SG550 / NSG 550 EXAM 2
N
2026-2027 | Diagnostic Reasoning
for Nurse Practitioners | Latest
Update | Verified Q&A | 100%
Correct | Grade A | Pass Guaranteed
ART A – MULTIPLE CHOICE (Q1‑60)
P
Q1 (Chest pain – clinical prediction rule):
A 58-year-old male presents with substernal chest pressure radiating to the jaw, onset 2 hours
ago. He is diaphoretic but hemodynamically stable. Which clinical prediction rule is most
appropriate to stratify his risk for major adverse cardiac events (MACE) before selecting further
testing?
A. Wells criteria
B. HEART score
C. TIMI risk score
D. CURB-65
[CORRECT] B
Rationale: The HEART score (History, ECG, Age, Risk factors, Troponin) is the validated tool for
risk-stratifying undifferentiated chest pain patients in the emergency setting to determine MACE
risk and guide admission vs. discharge decisions. The TIMI score applies specifically to
confirmed ACS/NSTEMI patients, not undifferentiated chest pain. Wells criteria are for DVT/PE,
and CURB-65 is for pneumonia severity.
Q2 (Dyspnea – PE rule-out):
A 42-year-old female with sudden-onset dyspnea and pleuritic chest pain has a normal HR (72
bpm), normal O₂ sat (98%), no unilateral leg swelling, no hemoptysis, and no recent surgery.
Her Wells score is calculated as 1.0 point. Which step is most appropriate next?
A. CT pulmonary angiography immediately
B. D-dimer testing
C. Apply the PERC rule
D. Begin empiric anticoagulation
[CORRECT] C
Rationale: When pretest probability is low (Wells ≤4) and the PERC (Pulmonary Embolism
Rule-out Criteria) rule can be satisfied, PE can be excluded without D-dimer or imaging. The
, ERC rule requires all 8 criteria to be negative; this patient meets them. Ordering CTPA first is
P
low-value care, and empiric anticoagulation without objective diagnosis is inappropriate.
Q3 (Abdominal pain – biliary disease):
A 45-year-old obese female presents with postprandial right upper quadrant pain after a fatty
meal. Murphy sign is positive. Which diagnostic study is the first-line, most cost-effective initial
test?
A. CT abdomen with contrast
B. Hepatobiliary iminodiacetic acid (HIDA) scan
C. Right upper quadrant ultrasound
D. MRCP
[CORRECT] C
Rationale: Right upper quadrant ultrasound is the first-line imaging modality for suspected
cholelithiasis/cholecystitis due to high sensitivity for gallstones and wall thickening, plus it avoids
radiation and contrast. HIDA is reserved for suspected acalculous cholecystitis when ultrasound
is equivocal. CT and MRCP are higher-cost studies not indicated for initial evaluation.
Q4 (Headache – secondary red flags):
A 68-year-old woman presents with new-onset headache, jaw claudication while chewing, and
visual disturbances. Her ESR is 72 mm/hr. Which diagnosis must be prioritized, and what is the
immediate next step?
A. Migraine; start sumatriptan
B. Tension-type headache; reassurance and analgesics
C. Giant cell arteritis (GCA); start high-dose corticosteroids immediately
D. Cluster headache; high-flow oxygen
[CORRECT] C
Rationale: Giant cell arteritis is a vision-threatening secondary headache cause in patients >50
years with elevated inflammatory markers, jaw claudication, and visual symptoms. High-dose
corticosteroids must be initiated immediately to prevent irreversible vision loss, even before
temporal artery biopsy confirms the diagnosis. Delaying treatment to obtain biopsy is a critical
diagnostic error.
Q5 (Syncope – cardiac vs. non-cardiac):
A 72-year-old man collapses while running, with no prodrome, and awakens immediately. He
has a history of CHF and prior MI. Which feature most strongly predicts a cardiac cause of
syncope?
A. Warm environment and diaphoresis before the event
B. Absence of prodromal symptoms and exertional onset
C. Urinary incontinence during the episode
D. Tongue laceration on the side
[CORRECT] B
Rationale: Exertional syncope without prodrome in a patient with structural heart disease is
highly predictive of a cardiac etiology (arrhythmia, outflow obstruction) and carries a high risk of
sudden death. Vasovagal syncope typically has a prodrome (nausea, warmth, diaphoresis).
Tongue biting (side) suggests seizure, not syncope.
Q6 (Fatigue – thyroid dysfunction):
, 35-year-old female reports 3 months of fatigue, weight gain, constipation, and dry skin. Her
A
TSH is 8.5 mIU/L (elevated) and free T4 is low-normal. Which diagnostic reasoning principle
applies?
A. Pattern recognition of hypothyroidism with confirmatory TSH
B. Analytical reasoning using a decision tree
C. Probabilistic reasoning with likelihood ratios
D. Diagnostic momentum from prior provider notes
[CORRECT] A
Rationale: This presentation demonstrates pattern recognition—the constellation of fatigue,
weight gain, constipation, dry skin, and elevated TSH forms a classic hypothyroid pattern. While
TSH confirms the diagnosis, the initial hypothesis was generated through pattern recognition,
which is efficient for common, classic presentations. Diagnostic momentum would be
inappropriately accepting a prior label without verification.
Q7 (Chest pain – stress testing selection):
A 55-year-old male with intermediate-risk chest pain, normal initial troponins, and a normal
resting ECG is able to exercise. Which stress test modality is most appropriate and
cost-effective?
A. Dobutamine stress echocardiography
B. Exercise stress ECG (treadmill)
C. Adenosine stress MRI
D. Pharmacologic nuclear stress test
[CORRECT] B
Rationale: Exercise stress ECG is the first-line, most cost-effective test for patients with
intermediate-risk chest pain who can exercise and have an interpretable baseline ECG. It
provides both diagnostic (ST changes) and prognostic (exercise capacity) data. Pharmacologic
stress testing is reserved for patients unable to exercise or with baseline ECG abnormalities
(e.g., LBBB, paced rhythm).
Q8 (Dyspnea – PFT interpretation):
A 68-year-old male with a 40 pack-year smoking history has FEV₁/FVC = 0.62, FEV₁ = 68%
predicted, and DLCO = 55% predicted. Which pattern is present?
A. Restrictive lung disease
B. Obstructive lung disease with air trapping
C. Mixed obstructive-restrictive
D. Obstructive with impaired gas transfer
[CORRECT] D
Rationale: An FEV₁/FVC <0.70 confirms obstruction, and a reduced DLCO in a smoker
suggests emphysema/COPD with impaired gas transfer. Pure obstruction without parenchymal
destruction (e.g., chronic bronchitis) typically preserves DLCO. Restrictive disease shows a
normal or elevated FEV₁/FVC ratio with reduced total lung capacity.
Q9 (Abdominal pain – appendicitis in pregnancy):
A 24-year-old female at 18 weeks gestation presents with right lower quadrant pain, nausea,
and low-grade fever. Which diagnostic approach is safest and most accurate?
A. CT abdomen with contrast
B. MRI abdomen without gadolinium
N
2026-2027 | Diagnostic Reasoning
for Nurse Practitioners | Latest
Update | Verified Q&A | 100%
Correct | Grade A | Pass Guaranteed
ART A – MULTIPLE CHOICE (Q1‑60)
P
Q1 (Chest pain – clinical prediction rule):
A 58-year-old male presents with substernal chest pressure radiating to the jaw, onset 2 hours
ago. He is diaphoretic but hemodynamically stable. Which clinical prediction rule is most
appropriate to stratify his risk for major adverse cardiac events (MACE) before selecting further
testing?
A. Wells criteria
B. HEART score
C. TIMI risk score
D. CURB-65
[CORRECT] B
Rationale: The HEART score (History, ECG, Age, Risk factors, Troponin) is the validated tool for
risk-stratifying undifferentiated chest pain patients in the emergency setting to determine MACE
risk and guide admission vs. discharge decisions. The TIMI score applies specifically to
confirmed ACS/NSTEMI patients, not undifferentiated chest pain. Wells criteria are for DVT/PE,
and CURB-65 is for pneumonia severity.
Q2 (Dyspnea – PE rule-out):
A 42-year-old female with sudden-onset dyspnea and pleuritic chest pain has a normal HR (72
bpm), normal O₂ sat (98%), no unilateral leg swelling, no hemoptysis, and no recent surgery.
Her Wells score is calculated as 1.0 point. Which step is most appropriate next?
A. CT pulmonary angiography immediately
B. D-dimer testing
C. Apply the PERC rule
D. Begin empiric anticoagulation
[CORRECT] C
Rationale: When pretest probability is low (Wells ≤4) and the PERC (Pulmonary Embolism
Rule-out Criteria) rule can be satisfied, PE can be excluded without D-dimer or imaging. The
, ERC rule requires all 8 criteria to be negative; this patient meets them. Ordering CTPA first is
P
low-value care, and empiric anticoagulation without objective diagnosis is inappropriate.
Q3 (Abdominal pain – biliary disease):
A 45-year-old obese female presents with postprandial right upper quadrant pain after a fatty
meal. Murphy sign is positive. Which diagnostic study is the first-line, most cost-effective initial
test?
A. CT abdomen with contrast
B. Hepatobiliary iminodiacetic acid (HIDA) scan
C. Right upper quadrant ultrasound
D. MRCP
[CORRECT] C
Rationale: Right upper quadrant ultrasound is the first-line imaging modality for suspected
cholelithiasis/cholecystitis due to high sensitivity for gallstones and wall thickening, plus it avoids
radiation and contrast. HIDA is reserved for suspected acalculous cholecystitis when ultrasound
is equivocal. CT and MRCP are higher-cost studies not indicated for initial evaluation.
Q4 (Headache – secondary red flags):
A 68-year-old woman presents with new-onset headache, jaw claudication while chewing, and
visual disturbances. Her ESR is 72 mm/hr. Which diagnosis must be prioritized, and what is the
immediate next step?
A. Migraine; start sumatriptan
B. Tension-type headache; reassurance and analgesics
C. Giant cell arteritis (GCA); start high-dose corticosteroids immediately
D. Cluster headache; high-flow oxygen
[CORRECT] C
Rationale: Giant cell arteritis is a vision-threatening secondary headache cause in patients >50
years with elevated inflammatory markers, jaw claudication, and visual symptoms. High-dose
corticosteroids must be initiated immediately to prevent irreversible vision loss, even before
temporal artery biopsy confirms the diagnosis. Delaying treatment to obtain biopsy is a critical
diagnostic error.
Q5 (Syncope – cardiac vs. non-cardiac):
A 72-year-old man collapses while running, with no prodrome, and awakens immediately. He
has a history of CHF and prior MI. Which feature most strongly predicts a cardiac cause of
syncope?
A. Warm environment and diaphoresis before the event
B. Absence of prodromal symptoms and exertional onset
C. Urinary incontinence during the episode
D. Tongue laceration on the side
[CORRECT] B
Rationale: Exertional syncope without prodrome in a patient with structural heart disease is
highly predictive of a cardiac etiology (arrhythmia, outflow obstruction) and carries a high risk of
sudden death. Vasovagal syncope typically has a prodrome (nausea, warmth, diaphoresis).
Tongue biting (side) suggests seizure, not syncope.
Q6 (Fatigue – thyroid dysfunction):
, 35-year-old female reports 3 months of fatigue, weight gain, constipation, and dry skin. Her
A
TSH is 8.5 mIU/L (elevated) and free T4 is low-normal. Which diagnostic reasoning principle
applies?
A. Pattern recognition of hypothyroidism with confirmatory TSH
B. Analytical reasoning using a decision tree
C. Probabilistic reasoning with likelihood ratios
D. Diagnostic momentum from prior provider notes
[CORRECT] A
Rationale: This presentation demonstrates pattern recognition—the constellation of fatigue,
weight gain, constipation, dry skin, and elevated TSH forms a classic hypothyroid pattern. While
TSH confirms the diagnosis, the initial hypothesis was generated through pattern recognition,
which is efficient for common, classic presentations. Diagnostic momentum would be
inappropriately accepting a prior label without verification.
Q7 (Chest pain – stress testing selection):
A 55-year-old male with intermediate-risk chest pain, normal initial troponins, and a normal
resting ECG is able to exercise. Which stress test modality is most appropriate and
cost-effective?
A. Dobutamine stress echocardiography
B. Exercise stress ECG (treadmill)
C. Adenosine stress MRI
D. Pharmacologic nuclear stress test
[CORRECT] B
Rationale: Exercise stress ECG is the first-line, most cost-effective test for patients with
intermediate-risk chest pain who can exercise and have an interpretable baseline ECG. It
provides both diagnostic (ST changes) and prognostic (exercise capacity) data. Pharmacologic
stress testing is reserved for patients unable to exercise or with baseline ECG abnormalities
(e.g., LBBB, paced rhythm).
Q8 (Dyspnea – PFT interpretation):
A 68-year-old male with a 40 pack-year smoking history has FEV₁/FVC = 0.62, FEV₁ = 68%
predicted, and DLCO = 55% predicted. Which pattern is present?
A. Restrictive lung disease
B. Obstructive lung disease with air trapping
C. Mixed obstructive-restrictive
D. Obstructive with impaired gas transfer
[CORRECT] D
Rationale: An FEV₁/FVC <0.70 confirms obstruction, and a reduced DLCO in a smoker
suggests emphysema/COPD with impaired gas transfer. Pure obstruction without parenchymal
destruction (e.g., chronic bronchitis) typically preserves DLCO. Restrictive disease shows a
normal or elevated FEV₁/FVC ratio with reduced total lung capacity.
Q9 (Abdominal pain – appendicitis in pregnancy):
A 24-year-old female at 18 weeks gestation presents with right lower quadrant pain, nausea,
and low-grade fever. Which diagnostic approach is safest and most accurate?
A. CT abdomen with contrast
B. MRI abdomen without gadolinium
