NSG6020 Final Exam Updated Questions and Answers (Verified
Answers)
Comprehensive Primary Care and Health Assessment for Nurse Practitioners
South University - Advanced Practice Nursing Education
Aligned with 2026-2027 South University NSG6020 Curriculum Standards, ANCC/AANP Competencies,
and Current Evidence-Based Clinical Practice Guidelines
Total Questions: 100 Format: Multiple Choice (A-D)
Distribution: 10 Sections Cognitive Levels: 20% Recall, 50% Application, 30%
Analysis
Focus: Advanced Health Assessment, Difficulty: Graduate-Level Practicum
Cardiovascular, Respiratory,
GI/GU/Renal,
Neurological, Musculoskeletal,
Endocrine, Dermatological,
Mental Health, Special Populations,
Preventive Health, Ethics
________________________________________________________________________________
Section 1: Advanced Health Assessment and Diagnostic Reasoning
Q1. A 62-year-old woman presents for an annual wellness visit. She reports occasional headaches and fatigue but denies
chest pain, dyspnea, or syncope. Her blood pressure is 158/92 mmHg on two separate readings. BMI is 31 kg/m². She has no
known chronic conditions and takes no medications. Family history is notable for myocardial infarction in her father at age
58. According to the ACC/AHA 2017 hypertension guideline, what is the most appropriate next step in management?
A. Repeat blood pressure measurement in 3 months
B. Initiate lifestyle modifications only, as she has stage 1 hypertension without compelling comorbidities
C. Initiate lifestyle modifications and start a thiazide diuretic, as her ASCVD 10-year risk will likely exceed
10% [CORRECT]
D. Order ambulatory blood pressure monitoring to rule out white-coat hypertension before any intervention
Correct Answer: C
Rationale: Per ACC/AHA 2017 guidelines, this patient has stage 2 hypertension (≥140/90 mmHg), which warrants both lifestyle
modifications and antihypertensive medication regardless of 10-year ASCVD risk. Option A delays necessary treatment; Option B applies
only to stage 1 hypertension without high ASCVD risk. While ABPM (Option D) can be useful, clinical guidelines support initiating
treatment in confirmed stage 2 hypertension without mandatory ABPM.
________________________________________________________________________________
Q2. A 45-year-old man with a 20-pack-year smoking history presents with a persistent cough for 3 weeks and a 10-pound
weight loss over 2 months. Chest X-ray reveals a 2.5 cm right upper lobe mass. Which diagnostic test should the nurse
,NSG6020 Final Exam | Comprehensive Primary Care and Health Assessment 100 Questions - South University 2026/2027
practitioner order next to establish a tissue diagnosis?
A. CT-guided percutaneous fine-needle aspiration biopsy
B. Bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)
[CORRECT]
C. Sputum cytology
D. PET-CT scan
Correct Answer: B
Rationale: EBUS-TBNA is the preferred initial diagnostic approach for a centrally located or accessible peripheral lung mass, as it
provides both tissue diagnosis and mediastinal staging simultaneously. Sputum cytology (Option C) has low sensitivity (~66%) and is not
first-line for a visible mass. CT-guided biopsy (Option A) is more appropriate for peripheral lesions not reachable by bronchoscopy.
PET-CT (Option D) is used for staging, not tissue diagnosis.
________________________________________________________________________________
Q3. A 28-year-old woman presents with a 2-day history of urinary frequency, dysuria, and suprapubic pressure. She is
afebrile, and physical exam is unremarkable except for mild suprapubic tenderness. She has no history of UTI. A urine
dipstick is positive for leukocyte esterase and nitrites. What is the most cost-effective diagnostic approach?
A. Obtain a urine culture and sensitivity, then prescribe antibiotics based on results
B. Treat empirically with trimethoprim-sulfamethoxazole for 3 days without obtaining a urine culture
[CORRECT]
C. Obtain a urine culture and start empiric antibiotics simultaneously
D. Order a renal ultrasound to rule out complications before treating
Correct Answer: B
Rationale: In an otherwise healthy, nonpregnant, premenopausal woman with classic uncomplicated acute cystitis, empiric antibiotic
therapy without a urine culture is the most cost-effective approach per IDSA and USPSTF guidelines. Urine cultures (Options A and C)
are reserved for recurrent UTI, complicated UTI, or treatment failure. Renal ultrasound (Option D) is unnecessary in uncomplicated
cystitis.
________________________________________________________________________________
Q4. A 72-year-old man presents with progressive memory loss over 18 months. His wife reports he frequently misplaces
items, forgets conversations, and has difficulty managing finances. He has no history of stroke, head trauma, or psychiatric
illness. Mini-Cog score is 18/30. Physical exam and basic metabolic panel are normal. Which of the following is the most
appropriate next diagnostic step?
A. Order a brain MRI without contrast to evaluate for structural lesions and atrophy patterns
B. Prescribe a cholinesterase inhibitor immediately and reassess in 3 months
C. Order a comprehensive thyroid panel, vitamin B12, and RPR to rule out reversible causes [CORRECT]
D. Refer directly to a neurologist for lumbar puncture and amyloid PET imaging
Correct Answer: C
Rationale: Before diagnosing dementia, reversible causes must be excluded per USPSTF and AAN guidelines; a basic workup includes
TSH, vitamin B12, and RPR. While brain MRI (Option A) is often indicated, it is not the first step before laboratory screening for
reversible etiologies. Prescribing a cholinesterase inhibitor (Option B) before establishing a diagnosis is premature. Lumbar puncture and
amyloid PET (Option D) are research tools not indicated for initial evaluation.
________________________________________________________________________________
Q5. A 55-year-old woman with type 2 diabetes mellitus and hypertension presents for routine follow-up. Her HbA1c is
7.8%, blood pressure is 138/86 mmHg, and LDL-C is 118 mg/dL. She takes metformin 1000 mg twice daily and lisinopril
20 mg daily. Her 10-year ASCVD risk is 12%. According to current guidelines, which preventive service is most clearly
indicated?
2
,NSG6020 Final Exam | Comprehensive Primary Care and Health Assessment 100 Questions - South University 2026/2027
A. Coronary artery calcium (CAC) scoring to refine statin therapy decision-making
B. Initiation of a moderate-intensity statin given her 10-year ASCVD risk of 12% [CORRECT]
C. Aspirin 81 mg daily for primary prevention of cardiovascular events
D. Screening for abdominal aortic aneurysm with ultrasound
Correct Answer: B
Rationale: Per ACC/AHA 2018 cholesterol guidelines, a 10-year ASCVD risk ≥7.5% warrants a discussion about initiating a
moderate-to-high-intensity statin. Her age, diabetes, and 12% risk clearly support statin initiation. CAC scoring (Option A) may be used
for borderline risk (5-7.5%) but is not required at 12%. Aspirin for primary prevention (Option C) is no longer routinely recommended
per USPSTF 2022 guidelines for her risk profile. AAA screening (Option D) is indicated only for men aged 65-75 who have ever
smoked.
________________________________________________________________________________
Q6. A 38-year-old woman presents with a 6-week history of diffuse joint pain, morning stiffness lasting >60 minutes, and
fatigue. She reports swelling in her wrists and PIP joints bilaterally. ESR is 45 mm/hr and CRP is 2.8 mg/dL. RF is positive
(titer 1:320) and anti-CCP is positive. Which of the following is the most appropriate initial diagnostic classification?
A. Osteoarthritis, given her age and bilateral joint involvement
B. Systemic lupus erythematosus, given the positive RF and constitutional symptoms
C. Rheumatoid arthritis, meeting the 2010 ACR/EULAR classification criteria [CORRECT]
D. Fibromyalgia, as chronic widespread pain is the primary presentation
Correct Answer: C
Rationale: This patient meets the 2010 ACR/EULAR classification criteria for rheumatoid arthritis with joint involvement (wrists, PIP
joints), seropositivity (RF and anti-CCP), elevated acute-phase reactants (ESR, CRP), and symptom duration >6 weeks. Osteoarthritis
(Option A) does not cause prolonged morning stiffness or elevated inflammatory markers. SLE (Option B) requires additional criteria
such as malar rash, renal involvement, or antinuclear antibodies. Fibromyalgia (Option D) does not cause joint swelling or elevated
inflammatory markers.
________________________________________________________________________________
Q7. A 25-year-old man presents after a syncopal episode during basketball practice. He denies preceding palpitations, chest
pain, or dyspnea. His father died suddenly at age 42. Physical exam reveals a systolic murmur that increases with Valsalva
maneuver. ECG shows left ventricular hypertrophy with deep septal Q waves. What is the most likely diagnosis?
A. Aortic stenosis
B. Hypertrophic cardiomyopathy (HCM) [CORRECT]
C. Athletic heart syndrome
D. Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Correct Answer: B
Rationale: HCM is the most common cause of sudden cardiac death in young athletes and is characterized by asymmetric septal
hypertrophy, a systolic murmur that intensifies with Valsalva (due to reduced preload worsening outflow obstruction), and ECG findings
of LVH with septal Q waves. Aortic stenosis (Option A) typically presents in older adults with a systolic ejection click and murmur that
decreases with Valsalva. Athletic heart (Option C) is a benign adaptation with symmetric hypertrophy and normal diastolic function.
ARVC (Option D) presents with right-sided findings and ventricular arrhythmias.
________________________________________________________________________________
Q8. A 50-year-old woman presents with a breast lump she discovered 2 weeks ago during breast self-examination. It is firm,
non-tender, 2 cm in diameter, and located in the upper outer quadrant of the right breast. There are no skin changes or
axillary lymphadenopathy. Her mammogram from 6 months ago was negative. What is the most appropriate next step?
A. Reassure the patient and repeat mammogram in 6 months, as the recent mammogram was negative
B. Order a diagnostic mammogram and breast ultrasound of the right breast [CORRECT]
3
, NSG6020 Final Exam | Comprehensive Primary Care and Health Assessment 100 Questions - South University 2026/2027
C. Refer for core needle biopsy immediately without additional imaging
D. Recommend observation for 4 weeks, as many palpable lumps are cystic and resolve spontaneously
Correct Answer: B
Rationale: A palpable breast mass requires diagnostic evaluation regardless of a recent negative screening mammogram, as up to 15% of
palpable cancers are missed on mammography. A diagnostic mammogram with targeted ultrasound (Option B) is the standard next step
per ACR guidelines. Option A is dangerous because screening mammography has false-negative rates. Option C skips necessary imaging
for characterization. Option D delays diagnosis of a potentially malignant lesion.
________________________________________________________________________________
Q9. A 68-year-old man presents with lower back pain radiating down the left leg for 4 weeks. Pain worsens with sitting and
forward flexion and improves with standing. He has no bowel or bladder incontinence, no saddle anesthesia, and no
significant weakness on exam. Straight leg raise is positive at 40 degrees on the left. What is the most appropriate initial
management strategy?
A. Order an MRI of the lumbar spine immediately to evaluate for disc herniation
B. Prescribe an oral corticosteroid taper and refer for physical therapy
C. Initiate conservative management with NSAIDs, activity modification, and reassessment in 4-6 weeks
[CORRECT]
D. Order lumbar X-rays to rule out fracture or malignancy before any treatment
Correct Answer: C
Rationale: This patient has classic radiculopathy without red flag symptoms. Per ACP and AANS/CNS guidelines, initial management of
acute lumbar radiculopathy without red flags includes conservative measures: NSAIDs, activity modification, and reassessment at 4-6
weeks. MRI (Option A) is indicated only if symptoms persist beyond 6 weeks or red flags develop. Oral corticosteroids (Option B) have
limited evidence for radiculopathy. Lumbar X-rays (Option D) are low-yield and not routinely recommended per ACR Appropriateness
Criteria.
________________________________________________________________________________
Q10. A nurse practitioner documents the following in a patient chart: 'Patient is a 58-year-old male with a chief complaint
of chest pain. Exam reveals BP 140/88, HR 92, RR 18, T 98.6°F. Lungs clear, heart RRR without murmurs. ECG shows
NSR with T-wave inversions in leads V1-V3. Troponin I pending.' Which documentation format is being used?
A. SOAP format [CORRECT]
B. PIE format
C. DAP format
D. Problem-oriented medical record (POMR)
Correct Answer: A
Rationale: The documentation follows the SOAP (Subjective, Objective, Assessment, Plan) format, with the subjective chief complaint
('chest pain') followed by objective findings (vital signs, exam, ECG, pending labs). PIE (Problem-Intervention-Evaluation, Option B) is a
nursing documentation format. DAP (Data-Assessment-Plan, Option C) is a condensed format. POMR (Option D) organizes the entire
chart by problem list, not individual notes.
________________________________________________________________________________
Q11. A 42-year-old woman presents with intermittent episodes of palpitations, sweating, and anxiety that occur
unpredictably. Episodes last 10-15 minutes and resolve spontaneously. She has no significant medical history. Physical exam
and resting ECG are normal. Which of the following is the most appropriate initial diagnostic test to evaluate these
episodes?
A. 24-hour Holter monitor
B. 30-day event monitor [CORRECT]
C. Echocardiogram
4
Answers)
Comprehensive Primary Care and Health Assessment for Nurse Practitioners
South University - Advanced Practice Nursing Education
Aligned with 2026-2027 South University NSG6020 Curriculum Standards, ANCC/AANP Competencies,
and Current Evidence-Based Clinical Practice Guidelines
Total Questions: 100 Format: Multiple Choice (A-D)
Distribution: 10 Sections Cognitive Levels: 20% Recall, 50% Application, 30%
Analysis
Focus: Advanced Health Assessment, Difficulty: Graduate-Level Practicum
Cardiovascular, Respiratory,
GI/GU/Renal,
Neurological, Musculoskeletal,
Endocrine, Dermatological,
Mental Health, Special Populations,
Preventive Health, Ethics
________________________________________________________________________________
Section 1: Advanced Health Assessment and Diagnostic Reasoning
Q1. A 62-year-old woman presents for an annual wellness visit. She reports occasional headaches and fatigue but denies
chest pain, dyspnea, or syncope. Her blood pressure is 158/92 mmHg on two separate readings. BMI is 31 kg/m². She has no
known chronic conditions and takes no medications. Family history is notable for myocardial infarction in her father at age
58. According to the ACC/AHA 2017 hypertension guideline, what is the most appropriate next step in management?
A. Repeat blood pressure measurement in 3 months
B. Initiate lifestyle modifications only, as she has stage 1 hypertension without compelling comorbidities
C. Initiate lifestyle modifications and start a thiazide diuretic, as her ASCVD 10-year risk will likely exceed
10% [CORRECT]
D. Order ambulatory blood pressure monitoring to rule out white-coat hypertension before any intervention
Correct Answer: C
Rationale: Per ACC/AHA 2017 guidelines, this patient has stage 2 hypertension (≥140/90 mmHg), which warrants both lifestyle
modifications and antihypertensive medication regardless of 10-year ASCVD risk. Option A delays necessary treatment; Option B applies
only to stage 1 hypertension without high ASCVD risk. While ABPM (Option D) can be useful, clinical guidelines support initiating
treatment in confirmed stage 2 hypertension without mandatory ABPM.
________________________________________________________________________________
Q2. A 45-year-old man with a 20-pack-year smoking history presents with a persistent cough for 3 weeks and a 10-pound
weight loss over 2 months. Chest X-ray reveals a 2.5 cm right upper lobe mass. Which diagnostic test should the nurse
,NSG6020 Final Exam | Comprehensive Primary Care and Health Assessment 100 Questions - South University 2026/2027
practitioner order next to establish a tissue diagnosis?
A. CT-guided percutaneous fine-needle aspiration biopsy
B. Bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)
[CORRECT]
C. Sputum cytology
D. PET-CT scan
Correct Answer: B
Rationale: EBUS-TBNA is the preferred initial diagnostic approach for a centrally located or accessible peripheral lung mass, as it
provides both tissue diagnosis and mediastinal staging simultaneously. Sputum cytology (Option C) has low sensitivity (~66%) and is not
first-line for a visible mass. CT-guided biopsy (Option A) is more appropriate for peripheral lesions not reachable by bronchoscopy.
PET-CT (Option D) is used for staging, not tissue diagnosis.
________________________________________________________________________________
Q3. A 28-year-old woman presents with a 2-day history of urinary frequency, dysuria, and suprapubic pressure. She is
afebrile, and physical exam is unremarkable except for mild suprapubic tenderness. She has no history of UTI. A urine
dipstick is positive for leukocyte esterase and nitrites. What is the most cost-effective diagnostic approach?
A. Obtain a urine culture and sensitivity, then prescribe antibiotics based on results
B. Treat empirically with trimethoprim-sulfamethoxazole for 3 days without obtaining a urine culture
[CORRECT]
C. Obtain a urine culture and start empiric antibiotics simultaneously
D. Order a renal ultrasound to rule out complications before treating
Correct Answer: B
Rationale: In an otherwise healthy, nonpregnant, premenopausal woman with classic uncomplicated acute cystitis, empiric antibiotic
therapy without a urine culture is the most cost-effective approach per IDSA and USPSTF guidelines. Urine cultures (Options A and C)
are reserved for recurrent UTI, complicated UTI, or treatment failure. Renal ultrasound (Option D) is unnecessary in uncomplicated
cystitis.
________________________________________________________________________________
Q4. A 72-year-old man presents with progressive memory loss over 18 months. His wife reports he frequently misplaces
items, forgets conversations, and has difficulty managing finances. He has no history of stroke, head trauma, or psychiatric
illness. Mini-Cog score is 18/30. Physical exam and basic metabolic panel are normal. Which of the following is the most
appropriate next diagnostic step?
A. Order a brain MRI without contrast to evaluate for structural lesions and atrophy patterns
B. Prescribe a cholinesterase inhibitor immediately and reassess in 3 months
C. Order a comprehensive thyroid panel, vitamin B12, and RPR to rule out reversible causes [CORRECT]
D. Refer directly to a neurologist for lumbar puncture and amyloid PET imaging
Correct Answer: C
Rationale: Before diagnosing dementia, reversible causes must be excluded per USPSTF and AAN guidelines; a basic workup includes
TSH, vitamin B12, and RPR. While brain MRI (Option A) is often indicated, it is not the first step before laboratory screening for
reversible etiologies. Prescribing a cholinesterase inhibitor (Option B) before establishing a diagnosis is premature. Lumbar puncture and
amyloid PET (Option D) are research tools not indicated for initial evaluation.
________________________________________________________________________________
Q5. A 55-year-old woman with type 2 diabetes mellitus and hypertension presents for routine follow-up. Her HbA1c is
7.8%, blood pressure is 138/86 mmHg, and LDL-C is 118 mg/dL. She takes metformin 1000 mg twice daily and lisinopril
20 mg daily. Her 10-year ASCVD risk is 12%. According to current guidelines, which preventive service is most clearly
indicated?
2
,NSG6020 Final Exam | Comprehensive Primary Care and Health Assessment 100 Questions - South University 2026/2027
A. Coronary artery calcium (CAC) scoring to refine statin therapy decision-making
B. Initiation of a moderate-intensity statin given her 10-year ASCVD risk of 12% [CORRECT]
C. Aspirin 81 mg daily for primary prevention of cardiovascular events
D. Screening for abdominal aortic aneurysm with ultrasound
Correct Answer: B
Rationale: Per ACC/AHA 2018 cholesterol guidelines, a 10-year ASCVD risk ≥7.5% warrants a discussion about initiating a
moderate-to-high-intensity statin. Her age, diabetes, and 12% risk clearly support statin initiation. CAC scoring (Option A) may be used
for borderline risk (5-7.5%) but is not required at 12%. Aspirin for primary prevention (Option C) is no longer routinely recommended
per USPSTF 2022 guidelines for her risk profile. AAA screening (Option D) is indicated only for men aged 65-75 who have ever
smoked.
________________________________________________________________________________
Q6. A 38-year-old woman presents with a 6-week history of diffuse joint pain, morning stiffness lasting >60 minutes, and
fatigue. She reports swelling in her wrists and PIP joints bilaterally. ESR is 45 mm/hr and CRP is 2.8 mg/dL. RF is positive
(titer 1:320) and anti-CCP is positive. Which of the following is the most appropriate initial diagnostic classification?
A. Osteoarthritis, given her age and bilateral joint involvement
B. Systemic lupus erythematosus, given the positive RF and constitutional symptoms
C. Rheumatoid arthritis, meeting the 2010 ACR/EULAR classification criteria [CORRECT]
D. Fibromyalgia, as chronic widespread pain is the primary presentation
Correct Answer: C
Rationale: This patient meets the 2010 ACR/EULAR classification criteria for rheumatoid arthritis with joint involvement (wrists, PIP
joints), seropositivity (RF and anti-CCP), elevated acute-phase reactants (ESR, CRP), and symptom duration >6 weeks. Osteoarthritis
(Option A) does not cause prolonged morning stiffness or elevated inflammatory markers. SLE (Option B) requires additional criteria
such as malar rash, renal involvement, or antinuclear antibodies. Fibromyalgia (Option D) does not cause joint swelling or elevated
inflammatory markers.
________________________________________________________________________________
Q7. A 25-year-old man presents after a syncopal episode during basketball practice. He denies preceding palpitations, chest
pain, or dyspnea. His father died suddenly at age 42. Physical exam reveals a systolic murmur that increases with Valsalva
maneuver. ECG shows left ventricular hypertrophy with deep septal Q waves. What is the most likely diagnosis?
A. Aortic stenosis
B. Hypertrophic cardiomyopathy (HCM) [CORRECT]
C. Athletic heart syndrome
D. Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Correct Answer: B
Rationale: HCM is the most common cause of sudden cardiac death in young athletes and is characterized by asymmetric septal
hypertrophy, a systolic murmur that intensifies with Valsalva (due to reduced preload worsening outflow obstruction), and ECG findings
of LVH with septal Q waves. Aortic stenosis (Option A) typically presents in older adults with a systolic ejection click and murmur that
decreases with Valsalva. Athletic heart (Option C) is a benign adaptation with symmetric hypertrophy and normal diastolic function.
ARVC (Option D) presents with right-sided findings and ventricular arrhythmias.
________________________________________________________________________________
Q8. A 50-year-old woman presents with a breast lump she discovered 2 weeks ago during breast self-examination. It is firm,
non-tender, 2 cm in diameter, and located in the upper outer quadrant of the right breast. There are no skin changes or
axillary lymphadenopathy. Her mammogram from 6 months ago was negative. What is the most appropriate next step?
A. Reassure the patient and repeat mammogram in 6 months, as the recent mammogram was negative
B. Order a diagnostic mammogram and breast ultrasound of the right breast [CORRECT]
3
, NSG6020 Final Exam | Comprehensive Primary Care and Health Assessment 100 Questions - South University 2026/2027
C. Refer for core needle biopsy immediately without additional imaging
D. Recommend observation for 4 weeks, as many palpable lumps are cystic and resolve spontaneously
Correct Answer: B
Rationale: A palpable breast mass requires diagnostic evaluation regardless of a recent negative screening mammogram, as up to 15% of
palpable cancers are missed on mammography. A diagnostic mammogram with targeted ultrasound (Option B) is the standard next step
per ACR guidelines. Option A is dangerous because screening mammography has false-negative rates. Option C skips necessary imaging
for characterization. Option D delays diagnosis of a potentially malignant lesion.
________________________________________________________________________________
Q9. A 68-year-old man presents with lower back pain radiating down the left leg for 4 weeks. Pain worsens with sitting and
forward flexion and improves with standing. He has no bowel or bladder incontinence, no saddle anesthesia, and no
significant weakness on exam. Straight leg raise is positive at 40 degrees on the left. What is the most appropriate initial
management strategy?
A. Order an MRI of the lumbar spine immediately to evaluate for disc herniation
B. Prescribe an oral corticosteroid taper and refer for physical therapy
C. Initiate conservative management with NSAIDs, activity modification, and reassessment in 4-6 weeks
[CORRECT]
D. Order lumbar X-rays to rule out fracture or malignancy before any treatment
Correct Answer: C
Rationale: This patient has classic radiculopathy without red flag symptoms. Per ACP and AANS/CNS guidelines, initial management of
acute lumbar radiculopathy without red flags includes conservative measures: NSAIDs, activity modification, and reassessment at 4-6
weeks. MRI (Option A) is indicated only if symptoms persist beyond 6 weeks or red flags develop. Oral corticosteroids (Option B) have
limited evidence for radiculopathy. Lumbar X-rays (Option D) are low-yield and not routinely recommended per ACR Appropriateness
Criteria.
________________________________________________________________________________
Q10. A nurse practitioner documents the following in a patient chart: 'Patient is a 58-year-old male with a chief complaint
of chest pain. Exam reveals BP 140/88, HR 92, RR 18, T 98.6°F. Lungs clear, heart RRR without murmurs. ECG shows
NSR with T-wave inversions in leads V1-V3. Troponin I pending.' Which documentation format is being used?
A. SOAP format [CORRECT]
B. PIE format
C. DAP format
D. Problem-oriented medical record (POMR)
Correct Answer: A
Rationale: The documentation follows the SOAP (Subjective, Objective, Assessment, Plan) format, with the subjective chief complaint
('chest pain') followed by objective findings (vital signs, exam, ECG, pending labs). PIE (Problem-Intervention-Evaluation, Option B) is a
nursing documentation format. DAP (Data-Assessment-Plan, Option C) is a condensed format. POMR (Option D) organizes the entire
chart by problem list, not individual notes.
________________________________________________________________________________
Q11. A 42-year-old woman presents with intermittent episodes of palpitations, sweating, and anxiety that occur
unpredictably. Episodes last 10-15 minutes and resolve spontaneously. She has no significant medical history. Physical exam
and resting ECG are normal. Which of the following is the most appropriate initial diagnostic test to evaluate these
episodes?
A. 24-hour Holter monitor
B. 30-day event monitor [CORRECT]
C. Echocardiogram
4
