NR509 Advanced Physical Assessment
COMPREHENSIVE PRACTICE EXAM — 120
Questions 2025/2026 Edition | All Topics
Covered | Answer Rationales Included
Question 1
A 62-year-old male presents with complaints of exertional chest pressure that
resolves with rest. During auscultation, you appreciate a soft, high-pitched
decrescendo diastolic murmur best heard at the left sternal border. Which
maneuver would MOST increase the intensity of this murmur?
A. Handgrip exercise
B. Valsalva maneuver
C. Rapid squatting
D. Standing abruptly
✓ Correct Answer-: A
Rationale: This murmur is classic for aortic regurgitation. Handgrip exercise
increases systemic vascular resistance, which increases aortic regurgitation and
the intensity of the murmur. Valsalva and standing decrease preload and typically
decrease most murmurs except HOCM and MVP.
Question 2
A 55-year-old woman with a history of hypertension presents for routine
examination. You note a sustained, nondisplaced left ventricular apical impulse.
This finding is MOST consistent with:
A. Left ventricular hypertrophy
B. Left ventricular dilation
C. Right ventricular hypertrophy
D. Normal variant
,✓ Correct Answer-: A
Rationale: A sustained apical impulse (lasting through more than the first half of
systole) indicates pressure overload of the left ventricle, as seen in hypertension
or aortic stenosis. Left ventricular dilation would produce a displaced, diffuse
PMI.
Question 3
During cardiac auscultation, you appreciate an S4 heart sound. This finding is
associated with which of the following pathophysiologic mechanisms?
A. Increased ventricular compliance
B. Decreased ventricular compliance
C. Rapid ventricular filling in early diastole
D. Premature closure of the mitral valve
✓ Correct Answer-: B
Rationale: S4 (atrial gallop) occurs during atrial systole when a noncompliant
ventricle resists filling. It is associated with conditions that decrease ventricular
compliance, such as hypertension, aortic stenosis, hypertrophic cardiomyopathy,
and myocardial ischemia.
Question 4
A 48-year-old man presents with palpitations. On examination, you note an
irregularly irregular heart rhythm with variable S1 intensity. There are no audible
murmurs. The most likely diagnosis is:
A. Sinus arrhythmia
B. Atrial fibrillation
C. Premature ventricular contractions
D. Atrial flutter with variable block
✓ Correct Answer-: B
,Rationale: Atrial fibrillation produces an irregularly irregular rhythm with loss of
consistent AV synchrony, resulting in variable S1 intensity. The absence of
consistent AV conduction distinguishes it from atrial flutter with variable block,
which typically has some regularity to the irregularity.
Question 5
A 70-year-old female is noted to have a high-pitched early diastolic murmur best
heard at the left sternal border. BP is 150/50 mmHg with bounding pulses. Which
of the following is the MOST likely diagnosis?
A. Mitral stenosis
B. Aortic regurgitation
C. Pulmonic stenosis
D. Tricuspid regurgitation
✓ Correct Answer-: B
Rationale: Aortic regurgitation produces a high-pitched, blowing decrescendo
diastolic murmur best heard at the left sternal border (Erb's point). Widened
pulse pressure and bounding pulses (Corrigan's sign) are associated findings due
to increased stroke volume and rapid runoff.
Question 6
A patient with known hypertrophic obstructive cardiomyopathy (HOCM)
undergoes a physical examination. Which maneuver would be expected to
DECREASE the intensity of the systolic murmur?
A. Valsalva maneuver
B. Standing from squatting position
C. Squatting from standing position
D. Administration of nitroglycerin
✓ Correct Answer-: C
, Rationale: In HOCM, squatting increases venous return (preload) and afterload,
which decreases the degree of obstruction and softens the murmur. All
maneuvers that decrease preload (Valsalva, standing, nitroglycerin) increase
obstruction and intensify the murmur.
Question 7
Auscultation of the heart reveals a mid-systolic click followed by a late systolic
murmur at the apex. When the patient stands suddenly, the click moves closer to
S1. This change indicates:
A. Increased left ventricular volume
B. Decreased left ventricular volume
C. Increased left ventricular pressure
D. Decreased heart rate
✓ Correct Answer-: B
Rationale: In mitral valve prolapse, standing decreases venous return and left
ventricular volume, causing the mitral valve leaflets to prolapse earlier in systole.
This moves the click closer to S1. Squatting has the opposite effect, moving the
click toward S2.
Question 8
A 65-year-old male with a history of myocardial infarction presents with dyspnea
on exertion. Cardiac auscultation reveals a holosystolic murmur at the apex
radiating to the axilla. This finding is MOST consistent with:
A. Tricuspid regurgitation
B. Mitral regurgitation
C. Ventricular septal defect
D. Aortic stenosis
✓ Correct Answer-: B
COMPREHENSIVE PRACTICE EXAM — 120
Questions 2025/2026 Edition | All Topics
Covered | Answer Rationales Included
Question 1
A 62-year-old male presents with complaints of exertional chest pressure that
resolves with rest. During auscultation, you appreciate a soft, high-pitched
decrescendo diastolic murmur best heard at the left sternal border. Which
maneuver would MOST increase the intensity of this murmur?
A. Handgrip exercise
B. Valsalva maneuver
C. Rapid squatting
D. Standing abruptly
✓ Correct Answer-: A
Rationale: This murmur is classic for aortic regurgitation. Handgrip exercise
increases systemic vascular resistance, which increases aortic regurgitation and
the intensity of the murmur. Valsalva and standing decrease preload and typically
decrease most murmurs except HOCM and MVP.
Question 2
A 55-year-old woman with a history of hypertension presents for routine
examination. You note a sustained, nondisplaced left ventricular apical impulse.
This finding is MOST consistent with:
A. Left ventricular hypertrophy
B. Left ventricular dilation
C. Right ventricular hypertrophy
D. Normal variant
,✓ Correct Answer-: A
Rationale: A sustained apical impulse (lasting through more than the first half of
systole) indicates pressure overload of the left ventricle, as seen in hypertension
or aortic stenosis. Left ventricular dilation would produce a displaced, diffuse
PMI.
Question 3
During cardiac auscultation, you appreciate an S4 heart sound. This finding is
associated with which of the following pathophysiologic mechanisms?
A. Increased ventricular compliance
B. Decreased ventricular compliance
C. Rapid ventricular filling in early diastole
D. Premature closure of the mitral valve
✓ Correct Answer-: B
Rationale: S4 (atrial gallop) occurs during atrial systole when a noncompliant
ventricle resists filling. It is associated with conditions that decrease ventricular
compliance, such as hypertension, aortic stenosis, hypertrophic cardiomyopathy,
and myocardial ischemia.
Question 4
A 48-year-old man presents with palpitations. On examination, you note an
irregularly irregular heart rhythm with variable S1 intensity. There are no audible
murmurs. The most likely diagnosis is:
A. Sinus arrhythmia
B. Atrial fibrillation
C. Premature ventricular contractions
D. Atrial flutter with variable block
✓ Correct Answer-: B
,Rationale: Atrial fibrillation produces an irregularly irregular rhythm with loss of
consistent AV synchrony, resulting in variable S1 intensity. The absence of
consistent AV conduction distinguishes it from atrial flutter with variable block,
which typically has some regularity to the irregularity.
Question 5
A 70-year-old female is noted to have a high-pitched early diastolic murmur best
heard at the left sternal border. BP is 150/50 mmHg with bounding pulses. Which
of the following is the MOST likely diagnosis?
A. Mitral stenosis
B. Aortic regurgitation
C. Pulmonic stenosis
D. Tricuspid regurgitation
✓ Correct Answer-: B
Rationale: Aortic regurgitation produces a high-pitched, blowing decrescendo
diastolic murmur best heard at the left sternal border (Erb's point). Widened
pulse pressure and bounding pulses (Corrigan's sign) are associated findings due
to increased stroke volume and rapid runoff.
Question 6
A patient with known hypertrophic obstructive cardiomyopathy (HOCM)
undergoes a physical examination. Which maneuver would be expected to
DECREASE the intensity of the systolic murmur?
A. Valsalva maneuver
B. Standing from squatting position
C. Squatting from standing position
D. Administration of nitroglycerin
✓ Correct Answer-: C
, Rationale: In HOCM, squatting increases venous return (preload) and afterload,
which decreases the degree of obstruction and softens the murmur. All
maneuvers that decrease preload (Valsalva, standing, nitroglycerin) increase
obstruction and intensify the murmur.
Question 7
Auscultation of the heart reveals a mid-systolic click followed by a late systolic
murmur at the apex. When the patient stands suddenly, the click moves closer to
S1. This change indicates:
A. Increased left ventricular volume
B. Decreased left ventricular volume
C. Increased left ventricular pressure
D. Decreased heart rate
✓ Correct Answer-: B
Rationale: In mitral valve prolapse, standing decreases venous return and left
ventricular volume, causing the mitral valve leaflets to prolapse earlier in systole.
This moves the click closer to S1. Squatting has the opposite effect, moving the
click toward S2.
Question 8
A 65-year-old male with a history of myocardial infarction presents with dyspnea
on exertion. Cardiac auscultation reveals a holosystolic murmur at the apex
radiating to the axilla. This finding is MOST consistent with:
A. Tricuspid regurgitation
B. Mitral regurgitation
C. Ventricular septal defect
D. Aortic stenosis
✓ Correct Answer-: B
