GCU NUR 634 Advanced Health
Assessment and Diagnostic Reasoning
With Skills Lab Midterm Examination -
Summer/Fall 2026
1. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the
hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the
ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin
condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage
to the subcutaneous tissue. The underlying muscle is not affected. You diagnose this as a
pressure ulcer. What is the stage of this ulcer?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
ANSWER: C
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with damage to or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer
presents as a deep crater with or without undermining of adjacent tissue. Stage 1 involves
intact skin with non-blanchable erythema. Stage 2 involves partial-thickness skin loss involving
epidermis and/or dermis. Stage 4 involves full-thickness skin loss with extensive destruction,
tissue necrosis, or damage to muscle, bone, or supporting structures.
,2. A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You
elicit the information that the dizziness is a spinning sensation of sudden onset, worse with
head position changes. The episodes last a few seconds and then go away, and they are
accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a
physical examination of the head and neck and note that the patient's hearing is intact to
Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description,
what is the most likely diagnosis?
A. Benign positional vertigo
B. Vestibular neuronitis
C. Ménière's disease
D. Cerebellar stroke
ANSWER: A
Rationale: Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of
vertigo (lasting seconds) triggered by changes in head position. It is typically associated with
nausea but no hearing loss or tinnitus. Vestibular neuronitis presents with acute, continuous
vertigo lasting days, often following a viral infection. Ménière's disease involves episodic vertigo
lasting hours with tinnitus and hearing loss. Cerebellar stroke would present with more severe
neurological deficits and abnormal gait.
3. A 65-year-old male with a history of hypertension and diabetes presents with a painful rash
on his right thorax. He reports that the rash started as tingling and burning sensations 3 days
before the lesions appeared. On examination, you note grouped vesicles on an erythematous
base in a dermatomal distribution along the right T4-T5 region. What is the most appropriate
initial treatment?
A. Acyclovir
B. Cephalexin
C. Prednisone
D. Hydrocortisone cream
,ANSWER: A
Rationale: This patient presents with herpes zoster (shingles), characterized by a vesicular rash
in a dermatomal distribution preceded by prodromal pain. Antiviral therapy (acyclovir,
valacyclovir, or famciclovir) is the mainstay of treatment and should be initiated within 72 hours
of rash onset to reduce acute pain and prevent postherpetic neuralgia. Cephalexin is an
antibiotic and would not be effective against a viral infection. Prednisone may be used as
adjunctive therapy in certain cases but is not the primary treatment. Hydrocortisone cream is a
topical corticosteroid and would not be adequate for this condition.
4. A 28-year-old pregnant woman at 34 weeks gestation presents with a 2-day history of fever,
chills, and flank pain. She reports frequency and urgency of urination. Her temperature is
38.5°C, blood pressure is 125/78 mmHg, and pulse is 95 bpm. Costovertebral angle tenderness
is present on the right side. Urinalysis shows leukocyte esterase positive and nitrites positive.
Which of the following is the most appropriate next step?
A. Oral nitrofurantoin for 7 days
B. Intravenous ceftriaxone and hospital admission
C. Oral amoxicillin for 5 days
D. Urine culture and sensitivity
ANSWER: B
Rationale: This patient presents with acute pyelonephritis during pregnancy, which requires
hospitalization for intravenous antibiotics due to the risk of complications including sepsis,
preterm labor, and acute respiratory distress syndrome. Nitrofurantoin is contraindicated in
pregnancy near term and is not appropriate for pyelonephritis. Amoxicillin would not provide
adequate coverage for the most likely organisms. While urine culture is important, the severity
of the presentation warrants immediate intravenous antibiotic therapy.
, 5. A 55-year-old female presents with a complaint of fatigue, weight gain, and cold intolerance
over the past 6 months. On examination, you note a pulse rate of 60 bpm, dry skin, and delayed
deep tendon reflexes. Laboratory studies reveal TSH of 12.5 mIU/L (normal 0.4-4.0) and free T4
of 0.5 ng/dL (normal 0.8-1.8). What is the most likely diagnosis?
A. Subclinical hypothyroidism
B. Overt hypothyroidism
C. Euthyroid sick syndrome
D. Hyperthyroidism
ANSWER: B
Rationale: Overt hypothyroidism is characterized by elevated TSH (>10 mIU/L) and low free T4
with clinical manifestations including fatigue, weight gain, cold intolerance, dry skin, and
delayed reflexes. Subclinical hypothyroidism presents with elevated TSH but normal free T4
levels. Euthyroid sick syndrome occurs in acutely ill patients with low T3 and T4 but normal or
low TSH. Hyperthyroidism would present with low TSH and elevated free T4.
6. A 72-year-old male with a history of benign prostatic hyperplasia presents with acute urinary
retention. He has not urinated in 12 hours and is experiencing suprapubic pain. His post-void
residual volume is 800 mL on bladder ultrasound. Which of the following is the most
appropriate initial management?
A. Alpha-blocker therapy
B. Transurethral resection of the prostate
C. Urinary catheterization
D. Finasteride therapy
ANSWER: C
Assessment and Diagnostic Reasoning
With Skills Lab Midterm Examination -
Summer/Fall 2026
1. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the
hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the
ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin
condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage
to the subcutaneous tissue. The underlying muscle is not affected. You diagnose this as a
pressure ulcer. What is the stage of this ulcer?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
ANSWER: C
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with damage to or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer
presents as a deep crater with or without undermining of adjacent tissue. Stage 1 involves
intact skin with non-blanchable erythema. Stage 2 involves partial-thickness skin loss involving
epidermis and/or dermis. Stage 4 involves full-thickness skin loss with extensive destruction,
tissue necrosis, or damage to muscle, bone, or supporting structures.
,2. A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You
elicit the information that the dizziness is a spinning sensation of sudden onset, worse with
head position changes. The episodes last a few seconds and then go away, and they are
accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a
physical examination of the head and neck and note that the patient's hearing is intact to
Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description,
what is the most likely diagnosis?
A. Benign positional vertigo
B. Vestibular neuronitis
C. Ménière's disease
D. Cerebellar stroke
ANSWER: A
Rationale: Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of
vertigo (lasting seconds) triggered by changes in head position. It is typically associated with
nausea but no hearing loss or tinnitus. Vestibular neuronitis presents with acute, continuous
vertigo lasting days, often following a viral infection. Ménière's disease involves episodic vertigo
lasting hours with tinnitus and hearing loss. Cerebellar stroke would present with more severe
neurological deficits and abnormal gait.
3. A 65-year-old male with a history of hypertension and diabetes presents with a painful rash
on his right thorax. He reports that the rash started as tingling and burning sensations 3 days
before the lesions appeared. On examination, you note grouped vesicles on an erythematous
base in a dermatomal distribution along the right T4-T5 region. What is the most appropriate
initial treatment?
A. Acyclovir
B. Cephalexin
C. Prednisone
D. Hydrocortisone cream
,ANSWER: A
Rationale: This patient presents with herpes zoster (shingles), characterized by a vesicular rash
in a dermatomal distribution preceded by prodromal pain. Antiviral therapy (acyclovir,
valacyclovir, or famciclovir) is the mainstay of treatment and should be initiated within 72 hours
of rash onset to reduce acute pain and prevent postherpetic neuralgia. Cephalexin is an
antibiotic and would not be effective against a viral infection. Prednisone may be used as
adjunctive therapy in certain cases but is not the primary treatment. Hydrocortisone cream is a
topical corticosteroid and would not be adequate for this condition.
4. A 28-year-old pregnant woman at 34 weeks gestation presents with a 2-day history of fever,
chills, and flank pain. She reports frequency and urgency of urination. Her temperature is
38.5°C, blood pressure is 125/78 mmHg, and pulse is 95 bpm. Costovertebral angle tenderness
is present on the right side. Urinalysis shows leukocyte esterase positive and nitrites positive.
Which of the following is the most appropriate next step?
A. Oral nitrofurantoin for 7 days
B. Intravenous ceftriaxone and hospital admission
C. Oral amoxicillin for 5 days
D. Urine culture and sensitivity
ANSWER: B
Rationale: This patient presents with acute pyelonephritis during pregnancy, which requires
hospitalization for intravenous antibiotics due to the risk of complications including sepsis,
preterm labor, and acute respiratory distress syndrome. Nitrofurantoin is contraindicated in
pregnancy near term and is not appropriate for pyelonephritis. Amoxicillin would not provide
adequate coverage for the most likely organisms. While urine culture is important, the severity
of the presentation warrants immediate intravenous antibiotic therapy.
, 5. A 55-year-old female presents with a complaint of fatigue, weight gain, and cold intolerance
over the past 6 months. On examination, you note a pulse rate of 60 bpm, dry skin, and delayed
deep tendon reflexes. Laboratory studies reveal TSH of 12.5 mIU/L (normal 0.4-4.0) and free T4
of 0.5 ng/dL (normal 0.8-1.8). What is the most likely diagnosis?
A. Subclinical hypothyroidism
B. Overt hypothyroidism
C. Euthyroid sick syndrome
D. Hyperthyroidism
ANSWER: B
Rationale: Overt hypothyroidism is characterized by elevated TSH (>10 mIU/L) and low free T4
with clinical manifestations including fatigue, weight gain, cold intolerance, dry skin, and
delayed reflexes. Subclinical hypothyroidism presents with elevated TSH but normal free T4
levels. Euthyroid sick syndrome occurs in acutely ill patients with low T3 and T4 but normal or
low TSH. Hyperthyroidism would present with low TSH and elevated free T4.
6. A 72-year-old male with a history of benign prostatic hyperplasia presents with acute urinary
retention. He has not urinated in 12 hours and is experiencing suprapubic pain. His post-void
residual volume is 800 mL on bladder ultrasound. Which of the following is the most
appropriate initial management?
A. Alpha-blocker therapy
B. Transurethral resection of the prostate
C. Urinary catheterization
D. Finasteride therapy
ANSWER: C
