ADVANCED HEALTH ASSESSMENT AND
DIAGNOSTIC REASONING, 4TH EDITION TEST
BANK BY JACQUELINE RHOADS, ALL
CHAPTERS 1 - 18, VERIFIED NEWEST VERSION
1. A 45-year-old patient presents with acute-onset, severe, tearing chest pain radiating to the back,
accompanied by a difference in blood pressure between arms. A chest X-ray shows a widened
mediastinum. Which diagnostic test is most appropriate to confirm the suspected diagnosis?
A. CT angiography of the chest
B. Transthoracic echocardiogram
C. Ventilation-perfusion scan
D. Coronary angiography
Answer: A
Rationale: CT angiography is the gold standard for diagnosing aortic dissection, providing detailed
images of the aorta and identifying intimal flaps. Transthoracic echocardiogram may be used but is less
sensitive. VQ scan is for pulmonary embolism. Coronary angiography evaluates coronary arteries, not
the aorta.
2. A patient with a history of chronic obstructive pulmonary disease (COPD) presents with
increased dyspnea, purulent sputum, and fever. Arterial blood gas shows pH 7.32, PaCO2 65 mm
Hg, PaO2 55 mm Hg, HCO3- 30 mEq/L. Which acid-base disorder is most consistent with these
findings?
A. Acute respiratory acidosis with metabolic compensation
B. Acute respiratory alkalosis with metabolic compensation
C. Chronic respiratory acidosis with metabolic compensation
D. Chronic respiratory alkalosis with metabolic compensation
Answer: C
Rationale: The elevated PaCO2 indicates respiratory acidosis. The elevated HCO3- (30 mEq/L) suggests
metabolic compensation, which typically occurs over days in chronic respiratory acidosis. The pH is
acidic but not severely so, consistent with a chronic process. Acute respiratory acidosis would have a
normal HCO3-.
3. A patient presents with a palpable, non-tender, firm lymph node in the supraclavicular area.
Which of the following is the most likely underlying etiology?
A. Metastatic malignancy from a thoracic or abdominal primary
B. Reactive hyperplasia from a local infection
C. Granulomatous disease such as tuberculosis
Page 1
,D. Lymphoma with systemic involvement
Answer: A
Rationale: The supraclavicular node (Virchow's node) is a classic site for metastasis from thoracic (left
side) or abdominal (right side) malignancies. Reactive nodes are usually tender and mobile.
Tuberculosis often presents with matted nodes. Lymphoma typically presents with multiple, rubbery
nodes.
4. During a cardiac examination, a patient has a holosystolic murmur heard best at the apex,
radiating to the axilla. The murmur does not change with respiration. Which valvular abnormality
is most likely?
A. Mitral regurgitation
B. Tricuspid regurgitation
C. Aortic stenosis
D. Mitral stenosis
Answer: A
Rationale: Mitral regurgitation produces a holosystolic murmur at the apex radiating to the axilla, and it
is unaffected by respiration. Tricuspid regurgitation is heard at the left lower sternal border and
increases with inspiration. Aortic stenosis is systolic but not holosystolic and heard at the base. Mitral
stenosis produces a diastolic murmur.
5. A patient with type 2 diabetes mellitus has a fasting plasma glucose of 130 mg/dL and a
hemoglobin A1c of 7.2%. According to current American Diabetes Association guidelines, what is
the most appropriate initial pharmacologic management?
A. Metformin monotherapy
B. Insulin glargine once daily
C. Sulfonylurea monotherapy
D. GLP-1 receptor agonist monotherapy
Answer: A
Rationale: The ADA recommends metformin as first-line pharmacotherapy for type 2 diabetes due to its
efficacy, safety, and cardiovascular benefits. Insulin is reserved for severe hyperglycemia or later stages.
Sulfonylureas are second-line. GLP-1 agonists are considered after metformin or if cardiovascular risk
is high.
6. A patient has a serum sodium of 122 mEq/L, serum osmolality of 255 mOsm/kg, urine
osmolality of 600 mOsm/kg, and urine sodium of 45 mEq/L. The patient is euvolemic on exam.
Which of the following is the most likely diagnosis?
A. Syndrome of inappropriate antidiuretic hormone (SIADH)
B. Psychogenic polydipsia
C. Cerebral salt wasting
D. Hypovolemic hyponatremia
Answer: A
Rationale: Euvolemic hyponatremia with low serum osmolality, inappropriately concentrated urine
(urine osmolality >100), and urine sodium >20 mEq/L is classic for SIADH. Psychogenic polydipsia
Page 2
,would have dilute urine. Cerebral salt wasting usually occurs in neurosurgical patients and involves
volume depletion. Hypovolemic hyponatremia would have urine sodium <20.
7. A patient with an acute exacerbation of asthma has a peak expiratory flow (PEF) of 40% of
predicted. Which of the following assessment findings would indicate the need for immediate
intensive care unit (ICU) admission?
A. Pulsus paradoxus of 15 mm Hg
B. Respiratory rate of 28 breaths per minute
C. Use of accessory muscles
D. Silent chest on auscultation
Answer: D
Rationale: A silent chest indicates severely reduced airflow and impending respiratory arrest, requiring
ICU care. Pulsus paradoxus >10 mm Hg is common in moderate-severe asthma but not an ICU criterion
alone. Tachypnea and accessory muscle use are signs of moderate-severe exacerbation but not
immediate ICU.
8. A patient presents with acute onset of severe epigastric pain radiating to the back, nausea, and
vomiting. Serum lipase is 450 U/L (normal <60). Which of the following is the most appropriate
next step in management?
A. Obtain a contrast-enhanced CT scan of the abdomen
B. Start intravenous fluids and monitor for complications
C. Perform endoscopic retrograde cholangiopancreatography (ERCP)
D. Administer intravenous antibiotics empirically
Answer: B
Rationale: In acute pancreatitis, initial management is supportive with aggressive IV fluids, pain control,
and monitoring for complications. CT is indicated if diagnosis is uncertain or to assess for
complications. ERCP is reserved for suspected gallstone pancreatitis with cholangitis. Antibiotics are
not routine unless infection is suspected.
9. A patient with chronic kidney disease stage 4 has a serum creatinine of 3.2 mg/dL and a
potassium of 5.8 mEq/L. The electrocardiogram shows peaked T waves. Which of the following
interventions should be performed first?
A. Intravenous calcium gluconate
B. Intravenous insulin and glucose
C. Oral sodium polystyrene sulfonate
D. Hemodialysis
Answer: A
Rationale: Peaked T waves indicate hyperkalemia with cardiac toxicity. IV calcium gluconate stabilizes
the cardiac membrane and is the first-line intervention. Insulin and glucose shift potassium
intracellularly but take longer. Sodium polystyrene sulfonate is slow and not urgent. Dialysis is definitive
but not immediately available.
Page 3
, 10. A patient with known cirrhosis presents with hematemesis and melena. Vital signs show heart
rate 110 bpm, blood pressure 90/60 mm Hg. Which intervention is most likely to reduce mortality
in this scenario?
A. Administration of octreotide and urgent upper endoscopy
B. Insertion of a Sengstaken-Blakemore tube
C. Transjugular intrahepatic portosystemic shunt (TIPS)
D. Beta-blocker therapy
Answer: A
Rationale: Variceal hemorrhage is a medical emergency. Octreotide reduces portal pressure, and urgent
endoscopy with band ligation is the standard of care to control bleeding and reduce mortality. Balloon
tamponade is temporary. TIPS is a rescue therapy. Beta-blockers are for primary prophylaxis, not acute
bleeding.
11. A 45-year-old patient with a history of chronic kidney disease (stage 3) presents with fatigue,
pallor, and dyspnea on exertion. Laboratory studies reveal hemoglobin 9.2 g/dL, MCV 78 fL,
reticulocyte count 0.5%, and serum ferritin 600 ng/mL. Which diagnostic finding is most likely to
differentiate the underlying cause of anemia from iron deficiency anemia?
A. Elevated soluble transferrin receptor level
B. Low serum erythropoietin level relative to hemoglobin
C. Increased red cell distribution width (RDW)
D. Positive direct Coombs test
Answer: B
Rationale: In chronic kidney disease, anemia is primarily due to inadequate erythropoietin production. A
low serum erythropoietin level relative to the degree of anemia is characteristic. Elevated soluble
transferrin receptor is seen in iron deficiency, not in anemia of chronic disease. RDW is elevated in iron
deficiency but not specific. Direct Coombs test indicates autoimmune hemolytic anemia.
12. A patient with suspected pulmonary embolism undergoes ventilation-perfusion (V/Q) scanning.
The scan shows a high-probability pattern for PE. However, the patient has a history of chronic
obstructive pulmonary disease (COPD) with severe emphysema. Which of the following findings
on the V/Q scan would most strongly suggest that the high-probability interpretation is a false
positive?
A. Multiple matched V/Q defects in areas of emphysema
B. Single segmental perfusion defect with normal ventilation
C. Diffuse patchy ventilation defects with corresponding perfusion defects
D. Chest radiograph showing hyperinflation and bullae
Answer: A
Rationale: In COPD with emphysema, matched V/Q defects are common due to destruction of
alveolar-capillary units, leading to false-positive high-probability scans. A single segmental perfusion
defect with normal ventilation is classic for PE. Diffuse matched defects are not typical for PE. Chest
radiograph findings do not directly affect V/Q interpretation.
Page 4
DIAGNOSTIC REASONING, 4TH EDITION TEST
BANK BY JACQUELINE RHOADS, ALL
CHAPTERS 1 - 18, VERIFIED NEWEST VERSION
1. A 45-year-old patient presents with acute-onset, severe, tearing chest pain radiating to the back,
accompanied by a difference in blood pressure between arms. A chest X-ray shows a widened
mediastinum. Which diagnostic test is most appropriate to confirm the suspected diagnosis?
A. CT angiography of the chest
B. Transthoracic echocardiogram
C. Ventilation-perfusion scan
D. Coronary angiography
Answer: A
Rationale: CT angiography is the gold standard for diagnosing aortic dissection, providing detailed
images of the aorta and identifying intimal flaps. Transthoracic echocardiogram may be used but is less
sensitive. VQ scan is for pulmonary embolism. Coronary angiography evaluates coronary arteries, not
the aorta.
2. A patient with a history of chronic obstructive pulmonary disease (COPD) presents with
increased dyspnea, purulent sputum, and fever. Arterial blood gas shows pH 7.32, PaCO2 65 mm
Hg, PaO2 55 mm Hg, HCO3- 30 mEq/L. Which acid-base disorder is most consistent with these
findings?
A. Acute respiratory acidosis with metabolic compensation
B. Acute respiratory alkalosis with metabolic compensation
C. Chronic respiratory acidosis with metabolic compensation
D. Chronic respiratory alkalosis with metabolic compensation
Answer: C
Rationale: The elevated PaCO2 indicates respiratory acidosis. The elevated HCO3- (30 mEq/L) suggests
metabolic compensation, which typically occurs over days in chronic respiratory acidosis. The pH is
acidic but not severely so, consistent with a chronic process. Acute respiratory acidosis would have a
normal HCO3-.
3. A patient presents with a palpable, non-tender, firm lymph node in the supraclavicular area.
Which of the following is the most likely underlying etiology?
A. Metastatic malignancy from a thoracic or abdominal primary
B. Reactive hyperplasia from a local infection
C. Granulomatous disease such as tuberculosis
Page 1
,D. Lymphoma with systemic involvement
Answer: A
Rationale: The supraclavicular node (Virchow's node) is a classic site for metastasis from thoracic (left
side) or abdominal (right side) malignancies. Reactive nodes are usually tender and mobile.
Tuberculosis often presents with matted nodes. Lymphoma typically presents with multiple, rubbery
nodes.
4. During a cardiac examination, a patient has a holosystolic murmur heard best at the apex,
radiating to the axilla. The murmur does not change with respiration. Which valvular abnormality
is most likely?
A. Mitral regurgitation
B. Tricuspid regurgitation
C. Aortic stenosis
D. Mitral stenosis
Answer: A
Rationale: Mitral regurgitation produces a holosystolic murmur at the apex radiating to the axilla, and it
is unaffected by respiration. Tricuspid regurgitation is heard at the left lower sternal border and
increases with inspiration. Aortic stenosis is systolic but not holosystolic and heard at the base. Mitral
stenosis produces a diastolic murmur.
5. A patient with type 2 diabetes mellitus has a fasting plasma glucose of 130 mg/dL and a
hemoglobin A1c of 7.2%. According to current American Diabetes Association guidelines, what is
the most appropriate initial pharmacologic management?
A. Metformin monotherapy
B. Insulin glargine once daily
C. Sulfonylurea monotherapy
D. GLP-1 receptor agonist monotherapy
Answer: A
Rationale: The ADA recommends metformin as first-line pharmacotherapy for type 2 diabetes due to its
efficacy, safety, and cardiovascular benefits. Insulin is reserved for severe hyperglycemia or later stages.
Sulfonylureas are second-line. GLP-1 agonists are considered after metformin or if cardiovascular risk
is high.
6. A patient has a serum sodium of 122 mEq/L, serum osmolality of 255 mOsm/kg, urine
osmolality of 600 mOsm/kg, and urine sodium of 45 mEq/L. The patient is euvolemic on exam.
Which of the following is the most likely diagnosis?
A. Syndrome of inappropriate antidiuretic hormone (SIADH)
B. Psychogenic polydipsia
C. Cerebral salt wasting
D. Hypovolemic hyponatremia
Answer: A
Rationale: Euvolemic hyponatremia with low serum osmolality, inappropriately concentrated urine
(urine osmolality >100), and urine sodium >20 mEq/L is classic for SIADH. Psychogenic polydipsia
Page 2
,would have dilute urine. Cerebral salt wasting usually occurs in neurosurgical patients and involves
volume depletion. Hypovolemic hyponatremia would have urine sodium <20.
7. A patient with an acute exacerbation of asthma has a peak expiratory flow (PEF) of 40% of
predicted. Which of the following assessment findings would indicate the need for immediate
intensive care unit (ICU) admission?
A. Pulsus paradoxus of 15 mm Hg
B. Respiratory rate of 28 breaths per minute
C. Use of accessory muscles
D. Silent chest on auscultation
Answer: D
Rationale: A silent chest indicates severely reduced airflow and impending respiratory arrest, requiring
ICU care. Pulsus paradoxus >10 mm Hg is common in moderate-severe asthma but not an ICU criterion
alone. Tachypnea and accessory muscle use are signs of moderate-severe exacerbation but not
immediate ICU.
8. A patient presents with acute onset of severe epigastric pain radiating to the back, nausea, and
vomiting. Serum lipase is 450 U/L (normal <60). Which of the following is the most appropriate
next step in management?
A. Obtain a contrast-enhanced CT scan of the abdomen
B. Start intravenous fluids and monitor for complications
C. Perform endoscopic retrograde cholangiopancreatography (ERCP)
D. Administer intravenous antibiotics empirically
Answer: B
Rationale: In acute pancreatitis, initial management is supportive with aggressive IV fluids, pain control,
and monitoring for complications. CT is indicated if diagnosis is uncertain or to assess for
complications. ERCP is reserved for suspected gallstone pancreatitis with cholangitis. Antibiotics are
not routine unless infection is suspected.
9. A patient with chronic kidney disease stage 4 has a serum creatinine of 3.2 mg/dL and a
potassium of 5.8 mEq/L. The electrocardiogram shows peaked T waves. Which of the following
interventions should be performed first?
A. Intravenous calcium gluconate
B. Intravenous insulin and glucose
C. Oral sodium polystyrene sulfonate
D. Hemodialysis
Answer: A
Rationale: Peaked T waves indicate hyperkalemia with cardiac toxicity. IV calcium gluconate stabilizes
the cardiac membrane and is the first-line intervention. Insulin and glucose shift potassium
intracellularly but take longer. Sodium polystyrene sulfonate is slow and not urgent. Dialysis is definitive
but not immediately available.
Page 3
, 10. A patient with known cirrhosis presents with hematemesis and melena. Vital signs show heart
rate 110 bpm, blood pressure 90/60 mm Hg. Which intervention is most likely to reduce mortality
in this scenario?
A. Administration of octreotide and urgent upper endoscopy
B. Insertion of a Sengstaken-Blakemore tube
C. Transjugular intrahepatic portosystemic shunt (TIPS)
D. Beta-blocker therapy
Answer: A
Rationale: Variceal hemorrhage is a medical emergency. Octreotide reduces portal pressure, and urgent
endoscopy with band ligation is the standard of care to control bleeding and reduce mortality. Balloon
tamponade is temporary. TIPS is a rescue therapy. Beta-blockers are for primary prophylaxis, not acute
bleeding.
11. A 45-year-old patient with a history of chronic kidney disease (stage 3) presents with fatigue,
pallor, and dyspnea on exertion. Laboratory studies reveal hemoglobin 9.2 g/dL, MCV 78 fL,
reticulocyte count 0.5%, and serum ferritin 600 ng/mL. Which diagnostic finding is most likely to
differentiate the underlying cause of anemia from iron deficiency anemia?
A. Elevated soluble transferrin receptor level
B. Low serum erythropoietin level relative to hemoglobin
C. Increased red cell distribution width (RDW)
D. Positive direct Coombs test
Answer: B
Rationale: In chronic kidney disease, anemia is primarily due to inadequate erythropoietin production. A
low serum erythropoietin level relative to the degree of anemia is characteristic. Elevated soluble
transferrin receptor is seen in iron deficiency, not in anemia of chronic disease. RDW is elevated in iron
deficiency but not specific. Direct Coombs test indicates autoimmune hemolytic anemia.
12. A patient with suspected pulmonary embolism undergoes ventilation-perfusion (V/Q) scanning.
The scan shows a high-probability pattern for PE. However, the patient has a history of chronic
obstructive pulmonary disease (COPD) with severe emphysema. Which of the following findings
on the V/Q scan would most strongly suggest that the high-probability interpretation is a false
positive?
A. Multiple matched V/Q defects in areas of emphysema
B. Single segmental perfusion defect with normal ventilation
C. Diffuse patchy ventilation defects with corresponding perfusion defects
D. Chest radiograph showing hyperinflation and bullae
Answer: A
Rationale: In COPD with emphysema, matched V/Q defects are common due to destruction of
alveolar-capillary units, leading to false-positive high-probability scans. A single segmental perfusion
defect with normal ventilation is classic for PE. Diffuse matched defects are not typical for PE. Chest
radiograph findings do not directly affect V/Q interpretation.
Page 4
