NR509 FINAL EXAM 200 QUESTIONS & CORRECT
ANSWERS LATEST 2026/2027
An overweight 26-year-old public servant presents to the Emergency Department
with 12 hours of intense abdominal pain, light-headedness, and a fainting episode
that finally prompted her to seek medical attention. She has a strong family history
of gallstones and is concerned about this possibility. She has not had any vomiting
or diarrhea. She had a normal bowel movement this morning. Her β-human
chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last
period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure,
86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC
orally. The clinician performs an abdominal exam prior to her pelvic exam and, on
palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What
is the most likely diagnosis?
a. Ruptured tubal (or ectopic) pregnancy
b. Acute cholecystitis
c. Ruptured appendix
d. Perforated bowel wall
e. Ruptured ovarian cyst
a. Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension,
positive β-hCG, and findings suggestive of peritoneal inflammation/irritation
strongly suggest a ruptured ectopic pregnancy with significant intra-abdominal
bleeding leading to peritoneal signs. This case is emergent and requires immediate
treatment of her hypotension and presumed blood loss as well as gynecological
consult for emergent surgery. Ruptured ectopic pregnancies can lead to life-
threatening intra-abdominal bleeding. Although acute cholecystitis, ruptured
appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities,
the positive β-hCG testing and her unstable vital signs make ruptured ectopic
pregnancy more likely.
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a
well visit. Basic labs are performed to screen for diabetes mellitus and
,dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all
normal expect for moderate elevations of aspartate aminotransferase, alanine
aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a
mildly elevated total bilirubin. He presents for a follow-up appointment and the
clinician performs an abdominal exam to assess his liver. Which of the following
findings would be most consistent with hepatomegaly?
a. Liver span of 11 cm at the midclavicular line
b. Liver span of 8 cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration
Rationale: The liver being palpable 3 cm below the right costal margin,
midclavicular line, would be considered normal on inspiration when the liver is
pushed down into the abdominal cavity on inspiration, but is abnormal on
expiration. Findings to support hepatomegaly would be more convincing if, by
percussion, the liver span was >12 cm at the midclavicular line. For patients with
obstructive lung disease, air trapping in the lungs may displace the liver
downwards into the abdominal cavity. The liver span and dullness to percussion
refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular
line and 4-8 cm at the midsternal line are considered normal.
A 63-year-old underweight administrative clerk with a 50-pack-year smoking
history presents with a several month history of recurrent epigastric abdominal
discomfort. She feels fairly well otherwise and denies any nausea, vomiting,
diarrhea, or constipation. She reports that a first cousin died from a ruptured
aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92;
respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body
mass index is 17.6. On exam, her abdominal aorta is prominent, which is
concerning for an abdominal aortic aneurysm (AAA). Which of the following is
her most significant risk factor for an AAA?
a. Female gender
b. History of smoking
c. Underweight
,d. Family history of ruptured aneurysm
e. Hypertension
b. History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male
gender, not female gender, is considered as risk factor. Underweight is not a risk
factor for AAA. Family history of ruptured aneurysm is vague and could be a
cerebral aneurysm. Further, her family history is in a first-degree cousin not a first-
degree relative (biologic parents, siblings, and children). Hypertension could
contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of
hypertension is not based on one elevated blood pressure reading.
A 76-year-old retired man with a history of prostate cancer and hypertension has
been screened annually for colon cancer using high sensitivity fecal occult blood
testing (FOBT). He presents for follow-up of his hypertension, during which the
clinician scans his chart to ensure he is up to date with his preventive health care.
He has a positive FOBT on one occasion at age 66 years and subsequently went for
a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on
colonoscopy. He has no first-degree relatives with a history of colorectal cancer or
adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF)
screening recommendations for this patient?
a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years
a. Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages
76-85 years, the gain in life years is small compared to colonoscopy risks. It is
advised to discuss individualized risks and benefits with the patient. Annual FOBT
screening may continue until age 80-85 years if benefits to doing so outweigh risks
for the individual patient; however, screening should not be routinely continued. In
general, a life expectancy >7 years is necessary for screening to be potentially
beneficial. There is no indication to repeat a colonoscopy given the absence of any
cancerous or precancerous findings on his colonoscopy 10 years ago.
Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option,
but again screening is not routinely recommended for patients age >75 years.
, An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a
3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks
each episode and is associated with onset of constipation. She describes infrequent,
small hard stool that she finds very difficult to pass. She has tried to increase
dietary fiber and water intake, but usually this is not sufficient and she resorts to
over-the-counter laxatives, which she finds upset her stomach but do resolve the
constipation. Symptoms typically gradually resolve with bowel movements. Which
of the following is the most likely physiological mechanism for her constipation?
a. A large, firm fecal mass in the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations
c. Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable
bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea
predominant, constipation predominant, or mixed. Other functional causes for her
constipation should be excluded prior to making this diagnosis. A large firm fecal
mass in the rectum is characteristic of fecal impaction, which is common in
debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet
low in fiber. This patient had not found that increasing fiber helps her constipation.
Spasm of the external sphincter is associated with painful anal lesions, which this
patient does not report. Impairment of autonomic innervations is characteristic of
patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She
has no known diagnosis that would increase suspicion of neurological impairment.
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic
sinusitis and bronchiectasis that is associated with a rare congenital condition
called Kartagener syndrome. The preceptor notes that she has situs inversus and
asks for a physical exam. Which of the following descriptions best fits with
findings on the abdominal exam?
a. Tympany to percussion in the right upper quadrant, dullness to percussion of the
left upper quadrant
b. Protuberant abdomen that has scattered areas of tympany and dullness; stool is
felt on palpation
c. Liver dullness in the right upper quadrant that is displaced downward by the low
diaphragm due to chronic obstructive pulmonary disease
ANSWERS LATEST 2026/2027
An overweight 26-year-old public servant presents to the Emergency Department
with 12 hours of intense abdominal pain, light-headedness, and a fainting episode
that finally prompted her to seek medical attention. She has a strong family history
of gallstones and is concerned about this possibility. She has not had any vomiting
or diarrhea. She had a normal bowel movement this morning. Her β-human
chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last
period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure,
86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC
orally. The clinician performs an abdominal exam prior to her pelvic exam and, on
palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What
is the most likely diagnosis?
a. Ruptured tubal (or ectopic) pregnancy
b. Acute cholecystitis
c. Ruptured appendix
d. Perforated bowel wall
e. Ruptured ovarian cyst
a. Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension,
positive β-hCG, and findings suggestive of peritoneal inflammation/irritation
strongly suggest a ruptured ectopic pregnancy with significant intra-abdominal
bleeding leading to peritoneal signs. This case is emergent and requires immediate
treatment of her hypotension and presumed blood loss as well as gynecological
consult for emergent surgery. Ruptured ectopic pregnancies can lead to life-
threatening intra-abdominal bleeding. Although acute cholecystitis, ruptured
appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities,
the positive β-hCG testing and her unstable vital signs make ruptured ectopic
pregnancy more likely.
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a
well visit. Basic labs are performed to screen for diabetes mellitus and
,dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all
normal expect for moderate elevations of aspartate aminotransferase, alanine
aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a
mildly elevated total bilirubin. He presents for a follow-up appointment and the
clinician performs an abdominal exam to assess his liver. Which of the following
findings would be most consistent with hepatomegaly?
a. Liver span of 11 cm at the midclavicular line
b. Liver span of 8 cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration
Rationale: The liver being palpable 3 cm below the right costal margin,
midclavicular line, would be considered normal on inspiration when the liver is
pushed down into the abdominal cavity on inspiration, but is abnormal on
expiration. Findings to support hepatomegaly would be more convincing if, by
percussion, the liver span was >12 cm at the midclavicular line. For patients with
obstructive lung disease, air trapping in the lungs may displace the liver
downwards into the abdominal cavity. The liver span and dullness to percussion
refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular
line and 4-8 cm at the midsternal line are considered normal.
A 63-year-old underweight administrative clerk with a 50-pack-year smoking
history presents with a several month history of recurrent epigastric abdominal
discomfort. She feels fairly well otherwise and denies any nausea, vomiting,
diarrhea, or constipation. She reports that a first cousin died from a ruptured
aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92;
respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body
mass index is 17.6. On exam, her abdominal aorta is prominent, which is
concerning for an abdominal aortic aneurysm (AAA). Which of the following is
her most significant risk factor for an AAA?
a. Female gender
b. History of smoking
c. Underweight
,d. Family history of ruptured aneurysm
e. Hypertension
b. History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male
gender, not female gender, is considered as risk factor. Underweight is not a risk
factor for AAA. Family history of ruptured aneurysm is vague and could be a
cerebral aneurysm. Further, her family history is in a first-degree cousin not a first-
degree relative (biologic parents, siblings, and children). Hypertension could
contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of
hypertension is not based on one elevated blood pressure reading.
A 76-year-old retired man with a history of prostate cancer and hypertension has
been screened annually for colon cancer using high sensitivity fecal occult blood
testing (FOBT). He presents for follow-up of his hypertension, during which the
clinician scans his chart to ensure he is up to date with his preventive health care.
He has a positive FOBT on one occasion at age 66 years and subsequently went for
a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on
colonoscopy. He has no first-degree relatives with a history of colorectal cancer or
adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF)
screening recommendations for this patient?
a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years
a. Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages
76-85 years, the gain in life years is small compared to colonoscopy risks. It is
advised to discuss individualized risks and benefits with the patient. Annual FOBT
screening may continue until age 80-85 years if benefits to doing so outweigh risks
for the individual patient; however, screening should not be routinely continued. In
general, a life expectancy >7 years is necessary for screening to be potentially
beneficial. There is no indication to repeat a colonoscopy given the absence of any
cancerous or precancerous findings on his colonoscopy 10 years ago.
Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option,
but again screening is not routinely recommended for patients age >75 years.
, An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a
3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks
each episode and is associated with onset of constipation. She describes infrequent,
small hard stool that she finds very difficult to pass. She has tried to increase
dietary fiber and water intake, but usually this is not sufficient and she resorts to
over-the-counter laxatives, which she finds upset her stomach but do resolve the
constipation. Symptoms typically gradually resolve with bowel movements. Which
of the following is the most likely physiological mechanism for her constipation?
a. A large, firm fecal mass in the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations
c. Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable
bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea
predominant, constipation predominant, or mixed. Other functional causes for her
constipation should be excluded prior to making this diagnosis. A large firm fecal
mass in the rectum is characteristic of fecal impaction, which is common in
debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet
low in fiber. This patient had not found that increasing fiber helps her constipation.
Spasm of the external sphincter is associated with painful anal lesions, which this
patient does not report. Impairment of autonomic innervations is characteristic of
patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She
has no known diagnosis that would increase suspicion of neurological impairment.
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic
sinusitis and bronchiectasis that is associated with a rare congenital condition
called Kartagener syndrome. The preceptor notes that she has situs inversus and
asks for a physical exam. Which of the following descriptions best fits with
findings on the abdominal exam?
a. Tympany to percussion in the right upper quadrant, dullness to percussion of the
left upper quadrant
b. Protuberant abdomen that has scattered areas of tympany and dullness; stool is
felt on palpation
c. Liver dullness in the right upper quadrant that is displaced downward by the low
diaphragm due to chronic obstructive pulmonary disease
