NR509 WEEK 4 MIDTERM COMPLETE ACTUAL
EXAM 150 DETAILED QUESTIONS &CORRECT
ANSWERS | NR-509 ADVANCED PHYSICAL
ASSESSMENT NR 509 MIDTERM EXAMPLIFY
ONLINE PROCTORED EXAM | ALREADY
GRADED A+..
1. A patient presents with a palpable purpuric rash on the lower extremities and arthralgias.
Laboratory findings show normal platelet count and prolonged bleeding time. Which of the
following is the most likely diagnosis?
A. Henoch-Schönlein purpura (IgA vasculitis)
B. Idiopathic thrombocytopenic purpura
C. Disseminated intravascular coagulation
D. Hemophilia A
Answer: A
Rationale: Henoch-Schönlein purpura (IgA vasculitis) presents with palpable purpura, arthralgias, and
normal platelet count. Prolonged bleeding time suggests platelet dysfunction, not thrombocytopenia. ITP
shows low platelets, DIC has abnormal coagulation studies, and hemophilia A has prolonged aPTT.
2. During cardiac auscultation, you hear a high-pitched, early diastolic decrescendo murmur best
heard at the left sternal border with the patient leaning forward and holding expiration. This
finding is most consistent with which valvular abnormality?
A. Aortic stenosis
B. Mitral regurgitation
C. Aortic regurgitation
D. Pulmonic stenosis
Answer: C
Rationale: Aortic regurgitation produces a high-pitched, early diastolic decrescendo murmur at the left
sternal border, enhanced by leaning forward and expiration. Aortic stenosis is systolic, mitral
regurgitation is holosystolic, and pulmonic stenosis is systolic with ejection click.
3. A patient with chronic liver disease develops asterixis and confusion. On physical exam, you note
a flapping tremor of the hands when the wrists are extended. Which of the following is the most
likely cause of this finding?
A. Hepatic encephalopathy due to ammonia accumulation
Page 1
,B. Wernicke encephalopathy from thiamine deficiency
C. Uremic encephalopathy from renal failure
D. Hypoglycemia-induced neuroglycopenia
Answer: A
Rationale: Asterixis is a classic sign of hepatic encephalopathy, often associated with elevated ammonia
levels. Wernicke encephalopathy presents with ophthalmoplegia, ataxia, and confusion but not asterixis.
Uremic encephalopathy and hypoglycemia can cause altered mental status but not typically asterixis.
4. A patient with suspected meningitis undergoes lumbar puncture. Cerebrospinal fluid analysis
reveals elevated protein, low glucose, and lymphocytic pleocytosis. Which of the following
pathogens is most likely responsible?
A. Neisseria meningitidis
B. Streptococcus pneumoniae
C. Mycobacterium tuberculosis
D. Herpes simplex virus
Answer: C
Rationale: Tuberculous meningitis typically shows elevated protein, low glucose, and lymphocytic
predominance. Bacterial meningitis (N. meningitidis, S. pneumoniae) shows neutrophilic pleocytosis and
low glucose. Viral meningitis (HSV) usually has normal glucose and lymphocytic pleocytosis but protein
may be mildly elevated.
5. A patient with a history of intravenous drug use presents with fever, tricuspid regurgitation
murmur, and septic pulmonary emboli. Which of the following is the most likely causative
organism?
A. Staphylococcus aureus
B. Streptococcus viridans
C. Enterococcus faecalis
D. Pseudomonas aeruginosa
Answer: A
Rationale: Staphylococcus aureus is the most common cause of acute infective endocarditis in IV drug
users, often affecting the tricuspid valve and causing septic emboli. Streptococcus viridans is more
common in subacute endocarditis with prior dental procedures. Enterococcus and Pseudomonas are less
frequent.
6. During a respiratory exam, you note that the trachea is deviated to the left, and there is
hyperresonance to percussion on the right with absent breath sounds. Which of the following is the
most likely diagnosis?
A. Right tension pneumothorax
B. Left pleural effusion
C. Right mainstem bronchus obstruction
D. Left pneumothorax
Answer: A
Page 2
,Rationale: Tracheal deviation away from the affected side (right) with hyperresonance and absent breath sounds indicates
tension pneumothorax. Pleural effusion would cause dullness, not hyperresonance. Bronchus obstruction would cause
decreased breath sounds but not hyperresonance or tracheal deviation.
7. A patient with severe abdominal pain has a positive psoas sign on the right. Which of the
following is the most likely underlying condition?
A. Acute appendicitis
B. Acute cholecystitis
C. Perforated duodenal ulcer
D. Diverticulitis
Answer: A
Rationale: A positive psoas sign indicates irritation of the psoas muscle, commonly due to a retrocecal
appendix. Appendicitis is the classic cause. Cholecystitis produces Murphy's sign, perforated ulcer may
cause generalized peritonitis, and diverticulitis typically presents with left lower quadrant pain.
8. A patient presents with a painless, firm, irregular thyroid nodule. Fine-needle aspiration
cytology shows follicular cells with nuclear grooves and pseudoinclusions. Which of the following is
the most likely diagnosis?
A. Papillary thyroid carcinoma
B. Follicular thyroid carcinoma
C. Medullary thyroid carcinoma
D. Anaplastic thyroid carcinoma
Answer: A
Rationale: Papillary thyroid carcinoma is the most common thyroid malignancy and is characterized by
nuclear grooves and pseudoinclusions on cytology. Follicular carcinoma lacks these nuclear features.
Medullary carcinoma arises from parafollicular cells and stains for calcitonin. Anaplastic carcinoma is
undifferentiated.
9. A patient with chronic kidney disease has a serum calcium of 7.2 mg/dL and phosphorus of 6.5
mg/dL. Which of the following physical exam findings is most likely to be present?
A. Positive Chvostek sign
B. Positive Trousseau sign
C. Both A and B
D. Neither A nor B
Answer: A
Rationale: Hypocalcemia (Ca 7.2) with hyperphosphatemia is common in CKD. Chvostek sign (facial
muscle twitching) is a sign of hypocalcemia. Trousseau sign (carpopedal spasm with BP cuff) is also a
sign of hypocalcemia, but it is more specific and sensitive. However, in CKD, acidosis may blunt
Trousseau. Given the numbers, both may be present, but the question asks 'most likely'—Chvostek is
often easier to elicit. Many texts state both are present. However, the best answer is both (C) as
hypocalcemia typically produces both signs. But note: Trousseau is more reliable. Since the question
says 'most likely', careful: In advanced CKD, hypocalcemia is common and both signs can be positive. I
will select C.
Page 3
, 10. A patient with suspected subarachnoid hemorrhage has a negative non-contrast head CT
performed 6 hours after symptom onset. Which of the following is the next best step?
A. Lumbar puncture for CSF analysis
B. CT angiography of the head
C. Magnetic resonance imaging (MRI) brain
D. Repeat non-contrast CT in 24 hours
Answer: A
Rationale: Non-contrast CT is highly sensitive for subarachnoid hemorrhage within 6 hours, but if
negative and suspicion remains, lumbar puncture is required to detect xanthochromia or red blood cells.
CTA is used to identify aneurysms after diagnosis. MRI is less sensitive for acute SAH. Repeat CT is not
standard.
11. A 45-year-old patient presents with acute onset of severe, tearing chest pain radiating to the
back, hypertension, and a widened mediastinum on chest X-ray. Which physical examination
finding would most strongly support the suspected diagnosis?
A. Pulsus paradoxus
B. Blood pressure differential >20 mmHg between arms
C. Loud S3 gallop
D. Carotid bruit
Answer: B
Rationale: A blood pressure differential >20 mmHg between arms is a classic sign of aortic dissection,
indicating involvement of the subclavian arteries. Pulsus paradoxus is seen in cardiac tamponade. Loud
S3 suggests heart failure. Carotid bruit indicates carotid artery stenosis.
12. Which of the following best describes the mechanism by which the J point elevation in early
repolarization differs from that in acute myocardial infarction?
A. Early repolarization shows concave ST elevation with tall T waves; MI shows convex ST elevation with
inverted T waves
B. Early repolarization is associated with reciprocal ST depression; MI is not
C. Early repolarization has PR segment depression; MI has PR elevation
D. Early repolarization is seen only in leads V1-V3; MI is seen in contiguous leads
Answer: A
Rationale: Early repolarization typically presents with concave ST elevation and tall, symmetrical T
waves, often in precordial leads. Acute MI usually shows convex (tombstone) ST elevation with evolving
T wave inversion. Reciprocal changes are more common in MI. PR depression is seen in pericarditis,
not early repolarization.
13. In assessing for ascites, which maneuver is most sensitive for detecting small volumes (150-500
mL) of peritoneal fluid?
A. Bulging flanks
B. Shifting dullness
C. Fluid wave
D. Puddle sign
Page 4
EXAM 150 DETAILED QUESTIONS &CORRECT
ANSWERS | NR-509 ADVANCED PHYSICAL
ASSESSMENT NR 509 MIDTERM EXAMPLIFY
ONLINE PROCTORED EXAM | ALREADY
GRADED A+..
1. A patient presents with a palpable purpuric rash on the lower extremities and arthralgias.
Laboratory findings show normal platelet count and prolonged bleeding time. Which of the
following is the most likely diagnosis?
A. Henoch-Schönlein purpura (IgA vasculitis)
B. Idiopathic thrombocytopenic purpura
C. Disseminated intravascular coagulation
D. Hemophilia A
Answer: A
Rationale: Henoch-Schönlein purpura (IgA vasculitis) presents with palpable purpura, arthralgias, and
normal platelet count. Prolonged bleeding time suggests platelet dysfunction, not thrombocytopenia. ITP
shows low platelets, DIC has abnormal coagulation studies, and hemophilia A has prolonged aPTT.
2. During cardiac auscultation, you hear a high-pitched, early diastolic decrescendo murmur best
heard at the left sternal border with the patient leaning forward and holding expiration. This
finding is most consistent with which valvular abnormality?
A. Aortic stenosis
B. Mitral regurgitation
C. Aortic regurgitation
D. Pulmonic stenosis
Answer: C
Rationale: Aortic regurgitation produces a high-pitched, early diastolic decrescendo murmur at the left
sternal border, enhanced by leaning forward and expiration. Aortic stenosis is systolic, mitral
regurgitation is holosystolic, and pulmonic stenosis is systolic with ejection click.
3. A patient with chronic liver disease develops asterixis and confusion. On physical exam, you note
a flapping tremor of the hands when the wrists are extended. Which of the following is the most
likely cause of this finding?
A. Hepatic encephalopathy due to ammonia accumulation
Page 1
,B. Wernicke encephalopathy from thiamine deficiency
C. Uremic encephalopathy from renal failure
D. Hypoglycemia-induced neuroglycopenia
Answer: A
Rationale: Asterixis is a classic sign of hepatic encephalopathy, often associated with elevated ammonia
levels. Wernicke encephalopathy presents with ophthalmoplegia, ataxia, and confusion but not asterixis.
Uremic encephalopathy and hypoglycemia can cause altered mental status but not typically asterixis.
4. A patient with suspected meningitis undergoes lumbar puncture. Cerebrospinal fluid analysis
reveals elevated protein, low glucose, and lymphocytic pleocytosis. Which of the following
pathogens is most likely responsible?
A. Neisseria meningitidis
B. Streptococcus pneumoniae
C. Mycobacterium tuberculosis
D. Herpes simplex virus
Answer: C
Rationale: Tuberculous meningitis typically shows elevated protein, low glucose, and lymphocytic
predominance. Bacterial meningitis (N. meningitidis, S. pneumoniae) shows neutrophilic pleocytosis and
low glucose. Viral meningitis (HSV) usually has normal glucose and lymphocytic pleocytosis but protein
may be mildly elevated.
5. A patient with a history of intravenous drug use presents with fever, tricuspid regurgitation
murmur, and septic pulmonary emboli. Which of the following is the most likely causative
organism?
A. Staphylococcus aureus
B. Streptococcus viridans
C. Enterococcus faecalis
D. Pseudomonas aeruginosa
Answer: A
Rationale: Staphylococcus aureus is the most common cause of acute infective endocarditis in IV drug
users, often affecting the tricuspid valve and causing septic emboli. Streptococcus viridans is more
common in subacute endocarditis with prior dental procedures. Enterococcus and Pseudomonas are less
frequent.
6. During a respiratory exam, you note that the trachea is deviated to the left, and there is
hyperresonance to percussion on the right with absent breath sounds. Which of the following is the
most likely diagnosis?
A. Right tension pneumothorax
B. Left pleural effusion
C. Right mainstem bronchus obstruction
D. Left pneumothorax
Answer: A
Page 2
,Rationale: Tracheal deviation away from the affected side (right) with hyperresonance and absent breath sounds indicates
tension pneumothorax. Pleural effusion would cause dullness, not hyperresonance. Bronchus obstruction would cause
decreased breath sounds but not hyperresonance or tracheal deviation.
7. A patient with severe abdominal pain has a positive psoas sign on the right. Which of the
following is the most likely underlying condition?
A. Acute appendicitis
B. Acute cholecystitis
C. Perforated duodenal ulcer
D. Diverticulitis
Answer: A
Rationale: A positive psoas sign indicates irritation of the psoas muscle, commonly due to a retrocecal
appendix. Appendicitis is the classic cause. Cholecystitis produces Murphy's sign, perforated ulcer may
cause generalized peritonitis, and diverticulitis typically presents with left lower quadrant pain.
8. A patient presents with a painless, firm, irregular thyroid nodule. Fine-needle aspiration
cytology shows follicular cells with nuclear grooves and pseudoinclusions. Which of the following is
the most likely diagnosis?
A. Papillary thyroid carcinoma
B. Follicular thyroid carcinoma
C. Medullary thyroid carcinoma
D. Anaplastic thyroid carcinoma
Answer: A
Rationale: Papillary thyroid carcinoma is the most common thyroid malignancy and is characterized by
nuclear grooves and pseudoinclusions on cytology. Follicular carcinoma lacks these nuclear features.
Medullary carcinoma arises from parafollicular cells and stains for calcitonin. Anaplastic carcinoma is
undifferentiated.
9. A patient with chronic kidney disease has a serum calcium of 7.2 mg/dL and phosphorus of 6.5
mg/dL. Which of the following physical exam findings is most likely to be present?
A. Positive Chvostek sign
B. Positive Trousseau sign
C. Both A and B
D. Neither A nor B
Answer: A
Rationale: Hypocalcemia (Ca 7.2) with hyperphosphatemia is common in CKD. Chvostek sign (facial
muscle twitching) is a sign of hypocalcemia. Trousseau sign (carpopedal spasm with BP cuff) is also a
sign of hypocalcemia, but it is more specific and sensitive. However, in CKD, acidosis may blunt
Trousseau. Given the numbers, both may be present, but the question asks 'most likely'—Chvostek is
often easier to elicit. Many texts state both are present. However, the best answer is both (C) as
hypocalcemia typically produces both signs. But note: Trousseau is more reliable. Since the question
says 'most likely', careful: In advanced CKD, hypocalcemia is common and both signs can be positive. I
will select C.
Page 3
, 10. A patient with suspected subarachnoid hemorrhage has a negative non-contrast head CT
performed 6 hours after symptom onset. Which of the following is the next best step?
A. Lumbar puncture for CSF analysis
B. CT angiography of the head
C. Magnetic resonance imaging (MRI) brain
D. Repeat non-contrast CT in 24 hours
Answer: A
Rationale: Non-contrast CT is highly sensitive for subarachnoid hemorrhage within 6 hours, but if
negative and suspicion remains, lumbar puncture is required to detect xanthochromia or red blood cells.
CTA is used to identify aneurysms after diagnosis. MRI is less sensitive for acute SAH. Repeat CT is not
standard.
11. A 45-year-old patient presents with acute onset of severe, tearing chest pain radiating to the
back, hypertension, and a widened mediastinum on chest X-ray. Which physical examination
finding would most strongly support the suspected diagnosis?
A. Pulsus paradoxus
B. Blood pressure differential >20 mmHg between arms
C. Loud S3 gallop
D. Carotid bruit
Answer: B
Rationale: A blood pressure differential >20 mmHg between arms is a classic sign of aortic dissection,
indicating involvement of the subclavian arteries. Pulsus paradoxus is seen in cardiac tamponade. Loud
S3 suggests heart failure. Carotid bruit indicates carotid artery stenosis.
12. Which of the following best describes the mechanism by which the J point elevation in early
repolarization differs from that in acute myocardial infarction?
A. Early repolarization shows concave ST elevation with tall T waves; MI shows convex ST elevation with
inverted T waves
B. Early repolarization is associated with reciprocal ST depression; MI is not
C. Early repolarization has PR segment depression; MI has PR elevation
D. Early repolarization is seen only in leads V1-V3; MI is seen in contiguous leads
Answer: A
Rationale: Early repolarization typically presents with concave ST elevation and tall, symmetrical T
waves, often in precordial leads. Acute MI usually shows convex (tombstone) ST elevation with evolving
T wave inversion. Reciprocal changes are more common in MI. PR depression is seen in pericarditis,
not early repolarization.
13. In assessing for ascites, which maneuver is most sensitive for detecting small volumes (150-500
mL) of peritoneal fluid?
A. Bulging flanks
B. Shifting dullness
C. Fluid wave
D. Puddle sign
Page 4
