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NR509 / NR 509 FINAL EXAM (LATEST )
QUESTIONS AND CORRECT DETAILED ANSWERS:
ADVANCED PHYSICAL ASSESSMENT - EXAMS OF NURSING
A 54-year-old female dietician presents for a routine annual examination. On review of systems,
she reports that she has had many breast findings over several years, including one biopsy with
normal pathology. She feels that her breasts have become far less lumpy since she underwent
menopause 3 years ago. Which of the following is true regarding changes in the breasts with
menopause?
a. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity
and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after
menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the
number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen dose from
endogenous and exogenous sources over the lifetime.
e. Mammography performs most poorly in the menopausal and postmenopau - ANSWER-c.
Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the
number of lobules.
Rationale: Glandular tissue of the breast atrophies with menopause, primarily due to a decrease
in the number of lobules. The consequent decrease in breast density makes mammograms ever
more useful during the age when breast cancer incidence starts to rise markedly.
An overweight 26-year-old public servant presents to the Emergency Department with 12 hours
of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to
seek medical attention. She has a strong family history of gallstones and is concerned about this
possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this
morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her
last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68;
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respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician
performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds
involuntary rigidity and rebound tenderness. What is the most likely diagnosis?
a. Ruptured tubal (or ectopic) pregnancy
b. Acute cholecystitis
c. Ruptured appendix
d. Perf - ANSWER-a. Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-
hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured
ectopic pregnancy with significant intra-abdominal bleeding leading to peritoneal signs. This
case is emergent and requires immediate treatment of her hypotension and presumed blood
loss as well as gynecological consult for emergent surgery
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit.
Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver
enzymes were also measured. His labs are all normal expect for moderate elevations of
aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline
phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up
appointment and the clinician performs an abdominal exam to assess his liver. Which of the
following findings would be most consistent with hepatomegaly?
a. Liver span of 11 cm at the midclavicular line
b. Liver span of 8 cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expirat - ANSWER-e.
Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would
be considered normal on inspiration when the liver is pushed down into the abdominal cavity
on inspiration, but is abnormal on expiration.
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A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents
with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well
otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first
cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood
pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her
body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an
abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for
an AAA?
a. Female gender
b. History of smoking
c. Underweight
d. Family history of ruptured aneurysm
e. Hypertension - ANSWER-b. History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not
female gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family
history of ruptured aneurysm is vague and could be a cerebral aneurysm. Further, her family
history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and
children). Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a
diagnosis of hypertension is not based on one elevated blood pressure reading.
A 76-year-old retired man with a history of prostate cancer and hypertension has been screened
annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for
follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to
date with his preventive health care. He has a positive FOBT on one occasion at age 66 years
and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were
found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or
adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening
recommendations for this patient?
a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
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c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years - ANSWER-a. Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years,
the gain in life years is small compared to colonoscopy risks. It is advised to discuss
individualized risks and benefits with the patient. Annual FOBT screening may continue until age
80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening
should not be routinely continued.
An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year
history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is
associated with onset of constipation. She describes infrequent, small hard stool that she finds
very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is
not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach
but do resolve the constipation. Symptoms typically gradually resolve with bowel movements.
Which of the following is the most likely physiological mechanism for her constipation?
a. A large, firm fecal mass in the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations - ANSWER-c. Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome
(IBS). IBS is characterized by three patterns: diarrhea predominant, constipation predominant,
or mixed. Other functional causes for her constipation should be excluded prior to making this
diagnosis.
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and
bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome.
NR509 / NR 509 FINAL EXAM (LATEST )
QUESTIONS AND CORRECT DETAILED ANSWERS:
ADVANCED PHYSICAL ASSESSMENT - EXAMS OF NURSING
A 54-year-old female dietician presents for a routine annual examination. On review of systems,
she reports that she has had many breast findings over several years, including one biopsy with
normal pathology. She feels that her breasts have become far less lumpy since she underwent
menopause 3 years ago. Which of the following is true regarding changes in the breasts with
menopause?
a. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity
and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after
menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the
number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen dose from
endogenous and exogenous sources over the lifetime.
e. Mammography performs most poorly in the menopausal and postmenopau - ANSWER-c.
Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the
number of lobules.
Rationale: Glandular tissue of the breast atrophies with menopause, primarily due to a decrease
in the number of lobules. The consequent decrease in breast density makes mammograms ever
more useful during the age when breast cancer incidence starts to rise markedly.
An overweight 26-year-old public servant presents to the Emergency Department with 12 hours
of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to
seek medical attention. She has a strong family history of gallstones and is concerned about this
possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this
morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her
last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68;
,2|Page
respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician
performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds
involuntary rigidity and rebound tenderness. What is the most likely diagnosis?
a. Ruptured tubal (or ectopic) pregnancy
b. Acute cholecystitis
c. Ruptured appendix
d. Perf - ANSWER-a. Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-
hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured
ectopic pregnancy with significant intra-abdominal bleeding leading to peritoneal signs. This
case is emergent and requires immediate treatment of her hypotension and presumed blood
loss as well as gynecological consult for emergent surgery
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit.
Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver
enzymes were also measured. His labs are all normal expect for moderate elevations of
aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline
phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up
appointment and the clinician performs an abdominal exam to assess his liver. Which of the
following findings would be most consistent with hepatomegaly?
a. Liver span of 11 cm at the midclavicular line
b. Liver span of 8 cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expirat - ANSWER-e.
Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would
be considered normal on inspiration when the liver is pushed down into the abdominal cavity
on inspiration, but is abnormal on expiration.
,3|Page
A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents
with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well
otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first
cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood
pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her
body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an
abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for
an AAA?
a. Female gender
b. History of smoking
c. Underweight
d. Family history of ruptured aneurysm
e. Hypertension - ANSWER-b. History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not
female gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family
history of ruptured aneurysm is vague and could be a cerebral aneurysm. Further, her family
history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and
children). Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a
diagnosis of hypertension is not based on one elevated blood pressure reading.
A 76-year-old retired man with a history of prostate cancer and hypertension has been screened
annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for
follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to
date with his preventive health care. He has a positive FOBT on one occasion at age 66 years
and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were
found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or
adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening
recommendations for this patient?
a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
, 4|Page
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years - ANSWER-a. Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years,
the gain in life years is small compared to colonoscopy risks. It is advised to discuss
individualized risks and benefits with the patient. Annual FOBT screening may continue until age
80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening
should not be routinely continued.
An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year
history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is
associated with onset of constipation. She describes infrequent, small hard stool that she finds
very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is
not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach
but do resolve the constipation. Symptoms typically gradually resolve with bowel movements.
Which of the following is the most likely physiological mechanism for her constipation?
a. A large, firm fecal mass in the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations - ANSWER-c. Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome
(IBS). IBS is characterized by three patterns: diarrhea predominant, constipation predominant,
or mixed. Other functional causes for her constipation should be excluded prior to making this
diagnosis.
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and
bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome.
