NR 509/ NR509 Midterm Exam V2 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain.

…..DLDD NR 509/ NR509 Midterm Exam V2 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain. Q. 1. Which of the following statements best describes a differential diagnosis list? ANSWER It is a list of potential/plausible diagnoses that may be causing the signs and symptoms. Q. 2. A 66-year-old female presents to the primary care office with complaints of jaw pain, fatigue, and nausea for the last 48 hours. What course of action is appropriate in the treatment of this patient? ANSWER Recognize these could be atypical symptoms of acute coronary syndrome and proceed accordingly. Q. 3. In an adult over the age of 40, an S3 assessment finding on cardiac auscultation may be indicative of what? Select all that apply. ANSWER heart failure, normal for athletes, ventricular volume overload from aortic or mitral regurgitation Q. 4. A 72-year-old male is admitted to intensive care from the Emergency Room for the initial complaint of chest pain. After the history and physical examination, the NP documents the following cardiovascular findings: JVP is 5 cm above the sternal angle with the head of the bed elevated to 50°. Carotid upstrokes are brisk; a bruit is heard over the left carotid artery. The PMI is diffuse, 3 cm in diameter, palpated at the anterior axillary line in the fifth and sixth intercostal spaces. S1 and S2 are soft. S3 is present at the apex. High-pitched harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla. Which of the following possible diagnoses is based on the accurate interpretation of the assessment findings? ANSWER These findings suggest heart failure. Q. 5. A 76-year-old male presents to the office for a routine physical examination. The NP documents the following skin findings: Decreased elasticity with multiple lentiginous macules on habitually sun- exposed skin. Multiple, discrete, brown, stuck-on, non-indurated, verrucous plaques on the back and abdomen varying from 1-2 centimeters. Which of the following is the most accurate interpretation of these findings? ANSWER These findings suggest seborrheic keratoses. Q. 6. A 14-year-old male presents to the clinic with his grandmother for a complaint of a sore throat. The patient is afebrile and denies cough. After completing the history and physical examination, the NP documented the following partial assessment findings: Throat Oral mucosa pink, dental caries in lower molars, tongue midline, uvula, and pharynx erythematous, bilateral tonsils enlarged, no exudates. Neck Trachea midline. Neck supple; thyroid isthmus midline, lobes palpable but not enlarged. Lymph Nodes Submandibular and anterior cervical lymph nodes tender, 1 cm × 1 cm, rubbery and mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy. Which of the following is the most accurate interpretation of the findings? ANSWER These findings suggest pharyngitis. Q. 7. The NP is assuming care for a 56-year-old female resident of a long-term assisted living facility. The woman is seated in a wheelchair next to a window in her private room. After completing the history and physical examination, the NP documented the following mental status findings: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed. Clock drawing is good. Which of the following is the most accurate interpretation of the findings? ANSWER These findings suggest depression. Q. 8. The NP conducted a physical assessment on a 74-year-old male with a complaint of shortness of breath. His history is significant for a 20 pack-year history of smoking. He uses 2 inhalers daily (medication unknown) but did not bring them with him to his appointment. The documentation for the respiratory findings is as follows: Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm bilaterally. Which of the following is the most accurate interpretation of the findings? ANSWER These findings suggest COPD. Q. 9. A 28-year-old female presents to the office for an annual physical examination. The NP is evaluating the cranial nerves (CNs) while assessing the eyes. The findings are represented in this image. Damage or inflammation of which of the following cranial nerve(s) is demonstrated in this image? ADA Description: Eyes looking right and looking left. ANSWER CN III, IV, VI Q. 10. Otoscopic examination of the patient's left ear reveals the assessment findings represented in this image. What is the best documentation for the assessment findings of the tympanic membrane and external auditory canal? ANSWER ADA Description: Left ear, tympanic membrane, and external canal. Bulging TM with gray, translucent appearance. No effusion. Non- erythematous external canal without exudate. Q. 11. A 44-year-old female presents with a painful skin rash on her neck for several days (see image). How would you best document the integumentary findings? ANSWER ADA Description: Rash on the neck. grouped, 2-5 mm vesicles on erythematous base on left anterior neck in a dermatomal distribution that does not cross the midline Q. 12. An NP is caring for a patient with depression. The patient reports not feeling suicidal although still depressed on their current regimen of medication. Documenting the lack of suicidal ideation is an example of what important aspect of clinical documentation? ANSWER including pertinent negatives Q. 13. The NP is establishing rapport with a patient during an initial encounter and prepares to ask the patient how they would like to be addressed. What additional consideration should the NP acknowledge when asking patients about their pronouns? ANSWER When asking patients about their own pronouns, it can be helpful to share your own. Q. 14. Orthopnea and paroxysmal nocturnal dyspnea (PND) generally occur in the following conditions? Select all that apply. ANSWER left ventricular heart failure, mitral stenosis, & obstructive lung disease Q. 15. A 19-year-old male sustained a laceration to the ulnar aspect of his mid- forearm. He did not have his injury evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the NP expect to find the first signs of lymphadenopathy? ANSWER epitrochlear nodes 16. An NP is evaluating a 74-year-old female for an open wound on the right lower leg (see image). She denies injury and reports the wound is very painful. On examination, the NP does not note any odor from the wound or increased warmth with palpation. Based on history and physical examination, which of the following most likely explains her signs and symptoms? ADA Description: Right, lower leg with open wound above the lateral ankle chronic venous insufficiency 17. A 42-year-old male complains of pain in his left leg. He does not remember injuring his leg; however, he notes that there is a small wound on the lateral aspect of his mid-shin. Upon examination, some mild erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What do these streaks likely represent? draining lymphatic channels 18. A 61-year-old female was recently diagnosed with ovarian cancer. She has not been feeling well lately and presents to the clinic with a cough and some mild shortness of breath for the past couple of days as well as worsening pain and swelling in her right groin and leg for about a week. On physical examination, 2+ edema of the right leg up to the thigh; 1+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and no significant erythema are noted. Based on the history and symptomatology, the NP should consider which high-risk differential diagnosis? pulmonary embolism 19. When assessing for the femoral pulse, between which anatomical landmarks should the NP begin deeply palpating? below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis 20. A 73-year-old male presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x-ray are normal. The NP notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on the history and physical examination, which of the following will most likely explain his signs and symptoms? dissecting aortic aneurysm 21. A 68-year-old female complains of a 3-month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid-calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following? neurogenic claudication 22. A 70-year-old male presents with progressive shortness of breath and two-pillow orthopnea. On physical examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other murmurs or thrills are auscultated on the physical exam. Which of the following interventions is most likely to improve the symptoms? removal of intravascular volume with diuresis 23. A 21-year-old male is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding? atrial septal defect 24. An NP student is examining a patient with a structurally normal heart. The student is having difficulty auscultating the splitting of the second heart sound. At what area on the chest would the student have the best opportunity of hearing this sound? second and third intercostal space at the left sternal border 25. A 77-year-old male is experiencing progressive shortness of breath and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valve condition? aortic stenosis 26. An 89-year-old female with a history of smoking two packs of cigarettes a day for 50 years complains to her NP of progressive shortness of breath. Downloaded at Knoowy - Upload your own study documents and earn money lOMoARcPSD| On cardiac examination, the NP finds the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what condition? pulmonary hypertension 27. A 16-year-old male arrives at the Emergency Department (ED) for shortness of breath following a motor vehicle accident. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The acute care NP decides that a chest tube needs to be placed in the fourth intercostal space. What steps are necessary to determine the accurate location of the fourth intercostal space? First, find the sternal angle and then move laterally to the second rib. Next, in descending order, move down to the second intercostal space, third rib, third intercostal space, fourth rib, and then the fourth intercostal space. 28. After examining a patient who is in the hospital for shortness of breath, percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice Which of the following is the most likely etiology? atelectasis 29. A 29-year-old male presents to the clinic with a cough for 2 months. When he lowers his gown so the NP can listen to his lungs, the NP notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest? pectus excavatum 30. An NP is percussing the lungs of a patient with chronic obstructive pulmonary disease (COPD) for resonance. Which of the following is an example of good percussion technique? Strike using the tip of the third finger. 31. An 18-year-old male presents to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had a fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma? wheezes 32. A 74-year-old female patient presents with a complaint of palpitations. While checking her pulse, you notice an irregular rhythm. During auscultation, you note every fourth beat sounds different. It sounds like a would you document your examination findings? regularly irregular rhythm 33. Regarding the eyes, which of the following physical assessment findings are expected as part of the normal aging process? blurring of near vision 34. An 81-year-old male presents to the vascular clinic with a painful sore on his right leg. On examination, the NP notes an ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely associated with these assessment findings? venous insufficiency 35. A 61-year-old female presents with the complaint of cough for 1 week. She is a smoker. The pulmonary examination revealed positive egophony with E-to-A change in the left lower lobe and crackles on auscultation. These assessment findings are strongly indicative of what etiology? lobar pneumonia 36. A 37-year-old female presents with left lower extremity swelling and redness that extends from the foot to the mid-calf. Her posterior calf is tender with palpation during knee extension and dorsiflexion of the left foot. The right lower extremity is unremarkable. She denies fever or injury. Which of the following history findings would be most significant given the presenting complaint? 12-hour car trip three days ago for a holiday visit 37. You are examining a 60-year-old male with a long-standing history of chronic obstructive pulmonary disease (COPD). The patient reports smoking since he was a teenager. Which of the following physical examination finding(s) are expected with the patient presentation? Select all that apply. AP diameter that exceeds 0.9, generalized hyperresonance to percussion over the lung fields 38. A 25-year-old female comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur? mitral murmur 39. Proper positioning of the patient is critically important during the physical assessment. During the physical examination, which is the best position to place the patient when assessing for the murmur of aortic regurgitation? sitting, leaning forward 40. Proper positioning of the patient during the physical examination is fundamental to conducting an effective and efficient cardiovascular assessment. During the physical examination, which is the best position to place the patient when auscultating for S1, S2, and murmurs? lying on the left side 41. A 40-year-old male presents with daily headaches that have worsened over the past several months. The headaches are worse with lying down and persist throughout the day. On funduscopic examination of the right eye, you note that the disk edge is indistinct, and the veins do not pulsate. What medical condition is most closely associated with these physical assessment findings? increased intracranial pressure 42. A 45-year-old male has noticed multiple small, blood-red, raised lesions over his chest and abdomen for the past several months. They are not painful, and he has not noted any bleeding or bruising. On physical examination, the NP notes more than 75 discrete, raised, red papules of varying size between 0.1-0.4 cm as represented in this image. Which of the following actions if taken by the NP is an appropriate next step? ADA Description: Bare chest with multiple scattered, discrete, red, papules. Reassure him that there is nothing to worry about. 43. A 15-year-old male presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on the history and physical examination findings, what is the most likely diagnosis? subconjunctival hemorrhage 44. A 32-year-old female presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear for about a week. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is unremarkable. What diagnosis would you assign this patient based on physical assessment findings? acute otitis externa 45. A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the tuning fork better on the left. Which of the following is most likely? otosclerosis of the left ear 46. A 21-year-old female presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. Which group of lymph nodes is this? posterior cervical lymph node group 47. When testing for nystagmus, the NP instructs the patient to: fix their gaze in the right and left peripheral fields 48. Identify the anatomical landmark on the neck between the fingers in this image. ADA Description: hands bilaterally on the anterior neck cricoid cartilage 49. A 57-year-old male complains of a tender growth under his tongue. He reports a history of cigarette use, but not for 20 years. He also reports a non- productive cough and general malaise. Upon inspection, you note the lesion cannot be removed and bleeds slightly when touched with a tongue blade. What medical condition is most likely associated with the history and physical exam findings? carcinoma on the tongue 51. Examination of the nose of a 27-year-old male during a routine appointment reveals the following (see red oval in the image). The patient denies pain, injury, or difficulty smelling. What medical condition is associated with this physical examination finding? ADA Description: Left nare with partial obstruction of the vestibule nasal polyp 52. A 25-year-old male complains of a swishing noise in both ears that never goes away for about 6 months. He is otherwise healthy, can work on his job (operating large, vibrating machinery) without problems, and is not taking any medications. A complete examination reveals an abnormality. Which abnormality is most often associated with tinnitus in this patient demographic? vertigo 53. An 82-year-old male is speaking loudly during an examination, suggesting that he may not be hearing well. What is a good question to ask him to help identify whether he has hearing loss? How well do you understand people in a noisy environment such as a restaurant 54. A 70-year-old male complains of double vision. Which of the following associated symptoms or signs discovered during the history and physical examination would be worrying about an underlying neurological problem (as opposed to pathology in the eye)? abnormality in extraocular movements on examination 55. Which of the following statements is true regarding aphasia? It is defined as an inability to produce or understand language. 56. Abstract thinking is an important component of the human thought process. A ability to understand questions that test his or her ability to answer appropriately is dependent upon several factors. Which one of the following answers is true in identifying a patient with concrete thinking and a reduced ability to think abstractly? an inability to discern the similarity between two words (e.g., a cat and a mouse by answering cat chases the mouse) 57. Which complaints/findings are considered patient identifiers for mental health screening? Select all that apply. substance abuse history, depression symptoms lasting longer than 6 weeks 58. A 42-year-old male presents with widespread pain. He reports almost daily headaches, pain in his back from an old motor vehicle accident, and generalized achiness and hypersensitivity throughout the body. He recounts ongoing pain since his early 20s and has sought treatment from several providers. Which of the following statements is true regarding chronic pain? Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for more than 3 6 months. 59. A 19-year-old male presents to the clinic after a syncopal episode. During your general survey, you note that he is very thin for his height. He admits that he eats only minimally to maintain a very low body weight that he feels is ideal. You suspect that he may have an eating disorder. Concerning the two most common eating disorders (anorexia nervosa and bulimia nervosa), which of the following statements is true? Both of these eating disorders are associated with a real or imagined fear of appearing fat 60. A 58-year-old male presents for his annual physical examination. The NP notes a systolic murmur on auscultation of the aorta. However, the NP does not immediately conclude that this patient has aortic stenosis. Which of the following is the accurate rationale for seeking additional information? systolic murmurs have high sensitivity but low specificity for aortic stenosis 61. A 45-year-old male presents to the clinic complaining of intense substernal chest pain and nausea. He appears pale and sweaty. At work that day, he filled in for an absent co-worker and was asked to perform heavy lifting not normally a part of his job. The NP questions the patient in detail about his nausea, eating habits, and digestive history. Which of the following steps of clinical reasoning has the NP failed to follow? give special consideration to potentially life-threatening problems 62. An NP student is interviewing an 80-year-old new patient brought to the obtains information about childhood illnesses and adult illnesses and then moves on to inquire about the family history. Which important area of the past medical history (PMH) was omitted? immunizations 63. A 65-year-old male presents to the office for an unscheduled visit. He complains of recurrent headaches. The patient reports gradual onset of dizziness and occasional numbness on the left side. Which of the following body systems or regions should be a priority focus during the physical assessment? neurological 64. A 59-year-old man presents to the office for a scheduled visit. He complains of feeling tired and hungry, despite getting sufficient rest and having a good appetite and access to food. The patient is obese and is wearing thermal socks with his sandals despite the warm weather outside. He says this is because his feet are always cold which body system should the NP begin the examination? head and neck 65. A 26-year-old male presents to the free clinic. He reports having active hepatitis C from intravenous drug use. He also suffers from uncontrolled asthma since childhood and bipolar disorder. On visit, his main concern is an abscess in his right arm at a heroin injection site. Which of the following is the best approach to the health history for this patient at his first visit? a comprehensive health history 66. A 29-year-old male complains of persistent cough and wheezing, particularly when he exercises. He says he smokes cigarettes "occasionally" and vapes e-cigarettes 3 times daily. Upon hearing this information, what is the best next step for the NP to proceed? determine the number of pack-years the patient smokes 67. A 16-year-old female presents to the office with his mother to establish care. The patient underwent treatment for sarcoma including an above-the- knee amputation 3 years ago. Since then, she has learned to ambulate with a prosthetic leg and recently began talking about sports again. The patient is very engaged in most of the visit, but when the topic of cancer arises, she becomes quiet. Which of the following statements would help to build trust between the provider and the patient? sounds like a frightening experience that you are recovering well 68. A 59-year-old male complains of several episodes of epigastric pain. His father died of pancreatic cancer at age 52 years. He recalls, pain was just like mine is now . . . The NP replies, Just like? after which the patient restarts his narrative. Which of the following is an example of the interviewing techniques employed by the NP? Echoing 69. A 65-year-old male presents as a new patient. He wishes to discuss issues with erectile dysfunction and fatigue. As the interview continues, the NP becomes suspicious that the patient is suffering from decompensated heart failure. When the patient mentions that he has had vague chest pain since last night, the NP feels that the focus must be redirected to this potentially emergent condition. Which of the following interview techniques is the most appropriate to effectively manage this visit? moving from open-ended to focused questions 70. A 38-year-old female is a well-established patient. She complains of irregular menstrual periods and pelvic pain. She says that she is having trouble sleeping and asks whether she could be given a The patient also says she is thinking of leaving her job. What is the best in caring for this patient? obtain a more complete description of problems 71. A 44-year-old female presents for follow-up care. She was diagnosed with systemic lupus erythematosus 6 months ago. Since her diagnosis, she has been minimally compliant with medications. The NP elects to explore the issues using the FIFE model to guide the encounter. Which of the following best defines the elements of the FIFE model? feelings, ideas, function, and expectations 72. A 17-year-old male presents to a sexually transmitted disease clinic. He prefers same-sex partners and is afraid that he contracted an infection from his last partner. The patient expresses that he is nervous and embarrassed by the situation. The nurse practitioner wishes to best connect with the patient at this critical juncture in his care with the clinic and ease his discomfort. Which of the following is an example of an active listening technique? using nonverbal communication to encourage the patient to expand their narrative 73. A 34-year-old male presents to the clinic to establish care. The patient has experienced several adversarial relationships with prior providers. He voluntarily left two practices within the previous year and was discharged from a third clinic due to misbehavior. The NP desires to utilize an approach to this patient that will most likely lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the NP to use? Permit the patient to lead the encounter to understand their thoughts, ideas, concerns, and requests. 74. A 23-year-old nurse practitioner (NP) student found that she felt nervous when called upon to examine men in her age group. On one occasion, she encountered a young male patient who appeared embarrassed to see her walk into the room. Which action if taken by the student would help to minimize their mutual discomfort? explain how the examination will proceed 75. A 62-year-old male presents to the urgent care clinic with complaints of pain, numbness, and tingling in the foot and lower leg for 3 hours. On physical examination, the NP notes the affected foot is cold, pale, and pulseless. Which action, if taken by the NP, is an appropriate next step? Refer the patient for emergency evaluation and treatment. 76. The usual starting position for the head of the bed or examining table when assessing jugular venous pressure (JVP) is? 30 degrees 77. A newborn has an embryologic defect affecting the aortic valve. What additional valve is most likely to be affected? pulmonic valve 78. A 13-year-old female is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When symptomatic, she also notices tingling around her lips. Her history and physical examination are unremarkable. Which of the following is the most likely etiology? situational anxiety 79. What assessment technique is being performed in this image? ADA Description: hands on bilateral thoracic back checking for lung expansion 80. The NP is performing a cardiac assessment on a 64-year-old male with a history of congestive heart failure (CHF) with left ventricular hypertrophy (LVH). Which of the following assessment findings is indicative of displacement of the point of maximal impulse (PMI)? PMI diameter measures 2.5 cm 81. A 12-year-old female complains of fullness as well as in the ear and sometimes pain. During the physical assessment you note mild conduction hearing loss. Identify the abnormal assessment findings in this image. What medical condition is associated with these findings? serous effusion 82. A 74-year-old male complains of non-traumatic right eye pain for 1 day. He suspects something accidentally got into his eye but does recall this happening. After flushing out his eye, the pain and blurred vision remains and is getting worse. His visual acuity is 20/20 OS and 20/100 OD. Which action if taken by the NP is the best next step? Refer to an ophthalmologist emergently for the possibility of a corneal ulcer, uveitis, or acute glaucoma. 83. A 42-year-old fair-skinned woman presents with an abnormal skin growth that was first noted 7 years ago. On examination, the NP notes a 2 × 3-cm lesion over her left bicep. Which of the following historical elements should raise the suspicion for malignancy? minimal but discernible increase in size over the past 6 months 84. Concerning hallucinations, an abnormal perception experienced by a patient, which of the following statements are true about this abnormality? Select all that apply. It may occur in association with several conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. Alcohol is a known cause of hallucinations. Of the following statements, which are true concerning mental health disorders in primary care? Select all that apply. Mood disorders make up approximately 25% of all diagnoses. Alcohol and substance abuse are considered mental health disorders. Somatoform disorders comprise 10% to 15% of mental health disorders and are relatively common. 86. Weight change may indicate the presence of important underlying pathology requiring further investigation. Which of the following patient scenarios best describes a significant weight change that requires further evaluation? a 45-year-old male with a baseline weight of 280 lb. who decides to undertake a light exercise regimen and loses 15% of his total body weight in 3 months 87. A 32-year-old female reports excessive stress at work and pain in the right lower quadrant. She states that last night she vomited twice. Her blood pressure is 120/75, heart rate is 93 bpm. The patient looks pale and is sweating lightly. Which of these assessment findings are objective? Select all that apply. An 18-year-old patient comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis? Pityriasis rosea A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis? Tinea versicolor You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, a sustained "beating" of the foot against your hand ensues. What does this represent? Clonus A patient presents with a daily headache which has worsened over the past several months. On funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate. Which is most likely? Increased intracranial pressure A patient complains of epistaxis. Which other cause should be considered? Hematemesis A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these? Heart failure You are excited about a positive test finding you have just noticed on physical examination of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only to find that there is no sign of the disease you thought would correlate with the finding. This same experience happens several times. What should you conclude? Continue using the test, perhaps doing less laboratory work and diagnostics. A 50-year-old woman presents with a new complaint of headache. The patient states, "this is worst headache of my life". Her concurrent conditions includes hypertension. Her history includes habitual ER visits for various complaints and panic attacks. Her most recent ER visit was last week. Today her BP is 200/110 with a HR of 95. Of the following diagnoses, which etiology has the highest priority? Subarachnoid hemorrhage A patient with alcoholism is brought in with confusion. You ask him to "stop traffic" with his palms and notice that every few seconds his palms suddenly move toward the floor. What does this indicate? Metabolic problems A 29-year-old computer programmer comes to your office for evaluation of a headache. The tightening sensation is located all over the head and is of moderate intensity. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain but not taken it away. Based on this description, what is your most likely diagnosis? Tension A 62-year-old smoker complains of "coughing up small amounts of blood," so you consider hemoptysis. Which other diagnoses should also be considered as an etiology for the complaint? Epistaxis You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system? Corticospinal tract When assessing for mitral stenosis, you should place the patient in what position? left lateral decubitus position A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient? Otitis externa When assessing for nystagmus the nurse practitioner instructs the patient to: fix their gaze on an object located in the distance A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? Orthopnea Which is true of examination of the olfactory nerve? Diminished responses may be seen in otherwise normal elderly. During the physical examination, which is the best position to place the patient when auscultating for S1, S2, and murmurs? Lying Supine For which of the following patients would a comprehensive health history be appropriate? A new patient with the chief complaint of "I am here to establish care" Identify the abnormal assessment findings in this image. Cotton-wool patches A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? Asthma A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She can see at 20 feet what a normal person could see at 100 feet. While examining a 43-year-old Hispanic female patient, you discover skin findings as represented in this image. She denies history of any known or diagnosed adult illnesses or medical conditions. What associated concurrent medical condition should you suspect? Diabetes mellitus Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination? Increased cup-to-disc ratio A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following diagnoses is still a potential concern? Hypertensive retinopathy A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type? Absence You have just asked a patient how he feels about his emphysema. He becomes silent, folds his arms across his chest and leans back in his chair, and then replies, "It is what it is." How should you respond? "You seem bothered by this question." A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? Posterior cervical A 55-year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture? Angina pectoris A 65-year-old woman presents to the clinic with an eye complaint. The medical assistant documents the visual acuity: Corrected right 20/40; Corrected left 20/60; Bilateral 20/60. The nurse practitioner surmises the following: The patient could read the 20/60 line with the left eye with glasses The following information is best placed in which category? "The patient has had three cesarean sections." Surgeries A 17-year-old high school student is brought in to your emergency room in a comatose state. His friends have accompanied him and tell you that they have been shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight. What size pupils do you expect to see in this comatose patient? Pinpoint pupils Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient? Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you. When using an interpreter to facilitate an interview, where should the interpreter be positioned? Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient The following information is best placed in which category? "The patient was treated for an asthma exacerbation in the hospital last year; the patient has never been intubated." Adult illnesses Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient-provider interview? Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story. Which cranial nerve is being assessed by the examiner in this image? XI A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test should you perform to assess for a herniated disc? Straight-leg raise When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate? Ask if it's okay to carry out the visit with both people in the room. You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is supported by the examiner and abducted to 90 degrees, he can then move his forearm side to side. This would represent which muscle strength grading? 2 Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted? Associated manifestations A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process? Allergic What is responsible for the inspiratory splitting of S2? Closure of aortic, then pulmonic valves A 19-year-old college sophomore comes to the clinic for evaluation of joint pains. The student has been back from spring break for 2 weeks; during her holiday, she went camping. She notes that she had a red spot, shaped like a target, but then it started spreading, and then the joint pains started. She used insect repellant but was in an area known to have ticks. She has never been sick and takes no medications routinely; she has never been sexually active. What is the most likely cause of her joint pain? Lyme disease You are performing a cranial nerve assessment of a 28-year-old female. She denies history of head injury or trauma. However, she has been treated in the past year for Lyme disease. Damage or inflammation of which of the following cranial nerves is demonstrated in this image? CN VI The components of the health history include all of the following except which one? Thorax and lungs Sudden, painful unilateral loss of vision may be caused by which of the following conditions? Optic neuritis Mark is a contractor who recently injured his back. He was told he had a "bulging disc" to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint? Cartilaginous You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning? Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer Which of the following anatomic landmark associations is correct? 2nd intercostal space for needle insertion in tension pneumothorax Common or concerning symptoms to inquire about in the Constituitional portion of the Review of Symptoms include all of the following except: Hemoptysis You are conducting a mental status examination and note impairment of speech and judgement, but the rest of your examination is intact. Where is the most likely location of the problem? Cerebrum A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading? Blood pressure cuff is tightly fitted. Which of the following findings are indicative of respiratory distress? Skin between the ribs moves inward with inspiration The following information is recorded in the comprehensive health history for a patient who is establishing care and has no focused concerns: "Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea." Which category does it belong to? Review of systems A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely? CN X lesion on the right A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient? Age A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? Subconjunctival hemorrhage A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for several years. He normally takes over-the-counter medications to ease the pain, but this time they haven't worked as well and he still has discomfort. He recently wallpapered the entire second floor in his house, which caused him great discomfort. The pain resolved with rest. He denies fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this description, what is the most likely pathologic process? Degenerative The following information is recorded in the health history: "The patient completed 8th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week." Which category does it belong to? Personal and social history Ms. Fields is a pleasant, obese female with a BMI of 39. BP 120/82, HR 80, R 18, Oxygen Saturation 98%. This information is: Objective Two weeks ago, Mary started a job which requires carrying 40-pound buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have? TENNIS ELBOW Lateral epicondylitis A 43-year-old female patient presents with concern about her skin lightening over the past 3 months. The findings are represented in this image. She denies recent illness or infection. Her physical examination is otherwise unremarkable. Which laboratory study is most important to include with her work-up? Thyroid panel consisting of TSH, free T3, and free T4 levels Mr. Tommie, a 48-year-old African American contractor, reports pain of the right great toe. "Feels like a ton of bricks fell on my foot". The pain extends up his legs. This information is: Subjective The nurse practitioner is assessing a patient's chief complaint of shoulder pain that started about 3 weeks ago. Upon physical exam, findings reveal atrophy of the supraspinatus and increased prominence of the scapular spine, pain with shoulder movement, and a positive drop arm test. The most likely diagnosis for these findings is: rotator cuff tendinitis or tear Common or concerning symptoms to inquire about during the constitutional survey of the ROS include all of the following EXCEPT: Cough A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small "pits" in his nails. What would account for these findings? SILVER Psoriasis You are conducting a physical examination on an 82-year-old male patient. You lift his shirt and discover skin lesions as represented in this image. What is you immediate next course of action? Reassure the patient the lesions are benign Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of breath. The shortness of breath occurs with exertion and improves with rest. It has been going on for several months and initially occurred only a couple of times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description? Severity A 38-year-old woman comes to you and has multiple small joints involved with pain, swelling, and stiffness. Which of the following is the most likely explanation? *Multiple small joints* gout is one Rheumatoid arthritis You examine a "sleepy" patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness? Obtunded In this image, what test is being performed? Weber