NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
NSG 550 / NSG 550 Exam 2 (Latest
Update)
Diagnostic Reasoning for Nurse Practitioners | Questions and Verified Answers | 100% Correct |
Grade A
Wilkes University - Passan School of Nursing
2026/2027 Academic Year | Advanced Practice Nursing Education
Total Questions Cognitive Levels Question Style
25% Recall / 55% Application / 20% 70% Scenario / 20% Recall / 10%
75 Multiple Choice
Analysis Clinical Judgment
Instructions: Select the single best answer for each question. Each question provides a rationale explaining the
correct response and why alternative options are incorrect, integrating Wilkes University NSG 550 diagnostic
reasoning competencies and evidence-based advanced practice nursing.
Section 1: Cardiovascular Diagnostic Reasoning (Q1-Q18)
Chest pain differential diagnosis, cardiac auscultation, murmurs, ECG interpretation, cardiac biomarkers, and hemodynamic
assessment. Focus on differentiating ACS, pericarditis, aortic dissection, pulmonary embolism, and valvular pathology.
Q1: A 58-year-old male presents to the clinic with substernal chest pressure described as "an
elephant sitting on my chest," radiating to his left jaw and arm, associated with diaphoresis and
nausea, ongoing for 45 minutes and unrelieved by rest. Vital signs: BP 148/92, HR 102, SpO2 96%.
Which finding on the 12-lead ECG would most strongly indicate the need for immediate
percutaneous coronary intervention (PCI)?
A. Diffuse ST elevation in leads I, II, III, aVF, V1-V6 with PR depression
B. ST elevation of 2 mm in leads II, III, and aVF with reciprocal ST depression in I and aVL
[CORRECT]
C. T wave inversion in leads V1-V4 without ST elevation
D. Normal ECG with nonspecific ST-T wave changes
Correct Answer: B
Rationale: ST elevation in II, III, and aVF with reciprocal depression in I and aVL indicates an acute inferior
STEMI, which is a STEMI equivalent requiring immediate reperfusion therapy (PCI within 90 minutes of first
medical contact - the "door-to-balloon" time). Diffuse ST elevation with PR depression is classic for
pericarditis, not ACS. T wave inversion alone suggests ischemia but not STEMI. A normal ECG does not
exclude ACS (NSTEMI may have a normal or nondiagnostic ECG), but it would not mandate immediate PCI.
Q2: A 67-year-old female presents with sudden, severe, tearing chest pain radiating to her back
between the shoulder blades. BP is 168/95 in the right arm and 142/88 in the left arm, with a
20-point systolic difference. HR 110. Which diagnostic test is the gold standard for confirming the
suspected diagnosis?
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 1
,NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
A. 12-lead ECG to evaluate for ST elevation
B. Transthoracic echocardiogram (TTE)
C. CT angiography of the chest and abdomen [CORRECT]
D. Cardiac troponin I level
Correct Answer: C
Rationale: The clinical presentation (sudden tearing chest pain radiating to the back, pulse deficit with >20
mmHg systolic difference between arms, hypertensive emergency) is classic for acute aortic dissection. CT
angiography is the gold standard diagnostic test, providing rapid, high-sensitivity visualization of the dissection
flap, true and false lumen, and branch vessel involvement. ECG is needed to exclude concurrent ACS but
cannot diagnose dissection. TTE has limited sensitivity for dissection. Troponin may be elevated if dissection
extends into coronary ostia but is not diagnostic of dissection itself.
Q3: A 42-year-old male presents with sharp, pleuritic chest pain that worsens when lying flat and
improves when sitting forward and leaning forward. He had a viral upper respiratory infection
two weeks ago. On auscultation, a triphasic scratching sound is heard best at the left sternal
border with the patient leaning forward. Which ECG finding is most characteristic of this
condition?
A. ST elevation in II, III, and aVF with reciprocal depression
B. Diffuse ST elevation in multiple leads with PR depression [CORRECT]
C. Deep T wave inversions in V1-V4
D. Electrical alternans on the rhythm strip
Correct Answer: B
Rationale: The presentation is classic for acute pericarditis: sharp pleuritic pain improved by sitting forward,
recent viral illness, and a pericardial friction rub (triphasic scratching sound). The hallmark ECG finding is
diffuse, concave ST elevation in multiple leads (often I, II, III, aVF, V2-V6) with PR depression, distinguishing
it from the localized, convex ST elevation of STEMI and the reciprocal changes of acute MI. Electrical
alternans is seen with large pericardial effusion causing cardiac swinging, not typical pericarditis.
Q4: A 65-year-old female is admitted with acute decompensated heart failure. On examination,
she has an S3 ventricular gallop, bilateral basilar crackles, and jugular venous distension. Which
diagnostic finding is most consistent with this clinical picture?
A. BNP of 80 pg/mL
B. BNP of 850 pg/mL with elevated troponin [CORRECT]
C. NT-proBNP of 150 pg/mL
D. Normal echocardiogram with LVEF of 65%
Correct Answer: B
Rationale: An S3 gallop, bilateral crackles, and JVD are classic physical examination findings of acute
decompensated heart failure. BNP > 400 pg/mL (or NT-proBNP > 450 in patients < 50, > 900 in patients
50-75) strongly supports the diagnosis of heart failure. A BNP of 850 pg/mL is markedly elevated and
consistent with acute HF exacerbation. Elevated troponin may indicate concurrent myocardial injury or type 2
MI from demand ischemia. BNP < 100 or NT-proBNP < 300 effectively excludes HF. A normal echo with
LVEF 65% would suggest HF with preserved ejection fraction (HFpEF), not a low-output picture.
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 2
,NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
Q5: A 72-year-old male presents with exertional chest pain, syncope on exertion, and dyspnea with
activity. On cardiac auscultation, a crescendo-decrescendo systolic murmur is heard best at the
second right intercostal space (2nd RICS) radiating to the carotid arteries. The carotid pulse is
delayed and weak (pulsus parvus et tardus). What is the most likely diagnosis?
A. Aortic regurgitation
B. Mitral stenosis
C. Aortic stenosis [CORRECT]
D. Hypertrophic obstructive cardiomyopathy (HOCM)
Correct Answer: C
Rationale: The triad of exertional angina, syncope, and dyspnea (the classic triad of severe aortic stenosis)
combined with a crescendo-decrescendo systolic ejection murmur at the 2nd RICS radiating to the carotids, and
a slow-rising, weak carotid pulse (pulsus parvus et tardus), is pathognomonic for aortic stenosis. Aortic
regurgitation causes a diastolic decrescendo murmur with a wide pulse pressure and bounding pulses. Mitral
stenosis produces a diastolic rumble at the apex with an opening snap. HOCM causes a systolic murmur that
increases with Valsalva, but the carotid findings and the symptom triad point to AS.
Q6: A 60-year-old male with a history of a myocardial infarction presents with progressive
dyspnea, orthopnea, and fatigue. Cardiac auscultation reveals a holosystolic murmur heard best
at the apex, radiating to the axilla. The PMI is displaced laterally. What is the most likely valvular
pathology?
A. Aortic stenosis
B. Mitral regurgitation [CORRECT]
C. Mitral stenosis
D. Tricuspid regurgitation
Correct Answer: B
Rationale: A holosystolic murmur at the apex radiating to the axilla, with a laterally displaced PMI indicating
left ventricular dilation, is classic for chronic mitral regurgitation. Post-MI mitral regurgitation often results
from papillary muscle dysfunction or left ventricular remodeling. Aortic stenosis produces a systolic ejection
murmur at the 2nd RICS radiating to the carotids. Mitral stenosis causes a diastolic rumble. Tricuspid
regurgitation produces a holosystolic murmur at the lower left sternal border that increases with inspiration
(Carvallo sign).
Q7: A 55-year-old male presents with a diastolic decrescendo murmur heard best at the left
sternal border (3rd/4th ICS). His BP is 160/55 with a wide pulse pressure of 105 mmHg. He has
bounding carotid pulses (Corrigan pulse) and a rapidly rising and collapsing radial pulse
(water-hammer pulse). Which additional finding is most consistent with this diagnosis?
A. Opening snap at the apex
B. Austin Flint murmur (mid-diastolic rumble at the apex) [CORRECT]
C. Loud S1 with a snapping quality
D. Fixed split S2
Correct Answer: B
Rationale: The diastolic decrescendo murmur at the left sternal border, wide pulse pressure, bounding pulses
(Corrigan), and water-hammer pulse are classic for chronic aortic regurgitation. The Austin Flint murmur is a
mid-diastolic rumble heard at the apex caused by the regurgitant jet impinging on the anterior mitral leaflet,
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 3
, NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
preventing full opening. An opening snap is characteristic of mitral stenosis. A loud snapping S1 is heard in
mitral stenosis. A fixed split S2 indicates atrial septal defect.
Q8: A 38-year-old female immigrant from Southeast Asia presents with progressive dyspnea on
exertion, orthopnea, and palpitations. On examination, she has a loud S1, an opening snap
following S2, and a low-pitched diastolic rumble heard best at the apex with the bell of the
stethoscope in the left lateral decubitus position. What is the most likely rhythm on ECG?
A. Normal sinus rhythm
B. Atrial fibrillation with irregularly irregular rhythm [CORRECT]
C. Ventricular tachycardia
D. Second-degree AV block (Mobitz I)
Correct Answer: B
Rationale: The loud S1, opening snap, and diastolic rumble at the apex are classic findings of mitral stenosis,
most commonly caused by rheumatic heart disease. Left atrial enlargement from the stenotic mitral valve leads
to electrical remodeling and atrial fibrillation, which is the most common arrhythmia associated with mitral
stenosis. The irregularly irregular rhythm is the hallmark of AF. The other arrhythmias are not characteristically
associated with mitral stenosis.
Q9: A 70-year-old male is being evaluated for syncope. During carotid sinus massage (after
excluding carotid bruits), there is a 4-second sinus pause on the ECG with reproduction of
lightheadedness. Which finding would differentiate carotid sinus hypersensitivity (CSH) from
sick sinus syndrome as the cause of syncope?
A. Atrial fibrillation on baseline ECG
B. Reproduction of symptoms with carotid sinus pressure and a pause > 3 seconds [CORRECT]
C. Persistent bradycardia of 45 bpm at rest without carotid pressure
D. ST elevation on the 12-lead ECG
Correct Answer: B
Rationale: Carotid sinus hypersensitivity is diagnosed when carotid sinus massage produces a sinus pause > 3
seconds (cardioinhibitory type), a fall in systolic BP > 50 mmHg (vasodepressor type), or both (mixed), with
reproduction of symptoms. Sick sinus syndrome manifests with persistent resting bradycardia, sinus pauses, or
tachy-brady syndrome without requiring carotid pressure to provoke. Reproduction of symptoms with carotid
pressure specifically indicates CSH. ST elevation suggests acute MI as an alternate cause of syncope.
Q10: A 19-year-old college basketball player suddenly collapses during a game. He is found in
ventricular fibrillation and is resuscitated. On subsequent evaluation, his ECG shows diffuse T
wave inversions and an echocardiogram reveals asymmetric left ventricular hypertrophy (septal
thickness 18 mm) with systolic anterior motion (SAM) of the mitral valve. Which murmur
characteristic is most consistent with hypertrophic obstructive cardiomyopathy (HOCM)?
A. Decreases with Valsalva maneuver
B. Increases with Valsalva maneuver and squat-to-stand maneuver [CORRECT]
C. Radiates to the carotid arteries
D. Best heard at the 2nd right intercostal space
Correct Answer: B
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 4
NSG 550 / NSG 550 Exam 2 (Latest
Update)
Diagnostic Reasoning for Nurse Practitioners | Questions and Verified Answers | 100% Correct |
Grade A
Wilkes University - Passan School of Nursing
2026/2027 Academic Year | Advanced Practice Nursing Education
Total Questions Cognitive Levels Question Style
25% Recall / 55% Application / 20% 70% Scenario / 20% Recall / 10%
75 Multiple Choice
Analysis Clinical Judgment
Instructions: Select the single best answer for each question. Each question provides a rationale explaining the
correct response and why alternative options are incorrect, integrating Wilkes University NSG 550 diagnostic
reasoning competencies and evidence-based advanced practice nursing.
Section 1: Cardiovascular Diagnostic Reasoning (Q1-Q18)
Chest pain differential diagnosis, cardiac auscultation, murmurs, ECG interpretation, cardiac biomarkers, and hemodynamic
assessment. Focus on differentiating ACS, pericarditis, aortic dissection, pulmonary embolism, and valvular pathology.
Q1: A 58-year-old male presents to the clinic with substernal chest pressure described as "an
elephant sitting on my chest," radiating to his left jaw and arm, associated with diaphoresis and
nausea, ongoing for 45 minutes and unrelieved by rest. Vital signs: BP 148/92, HR 102, SpO2 96%.
Which finding on the 12-lead ECG would most strongly indicate the need for immediate
percutaneous coronary intervention (PCI)?
A. Diffuse ST elevation in leads I, II, III, aVF, V1-V6 with PR depression
B. ST elevation of 2 mm in leads II, III, and aVF with reciprocal ST depression in I and aVL
[CORRECT]
C. T wave inversion in leads V1-V4 without ST elevation
D. Normal ECG with nonspecific ST-T wave changes
Correct Answer: B
Rationale: ST elevation in II, III, and aVF with reciprocal depression in I and aVL indicates an acute inferior
STEMI, which is a STEMI equivalent requiring immediate reperfusion therapy (PCI within 90 minutes of first
medical contact - the "door-to-balloon" time). Diffuse ST elevation with PR depression is classic for
pericarditis, not ACS. T wave inversion alone suggests ischemia but not STEMI. A normal ECG does not
exclude ACS (NSTEMI may have a normal or nondiagnostic ECG), but it would not mandate immediate PCI.
Q2: A 67-year-old female presents with sudden, severe, tearing chest pain radiating to her back
between the shoulder blades. BP is 168/95 in the right arm and 142/88 in the left arm, with a
20-point systolic difference. HR 110. Which diagnostic test is the gold standard for confirming the
suspected diagnosis?
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 1
,NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
A. 12-lead ECG to evaluate for ST elevation
B. Transthoracic echocardiogram (TTE)
C. CT angiography of the chest and abdomen [CORRECT]
D. Cardiac troponin I level
Correct Answer: C
Rationale: The clinical presentation (sudden tearing chest pain radiating to the back, pulse deficit with >20
mmHg systolic difference between arms, hypertensive emergency) is classic for acute aortic dissection. CT
angiography is the gold standard diagnostic test, providing rapid, high-sensitivity visualization of the dissection
flap, true and false lumen, and branch vessel involvement. ECG is needed to exclude concurrent ACS but
cannot diagnose dissection. TTE has limited sensitivity for dissection. Troponin may be elevated if dissection
extends into coronary ostia but is not diagnostic of dissection itself.
Q3: A 42-year-old male presents with sharp, pleuritic chest pain that worsens when lying flat and
improves when sitting forward and leaning forward. He had a viral upper respiratory infection
two weeks ago. On auscultation, a triphasic scratching sound is heard best at the left sternal
border with the patient leaning forward. Which ECG finding is most characteristic of this
condition?
A. ST elevation in II, III, and aVF with reciprocal depression
B. Diffuse ST elevation in multiple leads with PR depression [CORRECT]
C. Deep T wave inversions in V1-V4
D. Electrical alternans on the rhythm strip
Correct Answer: B
Rationale: The presentation is classic for acute pericarditis: sharp pleuritic pain improved by sitting forward,
recent viral illness, and a pericardial friction rub (triphasic scratching sound). The hallmark ECG finding is
diffuse, concave ST elevation in multiple leads (often I, II, III, aVF, V2-V6) with PR depression, distinguishing
it from the localized, convex ST elevation of STEMI and the reciprocal changes of acute MI. Electrical
alternans is seen with large pericardial effusion causing cardiac swinging, not typical pericarditis.
Q4: A 65-year-old female is admitted with acute decompensated heart failure. On examination,
she has an S3 ventricular gallop, bilateral basilar crackles, and jugular venous distension. Which
diagnostic finding is most consistent with this clinical picture?
A. BNP of 80 pg/mL
B. BNP of 850 pg/mL with elevated troponin [CORRECT]
C. NT-proBNP of 150 pg/mL
D. Normal echocardiogram with LVEF of 65%
Correct Answer: B
Rationale: An S3 gallop, bilateral crackles, and JVD are classic physical examination findings of acute
decompensated heart failure. BNP > 400 pg/mL (or NT-proBNP > 450 in patients < 50, > 900 in patients
50-75) strongly supports the diagnosis of heart failure. A BNP of 850 pg/mL is markedly elevated and
consistent with acute HF exacerbation. Elevated troponin may indicate concurrent myocardial injury or type 2
MI from demand ischemia. BNP < 100 or NT-proBNP < 300 effectively excludes HF. A normal echo with
LVEF 65% would suggest HF with preserved ejection fraction (HFpEF), not a low-output picture.
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 2
,NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
Q5: A 72-year-old male presents with exertional chest pain, syncope on exertion, and dyspnea with
activity. On cardiac auscultation, a crescendo-decrescendo systolic murmur is heard best at the
second right intercostal space (2nd RICS) radiating to the carotid arteries. The carotid pulse is
delayed and weak (pulsus parvus et tardus). What is the most likely diagnosis?
A. Aortic regurgitation
B. Mitral stenosis
C. Aortic stenosis [CORRECT]
D. Hypertrophic obstructive cardiomyopathy (HOCM)
Correct Answer: C
Rationale: The triad of exertional angina, syncope, and dyspnea (the classic triad of severe aortic stenosis)
combined with a crescendo-decrescendo systolic ejection murmur at the 2nd RICS radiating to the carotids, and
a slow-rising, weak carotid pulse (pulsus parvus et tardus), is pathognomonic for aortic stenosis. Aortic
regurgitation causes a diastolic decrescendo murmur with a wide pulse pressure and bounding pulses. Mitral
stenosis produces a diastolic rumble at the apex with an opening snap. HOCM causes a systolic murmur that
increases with Valsalva, but the carotid findings and the symptom triad point to AS.
Q6: A 60-year-old male with a history of a myocardial infarction presents with progressive
dyspnea, orthopnea, and fatigue. Cardiac auscultation reveals a holosystolic murmur heard best
at the apex, radiating to the axilla. The PMI is displaced laterally. What is the most likely valvular
pathology?
A. Aortic stenosis
B. Mitral regurgitation [CORRECT]
C. Mitral stenosis
D. Tricuspid regurgitation
Correct Answer: B
Rationale: A holosystolic murmur at the apex radiating to the axilla, with a laterally displaced PMI indicating
left ventricular dilation, is classic for chronic mitral regurgitation. Post-MI mitral regurgitation often results
from papillary muscle dysfunction or left ventricular remodeling. Aortic stenosis produces a systolic ejection
murmur at the 2nd RICS radiating to the carotids. Mitral stenosis causes a diastolic rumble. Tricuspid
regurgitation produces a holosystolic murmur at the lower left sternal border that increases with inspiration
(Carvallo sign).
Q7: A 55-year-old male presents with a diastolic decrescendo murmur heard best at the left
sternal border (3rd/4th ICS). His BP is 160/55 with a wide pulse pressure of 105 mmHg. He has
bounding carotid pulses (Corrigan pulse) and a rapidly rising and collapsing radial pulse
(water-hammer pulse). Which additional finding is most consistent with this diagnosis?
A. Opening snap at the apex
B. Austin Flint murmur (mid-diastolic rumble at the apex) [CORRECT]
C. Loud S1 with a snapping quality
D. Fixed split S2
Correct Answer: B
Rationale: The diastolic decrescendo murmur at the left sternal border, wide pulse pressure, bounding pulses
(Corrigan), and water-hammer pulse are classic for chronic aortic regurgitation. The Austin Flint murmur is a
mid-diastolic rumble heard at the apex caused by the regurgitant jet impinging on the anterior mitral leaflet,
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 3
, NSG 550 Exam 2 - Diagnostic Reasoning for Nurse Practitioners | Wilkes University
preventing full opening. An opening snap is characteristic of mitral stenosis. A loud snapping S1 is heard in
mitral stenosis. A fixed split S2 indicates atrial septal defect.
Q8: A 38-year-old female immigrant from Southeast Asia presents with progressive dyspnea on
exertion, orthopnea, and palpitations. On examination, she has a loud S1, an opening snap
following S2, and a low-pitched diastolic rumble heard best at the apex with the bell of the
stethoscope in the left lateral decubitus position. What is the most likely rhythm on ECG?
A. Normal sinus rhythm
B. Atrial fibrillation with irregularly irregular rhythm [CORRECT]
C. Ventricular tachycardia
D. Second-degree AV block (Mobitz I)
Correct Answer: B
Rationale: The loud S1, opening snap, and diastolic rumble at the apex are classic findings of mitral stenosis,
most commonly caused by rheumatic heart disease. Left atrial enlargement from the stenotic mitral valve leads
to electrical remodeling and atrial fibrillation, which is the most common arrhythmia associated with mitral
stenosis. The irregularly irregular rhythm is the hallmark of AF. The other arrhythmias are not characteristically
associated with mitral stenosis.
Q9: A 70-year-old male is being evaluated for syncope. During carotid sinus massage (after
excluding carotid bruits), there is a 4-second sinus pause on the ECG with reproduction of
lightheadedness. Which finding would differentiate carotid sinus hypersensitivity (CSH) from
sick sinus syndrome as the cause of syncope?
A. Atrial fibrillation on baseline ECG
B. Reproduction of symptoms with carotid sinus pressure and a pause > 3 seconds [CORRECT]
C. Persistent bradycardia of 45 bpm at rest without carotid pressure
D. ST elevation on the 12-lead ECG
Correct Answer: B
Rationale: Carotid sinus hypersensitivity is diagnosed when carotid sinus massage produces a sinus pause > 3
seconds (cardioinhibitory type), a fall in systolic BP > 50 mmHg (vasodepressor type), or both (mixed), with
reproduction of symptoms. Sick sinus syndrome manifests with persistent resting bradycardia, sinus pauses, or
tachy-brady syndrome without requiring carotid pressure to provoke. Reproduction of symptoms with carotid
pressure specifically indicates CSH. ST elevation suggests acute MI as an alternate cause of syncope.
Q10: A 19-year-old college basketball player suddenly collapses during a game. He is found in
ventricular fibrillation and is resuscitated. On subsequent evaluation, his ECG shows diffuse T
wave inversions and an echocardiogram reveals asymmetric left ventricular hypertrophy (septal
thickness 18 mm) with systolic anterior motion (SAM) of the mitral valve. Which murmur
characteristic is most consistent with hypertrophic obstructive cardiomyopathy (HOCM)?
A. Decreases with Valsalva maneuver
B. Increases with Valsalva maneuver and squat-to-stand maneuver [CORRECT]
C. Radiates to the carotid arteries
D. Best heard at the 2nd right intercostal space
Correct Answer: B
Wilkes University Passan School of Nursing | Latest 2026/2027 Update Page 4
