NR-509 Advanced Physical Assessment: Second Graduate-Level Proctoring
Examination Integrating Complex Physical Diagnosis, Pathophysiological Clues,
Clinical Reasoning, and Evidence-Based Decision-Making Across Practice
Settings
Instructions for the Learner
• One best answer per question.
• Questions require synthesis of physical findings, pathophysiology, and differential diagnosis.
• Suggested time: 3 minutes per question (7.5 hours total, or divided into multiple testing sessions).
Questions 1–150
Cardiovascular System (Questions 1–20)
1. A 62-year-old man with hypertension presents with a harsh systolic murmur at the right upper sternal border that
radiates to the carotids. The murmur becomes softer during the Valsalva maneuver. What is the most likely diagnosis?
A) Hypertrophic obstructive cardiomyopathy
B) Aortic stenosis
C) Mitral regurgitation
D) Pulmonic stenosis
Correct Answer: B
Rationale: Aortic stenosis murmur typically decreases with Valsalva (reduced preload). HOCM murmur
increases with Valsalva. The radiation to carotids favors AS.
2. A 48-year-old woman with systemic lupus erythematosus presents with dyspnea and a friction rub that is heard only
in left lateral decubitus position. Which of the following is most likely?
A) Pleural friction rub
B) Pericardial friction rub
C) Mediastinal crunch
D) Pneumothorax
Correct Answer: B
Rationale: Pericardial rub in SLE (pericarditis) may be position-dependent. Pleural rub changes with
respiration but not typically left lateral decubitus specific.
3. On cardiac auscultation, you hear an S4 gallop in a 70-year-old with hypertension. This finding indicates:
A) Reduced left ventricular compliance
B) Volume overload
C) Systolic heart failure
D) Mitral stenosis
Correct Answer: A
Rationale: S4 (atrial gallop) reflects increased resistance to atrial emptying due to reduced LV
compliance (hypertrophy, ischemia, hypertension).
,4. A 55-year-old with end-stage renal disease has a continuous murmur heard over the left clavicle and infraclavicular
area. What is the most likely cause?
A) Patent ductus arteriosus
B) Arteriovenous fistula for dialysis
C) Venous hum
D) Aortic coarctation
Correct Answer: B
Rationale: AV fistula (dialysis access) creates a continuous murmur (“machinery-like”) over the site.
Venous hum is continuous but neck location.
5. A patient with syncope has a midsystolic click and a late systolic murmur. The murmur intensity increases with
standing and decreases with squatting. This behavior is characteristic of:
A) Aortic stenosis
B) Mitral valve prolapse with regurgitation
C) Hypertrophic cardiomyopathy
D) Tricuspid regurgitation
Correct Answer: B
Rationale: MVP murmur lengthens and becomes louder with decreased preload (standing) and softer
with increased preload (squatting).
6. A patient presents with a new diastolic decrescendo murmur at the left sternal border. Which additional finding
would suggest acute rather than chronic aortic regurgitation?
A) Bounding pulses
B) Wide pulse pressure
C) Austin Flint murmur
D) Soft or absent S1
Correct Answer: D
Rationale: In acute AR, LV pressure rises rapidly, causing premature closure of mitral valve → soft S1.
Wide pulse pressure and bounding pulses take time to develop (chronic).
7. During jugular venous pressure assessment, you note large cannon a waves at irregular intervals. This is most
consistent with:
A) Atrial fibrillation
B) Complete heart block
C) Tricuspid regurgitation
D) Cardiac tamponade
Correct Answer: B
Rationale: Cannon a waves occur when atrium contracts against a closed tricuspid valve (AV
dissociation, e.g., complete heart block, ventricular tachycardia).
8. A 65-year-old with known heart failure has an S3 gallop. Which maneuver would accentuate the S3?
A) Standing
B) Valsalva
C) Leg raising
D) Squatting
,Correct Answer: C
Rationale: Passive leg raising increases preload → accentuates S3 (early diastolic filling sound).
9. A patient with hypertension has a blood pressure of 160/100 in the right arm and 140/90 in the left arm. On
palpation, the right radial pulse is bounding, while the left is weak. Which additional finding would most support
subclavian steal syndrome?
A) Left carotid bruit
B) Systolic bruit over left supraclavicular fossa
C) Right-sided cerebellar symptoms with left arm exercise
D) Delayed left radial pulse compared to right
Correct Answer: C
Rationale: Subclavian steal → vertebrobasilar symptoms (ataxia, dizziness) during ipsilateral arm
exercise due to reversed vertebral flow.
10. A 72-year-old presents with dyspnea and lower extremity edema. On exam, the jugular veins are distended with a
sharp x descent but no y descent. These JVP findings suggest:
A) Constrictive pericarditis
B) Cardiac tamponade
C) Right heart failure
D) Tricuspid stenosis
Correct Answer: B
Rationale: Tamponade → preserved x descent (ventricular ejection) but absent y descent (restricted
filling). Constrictive pericarditis has prominent y descent.
11. On auscultation, a patient has a fixed, widely split S2. Which other finding would you expect?
A) Systolic ejection murmur at left upper sternal border
B) Mid-diastolic rumble at apex
C) Opening snap
D) Pericardial knock
Correct Answer: A
*Rationale: Fixed wide split S2 = atrial septal defect (ASD) → often associated with pulmonic flow murmur (systolic
ejection murmur at LUSB).*
12. A 60-year-old with chronic alcoholism has an elevated JVP with a prominent v wave and rapid y descent. This is
most consistent with:
A) Cardiac tamponade
B) Constrictive pericarditis
C) Severe tricuspid regurgitation
D) Pulmonary hypertension
Correct Answer: C
Rationale: Large v wave + rapid y descent = severe TR. Rapid y descent occurs because RA pressure
falls rapidly in early diastole in TR.
13. A patient with endocarditis has a new murmur of aortic regurgitation. Which physical finding is most consistent
with acute severe AR?
A) Quincke pulse
, B) De Musset sign (head bobbing)
C) Low-pitched diastolic murmur
D) Pulsus bisferiens
Correct Answer: C
Rationale: Acute AR murmur is often low-pitched and short; chronic AR has high-pitched decrescendo
murmur. Quincke, De Musset, and bisferiens are chronic signs.
14. A 25-year-old asymptomatic athlete has a grade 2/6 midsystolic murmur at the left sternal border that increases
significantly with standing and decreases with handgrip. This suggests:
A) Hypertrophic cardiomyopathy
B) Aortic stenosis
C) Mitral valve prolapse
D) Innocent flow murmur
Correct Answer: A
Rationale: HCM murmur increases with standing (decreased preload) and decreases with handgrip
(increased afterload reduces gradient).
15. On precordial examination, you palpate a double apical impulse in a patient with hypertrophic cardiomyopathy.
This is due to:
A) Left ventricular dilation
B) Palpable S4
C) Bifid carotid pulse transmitted
D) Right ventricular heave
Correct Answer: B
*Rationale: Double apical impulse in HCM = palpable S4 (forceful atrial contraction into noncompliant LV) followed by
systolic impulse.*
16. A 50-year-old presents with sudden chest pain and a new murmur. On exam, you note a systolic thrill at the apex, a
loud S3, and a pansystolic murmur radiating to the axilla. Most likely:
A) Acute mitral regurgitation from papillary muscle rupture
B) Ventricular septal rupture
C) Aortic dissection with AR
D) Mitral stenosis
Correct Answer: A
*Rationale: Acute MR from papillary muscle rupture (post-MI) → apical thrill, loud S3, pansystolic murmur to axilla,
often with pulmonary edema.*
17. On auscultation of a patient with severe aortic stenosis, you note that S2 is paradoxically split. This indicates:
A) Delayed closure of pulmonic valve
B) Early closure of aortic valve
C) Delayed closure of aortic valve with prolonged LV systole
D) Right bundle branch block
Correct Answer: C
*Rationale: Paradoxical split S2 in AS = aortic valve closure markedly delayed (prolonged LV ejection), so A2 occurs
after P2 on expiration.*
Examination Integrating Complex Physical Diagnosis, Pathophysiological Clues,
Clinical Reasoning, and Evidence-Based Decision-Making Across Practice
Settings
Instructions for the Learner
• One best answer per question.
• Questions require synthesis of physical findings, pathophysiology, and differential diagnosis.
• Suggested time: 3 minutes per question (7.5 hours total, or divided into multiple testing sessions).
Questions 1–150
Cardiovascular System (Questions 1–20)
1. A 62-year-old man with hypertension presents with a harsh systolic murmur at the right upper sternal border that
radiates to the carotids. The murmur becomes softer during the Valsalva maneuver. What is the most likely diagnosis?
A) Hypertrophic obstructive cardiomyopathy
B) Aortic stenosis
C) Mitral regurgitation
D) Pulmonic stenosis
Correct Answer: B
Rationale: Aortic stenosis murmur typically decreases with Valsalva (reduced preload). HOCM murmur
increases with Valsalva. The radiation to carotids favors AS.
2. A 48-year-old woman with systemic lupus erythematosus presents with dyspnea and a friction rub that is heard only
in left lateral decubitus position. Which of the following is most likely?
A) Pleural friction rub
B) Pericardial friction rub
C) Mediastinal crunch
D) Pneumothorax
Correct Answer: B
Rationale: Pericardial rub in SLE (pericarditis) may be position-dependent. Pleural rub changes with
respiration but not typically left lateral decubitus specific.
3. On cardiac auscultation, you hear an S4 gallop in a 70-year-old with hypertension. This finding indicates:
A) Reduced left ventricular compliance
B) Volume overload
C) Systolic heart failure
D) Mitral stenosis
Correct Answer: A
Rationale: S4 (atrial gallop) reflects increased resistance to atrial emptying due to reduced LV
compliance (hypertrophy, ischemia, hypertension).
,4. A 55-year-old with end-stage renal disease has a continuous murmur heard over the left clavicle and infraclavicular
area. What is the most likely cause?
A) Patent ductus arteriosus
B) Arteriovenous fistula for dialysis
C) Venous hum
D) Aortic coarctation
Correct Answer: B
Rationale: AV fistula (dialysis access) creates a continuous murmur (“machinery-like”) over the site.
Venous hum is continuous but neck location.
5. A patient with syncope has a midsystolic click and a late systolic murmur. The murmur intensity increases with
standing and decreases with squatting. This behavior is characteristic of:
A) Aortic stenosis
B) Mitral valve prolapse with regurgitation
C) Hypertrophic cardiomyopathy
D) Tricuspid regurgitation
Correct Answer: B
Rationale: MVP murmur lengthens and becomes louder with decreased preload (standing) and softer
with increased preload (squatting).
6. A patient presents with a new diastolic decrescendo murmur at the left sternal border. Which additional finding
would suggest acute rather than chronic aortic regurgitation?
A) Bounding pulses
B) Wide pulse pressure
C) Austin Flint murmur
D) Soft or absent S1
Correct Answer: D
Rationale: In acute AR, LV pressure rises rapidly, causing premature closure of mitral valve → soft S1.
Wide pulse pressure and bounding pulses take time to develop (chronic).
7. During jugular venous pressure assessment, you note large cannon a waves at irregular intervals. This is most
consistent with:
A) Atrial fibrillation
B) Complete heart block
C) Tricuspid regurgitation
D) Cardiac tamponade
Correct Answer: B
Rationale: Cannon a waves occur when atrium contracts against a closed tricuspid valve (AV
dissociation, e.g., complete heart block, ventricular tachycardia).
8. A 65-year-old with known heart failure has an S3 gallop. Which maneuver would accentuate the S3?
A) Standing
B) Valsalva
C) Leg raising
D) Squatting
,Correct Answer: C
Rationale: Passive leg raising increases preload → accentuates S3 (early diastolic filling sound).
9. A patient with hypertension has a blood pressure of 160/100 in the right arm and 140/90 in the left arm. On
palpation, the right radial pulse is bounding, while the left is weak. Which additional finding would most support
subclavian steal syndrome?
A) Left carotid bruit
B) Systolic bruit over left supraclavicular fossa
C) Right-sided cerebellar symptoms with left arm exercise
D) Delayed left radial pulse compared to right
Correct Answer: C
Rationale: Subclavian steal → vertebrobasilar symptoms (ataxia, dizziness) during ipsilateral arm
exercise due to reversed vertebral flow.
10. A 72-year-old presents with dyspnea and lower extremity edema. On exam, the jugular veins are distended with a
sharp x descent but no y descent. These JVP findings suggest:
A) Constrictive pericarditis
B) Cardiac tamponade
C) Right heart failure
D) Tricuspid stenosis
Correct Answer: B
Rationale: Tamponade → preserved x descent (ventricular ejection) but absent y descent (restricted
filling). Constrictive pericarditis has prominent y descent.
11. On auscultation, a patient has a fixed, widely split S2. Which other finding would you expect?
A) Systolic ejection murmur at left upper sternal border
B) Mid-diastolic rumble at apex
C) Opening snap
D) Pericardial knock
Correct Answer: A
*Rationale: Fixed wide split S2 = atrial septal defect (ASD) → often associated with pulmonic flow murmur (systolic
ejection murmur at LUSB).*
12. A 60-year-old with chronic alcoholism has an elevated JVP with a prominent v wave and rapid y descent. This is
most consistent with:
A) Cardiac tamponade
B) Constrictive pericarditis
C) Severe tricuspid regurgitation
D) Pulmonary hypertension
Correct Answer: C
Rationale: Large v wave + rapid y descent = severe TR. Rapid y descent occurs because RA pressure
falls rapidly in early diastole in TR.
13. A patient with endocarditis has a new murmur of aortic regurgitation. Which physical finding is most consistent
with acute severe AR?
A) Quincke pulse
, B) De Musset sign (head bobbing)
C) Low-pitched diastolic murmur
D) Pulsus bisferiens
Correct Answer: C
Rationale: Acute AR murmur is often low-pitched and short; chronic AR has high-pitched decrescendo
murmur. Quincke, De Musset, and bisferiens are chronic signs.
14. A 25-year-old asymptomatic athlete has a grade 2/6 midsystolic murmur at the left sternal border that increases
significantly with standing and decreases with handgrip. This suggests:
A) Hypertrophic cardiomyopathy
B) Aortic stenosis
C) Mitral valve prolapse
D) Innocent flow murmur
Correct Answer: A
Rationale: HCM murmur increases with standing (decreased preload) and decreases with handgrip
(increased afterload reduces gradient).
15. On precordial examination, you palpate a double apical impulse in a patient with hypertrophic cardiomyopathy.
This is due to:
A) Left ventricular dilation
B) Palpable S4
C) Bifid carotid pulse transmitted
D) Right ventricular heave
Correct Answer: B
*Rationale: Double apical impulse in HCM = palpable S4 (forceful atrial contraction into noncompliant LV) followed by
systolic impulse.*
16. A 50-year-old presents with sudden chest pain and a new murmur. On exam, you note a systolic thrill at the apex, a
loud S3, and a pansystolic murmur radiating to the axilla. Most likely:
A) Acute mitral regurgitation from papillary muscle rupture
B) Ventricular septal rupture
C) Aortic dissection with AR
D) Mitral stenosis
Correct Answer: A
*Rationale: Acute MR from papillary muscle rupture (post-MI) → apical thrill, loud S3, pansystolic murmur to axilla,
often with pulmonary edema.*
17. On auscultation of a patient with severe aortic stenosis, you note that S2 is paradoxically split. This indicates:
A) Delayed closure of pulmonic valve
B) Early closure of aortic valve
C) Delayed closure of aortic valve with prolonged LV systole
D) Right bundle branch block
Correct Answer: C
*Rationale: Paradoxical split S2 in AS = aortic valve closure markedly delayed (prolonged LV ejection), so A2 occurs
after P2 on expiration.*
