comfortable. Cycloplegic refraction shows -3.25 D in each eye, axial length is longer than average for age, and the cornea and crystalline lens are normal in shape. Which refractive error does this optical configuration describe?

   1. A. Nearsightedness, in which light is focused in front of the retina
   2. B. Farsightedness, in which light is focused behind the retina
   3. C. Astigmatism, in which light is focused at more than one meridian
   4. D. Presbyopia, in which the lens no longer changes shape sufficiently

   Answer: A

   Explanation: The National Eye Institute describes nearsightedness as follows: "It happens when the eyeball grows too long from front to back, or when there are problems with the shape of the cornea (clear front layer of the eye) or the lens (an inner part of the eye that helps the eye focus). These problems make light focus in front of the retina, instead of on it." The long axial length with a normal cornea and lens, together with blurred distance and clear near vision, matches this description. Farsightedness is the opposite configuration, in which "the eyeball grows too short from front to back" so that light focuses behind the retina. Astigmatism arises when "your cornea or lens has a different shape than normal," which is excluded here. Presbyopia is a loss of near focusing that begins in middle age and does not blur distance vision.

   Reference: Types of Refractive Errors | National Eye Institute — Types of Refractive Errors, sections 'Nearsightedness (myopia)', 'Farsightedness (hyperopia)', 'Astigmatism' and 'Presbyopia'

3. 3A 26-year-old with a spherical equivalent of -9.50 D in each eye and best-corrected acuity of 20/20 asks why a dilated peripheral retinal examination is recommended at every visit. Which condition is severe nearsightedness specifically identified as increasing the risk of?

   1. A. Retinal detachment
   2. B. Angle-closure glaucoma
   3. C. Keratoconus
   4. D. Retinitis pigmentosa

   Answer: A

   Explanation: The National Eye Institute states: "Severe nearsightedness (also called high myopia) can increase the risk of other eye conditions, like retinal detachment (when the retina is pulled away from its normal position)." That is why peripheral retinal evaluation is emphasized in high myopia even when central acuity is normal. The other options name real conditions that are not the association identified here: angle closure is favoured by a short, crowded anterior segment rather than a long eye, keratoconus is a corneal ectasia that produces irregular astigmatism, and retinitis pigmentosa is an inherited photoreceptor dystrophy unrelated to axial length.

   Reference: Types of Refractive Errors | National Eye Institute — Types of Refractive Errors, 'Nearsightedness (myopia)' section

4. 4A patient with no other refractive error asks at what age the normal age-related loss of near focusing ability usually begins. According to the National Eye Institute, presbyopia usually begins after which age?

   1. A. 45
   2. B. 35
   3. C. 55
   4. D. 65

   Answer: A

   Explanation: The National Eye Institute states: "Everyone gets presbyopia as they get older — usually after age 45." The other values are plausible but incorrect points on the same age scale: onset is not typically in the mid-thirties, and by the mid-fifties most patients are already symptomatic. Age 65 is the age after which the same source states that presbyopia "usually stops getting worse," not the age at which it begins.

   Reference: Presbyopia | National Eye Institute — Presbyopia, 'What is presbyopia?' and 'What are the symptoms of presbyopia?' sections

5. 5Atropine sulfate ophthalmic solution 1% is selected to produce cycloplegia in a 7-year-old before refraction. How long before the intended time of maximal dilation should the drop be instilled?

   1. A. 40 minutes
   2. B. 10 minutes
   3. C. 2 hours
   4. D. 24 hours

   Answer: A

   Explanation: The labeling directs: "Apply 1 drop topically to the cul-de-sac of the conjunctiva, forty minutes prior to the intended maximal dilation time." Scheduling the drop at this interval allows the examination to be performed at peak effect. Ten minutes is too short an interval for maximal cycloplegia to develop, and neither 2 hours nor 24 hours is the interval specified in the labeling for reaching maximal dilation.

   Reference: DailyMed - ATROPINE- atropine sulfate solution/ drops — Atropine Sulfate Ophthalmic Solution 1%, section 2 Dosage and Administration

6. 6A patient record contains the results of a cycloplegic refraction, and the reviewer asks what that procedure involves. Which description matches the definition applied when best-corrected central visual acuity is determined?

   1. A. Refraction after drops that relax pupil constriction and temporarily paralyze the focusing muscles
   2. B. Refraction after drops that constrict the pupil and stimulate the focusing muscles to contract
   3. C. Refraction after drops that anesthetize the cornea and reduce reflex tearing during testing
   4. D. Refraction after drops that stain the tear film and disclose corneal epithelial defects

   Answer: A

   Explanation: The definition used in federal disability determinations reads: "Cycloplegic refraction is an examination of the eye performed after administering cycloplegic eye drops capable of relaxing the ability of the pupil to become smaller and temporarily paralyzing the focusing muscles." Paralysing accommodation is what allows the full latent refractive error to be measured. The other options describe agents that are real and are used in eye examinations, but they describe miotic, topical anaesthetic and vital-dye procedures, none of which is a cycloplegic refraction.

   Reference: 2.00 - Special Senses and Speech-Adult | Disability | SSA — 2.00 Special Senses and Speech, section A5d 'Cycloplegic refraction'

7. 7Cycloplegic refraction of a 4-year-old shows +6.00 D in each eye. The parents ask what else the child should be monitored for. Which pair of problems is severe farsightedness in children specifically associated with?

   1. A. Crossed eyes and amblyopia
   2. B. Retinal detachment and macular holes
   3. C. Keratoconus and corneal ectasia
   4. D. Cataract and lens subluxation

   Answer: A

   Explanation: The National Eye Institute states: "Children with severe farsightedness may also be at higher risk for other eye problems, like crossed eyes or amblyopia (lazy eye)." Uncorrected high hyperopia drives excessive accommodative effort and leaves a persistently defocused retinal image, so both strabismus and amblyopia must be looked for. Retinal detachment and macular holes are associated with high myopia rather than high hyperopia; keratoconus and post-surgical ectasia are corneal thinning disorders; cataract and lens subluxation are lens disorders that are not the association described for childhood hyperopia.

   Reference: Farsightedness (Hyperopia) | National Eye Institute — Farsightedness (Hyperopia), 'What are the symptoms of farsightedness?' section

8. 8A 9-year-old has early nearsightedness and a strong family history of myopia. Which factor has been associated with a lower likelihood of becoming nearsighted in children of this age?

   1. A. Spending more time outdoors
   2. B. Wearing tinted lenses outdoors
   3. C. Using a higher reading illumination
   4. D. Increasing the habitual working distance

   Answer: A

   Explanation: The National Eye Institute states: "Children who spend more time outdoors are less likely to be nearsighted, but experts aren't sure why." This is the association reported for childhood myopia, and the source is explicit that the mechanism is not established. The other options describe real modifications of the visual environment that are used for other purposes, such as glare control, reading comfort in presbyopia and near-work ergonomics, but none of them is identified as associated with a lower likelihood of becoming nearsighted.

   Reference: Nearsightedness (Myopia) | National Eye Institute — Nearsightedness (Myopia), 'Am I at risk for nearsightedness?' section

9. 9The parent of a child who received atropine sulfate ophthalmic solution 1% asks how long light sensitivity and blurred near vision may persist. What maximum duration does the labeling give?

   1. A. Up to 2 weeks
   2. B. Up to 6 hours
   3. C. Up to 3 days
   4. D. Up to 3 months

   Answer: A

   Explanation: The labeling states: "Photophobia and blurred vision due to pupil unresponsiveness and cycloplegia may last up to 2 weeks." This duration is what must be given when the family is counselled about school and reading. Six hours and three days understate the duration for this agent, and three months exceeds the period stated in the labeling.

   Reference: DailyMed - ATROPINE- atropine sulfate solution/ drops — Atropine Sulfate Ophthalmic Solution 1%, section 5.1 Photophobia and Blurred Vision

10. 10Best-corrected distance acuity was measured at a 10-foot test distance and recorded as 10/40. When this measurement is converted to the standard 20-foot notation, what is the result?

    1. A. 20/80
    2. B. 20/40
    3. C. 20/20
    4. D. 20/160

    Answer: A

    Explanation: Snellen notation is a ratio of test distance to the distance at which the smallest resolved letter subtends the standard angle, so converting to a 20-foot test distance requires doubling both terms. The worked example in the federal instructions reads: "For example, if your visual acuity is measured at 10 feet and is reported as 10/40, we will convert this measurement to 20/80." Option B is the result of leaving the denominator unchanged, option C of reducing both terms of the recorded fraction, and option D of doubling the denominator twice.

    Reference: 2.00 - Special Senses and Speech-Adult | Disability | SSA — 2.00 Special Senses and Speech, section A5a 'Visual acuity testing'