NR 509 Final Exam Questions and Correct
Answers, Updated 2024/2025 Solved 100%
Appendicitis
1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign, and
the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates to the
RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point
1. McBurney point lies 2 inches from the anterior superior spinous process of ilium on a
line drawn from that process to the umbilicus
2. Appendicitis is three times more likely if there is McBurney point tenderness.
Rovsing sign
Press deeply and evenly in the LLQ. Then quickly withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Psoas Sign
--Place your hand just above the patient's right knee and ask the patient to raise that
thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then
extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas
muscle contract; extension stretches it.
--Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting
irritation of the psoas muscle by an inflamed appendix.
Obturator Sign
--Less helpful
--Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally
at the hip. This maneuver stretches the internal obturator muscle.
--Right hypogastric pain is a positive obturator sign, from irritation of the obturator
muscle by an inflamed appendix. This sign has very low sensitivity.
Acute Cholecystits
RUQ pain
Murphy Sign
Murphy Sign
Hook your left thumb or the fingers of your right hand under the costal margin at the
point where the lateral border of the rectus muscle intersects with the costal margin.
Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin.
If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable
point. Ask the patient to take a deep breath, which forces the liver and gallbladder down
toward the examining fingers. Watch the patient's breathing and note the degree of
,tenderness.
--A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When
positive, Murphy sign triples the likelihood of acute cholecystitis.
Acute Pancreatitis Process
Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in
autodigestion and inflammation of the pancreas
Acute Pancreatitis Location
Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with
severe sequelae of organ failure
Acute Pancreatitis Quality
Usually steady
Acute PancreatitisTiming
Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors
Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected
medications, high triglycerides may exacerbate
Acute Pancreatitis Relieving factors
Leaning forward with trunk flexed
Acute Pancreatitis Associated Symptoms and Setting
Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of
alcohol abuse or gallstones
Peptic Ulcer Disease Process
Mucosal ulcer in stomach or duode-num >5 mm, covered with fibrin, ex-tending through
the muscularis mu-cosa; H. pylori infection present in 90% of peptic ulcers
Peptic Ulcer Disease Location
Epigastric, may radiate straight to the back
Peptic Ulcer Disease Quality
Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or
hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing
Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain
that (1) wakes the patient at night, and (2) occurs intermittently over a few wks,
disappears for months, then recurs
Peptic Ulcer Disease aggravating factors
Variable
Peptic Ulcer Disease relieving factors
Food and antacids may bring re-lief (less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting
Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer);
weight loss (more common in gastric ulcer); dyspepsia is more com-mon in the young
(20-29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30-60 yrs
GERD Process
Prolonged exposure of esophagus to gastric acid due to impaired esopha-geal motility
or excess relaxations of the lower esophageal sphincter; Helico-bacter pylori may be
present
, GERD Location
Chest or epigastric
GERD Quality
Heartburn, regurgitation
GERD timing
After meals, especially spicy foods
GERD aggravating factors
Lying down, bending over; physical activity; diseases such as scleroderma,
gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
GERD : relieving factors
Antacids, proton pump inhibi-tors; avoiding alcohol, smoking, fatty meals, chocolate,
selected drugs such as theophylline, cal-cium channel blockers
GERD associated symptoms and setting
Wheezing, chronic cough, short-ness of breath, hoarseness, choking sensation,
dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and
esopha-geal cancer
Diverticulitis process
Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually
in sigmoid or descend-ing colon
Diverticulitis location
Left lower quadrant
Diverticulitis quality
May be cramping at first, then steady
Diverticulitis timing
Often gradual onset
Diverticulitis aggravating factors
--
Diverticulitis relieving factors
Analgesia, bowel rest, antibiotics
Diverticulitis associated symptoms and setting
Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness
Hepatitis
-Tenderness over liver (liver inflammation)
--Hep A and B prevention: Vaccination
Hep A: spread through fecal matter and asymptomatic children
Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer (usually
asymptomatic until onset of advanced liver disease).
Hep C: Mainly percutaneous exposure.
Hepatitis B high risk
-Sexual contact: w/ partners infected, more than one parter in prior 6 mos, people
seeing eval of treatment for STD, men with men
-Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff of
facilties of DD, Health care, dialysis
-Others: Travel to endemic areas, chronic liver disease and HIV, people seeking
protection from Hep B.
--All adults in high risk-settings: STD clinics, HIV programs, Drug programs, correctional
Answers, Updated 2024/2025 Solved 100%
Appendicitis
1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign, and
the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates to the
RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point
1. McBurney point lies 2 inches from the anterior superior spinous process of ilium on a
line drawn from that process to the umbilicus
2. Appendicitis is three times more likely if there is McBurney point tenderness.
Rovsing sign
Press deeply and evenly in the LLQ. Then quickly withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Psoas Sign
--Place your hand just above the patient's right knee and ask the patient to raise that
thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then
extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas
muscle contract; extension stretches it.
--Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting
irritation of the psoas muscle by an inflamed appendix.
Obturator Sign
--Less helpful
--Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally
at the hip. This maneuver stretches the internal obturator muscle.
--Right hypogastric pain is a positive obturator sign, from irritation of the obturator
muscle by an inflamed appendix. This sign has very low sensitivity.
Acute Cholecystits
RUQ pain
Murphy Sign
Murphy Sign
Hook your left thumb or the fingers of your right hand under the costal margin at the
point where the lateral border of the rectus muscle intersects with the costal margin.
Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin.
If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable
point. Ask the patient to take a deep breath, which forces the liver and gallbladder down
toward the examining fingers. Watch the patient's breathing and note the degree of
,tenderness.
--A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When
positive, Murphy sign triples the likelihood of acute cholecystitis.
Acute Pancreatitis Process
Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in
autodigestion and inflammation of the pancreas
Acute Pancreatitis Location
Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with
severe sequelae of organ failure
Acute Pancreatitis Quality
Usually steady
Acute PancreatitisTiming
Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors
Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected
medications, high triglycerides may exacerbate
Acute Pancreatitis Relieving factors
Leaning forward with trunk flexed
Acute Pancreatitis Associated Symptoms and Setting
Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of
alcohol abuse or gallstones
Peptic Ulcer Disease Process
Mucosal ulcer in stomach or duode-num >5 mm, covered with fibrin, ex-tending through
the muscularis mu-cosa; H. pylori infection present in 90% of peptic ulcers
Peptic Ulcer Disease Location
Epigastric, may radiate straight to the back
Peptic Ulcer Disease Quality
Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or
hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing
Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain
that (1) wakes the patient at night, and (2) occurs intermittently over a few wks,
disappears for months, then recurs
Peptic Ulcer Disease aggravating factors
Variable
Peptic Ulcer Disease relieving factors
Food and antacids may bring re-lief (less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting
Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer);
weight loss (more common in gastric ulcer); dyspepsia is more com-mon in the young
(20-29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30-60 yrs
GERD Process
Prolonged exposure of esophagus to gastric acid due to impaired esopha-geal motility
or excess relaxations of the lower esophageal sphincter; Helico-bacter pylori may be
present
, GERD Location
Chest or epigastric
GERD Quality
Heartburn, regurgitation
GERD timing
After meals, especially spicy foods
GERD aggravating factors
Lying down, bending over; physical activity; diseases such as scleroderma,
gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
GERD : relieving factors
Antacids, proton pump inhibi-tors; avoiding alcohol, smoking, fatty meals, chocolate,
selected drugs such as theophylline, cal-cium channel blockers
GERD associated symptoms and setting
Wheezing, chronic cough, short-ness of breath, hoarseness, choking sensation,
dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and
esopha-geal cancer
Diverticulitis process
Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually
in sigmoid or descend-ing colon
Diverticulitis location
Left lower quadrant
Diverticulitis quality
May be cramping at first, then steady
Diverticulitis timing
Often gradual onset
Diverticulitis aggravating factors
--
Diverticulitis relieving factors
Analgesia, bowel rest, antibiotics
Diverticulitis associated symptoms and setting
Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness
Hepatitis
-Tenderness over liver (liver inflammation)
--Hep A and B prevention: Vaccination
Hep A: spread through fecal matter and asymptomatic children
Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer (usually
asymptomatic until onset of advanced liver disease).
Hep C: Mainly percutaneous exposure.
Hepatitis B high risk
-Sexual contact: w/ partners infected, more than one parter in prior 6 mos, people
seeing eval of treatment for STD, men with men
-Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff of
facilties of DD, Health care, dialysis
-Others: Travel to endemic areas, chronic liver disease and HIV, people seeking
protection from Hep B.
--All adults in high risk-settings: STD clinics, HIV programs, Drug programs, correctional
