NR 511 Final Exam Prep 2026 | 200 Differential Diagnosis
Questions with Answers & Rationales | Nursing Study Guide
SECTION A: RESPIRATORY & CARDIOVASCULAR DIFFERENTIALS (Questions 1–50)
1. A 58-year-old male with a 40-pack-year smoking history presents with progressive dyspnea on
exertion and a chronic cough productive of clear sputum. Spirometry shows FEV1/FVC ratio of 0.65.
Which diagnosis is most likely?
A. Chronic obstructive pulmonary disease (COPD)
B. Asthma
C. Congestive heart failure
D. Interstitial lung disease
Answer: A
Explanation: Post-bronchodilator FEV1/FVC <0.70 confirms airflow obstruction; smoking history points
to COPD.
2. A 22-year-old college student presents with acute onset of sharp, pleuritic chest pain and shortness of
breath after a 12-hour car ride. He is tachycardic and hypoxic. What is the most likely diagnosis?
A. Pulmonary embolism
B. Spontaneous pneumothorax
C. Pericarditis
D. Musculoskeletal chest pain
Answer: A
Explanation: Prolonged immobilization + pleuritic pain + hypoxia = pulmonary embolism until proven
otherwise.
3. A 65-year-old female with hypertension and diabetes reports substernal chest pressure that occurs
with exertion and resolves with rest over 5 minutes. ECG is normal. What is the most appropriate next
step?
A. Stress testing
,B. Troponin and admit
C. Chest X-ray
D. Reassurance and discharge
Answer: A
Explanation: Stable angina with risk factors requires further cardiac evaluation (stress test, CT coronary
angiogram).
4. A 45-year-old male presents with episodic palpitations, sweating, and headache lasting 10-15
minutes, associated with blood pressure spikes to 200/110 mm Hg. What is the most likely diagnosis?
A. Pheochromocytoma
B. Panic disorder
C. Hyperthyroidism
D. Atrial fibrillation
Answer: A
Explanation: Paroxysmal hypertension, palpitations, headache, and diaphoresis are classic for
pheochromocytoma.
5. A 30-year-old female with no risk factors reports acute onset of severe, tearing chest pain radiating to
the back. Blood pressure is 160/90 in the right arm and 110/70 in the left arm. What is the priority?
A. Emergent CT angiography for suspected aortic dissection
B. Administer tPA for myocardial infarction
C. Chest X-ray
D. Admit for observation
Answer: A
Explanation: BP differential and tearing pain are classic for aortic dissection; immediate imaging and
blood pressure control.
6. A 50-year-old obese male presents with worsening shortness of breath when lying flat, paroxysmal
nocturnal dyspnea, and bilateral ankle edema. What is the most likely underlying condition?
A. Heart failure with reduced ejection fraction
B. COPD exacerbation
,C. Pulmonary embolism
D. Pneumonia
Answer: A
Explanation: Orthopnea, PND, and edema suggest heart failure; obesity and hypertension are risk
factors.
7. A 28-year-old healthy male has sudden onset of right-sided pleuritic chest pain and dyspnea. On
exam, breath sounds are decreased on the right with hyperresonance to percussion. What is the most
likely diagnosis?
A. Spontaneous pneumothorax
B. Pulmonary embolism
C. Pleural effusion
D. Pericarditis
Answer: A
Explanation: Sudden pleuritic pain with decreased breath sounds and hyperresonance is classic for
spontaneous pneumothorax.
8. A 70-year-old smoker with COPD reports increased sputum purulence and volume, fever, and
increased dyspnea. What is the most likely diagnosis?
A. Acute exacerbation of COPD likely due to infection
B. Pneumonia
C. Pulmonary embolism
D. Lung cancer
Answer: A
Explanation: Increased purulent sputum, fever, and dyspnea in COPD patient indicate infectious
exacerbation.
9. A 35-year-old female presents with substernal chest pain that worsens when lying supine and
improves when sitting forward. She has a low-grade fever and a pericardial friction rub. What is the
most likely diagnosis?
A. Acute pericarditis
B. Myocardial infarction
, C. GERD
D. Costochondritis
Answer: A
Explanation: Positional chest pain relieved by leaning forward and friction rub are diagnostic of
pericarditis.
10. A 60-year-old male with a history of coronary artery disease reports chest pain at rest that lasts 20
minutes and is relieved with nitroglycerin. ECG shows ST depression. What is the most appropriate
diagnosis?
A. Unstable angina
B. NSTEMI
C. STEMI
D. Stable angina
Answer: A
Explanation: Rest angina without elevated troponin (if normal) is unstable angina; if troponin elevated,
NSTEMI.
11. A 25-year-old female presents with palpitations, heat intolerance, weight loss, and a fine tremor. She
has a diffusely enlarged thyroid gland. What is the most likely diagnosis?
A. Graves’ disease
B. Subacute thyroiditis
C. Toxic multinodular goiter
D. Anxiety disorder
Answer: A
Explanation: Hyperthyroidism with diffuse goiter and ophthalmopathy (if present) is Graves’ disease.
12. A 55-year-old diabetic male reports sudden onset of shortness of breath and right calf pain. He has
swelling and tenderness of the right calf. What is the most appropriate next step?
A. Lower extremity venous ultrasound
B. D-dimer
C. Chest CT angiogram
Questions with Answers & Rationales | Nursing Study Guide
SECTION A: RESPIRATORY & CARDIOVASCULAR DIFFERENTIALS (Questions 1–50)
1. A 58-year-old male with a 40-pack-year smoking history presents with progressive dyspnea on
exertion and a chronic cough productive of clear sputum. Spirometry shows FEV1/FVC ratio of 0.65.
Which diagnosis is most likely?
A. Chronic obstructive pulmonary disease (COPD)
B. Asthma
C. Congestive heart failure
D. Interstitial lung disease
Answer: A
Explanation: Post-bronchodilator FEV1/FVC <0.70 confirms airflow obstruction; smoking history points
to COPD.
2. A 22-year-old college student presents with acute onset of sharp, pleuritic chest pain and shortness of
breath after a 12-hour car ride. He is tachycardic and hypoxic. What is the most likely diagnosis?
A. Pulmonary embolism
B. Spontaneous pneumothorax
C. Pericarditis
D. Musculoskeletal chest pain
Answer: A
Explanation: Prolonged immobilization + pleuritic pain + hypoxia = pulmonary embolism until proven
otherwise.
3. A 65-year-old female with hypertension and diabetes reports substernal chest pressure that occurs
with exertion and resolves with rest over 5 minutes. ECG is normal. What is the most appropriate next
step?
A. Stress testing
,B. Troponin and admit
C. Chest X-ray
D. Reassurance and discharge
Answer: A
Explanation: Stable angina with risk factors requires further cardiac evaluation (stress test, CT coronary
angiogram).
4. A 45-year-old male presents with episodic palpitations, sweating, and headache lasting 10-15
minutes, associated with blood pressure spikes to 200/110 mm Hg. What is the most likely diagnosis?
A. Pheochromocytoma
B. Panic disorder
C. Hyperthyroidism
D. Atrial fibrillation
Answer: A
Explanation: Paroxysmal hypertension, palpitations, headache, and diaphoresis are classic for
pheochromocytoma.
5. A 30-year-old female with no risk factors reports acute onset of severe, tearing chest pain radiating to
the back. Blood pressure is 160/90 in the right arm and 110/70 in the left arm. What is the priority?
A. Emergent CT angiography for suspected aortic dissection
B. Administer tPA for myocardial infarction
C. Chest X-ray
D. Admit for observation
Answer: A
Explanation: BP differential and tearing pain are classic for aortic dissection; immediate imaging and
blood pressure control.
6. A 50-year-old obese male presents with worsening shortness of breath when lying flat, paroxysmal
nocturnal dyspnea, and bilateral ankle edema. What is the most likely underlying condition?
A. Heart failure with reduced ejection fraction
B. COPD exacerbation
,C. Pulmonary embolism
D. Pneumonia
Answer: A
Explanation: Orthopnea, PND, and edema suggest heart failure; obesity and hypertension are risk
factors.
7. A 28-year-old healthy male has sudden onset of right-sided pleuritic chest pain and dyspnea. On
exam, breath sounds are decreased on the right with hyperresonance to percussion. What is the most
likely diagnosis?
A. Spontaneous pneumothorax
B. Pulmonary embolism
C. Pleural effusion
D. Pericarditis
Answer: A
Explanation: Sudden pleuritic pain with decreased breath sounds and hyperresonance is classic for
spontaneous pneumothorax.
8. A 70-year-old smoker with COPD reports increased sputum purulence and volume, fever, and
increased dyspnea. What is the most likely diagnosis?
A. Acute exacerbation of COPD likely due to infection
B. Pneumonia
C. Pulmonary embolism
D. Lung cancer
Answer: A
Explanation: Increased purulent sputum, fever, and dyspnea in COPD patient indicate infectious
exacerbation.
9. A 35-year-old female presents with substernal chest pain that worsens when lying supine and
improves when sitting forward. She has a low-grade fever and a pericardial friction rub. What is the
most likely diagnosis?
A. Acute pericarditis
B. Myocardial infarction
, C. GERD
D. Costochondritis
Answer: A
Explanation: Positional chest pain relieved by leaning forward and friction rub are diagnostic of
pericarditis.
10. A 60-year-old male with a history of coronary artery disease reports chest pain at rest that lasts 20
minutes and is relieved with nitroglycerin. ECG shows ST depression. What is the most appropriate
diagnosis?
A. Unstable angina
B. NSTEMI
C. STEMI
D. Stable angina
Answer: A
Explanation: Rest angina without elevated troponin (if normal) is unstable angina; if troponin elevated,
NSTEMI.
11. A 25-year-old female presents with palpitations, heat intolerance, weight loss, and a fine tremor. She
has a diffusely enlarged thyroid gland. What is the most likely diagnosis?
A. Graves’ disease
B. Subacute thyroiditis
C. Toxic multinodular goiter
D. Anxiety disorder
Answer: A
Explanation: Hyperthyroidism with diffuse goiter and ophthalmopathy (if present) is Graves’ disease.
12. A 55-year-old diabetic male reports sudden onset of shortness of breath and right calf pain. He has
swelling and tenderness of the right calf. What is the most appropriate next step?
A. Lower extremity venous ultrasound
B. D-dimer
C. Chest CT angiogram
