NUR 612
EXAM III
(Advanced Health Assessment)
100% Exam-Focused | High-Yield | Scenario-Based
✔ Advanced, exam-style multiple-choice questions
✔ Select-All-That-Apply (SATA) questions
✔ Clinical scenario-based decision-making
✔ Pathophysiology-driven physical assessment integration
✔ Diagnostic reasoning and prioritization
✔ Board-style wording aligned with graduate nursing exams
✔ Clear, concise, exam-ready rationales
✔ No filler, no repetition, no outdated content
,A 54-year-old male presents with retrosternal chest pain radiating to the left arm and diaphoresis.
Auscultation reveals a fourth heart sound (S4) and a holosystolic murmur at the apex radiating to the
axilla. Which clinical finding is most consistent with the patient's likely diagnosis?
A) Pericardial friction rub
B) Pulsus paradoxus
C) Mitral regurgitation
D) Aortic stenosis
Correct Answer: C) Mitral regurgitation
Explanation / Rationale:
The holosystolic murmur at the apex radiating to the axilla is pathognomonic for mitral regurgitation,
which often complicates acute myocardial infarction due to papillary muscle dysfunction. An S4
indicates a stiff, non-compliant ventricle, commonly seen in ischemia or hypertension. A pericardial
rub suggests pericarditis, while pulsus paradoxus is associated with cardiac tamponade.
During a routine physical examination of a 65-year-old female, you note a persistent, high-pitched
blowing murmur best heard at the left sternal border in the second intercostal space. The murmur
radiates to the carotids and increases in intensity during expiration. Which valvular defect is primarily
indicated by these findings?
A) Tricuspid regurgitation
B) Mitral stenosis
C) Aortic regurgitation
D) Pulmonic stenosis
Correct Answer: C) Aortic regurgitation
Explanation / Rationale:
A high-pitched, blowing diastolic murmur at the left sternal border that radiates is classic for aortic
regurgitation. The fact that it increases with expiration helps distinguish it from right-sided murmurs,
which typically increase with inspiration. Mitral stenosis presents as a low-pitched rumble, while
tricuspid regurgitation is a systolic murmur.
,A 22-year-old college athlete presents with fever, fatigue, and a new-onset heart murmur. He reports
a recent sore throat that resolved spontaneously. Physical examination reveals splinter hemorrhages,
Osler nodes, and a pansystolic murmur at the lower left sternal border that increases with inspiration.
What is the most likely etiology of this murmur?
A) Infective endocarditis affecting the tricuspid valve
B) Rheumatic fever affecting the mitral valve
C) Acute pericarditis
D) Hypertrophic cardiomyopathy
Correct Answer: A) Infective endocarditis affecting the tricuspid valve
Explanation / Rationale:
The presence of Osler nodes, splinter hemorrhages, and fever strongly indicates infective endocarditis.
A pansystolic murmur at the lower left sternal border that increases with inspiration (Carvallo’s sign)
is specific for tricuspid regurgitation. While IV drug users are classic for tricuspid involvement, this can
occur in other populations.
You are assessing a 70-year-old patient with documented congestive heart failure. Upon auscultation,
you hear an extra heart sound immediately following the S2. This sound is low-pitched and best heard
at the apex with the patient in the left lateral decubitus position. Which heart sound are you
detecting?
A) S3
B) S4
C) Ejection click
D) Opening snap
Correct Answer: A) S3
Explanation / Rationale:
An S3 (ventricular gallop) is a low-pitched sound occurring early in diastole, caused by rapid
ventricular filling and is a hallmark of heart failure. An S4 occurs just before S1 (atrial gallop) and
indicates a stiff ventricle. An ejection click and opening snap are high-pitched sounds associated with
valvular abnormalities.
, A 45-year-old female presents with sudden onset of dyspnea and pleuritic chest pain. Her heart rate is
110 bpm, respiratory rate is 24, and blood pressure is 130/85 mmHg. Auscultation of the lungs is clear,
but the cardiovascular exam reveals a prominent P2 component of S2 and a right ventricular heave.
Which diagnostic test is the priority for this patient?
A) D-dimer assay
B) Ventilation-perfusion (V/Q) scan
C) Computed Tomography Pulmonary Angiography (CTPA)
D) Transthoracic echocardiogram
Correct Answer: C) Computed Tomography Pulmonary Angiography (CTPA)
Explanation / Rationale:
The clinical presentation suggests a Pulmonary Embolism (PE), supported by tachycardia, dyspnea,
and signs of right heart strain (loud P2, RV heave). CTPA is the gold standard imaging modality for
diagnosing PE in hemodynamically stable patients. While D-dimer has high sensitivity, its low
specificity makes it less useful as a definitive diagnostic tool in this high-probability scenario.
A patient with known chronic obstructive pulmonary disease (COPD) presents for follow-up. To assess
for the presence of cor pulmonale, which specific physical examination finding should the clinician
look for?
A) Clubbing of the fingers
B) Hyperresonance to percussion
C) Elevated Jugular Venous Pressure (JVP) with hepatojugular reflux
D) Diminished breath sounds bilaterally
Correct Answer: C) Elevated Jugular Venous Pressure (JVP) with hepatojugular reflux
Explanation / Rationale:
Cor pulmonale refers to right heart failure secondary to pulmonary hypertension, often caused by
COPD. Elevated JVP and a positive hepatojugular reflux are direct signs of right-sided heart failure.
Clubbing and hyperresonance are associated with lung pathology but do not specifically indicate heart
failure.
EXAM III
(Advanced Health Assessment)
100% Exam-Focused | High-Yield | Scenario-Based
✔ Advanced, exam-style multiple-choice questions
✔ Select-All-That-Apply (SATA) questions
✔ Clinical scenario-based decision-making
✔ Pathophysiology-driven physical assessment integration
✔ Diagnostic reasoning and prioritization
✔ Board-style wording aligned with graduate nursing exams
✔ Clear, concise, exam-ready rationales
✔ No filler, no repetition, no outdated content
,A 54-year-old male presents with retrosternal chest pain radiating to the left arm and diaphoresis.
Auscultation reveals a fourth heart sound (S4) and a holosystolic murmur at the apex radiating to the
axilla. Which clinical finding is most consistent with the patient's likely diagnosis?
A) Pericardial friction rub
B) Pulsus paradoxus
C) Mitral regurgitation
D) Aortic stenosis
Correct Answer: C) Mitral regurgitation
Explanation / Rationale:
The holosystolic murmur at the apex radiating to the axilla is pathognomonic for mitral regurgitation,
which often complicates acute myocardial infarction due to papillary muscle dysfunction. An S4
indicates a stiff, non-compliant ventricle, commonly seen in ischemia or hypertension. A pericardial
rub suggests pericarditis, while pulsus paradoxus is associated with cardiac tamponade.
During a routine physical examination of a 65-year-old female, you note a persistent, high-pitched
blowing murmur best heard at the left sternal border in the second intercostal space. The murmur
radiates to the carotids and increases in intensity during expiration. Which valvular defect is primarily
indicated by these findings?
A) Tricuspid regurgitation
B) Mitral stenosis
C) Aortic regurgitation
D) Pulmonic stenosis
Correct Answer: C) Aortic regurgitation
Explanation / Rationale:
A high-pitched, blowing diastolic murmur at the left sternal border that radiates is classic for aortic
regurgitation. The fact that it increases with expiration helps distinguish it from right-sided murmurs,
which typically increase with inspiration. Mitral stenosis presents as a low-pitched rumble, while
tricuspid regurgitation is a systolic murmur.
,A 22-year-old college athlete presents with fever, fatigue, and a new-onset heart murmur. He reports
a recent sore throat that resolved spontaneously. Physical examination reveals splinter hemorrhages,
Osler nodes, and a pansystolic murmur at the lower left sternal border that increases with inspiration.
What is the most likely etiology of this murmur?
A) Infective endocarditis affecting the tricuspid valve
B) Rheumatic fever affecting the mitral valve
C) Acute pericarditis
D) Hypertrophic cardiomyopathy
Correct Answer: A) Infective endocarditis affecting the tricuspid valve
Explanation / Rationale:
The presence of Osler nodes, splinter hemorrhages, and fever strongly indicates infective endocarditis.
A pansystolic murmur at the lower left sternal border that increases with inspiration (Carvallo’s sign)
is specific for tricuspid regurgitation. While IV drug users are classic for tricuspid involvement, this can
occur in other populations.
You are assessing a 70-year-old patient with documented congestive heart failure. Upon auscultation,
you hear an extra heart sound immediately following the S2. This sound is low-pitched and best heard
at the apex with the patient in the left lateral decubitus position. Which heart sound are you
detecting?
A) S3
B) S4
C) Ejection click
D) Opening snap
Correct Answer: A) S3
Explanation / Rationale:
An S3 (ventricular gallop) is a low-pitched sound occurring early in diastole, caused by rapid
ventricular filling and is a hallmark of heart failure. An S4 occurs just before S1 (atrial gallop) and
indicates a stiff ventricle. An ejection click and opening snap are high-pitched sounds associated with
valvular abnormalities.
, A 45-year-old female presents with sudden onset of dyspnea and pleuritic chest pain. Her heart rate is
110 bpm, respiratory rate is 24, and blood pressure is 130/85 mmHg. Auscultation of the lungs is clear,
but the cardiovascular exam reveals a prominent P2 component of S2 and a right ventricular heave.
Which diagnostic test is the priority for this patient?
A) D-dimer assay
B) Ventilation-perfusion (V/Q) scan
C) Computed Tomography Pulmonary Angiography (CTPA)
D) Transthoracic echocardiogram
Correct Answer: C) Computed Tomography Pulmonary Angiography (CTPA)
Explanation / Rationale:
The clinical presentation suggests a Pulmonary Embolism (PE), supported by tachycardia, dyspnea,
and signs of right heart strain (loud P2, RV heave). CTPA is the gold standard imaging modality for
diagnosing PE in hemodynamically stable patients. While D-dimer has high sensitivity, its low
specificity makes it less useful as a definitive diagnostic tool in this high-probability scenario.
A patient with known chronic obstructive pulmonary disease (COPD) presents for follow-up. To assess
for the presence of cor pulmonale, which specific physical examination finding should the clinician
look for?
A) Clubbing of the fingers
B) Hyperresonance to percussion
C) Elevated Jugular Venous Pressure (JVP) with hepatojugular reflux
D) Diminished breath sounds bilaterally
Correct Answer: C) Elevated Jugular Venous Pressure (JVP) with hepatojugular reflux
Explanation / Rationale:
Cor pulmonale refers to right heart failure secondary to pulmonary hypertension, often caused by
COPD. Elevated JVP and a positive hepatojugular reflux are direct signs of right-sided heart failure.
Clubbing and hyperresonance are associated with lung pathology but do not specifically indicate heart
failure.
