NU 650: ADVANCED HEALTH ASSESSMENT & CLINICAL DIAGNOSTIC
REASONING
MIDTERM PRACTICE EXAMINATION (100 QUESTIONS)
A 58-year-old male presents with exertional chest pressure relieved by rest. Which
initial diagnostic test is most appropriate to evaluate for ischemic heart disease?
A. Echocardiogram
B. Resting 12-lead ECG
C. Cardiac MRI
D. Coronary CT angiography
Correct Answer: B
Rationale: A resting 12-lead ECG is the initial, non-invasive test of choice for evaluating
suspected ischemic heart disease. It can reveal ST-T changes, prior MI, or arrhythmias.
Echocardiography and advanced imaging are reserved for further evaluation if ECG is
inconclusive or for assessing structural/functional abnormalities.
When performing a focused neurologic assessment on a patient with suspected stroke,
which finding indicates upper motor neuron involvement?
A. Flaccid paralysis
B. Hyperreflexia
C. Fasciculations
D. Decreased muscle tone
Correct Answer: B
Rationale: Upper motor neuron lesions typically present with hyperreflexia, spasticity,
and positive Babinski sign. Flaccid paralysis, fasciculations, and decreased tone are
characteristic of lower motor neuron pathology.
A patient reports a 3-week history of nonproductive cough, night sweats, and 5 lb
weight loss. Chest X-ray shows right upper lobe infiltrate with cavitation. Which
diagnostic test should be prioritized?
A. Sputum Gram stain
B. Acid-fast bacilli (AFB) smear and culture
C. Bronchoscopy with BAL
,D. CT chest without contrast
Correct Answer: B
Rationale: The clinical and radiographic presentation is highly suggestive of pulmonary
tuberculosis. AFB smear and culture of sputum are the gold standard initial tests for
Mycobacterium tuberculosis. Bronchoscopy is reserved for smear-negative or unable-
to-produce-sputum cases.
Which physical exam maneuver is most sensitive for detecting early diabetic peripheral
neuropathy?
A. Achilles reflex testing
B. Monofilament testing at 10 sites
C. Tuning fork vibration at 128 Hz
D. Romberg test
Correct Answer: B
Rationale: The 10-gram Semmes-Weinstein monofilament test is the most validated,
sensitive, and guideline-recommended screening tool for detecting loss of protective
sensation in diabetic neuropathy. Tuning forks and reflex testing are less sensitive for
early changes.
A 32-year-old female presents with fatigue, cold intolerance, and weight gain. TSH is
elevated, free T4 is low. Which antibody test is most likely to be positive?
A. Thyroglobulin antibody
B. Thyroid-stimulating immunoglobulin (TSI)
C. Anti-thyroid peroxidase (TPO) antibody
D. Calcitonin
Correct Answer: C
Rationale: Elevated TSH and low free T4 indicate primary hypothyroidism, most
commonly caused by Hashimoto’s thyroiditis. Anti-TPO antibodies are present in >90%
of cases. TSI is associated with Graves’ disease (hyperthyroidism).
During abdominal assessment, which finding suggests possible ascites?
A. Hyperactive bowel sounds
B. Shifting dullness
C. Positive Murphy’s sign
D. Rebound tenderness
,Correct Answer: B
Rationale: Shifting dullness is a classic physical exam finding indicating free fluid in the
peritoneal cavity (ascites). It is performed by percussing from tympany to dullness
while the patient turns supine to lateral decubitus.
A patient with hypertension is started on an ACE inhibitor. Which laboratory value
should be monitored within 1–2 weeks of initiation?
A. Serum sodium
B. Potassium and creatinine
C. ALT/AST
D. Calcium
Correct Answer: B
Rationale: ACE inhibitors can cause hyperkalemia and acute kidney injury by reducing
efferent arteriolar tone. Baseline and follow-up potassium and creatinine are standard
of care. Liver enzymes and calcium are not routinely affected.
Which cranial nerve is assessed when asking a patient to shrug shoulders against
resistance?
A. CN IX
B. CN X
C. CN XI
D. CN XII
Correct Answer: C
Rationale: Cranial Nerve XI (Accessory) innervates the sternocleidomastoid and
trapezius muscles. Shoulder shrug against resistance tests trapezius function. CN IX/X
are gag/swallow, CN XII is tongue movement.
A 45-year-old presents with acute onset severe epigastric pain radiating to the back,
nausea, and elevated lipase. Which etiology is most common?
A. Hypertriglyceridemia
B. Gallstones
C. Alcohol use
D. ERCP complication
Correct Answer: B
, Rationale: Gallstone pancreatitis is the most common cause of acute pancreatitis
worldwide (~40–50%). Alcohol is second. Hypertriglyceridemia and procedural
complications are less frequent.
Which finding on fundoscopic exam is pathognomonic for papilledema?
A. Cotton wool spots
B. Arteriovenous nicking
C. Blurred disc margins with venous engorgement
D. Macular star
Correct Answer: C
Rationale: Papilledema is optic disc swelling due to increased intracranial pressure.
Key features include blurred disc margins, loss of spontaneous venous pulsations, and
venous engorgement. Cotton wool spots indicate diabetic/hypertensive retinopathy.
A patient with COPD presents with increased dyspnea, purulent sputum, and wheezing.
Which initial pharmacologic intervention is recommended?
A. Oral corticosteroids only
B. Short-acting beta-agonist + ipratropium
C. Long-acting muscarinic antagonist
D. Antibiotics immediately
Correct Answer: B
Rationale: GOLD guidelines recommend SABA + SAMA as first-line for acute COPD
exacerbations. Systemic corticosteroids and antibiotics are added based on severity
and sputum characteristics, but bronchodilation is immediate priority.
Which heart sound is associated with mitral stenosis?
A. S3
B. S4
C. Opening snap followed by diastolic rumble
D. Mid-systolic click
Correct Answer: C
Rationale: Mitral stenosis produces an opening snap (due to abrupt halting of leaflet
motion) followed by a low-pitched diastolic rumble. S3/S4 are ventricular filling sounds;
mid-systolic click suggests mitral valve prolapse.
REASONING
MIDTERM PRACTICE EXAMINATION (100 QUESTIONS)
A 58-year-old male presents with exertional chest pressure relieved by rest. Which
initial diagnostic test is most appropriate to evaluate for ischemic heart disease?
A. Echocardiogram
B. Resting 12-lead ECG
C. Cardiac MRI
D. Coronary CT angiography
Correct Answer: B
Rationale: A resting 12-lead ECG is the initial, non-invasive test of choice for evaluating
suspected ischemic heart disease. It can reveal ST-T changes, prior MI, or arrhythmias.
Echocardiography and advanced imaging are reserved for further evaluation if ECG is
inconclusive or for assessing structural/functional abnormalities.
When performing a focused neurologic assessment on a patient with suspected stroke,
which finding indicates upper motor neuron involvement?
A. Flaccid paralysis
B. Hyperreflexia
C. Fasciculations
D. Decreased muscle tone
Correct Answer: B
Rationale: Upper motor neuron lesions typically present with hyperreflexia, spasticity,
and positive Babinski sign. Flaccid paralysis, fasciculations, and decreased tone are
characteristic of lower motor neuron pathology.
A patient reports a 3-week history of nonproductive cough, night sweats, and 5 lb
weight loss. Chest X-ray shows right upper lobe infiltrate with cavitation. Which
diagnostic test should be prioritized?
A. Sputum Gram stain
B. Acid-fast bacilli (AFB) smear and culture
C. Bronchoscopy with BAL
,D. CT chest without contrast
Correct Answer: B
Rationale: The clinical and radiographic presentation is highly suggestive of pulmonary
tuberculosis. AFB smear and culture of sputum are the gold standard initial tests for
Mycobacterium tuberculosis. Bronchoscopy is reserved for smear-negative or unable-
to-produce-sputum cases.
Which physical exam maneuver is most sensitive for detecting early diabetic peripheral
neuropathy?
A. Achilles reflex testing
B. Monofilament testing at 10 sites
C. Tuning fork vibration at 128 Hz
D. Romberg test
Correct Answer: B
Rationale: The 10-gram Semmes-Weinstein monofilament test is the most validated,
sensitive, and guideline-recommended screening tool for detecting loss of protective
sensation in diabetic neuropathy. Tuning forks and reflex testing are less sensitive for
early changes.
A 32-year-old female presents with fatigue, cold intolerance, and weight gain. TSH is
elevated, free T4 is low. Which antibody test is most likely to be positive?
A. Thyroglobulin antibody
B. Thyroid-stimulating immunoglobulin (TSI)
C. Anti-thyroid peroxidase (TPO) antibody
D. Calcitonin
Correct Answer: C
Rationale: Elevated TSH and low free T4 indicate primary hypothyroidism, most
commonly caused by Hashimoto’s thyroiditis. Anti-TPO antibodies are present in >90%
of cases. TSI is associated with Graves’ disease (hyperthyroidism).
During abdominal assessment, which finding suggests possible ascites?
A. Hyperactive bowel sounds
B. Shifting dullness
C. Positive Murphy’s sign
D. Rebound tenderness
,Correct Answer: B
Rationale: Shifting dullness is a classic physical exam finding indicating free fluid in the
peritoneal cavity (ascites). It is performed by percussing from tympany to dullness
while the patient turns supine to lateral decubitus.
A patient with hypertension is started on an ACE inhibitor. Which laboratory value
should be monitored within 1–2 weeks of initiation?
A. Serum sodium
B. Potassium and creatinine
C. ALT/AST
D. Calcium
Correct Answer: B
Rationale: ACE inhibitors can cause hyperkalemia and acute kidney injury by reducing
efferent arteriolar tone. Baseline and follow-up potassium and creatinine are standard
of care. Liver enzymes and calcium are not routinely affected.
Which cranial nerve is assessed when asking a patient to shrug shoulders against
resistance?
A. CN IX
B. CN X
C. CN XI
D. CN XII
Correct Answer: C
Rationale: Cranial Nerve XI (Accessory) innervates the sternocleidomastoid and
trapezius muscles. Shoulder shrug against resistance tests trapezius function. CN IX/X
are gag/swallow, CN XII is tongue movement.
A 45-year-old presents with acute onset severe epigastric pain radiating to the back,
nausea, and elevated lipase. Which etiology is most common?
A. Hypertriglyceridemia
B. Gallstones
C. Alcohol use
D. ERCP complication
Correct Answer: B
, Rationale: Gallstone pancreatitis is the most common cause of acute pancreatitis
worldwide (~40–50%). Alcohol is second. Hypertriglyceridemia and procedural
complications are less frequent.
Which finding on fundoscopic exam is pathognomonic for papilledema?
A. Cotton wool spots
B. Arteriovenous nicking
C. Blurred disc margins with venous engorgement
D. Macular star
Correct Answer: C
Rationale: Papilledema is optic disc swelling due to increased intracranial pressure.
Key features include blurred disc margins, loss of spontaneous venous pulsations, and
venous engorgement. Cotton wool spots indicate diabetic/hypertensive retinopathy.
A patient with COPD presents with increased dyspnea, purulent sputum, and wheezing.
Which initial pharmacologic intervention is recommended?
A. Oral corticosteroids only
B. Short-acting beta-agonist + ipratropium
C. Long-acting muscarinic antagonist
D. Antibiotics immediately
Correct Answer: B
Rationale: GOLD guidelines recommend SABA + SAMA as first-line for acute COPD
exacerbations. Systemic corticosteroids and antibiotics are added based on severity
and sputum characteristics, but bronchodilation is immediate priority.
Which heart sound is associated with mitral stenosis?
A. S3
B. S4
C. Opening snap followed by diastolic rumble
D. Mid-systolic click
Correct Answer: C
Rationale: Mitral stenosis produces an opening snap (due to abrupt halting of leaflet
motion) followed by a low-pitched diastolic rumble. S3/S4 are ventricular filling sounds;
mid-systolic click suggests mitral valve prolapse.
