NR 509 Advanced Physical Assessment
Week 8 Final Examination 2026
1. A 72-year-old male presents with a 3-day history of progressive dyspnea on exertion and orthopnea.
He has a history of hypertension and coronary artery disease. On auscultation, you note an S3 gallop and
fine, late-inspiratory crackles at the lung bases. Jugular venous pressure is estimated at 12 cm H2O.
What is the most likely underlying pathophysiological process?
A) Right ventricular hypertrophy
B) Left ventricular systolic dysfunction
C) Constrictive pericarditis
D) Pulmonary embolus
ANSWER: B) Left ventricular systolic dysfunction
Rationale:
A) Right ventricular hypertrophy is incorrect. While it can lead to right-sided heart failure, the presence
of an S3 gallop and pulmonary crackles are classic signs of left-sided failure.
B) Left ventricular systolic dysfunction is correct. An S3 gallop is an early diastolic filling sound often
indicative of a failing, volume-overloaded left ventricle. Fine, late-inspiratory crackles (pulmonary
edema) and orthopnea are hallmarks of left-sided heart failure.
C) Constrictive pericarditis is incorrect. It can cause elevated JVP and an S3, but a "pericardial knock" is
more specific, and pulmonary crackles are less prominent.
D) Pulmonary embolus is incorrect. While it can cause dyspnea and tachypnea, it typically presents with
a clear chest or focal findings, not diffuse late-inspiratory crackles and an S3.
2. A 55-year-old female with a history of rheumatoid arthritis reports a 2-month history of dry eyes and
a persistently dry mouth. She also notes some difficulty swallowing dry foods. On examination, her
parotid glands are non-tender but palpable. Which antibody is most likely to be positive in this patient?
A) Anti-histone antibodies
B) Anti-dsDNA antibodies
,C) Anti-SSA (Ro) and anti-SSB (La) antibodies
D) Anti-centromere antibodies
ANSWER: C) Anti-SSA (Ro) and anti-SSB (La) antibodies
Rationale:
A) Anti-histone antibodies are incorrect. They are associated with drug-induced lupus.
B) Anti-dsDNA antibodies are incorrect. They are highly specific for systemic lupus erythematosus (SLE),
not Sjögren's syndrome.
C) Anti-SSA (Ro) and anti-SSB (La) antibodies are correct. This patient's symptoms of dry eyes
(xerophthalmia) and dry mouth (xerostomia) are characteristic of Sjögren's syndrome, an autoimmune
condition where these antibodies are frequently found.
D) Anti-centromere antibodies are incorrect. They are associated with the limited cutaneous form of
systemic sclerosis (CREST syndrome).
3. During a cardiac examination, you appreciate a systolic ejection murmur at the right upper sternal
border that radiates to the carotids. The murmur is described as harsh and crescendo-decrescendo. The
patient is an asymptomatic 68-year-old male. Which of the following is the most appropriate next step
in management?
A) Schedule for immediate cardiac catheterization
B) Recommend infective endocarditis prophylaxis prior to dental work
C) Reassure the patient and schedule a routine follow-up in one year
D) Order an echocardiogram to assess the valve
ANSWER: D) Order an echocardiogram to assess the valve
Rationale:
A) Immediate cardiac catheterization is incorrect. This is an invasive procedure and is not the first step
for an asymptomatic patient with a new murmur.
B) Infective endocarditis prophylaxis is incorrect. Current guidelines only recommend it for patients with
prosthetic valves or a history of endocarditis, not for native valve disease.
C) Reassure the patient is incorrect. A new murmur, even in an asymptomatic patient, warrants further
evaluation to determine its significance.
,D) Order an echocardiogram is correct. This is a classic presentation for aortic stenosis. An
echocardiogram is the gold-standard non-invasive test to assess the valve morphology, gradient, and
severity of the stenosis, guiding further management.
4. A 25-year-old male presents with a chief complaint of "my heart is skipping beats." He reports feeling
palpitations that are intermittent and associated with mild lightheadedness. He denies chest pain or
syncope. On cardiac auscultation, the rhythm is irregularly irregular. What is the most likely diagnosis?
A) Premature Atrial Contractions
B) Atrial Fibrillation
C) Sinus Arrhythmia
D) Ventricular Tachycardia
ANSWER: B) Atrial Fibrillation
Rationale:
A) Premature Atrial Contractions are incorrect. They cause an irregular rhythm, but the underlying
rhythm is typically sinus, with occasional early beats.
B) Atrial Fibrillation is correct. An "irregularly irregular" rhythm is the hallmark of atrial fibrillation. The
atria are quivering instead of contracting effectively, leading to a chaotic and unpredictable ventricular
response.
C) Sinus Arrhythmia is incorrect. This is a normal variation in heart rate that is usually related to the
respiratory cycle, where the heart rate increases with inspiration and decreases with expiration.
D) Ventricular Tachycardia is incorrect. This is a regular, wide-complex tachycardia that is typically very
fast and often hemodynamically unstable.
5. A patient presents with a painful, red, swollen joint in the great toe. He reports this has happened
several times before. Which of the following dietary modifications is most appropriate to recommend?
A) Increase intake of purine-rich foods
B) Decrease intake of foods high in fructose
C) Increase intake of alcohol
D) Decrease intake of dairy products
ANSWER: B) Decrease intake of foods high in fructose
, Rationale:
A) Increase purine-rich foods is incorrect. Purines are metabolized to uric acid, which exacerbates gout.
B) Decrease intake of foods high in fructose is correct. This is a classic presentation of acute gouty
arthritis. Fructose is the only sugar known to increase uric acid levels, and dietary restriction is a key
component of management.
C) Increase alcohol is incorrect. Alcohol, especially beer, contributes to hyperuricemia.
D) Decrease dairy products is incorrect. Low-fat dairy products are actually recommended as they may
have a protective effect.
6. A 45-year-old female reports a 2-week history of fatigue, generalized weakness, and a rash on her
cheeks and nose that worsens with sun exposure. She also reports pain and stiffness in her hands,
wrists, and knees. On examination, you note erythematous patches on her malar regions. What is the
most appropriate initial serological test to order?
A) Rheumatoid factor (RF)
B) Anti-nuclear antibody (ANA)
C) Erythrocyte sedimentation rate (ESR)
D) Anti-cyclic citrullinated peptide (anti-CCP)
ANSWER: B) Anti-nuclear antibody (ANA)
Rationale:
A) Rheumatoid factor is incorrect. While it can be positive in SLE, it is more specific for rheumatoid
arthritis.
B) Anti-nuclear antibody (ANA) is correct. The malar rash and symptoms of fatigue and joint pain are
consistent with Systemic Lupus Erythematosus (SLE). An ANA test is the most sensitive screening test for
SLE.
C) Erythrocyte sedimentation rate (ESR) is incorrect. This is a non-specific marker of inflammation and
would not confirm a diagnosis of SLE.
D) Anti-CCP is incorrect. This is a highly specific marker for rheumatoid arthritis.
7. A patient with a history of chronic obstructive pulmonary disease (COPD) has an oxygen saturation of
88% on room air. He is being discharged home with 2L of oxygen via nasal cannula. What is the most
important instruction you should provide regarding his oxygen therapy?
A) Increase the oxygen flow rate to 4L if he feels short of breath.
Week 8 Final Examination 2026
1. A 72-year-old male presents with a 3-day history of progressive dyspnea on exertion and orthopnea.
He has a history of hypertension and coronary artery disease. On auscultation, you note an S3 gallop and
fine, late-inspiratory crackles at the lung bases. Jugular venous pressure is estimated at 12 cm H2O.
What is the most likely underlying pathophysiological process?
A) Right ventricular hypertrophy
B) Left ventricular systolic dysfunction
C) Constrictive pericarditis
D) Pulmonary embolus
ANSWER: B) Left ventricular systolic dysfunction
Rationale:
A) Right ventricular hypertrophy is incorrect. While it can lead to right-sided heart failure, the presence
of an S3 gallop and pulmonary crackles are classic signs of left-sided failure.
B) Left ventricular systolic dysfunction is correct. An S3 gallop is an early diastolic filling sound often
indicative of a failing, volume-overloaded left ventricle. Fine, late-inspiratory crackles (pulmonary
edema) and orthopnea are hallmarks of left-sided heart failure.
C) Constrictive pericarditis is incorrect. It can cause elevated JVP and an S3, but a "pericardial knock" is
more specific, and pulmonary crackles are less prominent.
D) Pulmonary embolus is incorrect. While it can cause dyspnea and tachypnea, it typically presents with
a clear chest or focal findings, not diffuse late-inspiratory crackles and an S3.
2. A 55-year-old female with a history of rheumatoid arthritis reports a 2-month history of dry eyes and
a persistently dry mouth. She also notes some difficulty swallowing dry foods. On examination, her
parotid glands are non-tender but palpable. Which antibody is most likely to be positive in this patient?
A) Anti-histone antibodies
B) Anti-dsDNA antibodies
,C) Anti-SSA (Ro) and anti-SSB (La) antibodies
D) Anti-centromere antibodies
ANSWER: C) Anti-SSA (Ro) and anti-SSB (La) antibodies
Rationale:
A) Anti-histone antibodies are incorrect. They are associated with drug-induced lupus.
B) Anti-dsDNA antibodies are incorrect. They are highly specific for systemic lupus erythematosus (SLE),
not Sjögren's syndrome.
C) Anti-SSA (Ro) and anti-SSB (La) antibodies are correct. This patient's symptoms of dry eyes
(xerophthalmia) and dry mouth (xerostomia) are characteristic of Sjögren's syndrome, an autoimmune
condition where these antibodies are frequently found.
D) Anti-centromere antibodies are incorrect. They are associated with the limited cutaneous form of
systemic sclerosis (CREST syndrome).
3. During a cardiac examination, you appreciate a systolic ejection murmur at the right upper sternal
border that radiates to the carotids. The murmur is described as harsh and crescendo-decrescendo. The
patient is an asymptomatic 68-year-old male. Which of the following is the most appropriate next step
in management?
A) Schedule for immediate cardiac catheterization
B) Recommend infective endocarditis prophylaxis prior to dental work
C) Reassure the patient and schedule a routine follow-up in one year
D) Order an echocardiogram to assess the valve
ANSWER: D) Order an echocardiogram to assess the valve
Rationale:
A) Immediate cardiac catheterization is incorrect. This is an invasive procedure and is not the first step
for an asymptomatic patient with a new murmur.
B) Infective endocarditis prophylaxis is incorrect. Current guidelines only recommend it for patients with
prosthetic valves or a history of endocarditis, not for native valve disease.
C) Reassure the patient is incorrect. A new murmur, even in an asymptomatic patient, warrants further
evaluation to determine its significance.
,D) Order an echocardiogram is correct. This is a classic presentation for aortic stenosis. An
echocardiogram is the gold-standard non-invasive test to assess the valve morphology, gradient, and
severity of the stenosis, guiding further management.
4. A 25-year-old male presents with a chief complaint of "my heart is skipping beats." He reports feeling
palpitations that are intermittent and associated with mild lightheadedness. He denies chest pain or
syncope. On cardiac auscultation, the rhythm is irregularly irregular. What is the most likely diagnosis?
A) Premature Atrial Contractions
B) Atrial Fibrillation
C) Sinus Arrhythmia
D) Ventricular Tachycardia
ANSWER: B) Atrial Fibrillation
Rationale:
A) Premature Atrial Contractions are incorrect. They cause an irregular rhythm, but the underlying
rhythm is typically sinus, with occasional early beats.
B) Atrial Fibrillation is correct. An "irregularly irregular" rhythm is the hallmark of atrial fibrillation. The
atria are quivering instead of contracting effectively, leading to a chaotic and unpredictable ventricular
response.
C) Sinus Arrhythmia is incorrect. This is a normal variation in heart rate that is usually related to the
respiratory cycle, where the heart rate increases with inspiration and decreases with expiration.
D) Ventricular Tachycardia is incorrect. This is a regular, wide-complex tachycardia that is typically very
fast and often hemodynamically unstable.
5. A patient presents with a painful, red, swollen joint in the great toe. He reports this has happened
several times before. Which of the following dietary modifications is most appropriate to recommend?
A) Increase intake of purine-rich foods
B) Decrease intake of foods high in fructose
C) Increase intake of alcohol
D) Decrease intake of dairy products
ANSWER: B) Decrease intake of foods high in fructose
, Rationale:
A) Increase purine-rich foods is incorrect. Purines are metabolized to uric acid, which exacerbates gout.
B) Decrease intake of foods high in fructose is correct. This is a classic presentation of acute gouty
arthritis. Fructose is the only sugar known to increase uric acid levels, and dietary restriction is a key
component of management.
C) Increase alcohol is incorrect. Alcohol, especially beer, contributes to hyperuricemia.
D) Decrease dairy products is incorrect. Low-fat dairy products are actually recommended as they may
have a protective effect.
6. A 45-year-old female reports a 2-week history of fatigue, generalized weakness, and a rash on her
cheeks and nose that worsens with sun exposure. She also reports pain and stiffness in her hands,
wrists, and knees. On examination, you note erythematous patches on her malar regions. What is the
most appropriate initial serological test to order?
A) Rheumatoid factor (RF)
B) Anti-nuclear antibody (ANA)
C) Erythrocyte sedimentation rate (ESR)
D) Anti-cyclic citrullinated peptide (anti-CCP)
ANSWER: B) Anti-nuclear antibody (ANA)
Rationale:
A) Rheumatoid factor is incorrect. While it can be positive in SLE, it is more specific for rheumatoid
arthritis.
B) Anti-nuclear antibody (ANA) is correct. The malar rash and symptoms of fatigue and joint pain are
consistent with Systemic Lupus Erythematosus (SLE). An ANA test is the most sensitive screening test for
SLE.
C) Erythrocyte sedimentation rate (ESR) is incorrect. This is a non-specific marker of inflammation and
would not confirm a diagnosis of SLE.
D) Anti-CCP is incorrect. This is a highly specific marker for rheumatoid arthritis.
7. A patient with a history of chronic obstructive pulmonary disease (COPD) has an oxygen saturation of
88% on room air. He is being discharged home with 2L of oxygen via nasal cannula. What is the most
important instruction you should provide regarding his oxygen therapy?
A) Increase the oxygen flow rate to 4L if he feels short of breath.
