NSG 550 Exam 3 Diagnostic Reasoning (2026/2027)
PDF | Nursing | Wilkes University, Exams of Nursing
Section 1: High-Risk Presentations & “Can’t Miss” Diagnoses (Q1–20)
1. A 45-year-old with sudden onset “worst headache of life,” neck stiffness,
and photophobia. Immediate next step?
A) MRI brain
B) Noncontrast CT head
C) Lumbar puncture
D) CTA head
Answer: B
Rationale: Noncontrast CT head is first-line to rule out subarachnoid
hemorrhage.
2. A 60-year-old with acute chest pain, tearing sensation radiating to back,
BP 200/110, difference in arm BPs. Most likely?
A) MI
B) Aortic dissection
C) Pulmonary embolism
D) Pericarditis
Answer: B
Rationale: Tearing pain + BP differential = aortic dissection until proven.
3. A 35-year-old with acute shortness of breath, pleuritic chest pain, and
unilateral leg swelling. Most likely?
A) Pneumonia
B) Pulmonary embolism
C) Asthma
D) Costochondritis
Answer: B
Rationale: Leg swelling + dyspnea = PE until proven.
,4. A 55-year-old with acute epigastric pain radiating to back, nausea, and
history of heavy alcohol use. Lipase 1500. Most likely?
A) Peptic ulcer disease
B) Acute pancreatitis
C) Cholecystitis
D) Mesenteric ischemia
Answer: B
Rationale: Lipase >3x upper limit of normal = acute pancreatitis.
5. A 25-year-old with acute scrotal pain, nausea, vomiting, and absent
cremasteric reflex. Most critical next step?
A) Urinalysis
B) Ultrasound with Doppler
C) Surgical exploration
D) Antibiotics
Answer: C
Rationale: High suspicion for testicular torsion → immediate surgical
exploration (time is testicle).
6. A 70-year-old with acute onset aphasia, right-sided weakness, and atrial
fibrillation. Last known well 90 minutes ago. Next step?
A) Aspirin 325 mg
B) Noncontrast CT head
C) CTA head/neck
D) MRI brain
Answer: B
Rationale: Noncontrast CT to rule out hemorrhage before thrombolysis.
7. A 40-year-old with acute vision loss, painful red eye, and halos around
lights. Most likely?
A) Retinal detachment
B) Acute angle-closure glaucoma
,C) Optic neuritis
D) Migraine
Answer: B
Rationale: Painful red eye + vision loss + halos = acute glaucoma emergency.
8. A 50-year-old with fever, nuchal rigidity, and altered mental status.
Immediate step after ABCs?
A) CT head
B) Lumbar puncture
C) Blood cultures
D) IV antibiotics
Answer: A
Rationale: CT before LP if suspect mass lesion or herniation risk.
9. A 30-year-old with acute chest pain, pericardial rub, and diffuse ST
elevation. Most likely?
A) STEMI
B) Pericarditis
C) Pulmonary embolism
D) Early repolarization
Answer: B
Rationale: Pericardial rub + diffuse ST elevation = acute pericarditis.
10. A 65-year-old with acute back pain, fever, and history of IV drug use.
Most likely?
A) Muscular strain
B) Vertebral osteomyelitis
C) Compression fracture
D) Metastatic cancer
Answer: B
Rationale: Fever + back pain + IVDU = discitis/osteomyelitis.
, 11. A 60-year-old with painless jaundice, weight loss, and palpable
gallbladder. Most likely?
A) Choledocholithiasis
B) Pancreatic cancer
C) Hepatitis
D) Gallstones
Answer: B
Rationale: Courvoisier’s law = pancreatic cancer.
12. A 55-year-old with acute shortness of breath, unilateral leg swelling, and
tachycardia. Wells PE score 6. Next step?
A) D-dimer
B) CTPA
C) V/Q scan
D) Lower extremity ultrasound
Answer: B
Rationale: High Wells score → CTPA directly.
13. A 45-year-old with acute severe headache, hypertension, and nausea. BP
220/120. Most likely?
A) Migraine
B) Hypertensive emergency with posterior reversible encephalopathy
syndrome (PRES)
C) Tension headache
D) Cluster headache
Answer: B
Rationale: Severe hypertension + headache = PRES or hypertensive
encephalopathy.
14. A 70-year-old with acute abdominal pain, bloody diarrhea, and atrial
fibrillation. Most likely?
A) Ulcerative colitis
B) Ischemic colitis
PDF | Nursing | Wilkes University, Exams of Nursing
Section 1: High-Risk Presentations & “Can’t Miss” Diagnoses (Q1–20)
1. A 45-year-old with sudden onset “worst headache of life,” neck stiffness,
and photophobia. Immediate next step?
A) MRI brain
B) Noncontrast CT head
C) Lumbar puncture
D) CTA head
Answer: B
Rationale: Noncontrast CT head is first-line to rule out subarachnoid
hemorrhage.
2. A 60-year-old with acute chest pain, tearing sensation radiating to back,
BP 200/110, difference in arm BPs. Most likely?
A) MI
B) Aortic dissection
C) Pulmonary embolism
D) Pericarditis
Answer: B
Rationale: Tearing pain + BP differential = aortic dissection until proven.
3. A 35-year-old with acute shortness of breath, pleuritic chest pain, and
unilateral leg swelling. Most likely?
A) Pneumonia
B) Pulmonary embolism
C) Asthma
D) Costochondritis
Answer: B
Rationale: Leg swelling + dyspnea = PE until proven.
,4. A 55-year-old with acute epigastric pain radiating to back, nausea, and
history of heavy alcohol use. Lipase 1500. Most likely?
A) Peptic ulcer disease
B) Acute pancreatitis
C) Cholecystitis
D) Mesenteric ischemia
Answer: B
Rationale: Lipase >3x upper limit of normal = acute pancreatitis.
5. A 25-year-old with acute scrotal pain, nausea, vomiting, and absent
cremasteric reflex. Most critical next step?
A) Urinalysis
B) Ultrasound with Doppler
C) Surgical exploration
D) Antibiotics
Answer: C
Rationale: High suspicion for testicular torsion → immediate surgical
exploration (time is testicle).
6. A 70-year-old with acute onset aphasia, right-sided weakness, and atrial
fibrillation. Last known well 90 minutes ago. Next step?
A) Aspirin 325 mg
B) Noncontrast CT head
C) CTA head/neck
D) MRI brain
Answer: B
Rationale: Noncontrast CT to rule out hemorrhage before thrombolysis.
7. A 40-year-old with acute vision loss, painful red eye, and halos around
lights. Most likely?
A) Retinal detachment
B) Acute angle-closure glaucoma
,C) Optic neuritis
D) Migraine
Answer: B
Rationale: Painful red eye + vision loss + halos = acute glaucoma emergency.
8. A 50-year-old with fever, nuchal rigidity, and altered mental status.
Immediate step after ABCs?
A) CT head
B) Lumbar puncture
C) Blood cultures
D) IV antibiotics
Answer: A
Rationale: CT before LP if suspect mass lesion or herniation risk.
9. A 30-year-old with acute chest pain, pericardial rub, and diffuse ST
elevation. Most likely?
A) STEMI
B) Pericarditis
C) Pulmonary embolism
D) Early repolarization
Answer: B
Rationale: Pericardial rub + diffuse ST elevation = acute pericarditis.
10. A 65-year-old with acute back pain, fever, and history of IV drug use.
Most likely?
A) Muscular strain
B) Vertebral osteomyelitis
C) Compression fracture
D) Metastatic cancer
Answer: B
Rationale: Fever + back pain + IVDU = discitis/osteomyelitis.
, 11. A 60-year-old with painless jaundice, weight loss, and palpable
gallbladder. Most likely?
A) Choledocholithiasis
B) Pancreatic cancer
C) Hepatitis
D) Gallstones
Answer: B
Rationale: Courvoisier’s law = pancreatic cancer.
12. A 55-year-old with acute shortness of breath, unilateral leg swelling, and
tachycardia. Wells PE score 6. Next step?
A) D-dimer
B) CTPA
C) V/Q scan
D) Lower extremity ultrasound
Answer: B
Rationale: High Wells score → CTPA directly.
13. A 45-year-old with acute severe headache, hypertension, and nausea. BP
220/120. Most likely?
A) Migraine
B) Hypertensive emergency with posterior reversible encephalopathy
syndrome (PRES)
C) Tension headache
D) Cluster headache
Answer: B
Rationale: Severe hypertension + headache = PRES or hypertensive
encephalopathy.
14. A 70-year-old with acute abdominal pain, bloody diarrhea, and atrial
fibrillation. Most likely?
A) Ulcerative colitis
B) Ischemic colitis
