NR509 Advanced Physical Assessment — Practice Exam 2025/2026
NR509 Advanced Physical Assessment
COMPREHENSIVE PRACTICE EXAM — 88 Questions
2025/2026 Edition | All Topics Covered | Answer
Rationales Included
Instructions
This practice exam contains 88 questions covering all major NR509 topic areas: Cardiovascular,
Peripheral Vascular, Respiratory, Neurological, Abdomen/GI, Musculoskeletal, HEENT,
Skin/Integumentary, and Mental Status/Psychiatric. Questions are designed at the application and
analysis level. The correct answer and detailed rationale are provided after each question. Topics are
distributed throughout. Estimated time: 120–150 minutes.
For study purposes only — not actual exam questions
,NR509 Advanced Physical Assessment — Practice Exam 2025/2026
Question 1 [Cardiovascular]
A 58-year-old male presents with a new murmur heard best at the right upper sternal border that
radiates to the carotid arteries. The murmur is harsh, crescendo-decrescendo, and peaks in mid-
systole. Which of the following is the MOST likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Tricuspid regurgitation
D. Pulmonic stenosis
✓ Correct Answer: B
Rationale: Aortic stenosis produces a harsh crescendo-decrescendo (diamond-shaped) systolic murmur
best heard at the right upper sternal border (aortic area, 2nd ICS RSB) that radiates to the carotid
arteries. Mitral regurgitation is holosystolic at the apex radiating to the axilla.
Question 2 [Cardiovascular]
During auscultation, you note a low-pitched, rumbling diastolic murmur heard best at the apex with
the bell of the stethoscope, in the left lateral decubitus position. Which maneuver would MOST
likely accentuate this murmur?
A. Having the patient squat
B. Having the patient stand rapidly
C. Having the patient perform a Valsalva maneuver
D. Having the patient exercise briefly
✓ Correct Answer: D
Rationale: This presentation is classic for mitral stenosis. Exercise (and left lateral decubitus position)
increases heart rate and cardiac output, augmenting flow across the stenotic mitral valve, thereby
accentuating the rumble. The bell detects low-frequency sounds best.
Question 3 [Cardiovascular]
A patient has a holosystolic murmur at the left lower sternal border that increases with inspiration.
Which condition is MOST consistent with this finding?
A. Mitral valve prolapse
B. Ventricular septal defect
C. Tricuspid regurgitation
D. Hypertrophic obstructive cardiomyopathy
✓ Correct Answer: C
Rationale: Tricuspid regurgitation produces a holosystolic murmur at the LLSB (tricuspid area). The
hallmark is that it increases with inspiration (Carvallo sign) because inspiration increases right-sided
venous return. VSD murmurs do not change with respiration.
Question 4 [Cardiovascular]
For study purposes only — not actual exam questions
,NR509 Advanced Physical Assessment — Practice Exam 2025/2026
A 45-year-old woman has a midsystolic click followed by a late systolic murmur at the apex. The
click moves CLOSER to S1 when she squats. This change indicates:
A. Increased left ventricular volume, delaying mitral valve prolapse
B. Decreased left ventricular volume, causing earlier prolapse
C. Increased heart rate causing earlier valve dysfunction
D. Decreased preload causing the click to disappear
✓ Correct Answer: A
Rationale: In MVP, squatting increases preload and LV volume. A larger LV delays when the leaflets
prolapse, moving the click later (toward S2) relative to systole — AWAY from S1. If the click moves
closer to S1, it suggests decreased LV volume (standing, Valsalva), not squatting. Therefore the correct
answer here acknowledges that squatting increases LV volume delaying MVP.
Question 5 [Cardiovascular]
A 70-year-old man with a history of CHF presents with an S3 gallop. This sound is best heard with
the:
A. Diaphragm of the stethoscope at the right sternal border
B. Bell of the stethoscope at the apex in left lateral decubitus
C. Diaphragm at the base of the heart during expiration
D. Bell at the right sternal border during inspiration
✓ Correct Answer: B
Rationale: S3 is a low-frequency sound occurring in early diastole due to rapid ventricular filling in a
volume-overloaded or poorly compliant ventricle. It is best auscultated with the BELL (detects low
frequencies) at the cardiac APEX with the patient in left lateral decubitus position, which brings the apex
closer to the chest wall.
Question 6 [Peripheral Vascular]
A 65-year-old male smoker complains of bilateral calf pain that occurs with walking and is relieved
by rest. Physical exam reveals absent dorsalis pedis pulses bilaterally and shiny, hairless skin on
both lower legs. The ANKLE-BRACHIAL INDEX (ABI) is 0.55. This indicates:
A. Normal arterial flow
B. Mild peripheral artery disease
C. Moderate-to-severe peripheral artery disease
D. Venous insufficiency
✓ Correct Answer: C
Rationale: ABI of 0.91–1.30 is normal. 0.71–0.90 = mild PAD. 0.41–0.70 = moderate-to-severe PAD. <
0.40 = critical limb ischemia. An ABI of 0.55 represents moderate-to-severe PAD with claudication
symptoms consistent with ischemic origin. Venous insufficiency would show edema, varicosities, and
venous stasis changes, not absent pulses.
Question 7 [Cardiovascular]
For study purposes only — not actual exam questions
, NR509 Advanced Physical Assessment — Practice Exam 2025/2026
When assessing jugular venous pressure (JVP), the patient is positioned at 30–45 degrees. The
vertical height of the pulsation above the sternal angle is 5 cm. What does this indicate?
A. Normal JVP
B. Elevated JVP suggesting right heart failure
C. Low JVP suggesting dehydration
D. The measurement is only valid at 90 degrees
✓ Correct Answer: B
Rationale: Normal JVP is ≤ 3–4 cm above the sternal angle (angle of Louis). A height of 5 cm above the
sternal angle indicates elevated JVP, suggesting elevated right atrial pressure as seen in right heart
failure, cardiac tamponade, or fluid overload.
Question 8 [Cardiovascular]
A patient demonstrates pulsus paradoxus of 15 mmHg. Which condition is MOST associated with
this finding?
A. Aortic regurgitation
B. Cardiac tamponade
C. Mitral stenosis
D. Left ventricular hypertrophy
✓ Correct Answer: B
Rationale: Pulsus paradoxus is an exaggerated drop in systolic BP (>10 mmHg) during inspiration. It is
classically associated with cardiac tamponade, severe asthma, and constrictive pericarditis. The finding
represents impaired LV filling due to pericardial fluid/pressure constraining cardiac chambers during
inspiration.
Question 9 [Respiratory]
A 55-year-old male with a 40-pack-year smoking history presents with progressive dyspnea and a
chronic productive cough. On exam you note a barrel chest, hyperresonance to percussion, and
diminished breath sounds bilaterally. Which additional finding is MOST expected?
A. Fine inspiratory crackles at the bases
B. Prolonged expiratory phase and expiratory wheezes
C. Bronchial breath sounds over the lower lobes
D. Dullness to percussion at the lung bases
✓ Correct Answer: B
Rationale: This presentation is classic for COPD/emphysema. Air trapping leads to a prolonged
expiratory phase (I:E ratio >1:3). Expiratory wheezes reflect airflow obstruction. Fine basilar crackles
suggest pulmonary edema or fibrosis. Bronchial breath sounds over consolidation suggest pneumonia.
Dullness at bases suggests effusion.
Question 10 [Respiratory]
For study purposes only — not actual exam questions
NR509 Advanced Physical Assessment
COMPREHENSIVE PRACTICE EXAM — 88 Questions
2025/2026 Edition | All Topics Covered | Answer
Rationales Included
Instructions
This practice exam contains 88 questions covering all major NR509 topic areas: Cardiovascular,
Peripheral Vascular, Respiratory, Neurological, Abdomen/GI, Musculoskeletal, HEENT,
Skin/Integumentary, and Mental Status/Psychiatric. Questions are designed at the application and
analysis level. The correct answer and detailed rationale are provided after each question. Topics are
distributed throughout. Estimated time: 120–150 minutes.
For study purposes only — not actual exam questions
,NR509 Advanced Physical Assessment — Practice Exam 2025/2026
Question 1 [Cardiovascular]
A 58-year-old male presents with a new murmur heard best at the right upper sternal border that
radiates to the carotid arteries. The murmur is harsh, crescendo-decrescendo, and peaks in mid-
systole. Which of the following is the MOST likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Tricuspid regurgitation
D. Pulmonic stenosis
✓ Correct Answer: B
Rationale: Aortic stenosis produces a harsh crescendo-decrescendo (diamond-shaped) systolic murmur
best heard at the right upper sternal border (aortic area, 2nd ICS RSB) that radiates to the carotid
arteries. Mitral regurgitation is holosystolic at the apex radiating to the axilla.
Question 2 [Cardiovascular]
During auscultation, you note a low-pitched, rumbling diastolic murmur heard best at the apex with
the bell of the stethoscope, in the left lateral decubitus position. Which maneuver would MOST
likely accentuate this murmur?
A. Having the patient squat
B. Having the patient stand rapidly
C. Having the patient perform a Valsalva maneuver
D. Having the patient exercise briefly
✓ Correct Answer: D
Rationale: This presentation is classic for mitral stenosis. Exercise (and left lateral decubitus position)
increases heart rate and cardiac output, augmenting flow across the stenotic mitral valve, thereby
accentuating the rumble. The bell detects low-frequency sounds best.
Question 3 [Cardiovascular]
A patient has a holosystolic murmur at the left lower sternal border that increases with inspiration.
Which condition is MOST consistent with this finding?
A. Mitral valve prolapse
B. Ventricular septal defect
C. Tricuspid regurgitation
D. Hypertrophic obstructive cardiomyopathy
✓ Correct Answer: C
Rationale: Tricuspid regurgitation produces a holosystolic murmur at the LLSB (tricuspid area). The
hallmark is that it increases with inspiration (Carvallo sign) because inspiration increases right-sided
venous return. VSD murmurs do not change with respiration.
Question 4 [Cardiovascular]
For study purposes only — not actual exam questions
,NR509 Advanced Physical Assessment — Practice Exam 2025/2026
A 45-year-old woman has a midsystolic click followed by a late systolic murmur at the apex. The
click moves CLOSER to S1 when she squats. This change indicates:
A. Increased left ventricular volume, delaying mitral valve prolapse
B. Decreased left ventricular volume, causing earlier prolapse
C. Increased heart rate causing earlier valve dysfunction
D. Decreased preload causing the click to disappear
✓ Correct Answer: A
Rationale: In MVP, squatting increases preload and LV volume. A larger LV delays when the leaflets
prolapse, moving the click later (toward S2) relative to systole — AWAY from S1. If the click moves
closer to S1, it suggests decreased LV volume (standing, Valsalva), not squatting. Therefore the correct
answer here acknowledges that squatting increases LV volume delaying MVP.
Question 5 [Cardiovascular]
A 70-year-old man with a history of CHF presents with an S3 gallop. This sound is best heard with
the:
A. Diaphragm of the stethoscope at the right sternal border
B. Bell of the stethoscope at the apex in left lateral decubitus
C. Diaphragm at the base of the heart during expiration
D. Bell at the right sternal border during inspiration
✓ Correct Answer: B
Rationale: S3 is a low-frequency sound occurring in early diastole due to rapid ventricular filling in a
volume-overloaded or poorly compliant ventricle. It is best auscultated with the BELL (detects low
frequencies) at the cardiac APEX with the patient in left lateral decubitus position, which brings the apex
closer to the chest wall.
Question 6 [Peripheral Vascular]
A 65-year-old male smoker complains of bilateral calf pain that occurs with walking and is relieved
by rest. Physical exam reveals absent dorsalis pedis pulses bilaterally and shiny, hairless skin on
both lower legs. The ANKLE-BRACHIAL INDEX (ABI) is 0.55. This indicates:
A. Normal arterial flow
B. Mild peripheral artery disease
C. Moderate-to-severe peripheral artery disease
D. Venous insufficiency
✓ Correct Answer: C
Rationale: ABI of 0.91–1.30 is normal. 0.71–0.90 = mild PAD. 0.41–0.70 = moderate-to-severe PAD. <
0.40 = critical limb ischemia. An ABI of 0.55 represents moderate-to-severe PAD with claudication
symptoms consistent with ischemic origin. Venous insufficiency would show edema, varicosities, and
venous stasis changes, not absent pulses.
Question 7 [Cardiovascular]
For study purposes only — not actual exam questions
, NR509 Advanced Physical Assessment — Practice Exam 2025/2026
When assessing jugular venous pressure (JVP), the patient is positioned at 30–45 degrees. The
vertical height of the pulsation above the sternal angle is 5 cm. What does this indicate?
A. Normal JVP
B. Elevated JVP suggesting right heart failure
C. Low JVP suggesting dehydration
D. The measurement is only valid at 90 degrees
✓ Correct Answer: B
Rationale: Normal JVP is ≤ 3–4 cm above the sternal angle (angle of Louis). A height of 5 cm above the
sternal angle indicates elevated JVP, suggesting elevated right atrial pressure as seen in right heart
failure, cardiac tamponade, or fluid overload.
Question 8 [Cardiovascular]
A patient demonstrates pulsus paradoxus of 15 mmHg. Which condition is MOST associated with
this finding?
A. Aortic regurgitation
B. Cardiac tamponade
C. Mitral stenosis
D. Left ventricular hypertrophy
✓ Correct Answer: B
Rationale: Pulsus paradoxus is an exaggerated drop in systolic BP (>10 mmHg) during inspiration. It is
classically associated with cardiac tamponade, severe asthma, and constrictive pericarditis. The finding
represents impaired LV filling due to pericardial fluid/pressure constraining cardiac chambers during
inspiration.
Question 9 [Respiratory]
A 55-year-old male with a 40-pack-year smoking history presents with progressive dyspnea and a
chronic productive cough. On exam you note a barrel chest, hyperresonance to percussion, and
diminished breath sounds bilaterally. Which additional finding is MOST expected?
A. Fine inspiratory crackles at the bases
B. Prolonged expiratory phase and expiratory wheezes
C. Bronchial breath sounds over the lower lobes
D. Dullness to percussion at the lung bases
✓ Correct Answer: B
Rationale: This presentation is classic for COPD/emphysema. Air trapping leads to a prolonged
expiratory phase (I:E ratio >1:3). Expiratory wheezes reflect airflow obstruction. Fine basilar crackles
suggest pulmonary edema or fibrosis. Bronchial breath sounds over consolidation suggest pneumonia.
Dullness at bases suggests effusion.
Question 10 [Respiratory]
For study purposes only — not actual exam questions
