NR-509 Advanced Physical Assessment: A 150-Question Graduate-Level
Practice Examination on Complex Physical Assessment,
Pathophysiologic Correlation, Diagnostic Reasoning, and Clinical
Decision-Making Across the Lifespan
Instructions for the Learner
• Each question has one best answer.
• Questions integrate assessment techniques, pathophysiology, differential diagnosis, and evidence-based clinical
reasoning.
• Time suggested: 3 minutes per question (7.5 hours total, or break into multiple sessions).
Questions 1–150
Cardiovascular System (Questions 1–20)
1. A 68-year-old man reports exertional chest pressure relieved by rest. On cardiac auscultation, you note a midsystolic
click followed by a late systolic murmur at the apex. Which finding is most likely on echocardiography?
A) Mitral annular calcification
B) Hypertrophic cardiomyopathy
C) Mitral valve prolapse with regurgitation
D) Aortic stenosis
Correct Answer: C
Rationale: Midsystolic click + late systolic murmur at apex = mitral valve prolapse with regurgitation.
The click occurs as chordae tense abruptly.
2. A 55-year-old female with end-stage renal disease has a high-pitched, early diastolic decrescendo murmur best heard
at the left sternal border. Which maneuver increases murmur intensity?
A) Standing quickly
B) Handgrip
C) Inspiration
D) Valsalva
Correct Answer: B
Rationale: Early diastolic decrescendo murmur = aortic regurgitation. Handgrip increases afterload,
worsening regurgitation and intensifying murmur. Inspiration affects right-sided murmurs.
3. During precordial palpation of a 45-year-old male with hypertension, you feel a sustained, forceful apical impulse
displaced to the left. This suggests:
A) Right ventricular hypertrophy
B) Dilated cardiomyopathy
C) Left ventricular hypertrophy
D) Pericardial effusion
Correct Answer: C
Rationale: Sustained, displaced apical impulse = pressure overload from hypertension causing
concentric LV hypertrophy.
,4. A 72-year-old presents with syncope during exertion. On exam, a harsh crescendo-decrescendo murmur at the right
upper sternal border radiates to the carotids. S2 is paradoxically split. Most likely diagnosis?
A) Hypertrophic obstructive cardiomyopathy
B) Aortic stenosis
C) Mitral regurgitation
D) Pulmonary stenosis
Correct Answer: B
*Rationale: Syncope on exertion + harsh murmur at 2nd RICS radiating to carotids + paradoxical split = severe aortic
stenosis.*
5. Which jugular venous pulse waveform abnormality is classically seen in cardiac tamponade?
A) Giant a wave
B) Large v wave
C) Prominent x descent but absent y descent
D) Prominent y descent
Correct Answer: C
Rationale: Tamponade = elevated JVP with steep x descent but blunted/absent y descent due to
restricted ventricular filling.
6. During auscultation of a 30-year-old pregnant woman at 28 weeks, you hear a continuous “machinery” murmur at
the left upper sternal border. What is the most likely cause?
A) Patent ductus arteriosus (congenital)
B) Mammary souffle
C) Venous hum
D) Aortic coarctation
Correct Answer: B
Rationale: Mammary souffle is a benign continuous murmur in late pregnancy due to increased breast
blood flow. Venous hum is also continuous but located lower neck.
7. A patient with a history of IV drug use presents with fever and a new regurgitant murmur. Which finding best
suggests acute aortic regurgitation rather than chronic?
A) Widened pulse pressure
B) Austin Flint murmur
C) Premature closure of mitral valve on echo
D) Water-hammer pulse
Correct Answer: C
Rationale: Premature closure of mitral valve (from rapid rise in LV diastolic pressure) suggests acute
AR. Wide pulse pressure and water-hammer pulse = chronic AR.
8. Which physical exam finding is most specific for constrictive pericarditis?
A) Kussmaul sign
B) Pulsus paradoxus >10 mmHg
C) Pericardial knock
D) Ewart sign
Correct Answer: C
Rationale: Pericardial knock (high-pitched early diastolic sound) is classic for constrictive pericarditis.
,Pulsus paradoxus more specific for tamponade.
9. A 62-year-old with COPD exacerbation has distant heart sounds and a non-palpable apex beat. You suspect:
A) Tension pneumothorax
B) Hyperinflation displacing the heart
C) Pericardial effusion
D) Left main stem bronchus obstruction
Correct Answer: B
Rationale: COPD with hyperinflation → vertical heart orientation, distant sounds, and non-palpable
apex. Pericardial effusion would cause muffled sounds but apex beat may still be palpable.
10. On auscultation, you hear an S3 gallop in a 75-year-old with known heart failure and preserved ejection fraction.
This indicates:
A) Severe mitral stenosis
B) Elevated filling pressures despite preserved EF
C) Constrictive pericarditis
D) Right atrial myxoma
Correct Answer: B
*Rationale: S3 reflects rapid deceleration of blood into a non-compliant ventricle, often from elevated filling pressures
(HFpEF or HFrEF).*
11. A patient’s blood pressure is 140/90 in the right arm and 100/70 in the left arm. On palpation, right radial and
brachial pulses are bounding while left are diminished. What is the most likely diagnosis?
A) Subclavian steal syndrome
B) Aortic dissection
C) Takayasu arteritis
D) Thoracic outlet syndrome
Correct Answer: C
*Rationale: Bilateral arm BP difference >10-20 mmHg with diminished pulses suggests Takayasu (pulseless disease).
Dissection presents acutely with severe chest pain.*
12. A 50-year-old with chronic kidney disease has a high-pitched scratchy sound that varies with respiration and
position, heard best leaning forward. This is most consistent with:
A) Pleural friction rub
B) Pericardial friction rub
C) Mediastinal crunch
D) Subcutaneous emphysema
Correct Answer: B
Rationale: Pericardial rub = high-pitched, to-and-fro, best heard with diaphragm while patient leans
forward. Uremia is a common cause.
13. Which finding is least likely in a patient with severe pulmonary hypertension?
A) Loud P2
B) Right ventricular heave
C) Prominent a wave in JVP
D) Split S2 that widens on expiration
Correct Answer: D
, Rationale: Pulmonary hypertension → loud P2, RV heave, prominent a wave. Physiologic splitting
widens on inspiration, not expiration (paradoxical split in severe PH is rare).
14. A 28-year-old asymptomatic athlete has a grade 2/6 midsystolic murmur at left sternal border that decreases with
standing and increases with squatting. This suggests:
A) Aortic stenosis
B) Hypertrophic cardiomyopathy
C) Mitral valve prolapse
D) Atrial septal defect
Correct Answer: B
Rationale: HCM murmur increases with decreased preload (standing) and decreases with increased
preload (squatting).
15. Which jugular venous pulse abnormality is most consistent with tricuspid regurgitation?
A) Giant a wave
B) Cannon a waves
C) Large systolic v wave with rapid y descent
D) Blunted x descent
Correct Answer: C
Rationale: TR → large v wave (systolic filling of RA from RV) and rapid y descent due to low RA
pressure early diastole.
16. A patient with fever, Janeway lesions, and Osler nodes has a new regurgitant murmur. Which is most likely true?
A) Blood cultures are likely negative
B) The murmur is from acute mitral regurgitation due to chordae rupture
C) Transesophageal echo is first-line imaging
D) Splinter hemorrhages are pathognomonic
Correct Answer: B
Rationale: Acute bacterial endocarditis can cause chordae rupture → acute MR. Janeway/Osler =
endocarditis. TTE first-line, TEE if negative high suspicion.
17. During carotid auscultation, you hear a bruit that is primarily diastolic in timing. This suggests:
A) Carotid artery stenosis
B) Arteriovenous fistula
C) Venous hum
D) Aortic regurgitation radiating to carotids
Correct Answer: D
Rationale: Diastolic bruit over carotids = transmitted aortic regurgitation murmur. Carotid stenosis
bruit is systolic.
18. A 40-year-old presents with syncope on standing, no heart murmur, but JVP shows giant a waves. ECG shows LV
hypertrophy. What is the most likely diagnosis?
A) Cardiac amyloidosis
B) HCM with latent obstruction
C) Aortic stenosis
D) Dehydration
Correct Answer: A
Practice Examination on Complex Physical Assessment,
Pathophysiologic Correlation, Diagnostic Reasoning, and Clinical
Decision-Making Across the Lifespan
Instructions for the Learner
• Each question has one best answer.
• Questions integrate assessment techniques, pathophysiology, differential diagnosis, and evidence-based clinical
reasoning.
• Time suggested: 3 minutes per question (7.5 hours total, or break into multiple sessions).
Questions 1–150
Cardiovascular System (Questions 1–20)
1. A 68-year-old man reports exertional chest pressure relieved by rest. On cardiac auscultation, you note a midsystolic
click followed by a late systolic murmur at the apex. Which finding is most likely on echocardiography?
A) Mitral annular calcification
B) Hypertrophic cardiomyopathy
C) Mitral valve prolapse with regurgitation
D) Aortic stenosis
Correct Answer: C
Rationale: Midsystolic click + late systolic murmur at apex = mitral valve prolapse with regurgitation.
The click occurs as chordae tense abruptly.
2. A 55-year-old female with end-stage renal disease has a high-pitched, early diastolic decrescendo murmur best heard
at the left sternal border. Which maneuver increases murmur intensity?
A) Standing quickly
B) Handgrip
C) Inspiration
D) Valsalva
Correct Answer: B
Rationale: Early diastolic decrescendo murmur = aortic regurgitation. Handgrip increases afterload,
worsening regurgitation and intensifying murmur. Inspiration affects right-sided murmurs.
3. During precordial palpation of a 45-year-old male with hypertension, you feel a sustained, forceful apical impulse
displaced to the left. This suggests:
A) Right ventricular hypertrophy
B) Dilated cardiomyopathy
C) Left ventricular hypertrophy
D) Pericardial effusion
Correct Answer: C
Rationale: Sustained, displaced apical impulse = pressure overload from hypertension causing
concentric LV hypertrophy.
,4. A 72-year-old presents with syncope during exertion. On exam, a harsh crescendo-decrescendo murmur at the right
upper sternal border radiates to the carotids. S2 is paradoxically split. Most likely diagnosis?
A) Hypertrophic obstructive cardiomyopathy
B) Aortic stenosis
C) Mitral regurgitation
D) Pulmonary stenosis
Correct Answer: B
*Rationale: Syncope on exertion + harsh murmur at 2nd RICS radiating to carotids + paradoxical split = severe aortic
stenosis.*
5. Which jugular venous pulse waveform abnormality is classically seen in cardiac tamponade?
A) Giant a wave
B) Large v wave
C) Prominent x descent but absent y descent
D) Prominent y descent
Correct Answer: C
Rationale: Tamponade = elevated JVP with steep x descent but blunted/absent y descent due to
restricted ventricular filling.
6. During auscultation of a 30-year-old pregnant woman at 28 weeks, you hear a continuous “machinery” murmur at
the left upper sternal border. What is the most likely cause?
A) Patent ductus arteriosus (congenital)
B) Mammary souffle
C) Venous hum
D) Aortic coarctation
Correct Answer: B
Rationale: Mammary souffle is a benign continuous murmur in late pregnancy due to increased breast
blood flow. Venous hum is also continuous but located lower neck.
7. A patient with a history of IV drug use presents with fever and a new regurgitant murmur. Which finding best
suggests acute aortic regurgitation rather than chronic?
A) Widened pulse pressure
B) Austin Flint murmur
C) Premature closure of mitral valve on echo
D) Water-hammer pulse
Correct Answer: C
Rationale: Premature closure of mitral valve (from rapid rise in LV diastolic pressure) suggests acute
AR. Wide pulse pressure and water-hammer pulse = chronic AR.
8. Which physical exam finding is most specific for constrictive pericarditis?
A) Kussmaul sign
B) Pulsus paradoxus >10 mmHg
C) Pericardial knock
D) Ewart sign
Correct Answer: C
Rationale: Pericardial knock (high-pitched early diastolic sound) is classic for constrictive pericarditis.
,Pulsus paradoxus more specific for tamponade.
9. A 62-year-old with COPD exacerbation has distant heart sounds and a non-palpable apex beat. You suspect:
A) Tension pneumothorax
B) Hyperinflation displacing the heart
C) Pericardial effusion
D) Left main stem bronchus obstruction
Correct Answer: B
Rationale: COPD with hyperinflation → vertical heart orientation, distant sounds, and non-palpable
apex. Pericardial effusion would cause muffled sounds but apex beat may still be palpable.
10. On auscultation, you hear an S3 gallop in a 75-year-old with known heart failure and preserved ejection fraction.
This indicates:
A) Severe mitral stenosis
B) Elevated filling pressures despite preserved EF
C) Constrictive pericarditis
D) Right atrial myxoma
Correct Answer: B
*Rationale: S3 reflects rapid deceleration of blood into a non-compliant ventricle, often from elevated filling pressures
(HFpEF or HFrEF).*
11. A patient’s blood pressure is 140/90 in the right arm and 100/70 in the left arm. On palpation, right radial and
brachial pulses are bounding while left are diminished. What is the most likely diagnosis?
A) Subclavian steal syndrome
B) Aortic dissection
C) Takayasu arteritis
D) Thoracic outlet syndrome
Correct Answer: C
*Rationale: Bilateral arm BP difference >10-20 mmHg with diminished pulses suggests Takayasu (pulseless disease).
Dissection presents acutely with severe chest pain.*
12. A 50-year-old with chronic kidney disease has a high-pitched scratchy sound that varies with respiration and
position, heard best leaning forward. This is most consistent with:
A) Pleural friction rub
B) Pericardial friction rub
C) Mediastinal crunch
D) Subcutaneous emphysema
Correct Answer: B
Rationale: Pericardial rub = high-pitched, to-and-fro, best heard with diaphragm while patient leans
forward. Uremia is a common cause.
13. Which finding is least likely in a patient with severe pulmonary hypertension?
A) Loud P2
B) Right ventricular heave
C) Prominent a wave in JVP
D) Split S2 that widens on expiration
Correct Answer: D
, Rationale: Pulmonary hypertension → loud P2, RV heave, prominent a wave. Physiologic splitting
widens on inspiration, not expiration (paradoxical split in severe PH is rare).
14. A 28-year-old asymptomatic athlete has a grade 2/6 midsystolic murmur at left sternal border that decreases with
standing and increases with squatting. This suggests:
A) Aortic stenosis
B) Hypertrophic cardiomyopathy
C) Mitral valve prolapse
D) Atrial septal defect
Correct Answer: B
Rationale: HCM murmur increases with decreased preload (standing) and decreases with increased
preload (squatting).
15. Which jugular venous pulse abnormality is most consistent with tricuspid regurgitation?
A) Giant a wave
B) Cannon a waves
C) Large systolic v wave with rapid y descent
D) Blunted x descent
Correct Answer: C
Rationale: TR → large v wave (systolic filling of RA from RV) and rapid y descent due to low RA
pressure early diastole.
16. A patient with fever, Janeway lesions, and Osler nodes has a new regurgitant murmur. Which is most likely true?
A) Blood cultures are likely negative
B) The murmur is from acute mitral regurgitation due to chordae rupture
C) Transesophageal echo is first-line imaging
D) Splinter hemorrhages are pathognomonic
Correct Answer: B
Rationale: Acute bacterial endocarditis can cause chordae rupture → acute MR. Janeway/Osler =
endocarditis. TTE first-line, TEE if negative high suspicion.
17. During carotid auscultation, you hear a bruit that is primarily diastolic in timing. This suggests:
A) Carotid artery stenosis
B) Arteriovenous fistula
C) Venous hum
D) Aortic regurgitation radiating to carotids
Correct Answer: D
Rationale: Diastolic bruit over carotids = transmitted aortic regurgitation murmur. Carotid stenosis
bruit is systolic.
18. A 40-year-old presents with syncope on standing, no heart murmur, but JVP shows giant a waves. ECG shows LV
hypertrophy. What is the most likely diagnosis?
A) Cardiac amyloidosis
B) HCM with latent obstruction
C) Aortic stenosis
D) Dehydration
Correct Answer: A
