MSN 610 Module 2 Cardiovascular, Pulmonary
& Neurological Assessment Actual Exam &
Complete Study Guide
DOMAIN 1: CARDIOVASCULAR & PERIPHERAL VASCULAR ASSESSMENT
(Q1-20)
1. During cardiac auscultation of a 68-year-old patient with hypertension, the nurse
practitioner hears a high-pitched, blowing decrescendo diastolic murmur best heard at
the 3rd left intercostal space. The murmur radiates to the apex. This finding is MOST
consistent with:
A. Aortic stenosis with calcification of the aortic valve
B. Mitral regurgitation from papillary muscle dysfunction
C. Aortic regurgitation with diastolic flow reversal into the left ventricle
D. Pulmonary stenosis with right ventricular hypertrophy
Correct Answer: C
Rationale: C is correct. Aortic regurgitation produces a high-pitched, blowing,
decrescendo diastolic murmur beginning immediately after S2, best heard at the 3rd left
intercostal space (Erb's point) or right sternal border, often radiating toward the apex.
The murmur results from diastolic backflow through the incompetent aortic valve.
Aortic stenosis (A) produces a harsh crescendo-decrescendo systolic murmur. Mitral
,regurgitation (B) is holosystolic. Pulmonary stenosis (D) is systolic and best heard at
the left upper sternal border.
2. When assessing for deep vein thrombosis, the nurse practitioner measures calf
circumference at the point of maximum girth. A difference of greater than 3 cm
between calves, combined with unilateral warmth, erythema, and Homan's sign (pain
with passive dorsiflexion), has a specificity for DVT of approximately:
A. 10-20% - indicating the test is not useful
B. 40-50% - moderate diagnostic value
C. 50-60% - when combined with clinical decision rules like Wells score
D. 90-100% - pathognomonic for thrombosis
Correct Answer: C
Rationale: C is correct. While individual physical findings for DVT have limited sensitivity,
combining calf circumference discrepancy >3 cm with Homan's sign, warmth, and
erythema within clinical decision rules (Wells score, D-dimer testing) achieves moderate
specificity (50-60%). No single physical finding is pathognomonic (D). Clinical decision
rules stratify patients into probability categories to guide diagnostic testing.
Over-reliance on Homan's sign alone (A) is problematic due to low sensitivity; however,
integrated assessment (C) informs evidence-based practice.
3. During assessment of the jugular venous pressure, the nurse practitioner observes
the internal jugular vein at 45 degrees with the head elevated. The top of the venous
pulsation is 6 cm above the sternal angle. The estimated central venous pressure is:
A. 2 cm H₂O - normal range
,B. 6 cm H₂O - elevated
C. 10 cm H₂O - calculated as 6 cm + 4 cm (distance to right atrium)
D. 14 cm H₂O - severely elevated
Correct Answer: C
Rationale: C is correct. JVP estimation: Add 5 cm (standard distance from sternal angle
to right atrium) or 4 cm in elderly/thin patients to the observed vertical height above the
sternal angle. Thus, 6 cm + 4 cm = 10 cm H₂O (or 11 cm using 5 cm). Normal JVP is <8
cm H₂O. A pressure of 10 cm indicates elevated right atrial pressure, consistent with
right heart failure, tricuspid regurgitation, constrictive pericarditis, or volume overload.
Two cm (A) is below normal. Six cm (B) ignores the anatomical correction. Fourteen cm
(D) overestimates.
4. The nurse practitioner palpates the point of maximal impulse (PMI) and finds it
displaced laterally to the 6th intercostal space, anterior axillary line. The impulse is
sustained and covers more than two intercostal spaces. These findings suggest:
A. Normal anatomical variant in athletic individuals
B. Left ventricular hypertrophy with pressure overload
C. Left ventricular dilation with volume overload and possible systolic dysfunction
D. Right ventricular hypertrophy with leftward displacement
Correct Answer: C
Rationale: C is correct. PMI displacement laterally (>5th ICS, MCL) with sustained,
enlarged duration (>2 intercostal spaces) indicates left ventricular enlargement. A
, sustained, diffuse impulse suggests volume overload with eccentric hypertrophy
(dilated cardiomyopathy, aortic/mitral regurgitation) rather than the sharp, brief impulse
of pressure overload (hypertension, aortic stenosis). Athletic hearts (A) may have
enlarged but non-displaced PMIs. Right ventricular hypertrophy (D) causes left
parasternal lift or epigastric pulsation, not lateral PMI displacement. An enlarged,
sustained PMI warrants echocardiographic evaluation.
5. During auscultation of a patient with infective endocarditis, the nurse practitioner
hears a harsh holosystolic murmur at the left lower sternal border that increases with
inspiration (Carvallo's sign). This finding indicates:
A. Mitral regurgitation from valve vegetation
B. Tricuspid regurgitation due to right-sided endocarditis
C. Tricuspid regurgitation with dynamic auscultatory findings
D. Ventricular septal defect with left-to-right shunt
Correct Answer: C
Rationale: C is correct. Carvallo's sign (increased murmur intensity with inspiration) is
pathognomonic for tricuspid regurgitation, as increased venous return during inspiration
increases right ventricular stroke volume and regurgitant flow. Tricuspid involvement in
endocarditis (especially in IV drug users) produces this finding. The left lower sternal
border location and holosystolic timing are characteristic. Mitral regurgitation (A) does
not change with respiration. While tricuspid regurgitation (B) is present, option C
specifically captures the dynamic auscultatory finding (Carvallo's sign) that confirms the
diagnosis. VSD (D) is fixed and doesn't vary with respiration.
& Neurological Assessment Actual Exam &
Complete Study Guide
DOMAIN 1: CARDIOVASCULAR & PERIPHERAL VASCULAR ASSESSMENT
(Q1-20)
1. During cardiac auscultation of a 68-year-old patient with hypertension, the nurse
practitioner hears a high-pitched, blowing decrescendo diastolic murmur best heard at
the 3rd left intercostal space. The murmur radiates to the apex. This finding is MOST
consistent with:
A. Aortic stenosis with calcification of the aortic valve
B. Mitral regurgitation from papillary muscle dysfunction
C. Aortic regurgitation with diastolic flow reversal into the left ventricle
D. Pulmonary stenosis with right ventricular hypertrophy
Correct Answer: C
Rationale: C is correct. Aortic regurgitation produces a high-pitched, blowing,
decrescendo diastolic murmur beginning immediately after S2, best heard at the 3rd left
intercostal space (Erb's point) or right sternal border, often radiating toward the apex.
The murmur results from diastolic backflow through the incompetent aortic valve.
Aortic stenosis (A) produces a harsh crescendo-decrescendo systolic murmur. Mitral
,regurgitation (B) is holosystolic. Pulmonary stenosis (D) is systolic and best heard at
the left upper sternal border.
2. When assessing for deep vein thrombosis, the nurse practitioner measures calf
circumference at the point of maximum girth. A difference of greater than 3 cm
between calves, combined with unilateral warmth, erythema, and Homan's sign (pain
with passive dorsiflexion), has a specificity for DVT of approximately:
A. 10-20% - indicating the test is not useful
B. 40-50% - moderate diagnostic value
C. 50-60% - when combined with clinical decision rules like Wells score
D. 90-100% - pathognomonic for thrombosis
Correct Answer: C
Rationale: C is correct. While individual physical findings for DVT have limited sensitivity,
combining calf circumference discrepancy >3 cm with Homan's sign, warmth, and
erythema within clinical decision rules (Wells score, D-dimer testing) achieves moderate
specificity (50-60%). No single physical finding is pathognomonic (D). Clinical decision
rules stratify patients into probability categories to guide diagnostic testing.
Over-reliance on Homan's sign alone (A) is problematic due to low sensitivity; however,
integrated assessment (C) informs evidence-based practice.
3. During assessment of the jugular venous pressure, the nurse practitioner observes
the internal jugular vein at 45 degrees with the head elevated. The top of the venous
pulsation is 6 cm above the sternal angle. The estimated central venous pressure is:
A. 2 cm H₂O - normal range
,B. 6 cm H₂O - elevated
C. 10 cm H₂O - calculated as 6 cm + 4 cm (distance to right atrium)
D. 14 cm H₂O - severely elevated
Correct Answer: C
Rationale: C is correct. JVP estimation: Add 5 cm (standard distance from sternal angle
to right atrium) or 4 cm in elderly/thin patients to the observed vertical height above the
sternal angle. Thus, 6 cm + 4 cm = 10 cm H₂O (or 11 cm using 5 cm). Normal JVP is <8
cm H₂O. A pressure of 10 cm indicates elevated right atrial pressure, consistent with
right heart failure, tricuspid regurgitation, constrictive pericarditis, or volume overload.
Two cm (A) is below normal. Six cm (B) ignores the anatomical correction. Fourteen cm
(D) overestimates.
4. The nurse practitioner palpates the point of maximal impulse (PMI) and finds it
displaced laterally to the 6th intercostal space, anterior axillary line. The impulse is
sustained and covers more than two intercostal spaces. These findings suggest:
A. Normal anatomical variant in athletic individuals
B. Left ventricular hypertrophy with pressure overload
C. Left ventricular dilation with volume overload and possible systolic dysfunction
D. Right ventricular hypertrophy with leftward displacement
Correct Answer: C
Rationale: C is correct. PMI displacement laterally (>5th ICS, MCL) with sustained,
enlarged duration (>2 intercostal spaces) indicates left ventricular enlargement. A
, sustained, diffuse impulse suggests volume overload with eccentric hypertrophy
(dilated cardiomyopathy, aortic/mitral regurgitation) rather than the sharp, brief impulse
of pressure overload (hypertension, aortic stenosis). Athletic hearts (A) may have
enlarged but non-displaced PMIs. Right ventricular hypertrophy (D) causes left
parasternal lift or epigastric pulsation, not lateral PMI displacement. An enlarged,
sustained PMI warrants echocardiographic evaluation.
5. During auscultation of a patient with infective endocarditis, the nurse practitioner
hears a harsh holosystolic murmur at the left lower sternal border that increases with
inspiration (Carvallo's sign). This finding indicates:
A. Mitral regurgitation from valve vegetation
B. Tricuspid regurgitation due to right-sided endocarditis
C. Tricuspid regurgitation with dynamic auscultatory findings
D. Ventricular septal defect with left-to-right shunt
Correct Answer: C
Rationale: C is correct. Carvallo's sign (increased murmur intensity with inspiration) is
pathognomonic for tricuspid regurgitation, as increased venous return during inspiration
increases right ventricular stroke volume and regurgitant flow. Tricuspid involvement in
endocarditis (especially in IV drug users) produces this finding. The left lower sternal
border location and holosystolic timing are characteristic. Mitral regurgitation (A) does
not change with respiration. While tricuspid regurgitation (B) is present, option C
specifically captures the dynamic auscultatory finding (Carvallo's sign) that confirms the
diagnosis. VSD (D) is fixed and doesn't vary with respiration.
