,Contents
NR509 ADVANCED PHYSICAL ASSESSMENT WEEK 1-4......... 3
WEEK 1 .................................................................................... 3
WEEK 2...................................................................................................... 140
WEEK 3 .................................................................................................. 474
WEEK 4 ................................................................................ 558
NR509 ADVANCED PHYSICAL ASSESSMENT MIDTERM..... 725
NR509 ADVANCED PHYSICAL ASSESSMENT MOST TESTED
FROM PAST PAPERS EXAMPLIFY ........................................ 807
,NR509 ADVANCED PHYSICAL ASSESSMENT WEEK 1-4
WEEK 1
Question 1:
A 72-year-old male with a 45-pack-year smoking history and known hypertension presents with a 3-month history
of progressive hoarseness, a dry cough, and occasional blood-tinged sputum. He denies fever, chills, or night
sweats. On examination, you note a left-sided Horner's syndrome (ptosis, miosis, and anhidrosis). Chest
auscultation reveals decreased breath sounds in the left upper lobe. Which of the following is the most likely
underlying mechanism for this presentation?
a. A primary squamous cell carcinoma of the larynx compressing the recurrent laryngeal nerve
b. A left upper lobe Pancoast tumor invading the sympathetic chain and brachial plexus
c. A tuberculous infection causing apical fibrosis and sympathetic nerve entrapment
d. A large left atrial myxoma embolizing to the bronchial circulation causing focal ischemia
Correct Answer: b. A left upper lobe Pancoast tumor invading the sympathetic chain and brachial plexus
Expert Rationale:
The correct answer is b. This patient's presentation is classic for a Pancoast tumor, a subtype of non-small cell lung
cancer (typically squamous cell or adenocarcinoma) that arises in the apex of the lung (superior sulcus). Key
features include: (1) progressive hoarseness due to invasion of the recurrent laryngeal nerve; (2) hemoptysis from
bronchial involvement; (3) Horner's syndrome (ptosis, miosis, and anhidrosis) from invasion of the cervical
sympathetic chain; and (4) upper lobe findings. Option a is incorrect because laryngeal cancer would present with
more prominent voice changes and would not cause Horner's syndrome. Option c is incorrect because tuberculosis
(TB) typically presents with constitutional symptoms like fever, night sweats, and weight loss; additionally, apical TB
can cause fibrosis but is less likely to produce a progressive neurological syndrome. Option d is incorrect because
an atrial myxoma would cause systemic embolic phenomena, not a localized apical process. Therefore, the most
likely mechanism is a Pancoast tumor invading local structures.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity / Respiratory Assessment
Question 2:
A 65-year-old female with a history of type 2 diabetes mellitus and chronic kidney disease stage 3 presents for a
routine physical examination. She reports no specific complaints but mentions that she has been feeling "off" and
has had some mild, diffuse abdominal discomfort. Her blood pressure is 148/92 mmHg, heart rate is 88 bpm, and
respiratory rate is 18/min. On abdominal auscultation, you note a high-pitched, systolic bruit in the epigastric
region that is loudest in the midline. The bruit is not present during diastole. Palpation reveals a non-tender, non-
pulsatile abdomen. What is the most likely underlying pathology and the most appropriate next diagnostic step?
, a. Aortic dissection with malperfusion; immediate CT angiography of the chest and abdomen
b. Fibromuscular dysplasia of the renal artery; duplex ultrasound of the renal arteries
c. Atherosclerotic renal artery stenosis; captopril-enhanced renal scintigraphy
d. Celiac artery compression syndrome; magnetic resonance angiography of the mesenteric vessels
Correct Answer: c. Atherosclerotic renal artery stenosis; captopril-enhanced renal scintigraphy
Expert Rationale:
The correct answer is c. This patient has multiple risk factors for atherosclerotic renal artery stenosis (RAS):
advanced age, type 2 diabetes, and chronic kidney disease. An epigastric bruit that is systolic and midline is a classic
finding of RAS. The absence of a diastolic component makes renal artery stenosis more likely than aortic disease
(which would have a continuous bruit). In patients with CKD, the gold-standard non-invasive test for RAS is
captopril-enhanced renal scintigraphy (or magnetic resonance angiography, depending on renal function). The bruit
is caused by turbulent flow through a stenosed renal artery. Option a is incorrect because an aortic dissection
would present with a tearing pain, pulse deficits, and a continuous bruit, not a non-tender abdomen. Option b is
incorrect because fibromuscular dysplasia is more common in younger women and typically affects the mid-to-
distal renal artery. Option d is incorrect because celiac artery compression syndrome typically presents with
postprandial pain and weight loss. The most likely pathology in this patient is atherosclerotic RAS.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity / Cardiovascular Assessment
Question 3:
A 45-year-old female presents with a 2-year history of progressive fatigue, bilateral hand swelling, and Raynaud's
phenomenon. She reports that her fingers turn white, then blue, and then red in response to cold exposure. On
examination, you note a "salt-and-pepper" appearance of the skin on her forearms and shins. Pulmonary
auscultation reveals fine, Velcro-like crackles at the lung bases bilaterally. Laboratory studies are pending. Which of
the following additional findings would most strongly support a diagnosis of systemic sclerosis (scleroderma) over
mixed connective tissue disease (MCTD)?
a. Positive anti-U1-RNP antibodies with high titers and absent anti-Scl-70 antibodies
b. Positive anti-Scl-70 (anti-topoisomerase I) antibodies and a positive anti-centromere antibody (ACA)
c. The presence of a Malar rash and oral ulcers with a positive anti-dsDNA antibody
d. ANA negative but positive anti-Jo-1 antibodies with periungual telangiectasias
Correct Answer: b. Positive anti-Scl-70 (anti-topoisomerase I) antibodies and a positive anti-centromere antibody
(ACA)
Expert Rationale:
The correct answer is b. Systemic sclerosis (SSc) has two major autoantibody profiles: anti-Scl-70 (anti-
topoisomerase I) is associated with diffuse cutaneous SSc and a higher risk of interstitial lung disease (ILD), while
anti-centromere antibodies (ACA) are associated with limited cutaneous SSc. The "salt-and-pepper" skin changes
and Velcro crackles (indicating ILD) suggest SSc. Option a describes MCTD, which is characterized by high-titer anti-
U1-RNP antibodies and generally lacks the severe skin changes of SSc. Option c describes SLE, which presents with
a malar rash and oral ulcers, not the skin changes described. Option d describes anti-synthetase syndrome
NR509 ADVANCED PHYSICAL ASSESSMENT WEEK 1-4......... 3
WEEK 1 .................................................................................... 3
WEEK 2...................................................................................................... 140
WEEK 3 .................................................................................................. 474
WEEK 4 ................................................................................ 558
NR509 ADVANCED PHYSICAL ASSESSMENT MIDTERM..... 725
NR509 ADVANCED PHYSICAL ASSESSMENT MOST TESTED
FROM PAST PAPERS EXAMPLIFY ........................................ 807
,NR509 ADVANCED PHYSICAL ASSESSMENT WEEK 1-4
WEEK 1
Question 1:
A 72-year-old male with a 45-pack-year smoking history and known hypertension presents with a 3-month history
of progressive hoarseness, a dry cough, and occasional blood-tinged sputum. He denies fever, chills, or night
sweats. On examination, you note a left-sided Horner's syndrome (ptosis, miosis, and anhidrosis). Chest
auscultation reveals decreased breath sounds in the left upper lobe. Which of the following is the most likely
underlying mechanism for this presentation?
a. A primary squamous cell carcinoma of the larynx compressing the recurrent laryngeal nerve
b. A left upper lobe Pancoast tumor invading the sympathetic chain and brachial plexus
c. A tuberculous infection causing apical fibrosis and sympathetic nerve entrapment
d. A large left atrial myxoma embolizing to the bronchial circulation causing focal ischemia
Correct Answer: b. A left upper lobe Pancoast tumor invading the sympathetic chain and brachial plexus
Expert Rationale:
The correct answer is b. This patient's presentation is classic for a Pancoast tumor, a subtype of non-small cell lung
cancer (typically squamous cell or adenocarcinoma) that arises in the apex of the lung (superior sulcus). Key
features include: (1) progressive hoarseness due to invasion of the recurrent laryngeal nerve; (2) hemoptysis from
bronchial involvement; (3) Horner's syndrome (ptosis, miosis, and anhidrosis) from invasion of the cervical
sympathetic chain; and (4) upper lobe findings. Option a is incorrect because laryngeal cancer would present with
more prominent voice changes and would not cause Horner's syndrome. Option c is incorrect because tuberculosis
(TB) typically presents with constitutional symptoms like fever, night sweats, and weight loss; additionally, apical TB
can cause fibrosis but is less likely to produce a progressive neurological syndrome. Option d is incorrect because
an atrial myxoma would cause systemic embolic phenomena, not a localized apical process. Therefore, the most
likely mechanism is a Pancoast tumor invading local structures.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity / Respiratory Assessment
Question 2:
A 65-year-old female with a history of type 2 diabetes mellitus and chronic kidney disease stage 3 presents for a
routine physical examination. She reports no specific complaints but mentions that she has been feeling "off" and
has had some mild, diffuse abdominal discomfort. Her blood pressure is 148/92 mmHg, heart rate is 88 bpm, and
respiratory rate is 18/min. On abdominal auscultation, you note a high-pitched, systolic bruit in the epigastric
region that is loudest in the midline. The bruit is not present during diastole. Palpation reveals a non-tender, non-
pulsatile abdomen. What is the most likely underlying pathology and the most appropriate next diagnostic step?
, a. Aortic dissection with malperfusion; immediate CT angiography of the chest and abdomen
b. Fibromuscular dysplasia of the renal artery; duplex ultrasound of the renal arteries
c. Atherosclerotic renal artery stenosis; captopril-enhanced renal scintigraphy
d. Celiac artery compression syndrome; magnetic resonance angiography of the mesenteric vessels
Correct Answer: c. Atherosclerotic renal artery stenosis; captopril-enhanced renal scintigraphy
Expert Rationale:
The correct answer is c. This patient has multiple risk factors for atherosclerotic renal artery stenosis (RAS):
advanced age, type 2 diabetes, and chronic kidney disease. An epigastric bruit that is systolic and midline is a classic
finding of RAS. The absence of a diastolic component makes renal artery stenosis more likely than aortic disease
(which would have a continuous bruit). In patients with CKD, the gold-standard non-invasive test for RAS is
captopril-enhanced renal scintigraphy (or magnetic resonance angiography, depending on renal function). The bruit
is caused by turbulent flow through a stenosed renal artery. Option a is incorrect because an aortic dissection
would present with a tearing pain, pulse deficits, and a continuous bruit, not a non-tender abdomen. Option b is
incorrect because fibromuscular dysplasia is more common in younger women and typically affects the mid-to-
distal renal artery. Option d is incorrect because celiac artery compression syndrome typically presents with
postprandial pain and weight loss. The most likely pathology in this patient is atherosclerotic RAS.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity / Cardiovascular Assessment
Question 3:
A 45-year-old female presents with a 2-year history of progressive fatigue, bilateral hand swelling, and Raynaud's
phenomenon. She reports that her fingers turn white, then blue, and then red in response to cold exposure. On
examination, you note a "salt-and-pepper" appearance of the skin on her forearms and shins. Pulmonary
auscultation reveals fine, Velcro-like crackles at the lung bases bilaterally. Laboratory studies are pending. Which of
the following additional findings would most strongly support a diagnosis of systemic sclerosis (scleroderma) over
mixed connective tissue disease (MCTD)?
a. Positive anti-U1-RNP antibodies with high titers and absent anti-Scl-70 antibodies
b. Positive anti-Scl-70 (anti-topoisomerase I) antibodies and a positive anti-centromere antibody (ACA)
c. The presence of a Malar rash and oral ulcers with a positive anti-dsDNA antibody
d. ANA negative but positive anti-Jo-1 antibodies with periungual telangiectasias
Correct Answer: b. Positive anti-Scl-70 (anti-topoisomerase I) antibodies and a positive anti-centromere antibody
(ACA)
Expert Rationale:
The correct answer is b. Systemic sclerosis (SSc) has two major autoantibody profiles: anti-Scl-70 (anti-
topoisomerase I) is associated with diffuse cutaneous SSc and a higher risk of interstitial lung disease (ILD), while
anti-centromere antibodies (ACA) are associated with limited cutaneous SSc. The "salt-and-pepper" skin changes
and Velcro crackles (indicating ILD) suggest SSc. Option a describes MCTD, which is characterized by high-titer anti-
U1-RNP antibodies and generally lacks the severe skin changes of SSc. Option c describes SLE, which presents with
a malar rash and oral ulcers, not the skin changes described. Option d describes anti-synthetase syndrome
