NSG 550 Exam 3 Diagnostic Reasoning (Wilkes,
2026/2027) – Q&A Study Pack
Advanced Diagnostic Reasoning for Nurse Practitioners | Key Domains: Formulation of Differential
Diagnoses, Interpretation of Diagnostic Studies (Labs, Imaging, EKG), Clinical Decision-Making
Models, Application of Clinical Practice Guidelines, Complex Case Analysis, and Evidence-Based
Management Plans | Expert-Aligned Structure | Exam-Ready Study Pack Format
Introduction
This structured NSG 550 Exam 3 Study Pack for Wilkes University for 2026/2027 provides a
focused set of complex, case-based questions with correct answers and rationales. It emphasizes the
advanced cognitive process of moving from patient data to a working diagnosis, requiring the
synthesis of assessment findings, diagnostic test interpretation, and guideline-based knowledge to
develop appropriate management strategies.
Study Pack Structure:
• Diagnostic Reasoning Exam Pack: (50 COMPLEX CASE STUDIES)
Answer Format
All correct answers (including the most likely diagnosis and the next appropriate step) must appear
in bold and cyan blue, accompanied by concise rationales explaining the key clinical clues that
support the primary diagnosis, the interpretation of critical lab or imaging results, the rationale for
choosing one diagnostic test over another, and why alternative diagnoses or actions are less likely or
incorrect based on the presented case.
1. A 62-year-old male presents with sudden-onset, tearing chest pain radiating to the back.
BP is 190/110 mm Hg in the right arm and 150/90 mm Hg in the left arm. What is the most
likely diagnosis and next step?
A. Myocardial infarction; administer aspirin and troponins
B. Aortic dissection; obtain a STAT CT angiogram
C. Pulmonary embolism; order D-dimer and CT pulmonary angiogram
D. Pneumothorax; perform chest X-ray
,B. Aortic dissection; obtain a STAT CT angiogram
The classic triad of aortic dissection is: (1) tearing chest/back pain, (2) pulse or BP asymmetry, and (3)
hypertension. This is a surgical emergency. CT angiogram is the gold standard for diagnosis. MI (A)
causes pressure-like pain without BP discrepancies. PE (C) presents with dyspnea and hypoxia.
Pneumothorax (D) causes sharp, pleuritic pain and absent breath sounds.
2. A 70-year-old female with atrial fibrillation presents with acute right-sided facial droop,
slurred speech, and left arm weakness. Symptoms began 2 hours ago. Non-contrast head CT
is normal. What is the most appropriate next step?
A. Administer aspirin 325 mg
B. Start heparin infusion
C. Administer IV alteplase
D. Order MRI brain
C. Administer IV alteplase
This is an acute ischemic stroke within the 4.5-hour window. Alteplase is indicated if CT shows no
hemorrhage and no contraindications (e.g., uncontrolled HTN, recent surgery). Aspirin (A) is given
after alteplase or if ineligible. Heparin (B) is not first-line in acute stroke. MRI (D) delays life-saving
intervention.
3. A 45-year-old male presents with weight loss, heat intolerance, tremor, and exophthalmos.
TSH is <0.01 mIU/L, free T4 is 4.0 ng/dL (normal 0.8–1.8). What is the diagnosis and
first-line treatment?
A. Hashimoto’s thyroiditis; levothyroxine
B. Subacute thyroiditis; prednisone
C. Graves’ disease; methimazole
D. Thyroid nodule; surgical referral
C. Graves’ disease; methimazole
, Graves’ disease is an autoimmune cause of hyperthyroidism characterized by low TSH, high T4, and
signs like exophthalmos and tremor. Methimazole is first-line therapy. Hashimoto’s (A) causes
hypothyroidism. Subacute thyroiditis (B) is painful and transient. Nodules (D) rarely cause
hyperthyroidism without other features.
4. A 55-year-old smoker presents with hemoptysis, 15-lb weight loss, and hoarseness. Chest
X-ray reveals a 4-cm right hilar mass. What is the most likely diagnosis and next step?
A. Pneumonia; start antibiotics
B. Tuberculosis; obtain sputum AFB
C. Lung cancer; refer for bronchoscopy and biopsy
D. Sarcoidosis; check ACE level
C. Lung cancer; refer for bronchoscopy and biopsy
In a smoker with hemoptysis, weight loss, hoarseness (recurrent laryngeal nerve involvement), and a
hilar mass, lung cancer is the leading diagnosis. Tissue diagnosis via bronchoscopy is essential.
Pneumonia (A) would show infiltrate, not mass. TB (B) is possible but less likely without fever/night
sweats in this context. Sarcoidosis (D) typically shows bilateral hilar lymphadenopathy.
5. A 50-year-old with cirrhosis presents with confusion, asterixis, and fetor hepaticus.
Ammonia is 150 µmol/L. What is the diagnosis and priority intervention?
A. Hepatic encephalopathy; administer lactulose
B. Hypoglycemia; give IV dextrose
C. Hyponatremia; give hypertonic saline
D. Sepsis; start broad-spectrum antibiotics
A. Hepatic encephalopathy; administer lactulose
These signs indicate hepatic encephalopathy due to elevated ammonia crossing the blood-brain
barrier. Lactulose acidifies the colon, trapping ammonia as ammonium (NH₄⁺), which is excreted in
2026/2027) – Q&A Study Pack
Advanced Diagnostic Reasoning for Nurse Practitioners | Key Domains: Formulation of Differential
Diagnoses, Interpretation of Diagnostic Studies (Labs, Imaging, EKG), Clinical Decision-Making
Models, Application of Clinical Practice Guidelines, Complex Case Analysis, and Evidence-Based
Management Plans | Expert-Aligned Structure | Exam-Ready Study Pack Format
Introduction
This structured NSG 550 Exam 3 Study Pack for Wilkes University for 2026/2027 provides a
focused set of complex, case-based questions with correct answers and rationales. It emphasizes the
advanced cognitive process of moving from patient data to a working diagnosis, requiring the
synthesis of assessment findings, diagnostic test interpretation, and guideline-based knowledge to
develop appropriate management strategies.
Study Pack Structure:
• Diagnostic Reasoning Exam Pack: (50 COMPLEX CASE STUDIES)
Answer Format
All correct answers (including the most likely diagnosis and the next appropriate step) must appear
in bold and cyan blue, accompanied by concise rationales explaining the key clinical clues that
support the primary diagnosis, the interpretation of critical lab or imaging results, the rationale for
choosing one diagnostic test over another, and why alternative diagnoses or actions are less likely or
incorrect based on the presented case.
1. A 62-year-old male presents with sudden-onset, tearing chest pain radiating to the back.
BP is 190/110 mm Hg in the right arm and 150/90 mm Hg in the left arm. What is the most
likely diagnosis and next step?
A. Myocardial infarction; administer aspirin and troponins
B. Aortic dissection; obtain a STAT CT angiogram
C. Pulmonary embolism; order D-dimer and CT pulmonary angiogram
D. Pneumothorax; perform chest X-ray
,B. Aortic dissection; obtain a STAT CT angiogram
The classic triad of aortic dissection is: (1) tearing chest/back pain, (2) pulse or BP asymmetry, and (3)
hypertension. This is a surgical emergency. CT angiogram is the gold standard for diagnosis. MI (A)
causes pressure-like pain without BP discrepancies. PE (C) presents with dyspnea and hypoxia.
Pneumothorax (D) causes sharp, pleuritic pain and absent breath sounds.
2. A 70-year-old female with atrial fibrillation presents with acute right-sided facial droop,
slurred speech, and left arm weakness. Symptoms began 2 hours ago. Non-contrast head CT
is normal. What is the most appropriate next step?
A. Administer aspirin 325 mg
B. Start heparin infusion
C. Administer IV alteplase
D. Order MRI brain
C. Administer IV alteplase
This is an acute ischemic stroke within the 4.5-hour window. Alteplase is indicated if CT shows no
hemorrhage and no contraindications (e.g., uncontrolled HTN, recent surgery). Aspirin (A) is given
after alteplase or if ineligible. Heparin (B) is not first-line in acute stroke. MRI (D) delays life-saving
intervention.
3. A 45-year-old male presents with weight loss, heat intolerance, tremor, and exophthalmos.
TSH is <0.01 mIU/L, free T4 is 4.0 ng/dL (normal 0.8–1.8). What is the diagnosis and
first-line treatment?
A. Hashimoto’s thyroiditis; levothyroxine
B. Subacute thyroiditis; prednisone
C. Graves’ disease; methimazole
D. Thyroid nodule; surgical referral
C. Graves’ disease; methimazole
, Graves’ disease is an autoimmune cause of hyperthyroidism characterized by low TSH, high T4, and
signs like exophthalmos and tremor. Methimazole is first-line therapy. Hashimoto’s (A) causes
hypothyroidism. Subacute thyroiditis (B) is painful and transient. Nodules (D) rarely cause
hyperthyroidism without other features.
4. A 55-year-old smoker presents with hemoptysis, 15-lb weight loss, and hoarseness. Chest
X-ray reveals a 4-cm right hilar mass. What is the most likely diagnosis and next step?
A. Pneumonia; start antibiotics
B. Tuberculosis; obtain sputum AFB
C. Lung cancer; refer for bronchoscopy and biopsy
D. Sarcoidosis; check ACE level
C. Lung cancer; refer for bronchoscopy and biopsy
In a smoker with hemoptysis, weight loss, hoarseness (recurrent laryngeal nerve involvement), and a
hilar mass, lung cancer is the leading diagnosis. Tissue diagnosis via bronchoscopy is essential.
Pneumonia (A) would show infiltrate, not mass. TB (B) is possible but less likely without fever/night
sweats in this context. Sarcoidosis (D) typically shows bilateral hilar lymphadenopathy.
5. A 50-year-old with cirrhosis presents with confusion, asterixis, and fetor hepaticus.
Ammonia is 150 µmol/L. What is the diagnosis and priority intervention?
A. Hepatic encephalopathy; administer lactulose
B. Hypoglycemia; give IV dextrose
C. Hyponatremia; give hypertonic saline
D. Sepsis; start broad-spectrum antibiotics
A. Hepatic encephalopathy; administer lactulose
These signs indicate hepatic encephalopathy due to elevated ammonia crossing the blood-brain
barrier. Lactulose acidifies the colon, trapping ammonia as ammonium (NH₄⁺), which is excreted in
