NR 569 Differential Diagnosis in Acute Care Practicum - Final Examination
NR 569 / NR 569 Final Exam (Latest 2026/2027)
Differential Diagnosis in Acute Care Practicum | Chamberlain University
75 Multiple-Choice Questions | Comprehensive Examination with Verified Rationales | Weeks 5-8 Content
Section 1: Gastrointestinal and Abdominal Differential Diagnosis (Questions 1-15)
1. A 28-year-old male presents to the emergency department with periumbilical pain that migrated to the right lower
quadrant over the past 12 hours. He reports anorexia, nausea, and one episode of non-bloody vomiting. On
examination, he has localized tenderness at McBurney's point with voluntary guarding. His WBC count is
13,500/uL. Which of the following is the most appropriate next step in management?
A. Discharge with oral antibiotics and follow-up in 48 hours
B. Order a CT abdomen/pelvis with contrast and prepare for surgical consultation [CORRECT]
C. Prescribe proton pump inhibitor therapy and schedule outpatient endoscopy
D. Administer IV morphine and observe for 6 hours before further intervention
Correct Answer: B
This patient's presentation is classic for acute appendicitis: periumbilical pain migrating to the RLQ, anorexia, nausea, and
McBurney's point tenderness with leukocytosis. CT abdomen/pelvis with contrast is the diagnostic imaging of choice to confirm the
diagnosis and assess for perforation, abscess, or alternative diagnoses. Surgical consultation should be obtained promptly because
appendectomy is the definitive treatment, and the risk of perforation increases significantly after 48 hours of symptoms.
Discharging without imaging or surgical evaluation risks perforation and peritonitis. PPIs are used for GERD/PUD, not
appendicitis. While analgesics should not be withheld, observation alone without definitive evaluation is inappropriate for suspected
appendicitis.
2. A 45-year-old female presents with severe right upper quadrant pain radiating to her right shoulder, fever of
101.2F, nausea, and vomiting after eating a fatty meal. On examination, the nurse practitioner elicits a positive
Murphy's sign. Which of the following diagnostic findings would most strongly support the diagnosis of acute
cholecystitis?
A. Thickened gallbladder wall greater than 3 mm, pericholecystic fluid, and gallstones on RUQ ultrasound
[CORRECT]
B. Elevated serum amylase and lipase greater than three times the upper limit of normal
C. Dilated common bile duct greater than 6 mm with elevated direct bilirubin on MRCP
D. Air in the biliary tree (pneumobilia) and multiple gallstones on abdominal CT
Correct Answer: A
Acute cholecystitis is inflammation of the gallbladder, most commonly caused by cystic duct obstruction by gallstones. RUQ
ultrasound is the initial diagnostic test of choice and typically reveals a thickened gallbladder wall (greater than 3 mm),
pericholecystic fluid, gallstones, and a positive sonographic Murphy's sign. Elevated amylase and lipase suggest pancreatitis, not
cholecystitis. A dilated common bile duct with elevated direct bilirubin suggests choledocholithiasis, which may coexist with
cholecystitis but requires ERCP for management. Pneumobilia suggests an abnormal connection between the biliary tree and the GI
tract, such as a gallstone ileus or prior sphincterotomy.
3. A 52-year-old male with a history of chronic alcohol abuse presents with severe epigastric pain radiating straight
through to his back, nausea, and vomiting. His serum lipase is 850 U/L (normal less than 60 U/L). The nurse
practitioner calculates a Ranson score and determines the patient has 4 criteria at admission. Which of the following
is the most appropriate interpretation?
A. Mild pancreatitis with low mortality risk; manage as outpatient
Chamberlain University - 2026/2027 Page 1
,NR 569 Differential Diagnosis in Acute Care Practicum - Final Examination
B. Moderate to severe pancreatitis with significant morbidity and mortality risk; ICU admission warranted
[CORRECT]
C. The Ranson score is not valid in alcohol-related pancreatitis; use APACHE-II instead
D. The pancreatitis is likely gallstone-related despite the alcohol history; order RUQ ultrasound
Correct Answer: B
This patient presents with classic acute pancreatitis: severe epigastric pain radiating to the back, elevated lipase greater than three
times normal, and a history of alcohol use. The Ranson criteria predict severity and mortality: a score of 3 or more at admission (or
48 hours) indicates severe pancreatitis with significant morbidity (10-20% mortality). Four criteria at admission strongly support
ICU-level care with aggressive IV fluid resuscitation, pain management, and close monitoring for systemic complications such as
necrosis, organ failure, and infection. The Ranson score is valid for both gallstone and alcohol-related pancreatitis. An RUQ
ultrasound may be indicated to assess for gallstones, but alcohol is the likely etiology in this patient with a chronic alcohol history.
4. A 65-year-old male presents with melena and fatigue. He reports taking ibuprofen 800 mg three times daily for
chronic knee pain for the past 3 months. His hemoglobin is 8.2 g/dL and his MCV is 76 fL. Which of the following
is the most likely diagnosis and the most appropriate initial diagnostic test?
A. Lower GI bleed from diverticulosis; order colonoscopy
B. Upper GI bleed from peptic ulcer disease; order esophagogastroduodenoscopy (EGD) [CORRECT]
C. Inflammatory bowel disease; order colonoscopy with biopsy
D. Colon cancer; order CT colonography and CEA level
Correct Answer: B
This patient has a classic presentation of an upper GI bleed: melena (black, tarry stools from digested blood proximal to the ligament
of Treitz), iron deficiency anemia (low hemoglobin, low MCV), and a clear risk factor (chronic NSAID use causing PUD). EGD is
the initial diagnostic test of choice for suspected upper GI bleeding, as it can identify the source (gastric or duodenal ulcer, gastritis,
esophagitis) and provide therapeutic intervention such as injection, cautery, or clipping. Colonoscopy evaluates the lower GI tract
and would not identify an upper GI source. IBD typically presents with bloody diarrhea and abdominal pain, not melena. Colon
cancer can cause anemia and hematochezia but is less likely to present with melena than an upper GI source.
5. A 38-year-old female presents with crampy left lower quadrant abdominal pain, fever of 100.8F, nausea, and a
change in bowel habits with constipation alternating with loose stools over the past 2 days. She has no history of
similar episodes. On abdominal examination, there is localized LLQ tenderness with voluntary guarding. Which of
the following is the most appropriate diagnostic test?
A. CT abdomen and pelvis with contrast [CORRECT]
B. Colonoscopy with biopsy
C. Abdominal ultrasound
D. Barium enema
Correct Answer: A
This patient's presentation (LLQ pain, fever, change in bowel habits, localized tenderness) is most consistent with acute diverticulitis,
which is inflammation of diverticula most commonly affecting the sigmoid colon. CT abdomen and pelvis with contrast is the
diagnostic gold standard, revealing colonic wall thickening, pericolic fat stranding, and possibly abscess or fistula formation.
Colonoscopy is contraindicated in acute diverticulitis due to the risk of perforation. Abdominal ultrasound has lower sensitivity and
specificity for diagnosing diverticulitis compared to CT. Barium enema is also contraindicated acutely due to perforation risk.
6. A 30-year-old male presents with chronic bloody diarrhea, abdominal pain, weight loss of 15 pounds over 2
months, and recurrent oral ulcers. Colonoscopy reveals skip lesions with transmural inflammation and a stricture in
the terminal ileum. Which of the following best describes this condition and its distinguishing features compared to
ulcerative colitis?
A. Ulcerative colitis; characterized by continuous mucosal inflammation limited to the colon with bloody diarrhea
B. Crohn's disease; characterized by transmural inflammation, skip lesions, fistula formation, and the
ability to affect any portion of the GI tract [CORRECT]
Chamberlain University - 2026/2027 Page 2
, NR 569 Differential Diagnosis in Acute Care Practicum - Final Examination
C. Irritable bowel syndrome with inflammatory features; requires dietary modification only
D. Ischemic colitis; characterized by watershed area infarction and resolves with conservative management
Correct Answer: B
This patient's presentation is classic for Crohn's disease, which is distinguished from ulcerative colitis by several key features:
transmural inflammation (affecting all layers of the bowel wall), skip lesions (areas of inflammation alternating with normal
mucosa), involvement of any portion of the GI tract from mouth to anus (terminal ileum is characteristic), fistula and stricture
formation, and non-bloody diarrhea (though bleeding can occur with colonic involvement). Ulcerative colitis, in contrast, is limited
to the colon and rectum, produces continuous (non-skip) mucosal inflammation, and typically presents with prominent bloody
diarrhea. IBS does not cause weight loss, oral ulcers, or inflammatory findings on colonoscopy.
7. A 55-year-old female with known cirrhosis presents with hematemesis of bright red blood. Her blood pressure is
85/50 mmHg, heart rate is 120 bpm, and she appears diaphoretic and confused. Which of the following is the most
appropriate immediate management priority?
A. Schedule an elective EGD for the next available appointment
B. Initiate IV fluid resuscitation, administer octreotide, and arrange emergent endoscopy [CORRECT]
C. Obtain a CT angiogram to localize the bleeding source before any intervention
D. Administer a proton pump inhibitor IV bolus and observe for 24 hours
Correct Answer: B
This patient with cirrhosis presenting with hematemesis and hemodynamic instability (hypotension, tachycardia, altered mental
status) most likely has bleeding esophageal or gastric varices secondary to portal hypertension. This is a medical emergency requiring
immediate intervention. The priority is IV fluid resuscitation to restore hemodynamic stability, octreotide (somatostatin analog) to
reduce portal pressure and slow variceal bleeding, and emergent endoscopy for band ligation or sclerotherapy. While PPIs may be
adjunctive, they are not the primary treatment for variceal bleeding. Delaying endoscopy for elective scheduling or imaging is
inappropriate in an unstable patient with active hemorrhage. Time is critical as variceal bleeding carries high mortality.
8. A 40-year-old male presents with a reducible bulge in the right inguinal area that is more pronounced when
standing and coughing. The bulge disappears when he lies down. Which type of hernia is most likely present, and
what is the most important complication the nurse practitioner should counsel the patient about?
A. Femoral hernia; risk of bowel obstruction due to the narrow femoral canal
B. Indirect inguinal hernia; risk of incarceration and strangulation requiring emergency surgery
[CORRECT]
C. Incisional hernia; risk of evisceration through the surgical wound
D. Umbilical hernia; risk of incarceration in adults with ascites
Correct Answer: B
A reducible inguinal bulge that is more prominent with standing and Valsalva maneuvers and reduces with lying down is
characteristic of an indirect inguinal hernia, the most common type of hernia in males. The indirect inguinal hernia protrudes
through the internal inguinal ring and follows the spermatic cord. The most important complication to counsel about is incarceration
(hernia contents become trapped and irreducible) and strangulation (compromised blood supply to the incarcerated contents), which
is a surgical emergency presenting with pain, erythema, signs of bowel obstruction, and systemic toxicity. Femoral hernias are more
common in females and have the highest rate of strangulation. Incisional hernias occur at prior surgical sites, and umbilical hernias
protrude through the umbilicus.
9. A 60-year-old male presents with progressive difficulty swallowing (dysphagia) that initially occurred with solid
foods and now also with liquids. He reports a 20-pound weight loss over 3 months, heartburn, and occasional
regurgitation. He has a 40-pack-year smoking history. Which of the following is the most concerning diagnosis, and
what is the most appropriate initial diagnostic test?
A. GERD with esophageal stricture; order a barium swallow study
B. Esophageal cancer; order esophagogastroduodenoscopy (EGD) with biopsy [CORRECT]
C. Achalasia; order esophageal manometry
Chamberlain University - 2026/2027 Page 3
NR 569 / NR 569 Final Exam (Latest 2026/2027)
Differential Diagnosis in Acute Care Practicum | Chamberlain University
75 Multiple-Choice Questions | Comprehensive Examination with Verified Rationales | Weeks 5-8 Content
Section 1: Gastrointestinal and Abdominal Differential Diagnosis (Questions 1-15)
1. A 28-year-old male presents to the emergency department with periumbilical pain that migrated to the right lower
quadrant over the past 12 hours. He reports anorexia, nausea, and one episode of non-bloody vomiting. On
examination, he has localized tenderness at McBurney's point with voluntary guarding. His WBC count is
13,500/uL. Which of the following is the most appropriate next step in management?
A. Discharge with oral antibiotics and follow-up in 48 hours
B. Order a CT abdomen/pelvis with contrast and prepare for surgical consultation [CORRECT]
C. Prescribe proton pump inhibitor therapy and schedule outpatient endoscopy
D. Administer IV morphine and observe for 6 hours before further intervention
Correct Answer: B
This patient's presentation is classic for acute appendicitis: periumbilical pain migrating to the RLQ, anorexia, nausea, and
McBurney's point tenderness with leukocytosis. CT abdomen/pelvis with contrast is the diagnostic imaging of choice to confirm the
diagnosis and assess for perforation, abscess, or alternative diagnoses. Surgical consultation should be obtained promptly because
appendectomy is the definitive treatment, and the risk of perforation increases significantly after 48 hours of symptoms.
Discharging without imaging or surgical evaluation risks perforation and peritonitis. PPIs are used for GERD/PUD, not
appendicitis. While analgesics should not be withheld, observation alone without definitive evaluation is inappropriate for suspected
appendicitis.
2. A 45-year-old female presents with severe right upper quadrant pain radiating to her right shoulder, fever of
101.2F, nausea, and vomiting after eating a fatty meal. On examination, the nurse practitioner elicits a positive
Murphy's sign. Which of the following diagnostic findings would most strongly support the diagnosis of acute
cholecystitis?
A. Thickened gallbladder wall greater than 3 mm, pericholecystic fluid, and gallstones on RUQ ultrasound
[CORRECT]
B. Elevated serum amylase and lipase greater than three times the upper limit of normal
C. Dilated common bile duct greater than 6 mm with elevated direct bilirubin on MRCP
D. Air in the biliary tree (pneumobilia) and multiple gallstones on abdominal CT
Correct Answer: A
Acute cholecystitis is inflammation of the gallbladder, most commonly caused by cystic duct obstruction by gallstones. RUQ
ultrasound is the initial diagnostic test of choice and typically reveals a thickened gallbladder wall (greater than 3 mm),
pericholecystic fluid, gallstones, and a positive sonographic Murphy's sign. Elevated amylase and lipase suggest pancreatitis, not
cholecystitis. A dilated common bile duct with elevated direct bilirubin suggests choledocholithiasis, which may coexist with
cholecystitis but requires ERCP for management. Pneumobilia suggests an abnormal connection between the biliary tree and the GI
tract, such as a gallstone ileus or prior sphincterotomy.
3. A 52-year-old male with a history of chronic alcohol abuse presents with severe epigastric pain radiating straight
through to his back, nausea, and vomiting. His serum lipase is 850 U/L (normal less than 60 U/L). The nurse
practitioner calculates a Ranson score and determines the patient has 4 criteria at admission. Which of the following
is the most appropriate interpretation?
A. Mild pancreatitis with low mortality risk; manage as outpatient
Chamberlain University - 2026/2027 Page 1
,NR 569 Differential Diagnosis in Acute Care Practicum - Final Examination
B. Moderate to severe pancreatitis with significant morbidity and mortality risk; ICU admission warranted
[CORRECT]
C. The Ranson score is not valid in alcohol-related pancreatitis; use APACHE-II instead
D. The pancreatitis is likely gallstone-related despite the alcohol history; order RUQ ultrasound
Correct Answer: B
This patient presents with classic acute pancreatitis: severe epigastric pain radiating to the back, elevated lipase greater than three
times normal, and a history of alcohol use. The Ranson criteria predict severity and mortality: a score of 3 or more at admission (or
48 hours) indicates severe pancreatitis with significant morbidity (10-20% mortality). Four criteria at admission strongly support
ICU-level care with aggressive IV fluid resuscitation, pain management, and close monitoring for systemic complications such as
necrosis, organ failure, and infection. The Ranson score is valid for both gallstone and alcohol-related pancreatitis. An RUQ
ultrasound may be indicated to assess for gallstones, but alcohol is the likely etiology in this patient with a chronic alcohol history.
4. A 65-year-old male presents with melena and fatigue. He reports taking ibuprofen 800 mg three times daily for
chronic knee pain for the past 3 months. His hemoglobin is 8.2 g/dL and his MCV is 76 fL. Which of the following
is the most likely diagnosis and the most appropriate initial diagnostic test?
A. Lower GI bleed from diverticulosis; order colonoscopy
B. Upper GI bleed from peptic ulcer disease; order esophagogastroduodenoscopy (EGD) [CORRECT]
C. Inflammatory bowel disease; order colonoscopy with biopsy
D. Colon cancer; order CT colonography and CEA level
Correct Answer: B
This patient has a classic presentation of an upper GI bleed: melena (black, tarry stools from digested blood proximal to the ligament
of Treitz), iron deficiency anemia (low hemoglobin, low MCV), and a clear risk factor (chronic NSAID use causing PUD). EGD is
the initial diagnostic test of choice for suspected upper GI bleeding, as it can identify the source (gastric or duodenal ulcer, gastritis,
esophagitis) and provide therapeutic intervention such as injection, cautery, or clipping. Colonoscopy evaluates the lower GI tract
and would not identify an upper GI source. IBD typically presents with bloody diarrhea and abdominal pain, not melena. Colon
cancer can cause anemia and hematochezia but is less likely to present with melena than an upper GI source.
5. A 38-year-old female presents with crampy left lower quadrant abdominal pain, fever of 100.8F, nausea, and a
change in bowel habits with constipation alternating with loose stools over the past 2 days. She has no history of
similar episodes. On abdominal examination, there is localized LLQ tenderness with voluntary guarding. Which of
the following is the most appropriate diagnostic test?
A. CT abdomen and pelvis with contrast [CORRECT]
B. Colonoscopy with biopsy
C. Abdominal ultrasound
D. Barium enema
Correct Answer: A
This patient's presentation (LLQ pain, fever, change in bowel habits, localized tenderness) is most consistent with acute diverticulitis,
which is inflammation of diverticula most commonly affecting the sigmoid colon. CT abdomen and pelvis with contrast is the
diagnostic gold standard, revealing colonic wall thickening, pericolic fat stranding, and possibly abscess or fistula formation.
Colonoscopy is contraindicated in acute diverticulitis due to the risk of perforation. Abdominal ultrasound has lower sensitivity and
specificity for diagnosing diverticulitis compared to CT. Barium enema is also contraindicated acutely due to perforation risk.
6. A 30-year-old male presents with chronic bloody diarrhea, abdominal pain, weight loss of 15 pounds over 2
months, and recurrent oral ulcers. Colonoscopy reveals skip lesions with transmural inflammation and a stricture in
the terminal ileum. Which of the following best describes this condition and its distinguishing features compared to
ulcerative colitis?
A. Ulcerative colitis; characterized by continuous mucosal inflammation limited to the colon with bloody diarrhea
B. Crohn's disease; characterized by transmural inflammation, skip lesions, fistula formation, and the
ability to affect any portion of the GI tract [CORRECT]
Chamberlain University - 2026/2027 Page 2
, NR 569 Differential Diagnosis in Acute Care Practicum - Final Examination
C. Irritable bowel syndrome with inflammatory features; requires dietary modification only
D. Ischemic colitis; characterized by watershed area infarction and resolves with conservative management
Correct Answer: B
This patient's presentation is classic for Crohn's disease, which is distinguished from ulcerative colitis by several key features:
transmural inflammation (affecting all layers of the bowel wall), skip lesions (areas of inflammation alternating with normal
mucosa), involvement of any portion of the GI tract from mouth to anus (terminal ileum is characteristic), fistula and stricture
formation, and non-bloody diarrhea (though bleeding can occur with colonic involvement). Ulcerative colitis, in contrast, is limited
to the colon and rectum, produces continuous (non-skip) mucosal inflammation, and typically presents with prominent bloody
diarrhea. IBS does not cause weight loss, oral ulcers, or inflammatory findings on colonoscopy.
7. A 55-year-old female with known cirrhosis presents with hematemesis of bright red blood. Her blood pressure is
85/50 mmHg, heart rate is 120 bpm, and she appears diaphoretic and confused. Which of the following is the most
appropriate immediate management priority?
A. Schedule an elective EGD for the next available appointment
B. Initiate IV fluid resuscitation, administer octreotide, and arrange emergent endoscopy [CORRECT]
C. Obtain a CT angiogram to localize the bleeding source before any intervention
D. Administer a proton pump inhibitor IV bolus and observe for 24 hours
Correct Answer: B
This patient with cirrhosis presenting with hematemesis and hemodynamic instability (hypotension, tachycardia, altered mental
status) most likely has bleeding esophageal or gastric varices secondary to portal hypertension. This is a medical emergency requiring
immediate intervention. The priority is IV fluid resuscitation to restore hemodynamic stability, octreotide (somatostatin analog) to
reduce portal pressure and slow variceal bleeding, and emergent endoscopy for band ligation or sclerotherapy. While PPIs may be
adjunctive, they are not the primary treatment for variceal bleeding. Delaying endoscopy for elective scheduling or imaging is
inappropriate in an unstable patient with active hemorrhage. Time is critical as variceal bleeding carries high mortality.
8. A 40-year-old male presents with a reducible bulge in the right inguinal area that is more pronounced when
standing and coughing. The bulge disappears when he lies down. Which type of hernia is most likely present, and
what is the most important complication the nurse practitioner should counsel the patient about?
A. Femoral hernia; risk of bowel obstruction due to the narrow femoral canal
B. Indirect inguinal hernia; risk of incarceration and strangulation requiring emergency surgery
[CORRECT]
C. Incisional hernia; risk of evisceration through the surgical wound
D. Umbilical hernia; risk of incarceration in adults with ascites
Correct Answer: B
A reducible inguinal bulge that is more prominent with standing and Valsalva maneuvers and reduces with lying down is
characteristic of an indirect inguinal hernia, the most common type of hernia in males. The indirect inguinal hernia protrudes
through the internal inguinal ring and follows the spermatic cord. The most important complication to counsel about is incarceration
(hernia contents become trapped and irreducible) and strangulation (compromised blood supply to the incarcerated contents), which
is a surgical emergency presenting with pain, erythema, signs of bowel obstruction, and systemic toxicity. Femoral hernias are more
common in females and have the highest rate of strangulation. Incisional hernias occur at prior surgical sites, and umbilical hernias
protrude through the umbilicus.
9. A 60-year-old male presents with progressive difficulty swallowing (dysphagia) that initially occurred with solid
foods and now also with liquids. He reports a 20-pound weight loss over 3 months, heartburn, and occasional
regurgitation. He has a 40-pack-year smoking history. Which of the following is the most concerning diagnosis, and
what is the most appropriate initial diagnostic test?
A. GERD with esophageal stricture; order a barium swallow study
B. Esophageal cancer; order esophagogastroduodenoscopy (EGD) with biopsy [CORRECT]
C. Achalasia; order esophageal manometry
Chamberlain University - 2026/2027 Page 3
