NUR 504 Exam 2: Advanced Health Assessment
and Differential Diagnosis - St. Thomas University
Updated and Latest Questions and Correct
Answers with Rationale
1. A 68-year-old patient presents with a harsh systolic crescendo-decrescendo murmur heard
best at the right second intercostal space. Which diagnosis is most consistent with this
finding?
A. Mitral Regurgitation
B. Mitral Stenosis
C. Aortic Regurgitation
D. Aortic Stenosis
Correct Answer: D
Rationale: Aortic stenosis is classically characterized by a systolic ejection murmur. It is
loudest at the right second intercostal space and often radiates to the carotid arteries.
Common symptoms associated with this condition include exertional dyspnea and syncope.
The crescendo-decrescendo pattern reflects the pressure changes as blood is forced
through the narrowed valve. This clinical presentation requires further evaluation with an
echocardiogram for definitive diagnosis.
2. During a physical examination, the clinician notes increased tactile fremitus over the lower
right lobe. Which condition is the most likely cause?
A. Pneumothorax
B. Lobar Pneumonia
C. Pleural Effusion
D. Asthma
Correct Answer: B
Rationale: Increased tactile fremitus occurs when there is consolidation in the lung tissue.
Lobar pneumonia fills the alveoli with fluid or exudate, which conducts sound vibrations
more effectively. Conversely, conditions like pneumothorax or pleural effusion typically
decrease or abolish fremitus. The clinician should also look for signs like dullness to
percussion in the same area. This finding is a critical indicator of solid or liquid
replacement of air in the lungs.
,3. A patient complains of severe right upper quadrant pain that radiates to the right scapula.
On examination, the patient stops breathing mid-inspiration during deep palpation of the
RUQ. What is this clinical sign called?
A. Rovsing’s Sign
B. Grey Turner’s Sign
C. Psoas Sign
D. Murphy’s Sign
Correct Answer: D
Rationale: Murphy’s sign is a clinical indicator specifically used to evaluate for acute
cholecystitis. It is performed by asking the patient to inhale while the clinician applies
pressure to the gallbladder area. A positive test occurs when the patient abruptly stops
inhaling due to pain. This occurs because the inflamed gallbladder descends and hits the
examiner’s fingers during inspiration. This maneuver is highly specific for gallbladder
inflammation in the clinical setting.
4. While assessing a patient with suspected heart failure, the clinician observes a sustained,
forceful outward thrust of the apex during palpation. This is documented as a:
A. Thrill
B. Bruit
C. Lift or Heave
D. Pulsus Alternans
Correct Answer: C
Rationale: A lift or heave is an abnormal palpation finding associated with ventricular
hypertrophy. It is felt as a rhythmic lifting impulse of the chest wall during systole. This
phenomenon is often caused by chronic pressure or volume overload in the heart
chambers. In contrast, a thrill is a palpable vibration associated with a loud heart murmur.
Recognizing these physical signs helps in identifying long-standing cardiovascular
structural changes.
5. Which physical exam finding is most indicative of a tension pneumothorax?
A. Tracheal deviation toward the affected side
B. Vesicular breath sounds on the affected side
C. Tracheal deviation toward the opposite side
D. Resonant percussion notes
Correct Answer: C
, Rationale: Tension pneumothorax is a life-threatening emergency where air enters the
pleural space and cannot escape. The increasing pressure causes the mediastinum to shift
away from the affected lung. This shift results in tracheal deviation toward the
contralateral side of the injury. Additional findings include absent breath sounds and
hyper-resonance on the side of the pneumothorax. Immediate decompression is required
to restore hemodynamic stability and lung function.
6. A 45-year-old male presents with epigastric pain that improves immediately after eating
but returns 2-3 hours later. This pattern is classic for:
A. Gastric Ulcer
B. Gastroesophageal Reflux Disease
C. Acute Pancreatitis
D. Duodenal Ulcer
Correct Answer: D
Rationale: Duodenal ulcers typically present with pain that is relieved by food intake. The
presence of food buffers the stomach acid, providing temporary relief to the patient.
However, pain often recurs as the stomach empties and acid enters the duodenum. Gastric
ulcers, by contrast, are usually aggravated by eating, leading to weight loss. Understanding
these temporal relationships is key to distinguishing types of peptic ulcer disease.
7. When auscultating the heart, the S2 sound is produced by the closure of which valves?
A. Mitral and Tricuspid
B. Aortic and Pulmonic
C. Mitral and Aortic
D. Tricuspid and Pulmonic
Correct Answer: B
Rationale: The second heart sound, S2, marks the beginning of diastole in the cardiac cycle.
It is generated by the closure of the semilunar valves, which are the aortic and pulmonic
valves. S2 is usually louder than S1 at the base of the heart. Physiologic splitting of S2 can
sometimes be heard during inspiration in healthy individuals. This sound signifies the
completion of ventricular ejection and the onset of ventricular relaxation.
8. A patient presents with sudden onset of pleuritic chest pain and shortness of breath. On
physical exam, the clinician finds unilateral swelling and tenderness of the left calf. What is
the most likely diagnosis?
A. Myocardial Infarction
B. Spontaneous Pneumothorax
C. Acute Pericarditis
and Differential Diagnosis - St. Thomas University
Updated and Latest Questions and Correct
Answers with Rationale
1. A 68-year-old patient presents with a harsh systolic crescendo-decrescendo murmur heard
best at the right second intercostal space. Which diagnosis is most consistent with this
finding?
A. Mitral Regurgitation
B. Mitral Stenosis
C. Aortic Regurgitation
D. Aortic Stenosis
Correct Answer: D
Rationale: Aortic stenosis is classically characterized by a systolic ejection murmur. It is
loudest at the right second intercostal space and often radiates to the carotid arteries.
Common symptoms associated with this condition include exertional dyspnea and syncope.
The crescendo-decrescendo pattern reflects the pressure changes as blood is forced
through the narrowed valve. This clinical presentation requires further evaluation with an
echocardiogram for definitive diagnosis.
2. During a physical examination, the clinician notes increased tactile fremitus over the lower
right lobe. Which condition is the most likely cause?
A. Pneumothorax
B. Lobar Pneumonia
C. Pleural Effusion
D. Asthma
Correct Answer: B
Rationale: Increased tactile fremitus occurs when there is consolidation in the lung tissue.
Lobar pneumonia fills the alveoli with fluid or exudate, which conducts sound vibrations
more effectively. Conversely, conditions like pneumothorax or pleural effusion typically
decrease or abolish fremitus. The clinician should also look for signs like dullness to
percussion in the same area. This finding is a critical indicator of solid or liquid
replacement of air in the lungs.
,3. A patient complains of severe right upper quadrant pain that radiates to the right scapula.
On examination, the patient stops breathing mid-inspiration during deep palpation of the
RUQ. What is this clinical sign called?
A. Rovsing’s Sign
B. Grey Turner’s Sign
C. Psoas Sign
D. Murphy’s Sign
Correct Answer: D
Rationale: Murphy’s sign is a clinical indicator specifically used to evaluate for acute
cholecystitis. It is performed by asking the patient to inhale while the clinician applies
pressure to the gallbladder area. A positive test occurs when the patient abruptly stops
inhaling due to pain. This occurs because the inflamed gallbladder descends and hits the
examiner’s fingers during inspiration. This maneuver is highly specific for gallbladder
inflammation in the clinical setting.
4. While assessing a patient with suspected heart failure, the clinician observes a sustained,
forceful outward thrust of the apex during palpation. This is documented as a:
A. Thrill
B. Bruit
C. Lift or Heave
D. Pulsus Alternans
Correct Answer: C
Rationale: A lift or heave is an abnormal palpation finding associated with ventricular
hypertrophy. It is felt as a rhythmic lifting impulse of the chest wall during systole. This
phenomenon is often caused by chronic pressure or volume overload in the heart
chambers. In contrast, a thrill is a palpable vibration associated with a loud heart murmur.
Recognizing these physical signs helps in identifying long-standing cardiovascular
structural changes.
5. Which physical exam finding is most indicative of a tension pneumothorax?
A. Tracheal deviation toward the affected side
B. Vesicular breath sounds on the affected side
C. Tracheal deviation toward the opposite side
D. Resonant percussion notes
Correct Answer: C
, Rationale: Tension pneumothorax is a life-threatening emergency where air enters the
pleural space and cannot escape. The increasing pressure causes the mediastinum to shift
away from the affected lung. This shift results in tracheal deviation toward the
contralateral side of the injury. Additional findings include absent breath sounds and
hyper-resonance on the side of the pneumothorax. Immediate decompression is required
to restore hemodynamic stability and lung function.
6. A 45-year-old male presents with epigastric pain that improves immediately after eating
but returns 2-3 hours later. This pattern is classic for:
A. Gastric Ulcer
B. Gastroesophageal Reflux Disease
C. Acute Pancreatitis
D. Duodenal Ulcer
Correct Answer: D
Rationale: Duodenal ulcers typically present with pain that is relieved by food intake. The
presence of food buffers the stomach acid, providing temporary relief to the patient.
However, pain often recurs as the stomach empties and acid enters the duodenum. Gastric
ulcers, by contrast, are usually aggravated by eating, leading to weight loss. Understanding
these temporal relationships is key to distinguishing types of peptic ulcer disease.
7. When auscultating the heart, the S2 sound is produced by the closure of which valves?
A. Mitral and Tricuspid
B. Aortic and Pulmonic
C. Mitral and Aortic
D. Tricuspid and Pulmonic
Correct Answer: B
Rationale: The second heart sound, S2, marks the beginning of diastole in the cardiac cycle.
It is generated by the closure of the semilunar valves, which are the aortic and pulmonic
valves. S2 is usually louder than S1 at the base of the heart. Physiologic splitting of S2 can
sometimes be heard during inspiration in healthy individuals. This sound signifies the
completion of ventricular ejection and the onset of ventricular relaxation.
8. A patient presents with sudden onset of pleuritic chest pain and shortness of breath. On
physical exam, the clinician finds unilateral swelling and tenderness of the left calf. What is
the most likely diagnosis?
A. Myocardial Infarction
B. Spontaneous Pneumothorax
C. Acute Pericarditis
