NUR 504 Final Exam: Advanced Health Assessment
and Differential Diagnosis - St. Thomas University
Updated and Latest Questions and Correct
Answers with Rationale
1. A 58-year-old male presents with sudden, sharp, tearing chest pain that radiates to his
back between the shoulder blades. Which of the following is the most likely diagnosis?
A. Acute Myocardial Infarction
B. Tension Pneumothorax
C. Pulmonary Embolism
D. Aortic Dissection
Correct Answer: D
Rationale: Sudden tearing chest pain radiating to the back is a classic presentation of an
aortic dissection. This condition involves a tear in the tunica intima of the aorta, allowing
blood to flow between the layers. Rapid diagnosis is essential as this is a surgical
emergency with high mortality. Computed tomography angiography is usually the
preferred imaging modality for confirmation. Clinicians must differentiate this from
myocardial infarction to avoid administering contraindicated anticoagulants.
2. When performing an abdominal assessment, you elicit sharp pain upon inspiration while
palpating the right upper quadrant. Which sign are you assessing?
A. Rovsing Sign
B. McBurney Sign
C. Psoas Sign
D. Murphy Sign
Correct Answer: D
Rationale: A positive Murphy sign is indicated by an arrest of inspiration due to pain
during RUQ palpation. This clinical finding is highly suggestive of acute cholecystitis or
gallbladder inflammation. The maneuver brings the inflamed gallbladder into contact with
the examiner’s hand during deep breathing. It is a critical component of the physical exam
for patients presenting with biliary colic symptoms. Other signs like Rovsing or Psoas are
typically used to evaluate for appendicitis rather than gallbladder issues.
3. During a cardiac auscultation, you hear a low-pitched extra heart sound early in diastole,
immediately following S2. What does this S3 sound most likely indicate in an older adult?
A. Heart failure or volume overload
,B. Ventricular hypertrophy
C. Normal physiological variant
D. Mitral valve stenosis
Correct Answer: A
Rationale: The S3 gallop is a ventricular filling sound heard during the rapid filling phase
of diastole. In older adults, it frequently signifies ventricular dysfunction or significant
volume overload. It is often associated with conditions such as congestive heart failure or
cardiomyopathy. While S3 can be normal in children and athletes, its appearance in seniors
warrants further investigation. This sound is best heard with the bell of the stethoscope at
the apex while the patient is in the left lateral decubitus position.
4. A patient presents with increased tactile fremitus and dullness to percussion over the right
lower lobe. Which of the following is the most likely underlying condition?
A. Pneumothorax
B. Lobar Pneumonia
C. Pleural Effusion
D. Chronic Obstructive Pulmonary Disease
Correct Answer: B
Rationale: Increased tactile fremitus occurs when lung tissue becomes consolidated, such
as in lobar pneumonia. Solid or liquid-filled tissue conducts vibrations more effectively
than the air-filled lungs of a healthy individual. Dullness to percussion further supports the
presence of a solid mass or fluid replacing air-filled space. In contrast, conditions like
pneumothorax or COPD would produce decreased fremitus and hyperresonance.
Recognizing these physical findings is essential for accurate respiratory differential
diagnosis.
5. A 24-year-old female complains of a sore throat, fever, and tender anterior cervical
lymphadenopathy. Which tool is used to estimate the probability of Group A Streptococcal
pharyngitis?
A. PHQ-9 Scale
B. Centor Criteria
C. CHADS2 Score
D. CURB-65 Criteria
Correct Answer: B
Rationale: The Centor Criteria is a validated clinical decision rule used to evaluate the
likelihood of bacterial pharyngitis. It considers symptoms such as fever, absence of cough,
, tonsillar exudates, and tender anterior cervical lymph nodes. A higher score increases the
probability of a Group A Streptococcus infection and guides the need for testing. Utilizing
this tool helps clinicians avoid the unnecessary prescription of antibiotics for viral
infections. While it assists in decision-making, a rapid antigen test or culture is often still
required for definitive diagnosis.
6. While assessing a patient’s cranial nerves, you observe that the patient is unable to puff
out their cheeks or smile symmetrically. Which cranial nerve is likely affected?
A. CN V (Trigeminal)
B. CN VII (Facial)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: B
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Weakness or paralysis in smiling, frowning, or puffing out cheeks indicates a
deficit in this nerve. This can be seen in conditions such as Bell’s palsy or as a result of a
cerebrovascular accident. Distinguishing between upper and lower motor neuron lesions is
critical for determining the etiology. The trigeminal nerve, by contrast, handles facial
sensation and the muscles of mastication.
7. An elderly patient presents with a history of hypertension and now complains of a
‘pulsating’ feeling in the abdomen. Which physical exam finding would most strongly suggest
an abdominal aortic aneurysm (AAA)?
A. Absent bowel sounds
B. A wide, palpable periumbilical mass
C. A periumbilical bruit
D. Tenderness at McBurney’s point
Correct Answer: B
Rationale: A wide, palpable, and pulsatile mass in the periumbilical area is a classic sign of
an abdominal aortic aneurysm. The width of the pulsation is more indicative of an
aneurysm than the strength of the pulse itself. In thin individuals, a normal pulse might be
felt, but a wide mass is always concerning. Screening is particularly important for older
men with a history of smoking and hypertension. If suspected, an ultrasound is the
standard initial imaging test to measure the diameter of the aorta.
8. A patient presents with a suspicious skin lesion. Which characteristic is NOT part of the
ABCDE criteria for assessing potential melanoma?
A. Asymmetry
and Differential Diagnosis - St. Thomas University
Updated and Latest Questions and Correct
Answers with Rationale
1. A 58-year-old male presents with sudden, sharp, tearing chest pain that radiates to his
back between the shoulder blades. Which of the following is the most likely diagnosis?
A. Acute Myocardial Infarction
B. Tension Pneumothorax
C. Pulmonary Embolism
D. Aortic Dissection
Correct Answer: D
Rationale: Sudden tearing chest pain radiating to the back is a classic presentation of an
aortic dissection. This condition involves a tear in the tunica intima of the aorta, allowing
blood to flow between the layers. Rapid diagnosis is essential as this is a surgical
emergency with high mortality. Computed tomography angiography is usually the
preferred imaging modality for confirmation. Clinicians must differentiate this from
myocardial infarction to avoid administering contraindicated anticoagulants.
2. When performing an abdominal assessment, you elicit sharp pain upon inspiration while
palpating the right upper quadrant. Which sign are you assessing?
A. Rovsing Sign
B. McBurney Sign
C. Psoas Sign
D. Murphy Sign
Correct Answer: D
Rationale: A positive Murphy sign is indicated by an arrest of inspiration due to pain
during RUQ palpation. This clinical finding is highly suggestive of acute cholecystitis or
gallbladder inflammation. The maneuver brings the inflamed gallbladder into contact with
the examiner’s hand during deep breathing. It is a critical component of the physical exam
for patients presenting with biliary colic symptoms. Other signs like Rovsing or Psoas are
typically used to evaluate for appendicitis rather than gallbladder issues.
3. During a cardiac auscultation, you hear a low-pitched extra heart sound early in diastole,
immediately following S2. What does this S3 sound most likely indicate in an older adult?
A. Heart failure or volume overload
,B. Ventricular hypertrophy
C. Normal physiological variant
D. Mitral valve stenosis
Correct Answer: A
Rationale: The S3 gallop is a ventricular filling sound heard during the rapid filling phase
of diastole. In older adults, it frequently signifies ventricular dysfunction or significant
volume overload. It is often associated with conditions such as congestive heart failure or
cardiomyopathy. While S3 can be normal in children and athletes, its appearance in seniors
warrants further investigation. This sound is best heard with the bell of the stethoscope at
the apex while the patient is in the left lateral decubitus position.
4. A patient presents with increased tactile fremitus and dullness to percussion over the right
lower lobe. Which of the following is the most likely underlying condition?
A. Pneumothorax
B. Lobar Pneumonia
C. Pleural Effusion
D. Chronic Obstructive Pulmonary Disease
Correct Answer: B
Rationale: Increased tactile fremitus occurs when lung tissue becomes consolidated, such
as in lobar pneumonia. Solid or liquid-filled tissue conducts vibrations more effectively
than the air-filled lungs of a healthy individual. Dullness to percussion further supports the
presence of a solid mass or fluid replacing air-filled space. In contrast, conditions like
pneumothorax or COPD would produce decreased fremitus and hyperresonance.
Recognizing these physical findings is essential for accurate respiratory differential
diagnosis.
5. A 24-year-old female complains of a sore throat, fever, and tender anterior cervical
lymphadenopathy. Which tool is used to estimate the probability of Group A Streptococcal
pharyngitis?
A. PHQ-9 Scale
B. Centor Criteria
C. CHADS2 Score
D. CURB-65 Criteria
Correct Answer: B
Rationale: The Centor Criteria is a validated clinical decision rule used to evaluate the
likelihood of bacterial pharyngitis. It considers symptoms such as fever, absence of cough,
, tonsillar exudates, and tender anterior cervical lymph nodes. A higher score increases the
probability of a Group A Streptococcus infection and guides the need for testing. Utilizing
this tool helps clinicians avoid the unnecessary prescription of antibiotics for viral
infections. While it assists in decision-making, a rapid antigen test or culture is often still
required for definitive diagnosis.
6. While assessing a patient’s cranial nerves, you observe that the patient is unable to puff
out their cheeks or smile symmetrically. Which cranial nerve is likely affected?
A. CN V (Trigeminal)
B. CN VII (Facial)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: B
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Weakness or paralysis in smiling, frowning, or puffing out cheeks indicates a
deficit in this nerve. This can be seen in conditions such as Bell’s palsy or as a result of a
cerebrovascular accident. Distinguishing between upper and lower motor neuron lesions is
critical for determining the etiology. The trigeminal nerve, by contrast, handles facial
sensation and the muscles of mastication.
7. An elderly patient presents with a history of hypertension and now complains of a
‘pulsating’ feeling in the abdomen. Which physical exam finding would most strongly suggest
an abdominal aortic aneurysm (AAA)?
A. Absent bowel sounds
B. A wide, palpable periumbilical mass
C. A periumbilical bruit
D. Tenderness at McBurney’s point
Correct Answer: B
Rationale: A wide, palpable, and pulsatile mass in the periumbilical area is a classic sign of
an abdominal aortic aneurysm. The width of the pulsation is more indicative of an
aneurysm than the strength of the pulse itself. In thin individuals, a normal pulse might be
felt, but a wide mass is always concerning. Screening is particularly important for older
men with a history of smoking and hypertension. If suspected, an ultrasound is the
standard initial imaging test to measure the diameter of the aorta.
8. A patient presents with a suspicious skin lesion. Which characteristic is NOT part of the
ABCDE criteria for assessing potential melanoma?
A. Asymmetry
