NR 509 Health
Assessment
FINAL .2025/26 questions
and well prepared
answerz…*
CHAPTER 19: Abdomen
An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of
intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek
medical attention. She has a strong family history of gallstones and is concerned about this possibility.
She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-
human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last periterm-12od was
10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min;
oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior
to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness.
What is the most likely diagnosis? - ANSWERS-Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-hCG, and
findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy
with significant intra-abdominal bleeding leading to peritoneal signs. This case is emergent and requires
immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for
emergent surgery. Ruptured ectopic pregnancies can lead to life-threatening intra-abdominal bleeding.
Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are
all possibilities, the positive β-hCG testing and her unstable vital signs make ruptured ectopic pregnancy
more likely.
,CHAPTER 19: Abdomen
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs
are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also
measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine
aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total
bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to
assess his liver. Which of the following findings would be most consistent with hepatomegaly? -
ANSWERS-Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be
considered normal on inspiration when the liver is pushed down into the abdominal cavity on
inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing
if, by percussion, the liver span was >12 cm at the midclavicular line. For patients with obstructive lung
disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity. The liver
span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid-
clavicular line and 4-8 cm at the midsternal line are considered normal.
CHAPTER 19: Abdomen
A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a
several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and
denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a
ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory
rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her
abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of
the following is her most significant risk factor for an AAA? - ANSWERS-History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not female
gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family history of ruptured
aneurysm is vague and could be a cerebral aneurysm. Further, her family history is in a first-degree
cousin not a first-degree relative (biologic parents, siblings, and children). Hypertension could contribute
to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one
elevated blood pressure reading.
CHAPTER 19: Abdomen
A 76-year-old retired man with a history of prostate cancer and hypertension has been screened
annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-
up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his
,preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went
for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no
first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S.
Preventive Services Task Force (USPSTF) screening recommendations for this patient? - ANSWERS-Do
not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain
in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and
benefits with the patient. Annual FOBT screening may continue until age 80-85 years if benefits to doing
so outweigh risks for the individual patient; however, screening should not be routinely continued. In
general, a life expectancy >7 years is necessary for screening to be potentially beneficial. There is no
indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his
colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening
option, but again screening is not routinely recommended for patients age >75 years.
CHAPTER 19: Abdomen
An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of
recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with
onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She
has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to
over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation.
Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely
physiological mechanism for her constipation? - ANSWERS-Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS
is characterized by three patterns: diarrhea predominant, constipation predominant, or mixed. Other
functional causes for her constipation should be excluded prior to making this diagnosis. A large firm
fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden
individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that
increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal
lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of
patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known
diagnosis that would increase suspicion of neurological impairment.
CHAPTER 19: Abdomen
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and
bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The
, preceptor notes that she has situs inversus and asks for a physical exam. Which of the following
descriptions best fits with findings on the abdominal exam? - ANSWERS-Tympany to percussion in the
right upper quadrant, dullness to percussion of the left upper quadrant
Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with
Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on
the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is
likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left
upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated
with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for
sinus inversus totalis.
CHAPTER 19: Abdomen
An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of
severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted.
The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam
findings supports peritonitis? - ANSWERS-Pressing down onto the abdomen firmly and slowly and
withdrawing the hand quickly produces pain
Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly
producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of
peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists
over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not
suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and
irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason. Localized
pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis.
Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of
the psoas muscle due to an inflamed appendix, but not peritonitis.
CHAPTER 19: Abdomen
A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10
months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating
to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is
the mechanism of his most likely diagnosis? - ANSWERS-Fibrosis of the pancreas
Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to
fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency
and diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not
Assessment
FINAL .2025/26 questions
and well prepared
answerz…*
CHAPTER 19: Abdomen
An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of
intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek
medical attention. She has a strong family history of gallstones and is concerned about this possibility.
She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-
human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last periterm-12od was
10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min;
oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior
to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness.
What is the most likely diagnosis? - ANSWERS-Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-hCG, and
findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy
with significant intra-abdominal bleeding leading to peritoneal signs. This case is emergent and requires
immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for
emergent surgery. Ruptured ectopic pregnancies can lead to life-threatening intra-abdominal bleeding.
Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are
all possibilities, the positive β-hCG testing and her unstable vital signs make ruptured ectopic pregnancy
more likely.
,CHAPTER 19: Abdomen
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs
are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also
measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine
aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total
bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to
assess his liver. Which of the following findings would be most consistent with hepatomegaly? -
ANSWERS-Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be
considered normal on inspiration when the liver is pushed down into the abdominal cavity on
inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing
if, by percussion, the liver span was >12 cm at the midclavicular line. For patients with obstructive lung
disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity. The liver
span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid-
clavicular line and 4-8 cm at the midsternal line are considered normal.
CHAPTER 19: Abdomen
A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a
several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and
denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a
ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory
rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her
abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of
the following is her most significant risk factor for an AAA? - ANSWERS-History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not female
gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family history of ruptured
aneurysm is vague and could be a cerebral aneurysm. Further, her family history is in a first-degree
cousin not a first-degree relative (biologic parents, siblings, and children). Hypertension could contribute
to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one
elevated blood pressure reading.
CHAPTER 19: Abdomen
A 76-year-old retired man with a history of prostate cancer and hypertension has been screened
annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-
up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his
,preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went
for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no
first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S.
Preventive Services Task Force (USPSTF) screening recommendations for this patient? - ANSWERS-Do
not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain
in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and
benefits with the patient. Annual FOBT screening may continue until age 80-85 years if benefits to doing
so outweigh risks for the individual patient; however, screening should not be routinely continued. In
general, a life expectancy >7 years is necessary for screening to be potentially beneficial. There is no
indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his
colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening
option, but again screening is not routinely recommended for patients age >75 years.
CHAPTER 19: Abdomen
An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of
recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with
onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She
has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to
over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation.
Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely
physiological mechanism for her constipation? - ANSWERS-Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS
is characterized by three patterns: diarrhea predominant, constipation predominant, or mixed. Other
functional causes for her constipation should be excluded prior to making this diagnosis. A large firm
fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden
individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that
increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal
lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of
patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known
diagnosis that would increase suspicion of neurological impairment.
CHAPTER 19: Abdomen
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and
bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The
, preceptor notes that she has situs inversus and asks for a physical exam. Which of the following
descriptions best fits with findings on the abdominal exam? - ANSWERS-Tympany to percussion in the
right upper quadrant, dullness to percussion of the left upper quadrant
Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with
Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on
the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is
likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left
upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated
with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for
sinus inversus totalis.
CHAPTER 19: Abdomen
An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of
severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted.
The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam
findings supports peritonitis? - ANSWERS-Pressing down onto the abdomen firmly and slowly and
withdrawing the hand quickly produces pain
Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly
producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of
peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists
over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not
suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and
irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason. Localized
pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis.
Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of
the psoas muscle due to an inflamed appendix, but not peritonitis.
CHAPTER 19: Abdomen
A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10
months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating
to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is
the mechanism of his most likely diagnosis? - ANSWERS-Fibrosis of the pancreas
Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to
fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency
and diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not
