NR 569 Midterm Exam Study Guide 2026–
2027: Comprehensive Acute Care
Differential Diagnosis Q&A
1.
A 58-year-old patient presents with sudden substernal chest pressure radiating to the left arm,
diaphoresis, and nausea. The discomfort began 20 minutes ago. Which diagnosis should be
prioritized?
A. Gastroesophageal reflux disease
B. Acute coronary syndrome
C. Costochondritis
D. Panic attack
Answer: B. Acute coronary syndrome
Rationale: Sudden pressure-like chest discomfort with radiation, diaphoresis, and nausea is
highly concerning for myocardial ischemia. Acute coronary syndrome must be considered before
less dangerous causes of chest pain. GERD may cause burning discomfort, but the associated
autonomic symptoms and radiation increase concern for ACS.
2.
A patient reports pleuritic chest pain and sudden shortness of breath after returning from a long
international flight. Heart rate is 116/min and oxygen saturation is 91%. Which diagnosis is most
concerning?
A. Pulmonary embolism
B. Acute bronchitis
C. Pneumonia
D. Stable angina
Answer: A. Pulmonary embolism
Rationale: Recent prolonged immobilization, tachycardia, hypoxemia, sudden dyspnea, and
pleuritic chest pain are classic features that should raise concern for pulmonary embolism.
,Pneumonia may cause dyspnea and pleuritic pain but commonly includes fever and infectious
symptoms.
3.
A 72-year-old patient develops unilateral facial drooping, right-arm weakness, and difficulty
speaking that began 45 minutes ago. What is the priority?
A. Administer oral aspirin immediately
B. Obtain urgent evaluation for acute stroke
C. Reassure the patient that symptoms are probably hypoglycemia
D. Schedule outpatient neurologic follow-up
Answer: B. Obtain urgent evaluation for acute stroke
Rationale: Sudden focal neurologic deficits strongly suggest an acute cerebrovascular event.
Time-sensitive stroke evaluation is essential because some treatments are highly dependent on
the time of symptom onset. Blood glucose should also be checked promptly because
hypoglycemia can mimic stroke.
4.
A 25-year-old patient has right lower-quadrant abdominal pain, anorexia, nausea, and low-grade
fever. Pain began near the umbilicus and migrated to the right lower quadrant. Which diagnosis
is most likely?
A. Acute appendicitis
B. Acute pancreatitis
C. Cholecystitis
D. Nephrolithiasis
Answer: A. Acute appendicitis
Rationale: Migration of abdominal pain from the periumbilical area to the right lower quadrant,
accompanied by anorexia, nausea, and fever, is characteristic of appendicitis. Nephrolithiasis
typically produces severe colicky flank pain that may radiate toward the groin.
5.
,A patient with asthma develops severe dyspnea and wheezing. After several minutes, the
wheezing becomes markedly diminished despite worsening respiratory distress. How should this
finding be interpreted?
A. The asthma attack is resolving
B. The patient is developing severe airflow obstruction
C. The patient has developed pulmonary edema
D. The patient is experiencing anxiety only
Answer: B. The patient is developing severe airflow obstruction
Rationale: A "silent chest" or markedly reduced breath sounds in a severely distressed asthmatic
patient can indicate critically reduced airflow. Diminishing wheezing does not necessarily
indicate improvement; it may indicate worsening obstruction and impending respiratory failure.
6.
A 64-year-old patient presents with crushing chest pain and an ECG showing ST-segment
elevation in contiguous leads. What does this finding suggest?
A. STEMI
B. GERD
C. Pericarditis only
D. Stable angina
Answer: A. STEMI
Rationale: ST-segment elevation in a compatible clinical setting may indicate acute ST-
elevation myocardial infarction. This is a time-sensitive emergency requiring immediate
evaluation and reperfusion-oriented management.
7.
A patient with diabetes presents with abdominal pain, vomiting, polyuria, polydipsia, and deep
rapid respirations. Which condition should be suspected?
A. Diabetic ketoacidosis
B. Hypothyroidism
C. Hypercalcemia
D. Simple gastroenteritis
Answer: A. Diabetic ketoacidosis
, Rationale: DKA commonly presents with hyperglycemia, dehydration, gastrointestinal
symptoms, and metabolic acidosis manifested by deep, rapid respirations. The respiratory pattern
represents compensatory hyperventilation.
8.
A patient presents with unilateral calf swelling and tenderness after several days of immobility.
What diagnosis should be considered?
A. Deep vein thrombosis
B. Cellulitis only
C. Osteoarthritis
D. Gout
Answer: A. Deep vein thrombosis
Rationale: Unilateral swelling, pain, and tenderness in a patient with an immobility risk factor
are concerning for DVT. Because DVT can lead to pulmonary embolism, appropriate diagnostic
evaluation is important.
9.
A 70-year-old patient with COPD presents with increased dyspnea, increased sputum production,
and a change in sputum character. Which diagnosis is most likely?
A. COPD exacerbation
B. Migraine
C. Acute appendicitis
D. Hypothyroidism
Answer: A. COPD exacerbation
Rationale: Acute worsening of respiratory symptoms beyond baseline in a patient with COPD is
characteristic of an exacerbation. Infection is a common trigger, although other causes such as
environmental exposures or cardiovascular disease may also contribute.
10.
A patient reports sudden severe headache described as "the worst headache of my life," followed
by vomiting and neck stiffness. Which diagnosis must be urgently excluded?
2027: Comprehensive Acute Care
Differential Diagnosis Q&A
1.
A 58-year-old patient presents with sudden substernal chest pressure radiating to the left arm,
diaphoresis, and nausea. The discomfort began 20 minutes ago. Which diagnosis should be
prioritized?
A. Gastroesophageal reflux disease
B. Acute coronary syndrome
C. Costochondritis
D. Panic attack
Answer: B. Acute coronary syndrome
Rationale: Sudden pressure-like chest discomfort with radiation, diaphoresis, and nausea is
highly concerning for myocardial ischemia. Acute coronary syndrome must be considered before
less dangerous causes of chest pain. GERD may cause burning discomfort, but the associated
autonomic symptoms and radiation increase concern for ACS.
2.
A patient reports pleuritic chest pain and sudden shortness of breath after returning from a long
international flight. Heart rate is 116/min and oxygen saturation is 91%. Which diagnosis is most
concerning?
A. Pulmonary embolism
B. Acute bronchitis
C. Pneumonia
D. Stable angina
Answer: A. Pulmonary embolism
Rationale: Recent prolonged immobilization, tachycardia, hypoxemia, sudden dyspnea, and
pleuritic chest pain are classic features that should raise concern for pulmonary embolism.
,Pneumonia may cause dyspnea and pleuritic pain but commonly includes fever and infectious
symptoms.
3.
A 72-year-old patient develops unilateral facial drooping, right-arm weakness, and difficulty
speaking that began 45 minutes ago. What is the priority?
A. Administer oral aspirin immediately
B. Obtain urgent evaluation for acute stroke
C. Reassure the patient that symptoms are probably hypoglycemia
D. Schedule outpatient neurologic follow-up
Answer: B. Obtain urgent evaluation for acute stroke
Rationale: Sudden focal neurologic deficits strongly suggest an acute cerebrovascular event.
Time-sensitive stroke evaluation is essential because some treatments are highly dependent on
the time of symptom onset. Blood glucose should also be checked promptly because
hypoglycemia can mimic stroke.
4.
A 25-year-old patient has right lower-quadrant abdominal pain, anorexia, nausea, and low-grade
fever. Pain began near the umbilicus and migrated to the right lower quadrant. Which diagnosis
is most likely?
A. Acute appendicitis
B. Acute pancreatitis
C. Cholecystitis
D. Nephrolithiasis
Answer: A. Acute appendicitis
Rationale: Migration of abdominal pain from the periumbilical area to the right lower quadrant,
accompanied by anorexia, nausea, and fever, is characteristic of appendicitis. Nephrolithiasis
typically produces severe colicky flank pain that may radiate toward the groin.
5.
,A patient with asthma develops severe dyspnea and wheezing. After several minutes, the
wheezing becomes markedly diminished despite worsening respiratory distress. How should this
finding be interpreted?
A. The asthma attack is resolving
B. The patient is developing severe airflow obstruction
C. The patient has developed pulmonary edema
D. The patient is experiencing anxiety only
Answer: B. The patient is developing severe airflow obstruction
Rationale: A "silent chest" or markedly reduced breath sounds in a severely distressed asthmatic
patient can indicate critically reduced airflow. Diminishing wheezing does not necessarily
indicate improvement; it may indicate worsening obstruction and impending respiratory failure.
6.
A 64-year-old patient presents with crushing chest pain and an ECG showing ST-segment
elevation in contiguous leads. What does this finding suggest?
A. STEMI
B. GERD
C. Pericarditis only
D. Stable angina
Answer: A. STEMI
Rationale: ST-segment elevation in a compatible clinical setting may indicate acute ST-
elevation myocardial infarction. This is a time-sensitive emergency requiring immediate
evaluation and reperfusion-oriented management.
7.
A patient with diabetes presents with abdominal pain, vomiting, polyuria, polydipsia, and deep
rapid respirations. Which condition should be suspected?
A. Diabetic ketoacidosis
B. Hypothyroidism
C. Hypercalcemia
D. Simple gastroenteritis
Answer: A. Diabetic ketoacidosis
, Rationale: DKA commonly presents with hyperglycemia, dehydration, gastrointestinal
symptoms, and metabolic acidosis manifested by deep, rapid respirations. The respiratory pattern
represents compensatory hyperventilation.
8.
A patient presents with unilateral calf swelling and tenderness after several days of immobility.
What diagnosis should be considered?
A. Deep vein thrombosis
B. Cellulitis only
C. Osteoarthritis
D. Gout
Answer: A. Deep vein thrombosis
Rationale: Unilateral swelling, pain, and tenderness in a patient with an immobility risk factor
are concerning for DVT. Because DVT can lead to pulmonary embolism, appropriate diagnostic
evaluation is important.
9.
A 70-year-old patient with COPD presents with increased dyspnea, increased sputum production,
and a change in sputum character. Which diagnosis is most likely?
A. COPD exacerbation
B. Migraine
C. Acute appendicitis
D. Hypothyroidism
Answer: A. COPD exacerbation
Rationale: Acute worsening of respiratory symptoms beyond baseline in a patient with COPD is
characteristic of an exacerbation. Infection is a common trigger, although other causes such as
environmental exposures or cardiovascular disease may also contribute.
10.
A patient reports sudden severe headache described as "the worst headache of my life," followed
by vomiting and neck stiffness. Which diagnosis must be urgently excluded?
