NUR 6130 Advanced Practice Nursing III
Official Competency Assessment Actual
Exam 2026/2027 with Detailed Rationales |
Complete Exam-Style Questions | Pass
Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: ADVANCED HEALTH ASSESSMENT & DIAGNOSTIC REASONING Q1 –
Q10
══════════════════════════════════════
Question 1 of 50
A 58-year-old male presents to the primary care clinic with a 3-week history of progressive
dyspnea on exertion and orthopnea. He reports sleeping on three pillows and waking twice
nightly with shortness of breath. On physical exam, you note a laterally displaced PMI, an S3
gallop, and 2+ pitting edema to the mid-shins. Auscultation of the lungs reveals bibasilar
crackles. Which diagnostic finding would most strongly support a diagnosis of systolic heart
failure with reduced ejection fraction?
A. Elevated BNP with an EF of 28% on echocardiography ✓ CORRECT
B. Preserved ejection fraction of 55% with concentric left ventricular hypertrophy
C. Elevated troponin I at 0.8 ng/mL without dynamic ECG changes
D. Normal BNP with elevated pulmonary artery pressures on echocardiography
Correct Answer: A
Rationale: An elevated BNP combined with a reduced ejection fraction below 35% is the
hallmark diagnostic combination for HFrEF, directly matching this patient's volume overload
and systolic dysfunction presentation. A preserved EF with LVH would suggest HFpEF, which
typically presents without an S3 gallop and often with a normal or minimally elevated BNP. In
practice, the displaced PMI and S3 gallop are classic physical exam clues that should prompt
immediate echocardiography to confirm systolic dysfunction.
Question 2 of 50
A 34-year-old woman presents to urgent care with a 2-day history of right-sided facial droop,
inability to close her right eye, and decreased taste sensation on the anterior two-thirds of
,her tongue. She denies any weakness in her extremities, slurred speech, or visual changes.
On exam, she has complete paralysis of the right forehead and lower face, with Bell
phenomenon noted when attempting to close the eye. Which additional finding on exam
would help distinguish a peripheral from a central cause of facial weakness?
A. Deviation of the tongue to the right on protrusion
B. Inability to raise the right eyebrow or wrinkle the forehead ✓ CORRECT
C. Presence of a right-sided pronator drift
D. Hyperreflexia in the right upper extremity
Correct Answer: B
Rationale: Peripheral facial nerve palsy affects both the upper and lower face because the
facial nerve innervates all facial muscles on the ipsilateral side, whereas central lesions
spare the forehead due to bilateral cortical innervation. Tongue deviation would suggest
hypoglossal nerve involvement, and pronator drift or hyperreflexia would indicate a central
process but are not specific to distinguishing facial weakness localization. When you see
complete forehead paralysis in the ED, it immediately points to a peripheral Bell palsy rather
than stroke, which changes your urgency and workup.
Question 3 of 50
A 67-year-old African American man with a 40-pack-year smoking history presents for a
Medicare wellness visit. He has no current respiratory symptoms but has lost 12 pounds over
the past 4 months without dieting. Chest X-ray ordered last month by his previous provider
showed a 2.1 cm spiculated nodule in the left upper lobe. Which next step in the diagnostic
workup is most appropriate according to current lung cancer screening and incidental nodule
guidelines?
A. Repeat chest X-ray in 3 months to assess for interval growth
B. Obtain a low-dose CT chest without contrast for further characterization ✓ CORRECT
C. Proceed directly to PET-CT for metabolic staging
D. Schedule bronchoscopy with transbronchial biopsy
Correct Answer: B
Rationale: A spiculated nodule greater than 8 mm in a high-risk patient requires further
characterization with CT, which provides better detail on margins, calcification, and solid
versus subsolid components than plain radiography. PET-CT is not the appropriate next step
for an uncharacterized nodule, and bronchoscopy is premature without first obtaining
cross-sectional imaging to guide the approach. In primary care, you will frequently see
incidental nodules on X-ray; the first rule is to get a diagnostic CT before any invasive
procedure, as this determines whether the Fleischner criteria or the more aggressive lung
cancer pathway applies.
Question 4 of 50
, A 42-year-old female kindergarten teacher presents with a 6-month history of intermittent
palpitations, heat intolerance, and a 15-pound unintentional weight loss despite increased
appetite. On exam, her resting heart rate is 112 bpm, she has a fine tremor in her outstretched
hands, and her thyroid is diffusely enlarged without nodules. Laboratory studies show a
suppressed TSH at 0.01 mIU/L and elevated free T4 at 2.8 ng/dL. Which physical exam finding
would be most specific for confirming the underlying etiology of her hyperthyroidism?
A. Exophthalmos with lid lag and periorbital edema ✓ CORRECT
B. A bruit audible over the carotid arteries bilaterally
C. Tenderness to palpation over the anterior neck
D. A single firm nodule palpable in the right thyroid lobe
Correct Answer: A
Rationale: Exophthalmos with lid lag is pathognomonic for Graves disease, which is the most
common cause of hyperthyroidism in this demographic and perfectly matches her diffuse
goiter and constitutional symptoms. Carotid bruits suggest atherosclerotic vascular disease,
thyroid tenderness points toward subacute thyroiditis, and a solitary nodule would indicate a
toxic adenoma rather than diffuse autoimmune disease. When you see the triad of
hyperthyroidism, diffuse goiter, and eye findings in a middle-aged woman, you can be highly
confident in Graves disease before antibody results return.
Question 5 of 50
A 71-year-old woman with hypertension and type 2 diabetes is brought to the clinic by her
daughter, who reports that her mother has become increasingly forgetful over the past 18
months, repeating questions and misplacing items daily. The daughter notes that her mother
got lost driving home from the grocery store last week. On mental status exam, the patient
scores 18/30 on the MoCA, with particular deficits in delayed recall, orientation, and
executive function. Her physical and neurological exams are otherwise unremarkable. Which
finding on further workup would be most consistent with a diagnosis of Alzheimer disease
rather than another dementia subtype?
A. MRI showing confluent periventricular white matter hyperintensities
B. CSF analysis demonstrating elevated beta-amyloid with decreased tau protein
C. MRI revealing progressive cortical atrophy disproportionate to white matter changes ✓
CORRECT
D. PET scan showing reduced dopamine transporter uptake in the striatum
Correct Answer: C
Rationale: Alzheimer disease is characterized by progressive cortical atrophy, particularly in
the medial temporal lobes and parietal regions, with relatively preserved white matter
compared to vascular dementia. Confluent white matter changes are more typical of vascular
cognitive impairment, and reduced dopamine transporter uptake is the hallmark of dementia
with Lewy bodies or Parkinson disease dementia. In advanced practice, when you see a
Official Competency Assessment Actual
Exam 2026/2027 with Detailed Rationales |
Complete Exam-Style Questions | Pass
Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: ADVANCED HEALTH ASSESSMENT & DIAGNOSTIC REASONING Q1 –
Q10
══════════════════════════════════════
Question 1 of 50
A 58-year-old male presents to the primary care clinic with a 3-week history of progressive
dyspnea on exertion and orthopnea. He reports sleeping on three pillows and waking twice
nightly with shortness of breath. On physical exam, you note a laterally displaced PMI, an S3
gallop, and 2+ pitting edema to the mid-shins. Auscultation of the lungs reveals bibasilar
crackles. Which diagnostic finding would most strongly support a diagnosis of systolic heart
failure with reduced ejection fraction?
A. Elevated BNP with an EF of 28% on echocardiography ✓ CORRECT
B. Preserved ejection fraction of 55% with concentric left ventricular hypertrophy
C. Elevated troponin I at 0.8 ng/mL without dynamic ECG changes
D. Normal BNP with elevated pulmonary artery pressures on echocardiography
Correct Answer: A
Rationale: An elevated BNP combined with a reduced ejection fraction below 35% is the
hallmark diagnostic combination for HFrEF, directly matching this patient's volume overload
and systolic dysfunction presentation. A preserved EF with LVH would suggest HFpEF, which
typically presents without an S3 gallop and often with a normal or minimally elevated BNP. In
practice, the displaced PMI and S3 gallop are classic physical exam clues that should prompt
immediate echocardiography to confirm systolic dysfunction.
Question 2 of 50
A 34-year-old woman presents to urgent care with a 2-day history of right-sided facial droop,
inability to close her right eye, and decreased taste sensation on the anterior two-thirds of
,her tongue. She denies any weakness in her extremities, slurred speech, or visual changes.
On exam, she has complete paralysis of the right forehead and lower face, with Bell
phenomenon noted when attempting to close the eye. Which additional finding on exam
would help distinguish a peripheral from a central cause of facial weakness?
A. Deviation of the tongue to the right on protrusion
B. Inability to raise the right eyebrow or wrinkle the forehead ✓ CORRECT
C. Presence of a right-sided pronator drift
D. Hyperreflexia in the right upper extremity
Correct Answer: B
Rationale: Peripheral facial nerve palsy affects both the upper and lower face because the
facial nerve innervates all facial muscles on the ipsilateral side, whereas central lesions
spare the forehead due to bilateral cortical innervation. Tongue deviation would suggest
hypoglossal nerve involvement, and pronator drift or hyperreflexia would indicate a central
process but are not specific to distinguishing facial weakness localization. When you see
complete forehead paralysis in the ED, it immediately points to a peripheral Bell palsy rather
than stroke, which changes your urgency and workup.
Question 3 of 50
A 67-year-old African American man with a 40-pack-year smoking history presents for a
Medicare wellness visit. He has no current respiratory symptoms but has lost 12 pounds over
the past 4 months without dieting. Chest X-ray ordered last month by his previous provider
showed a 2.1 cm spiculated nodule in the left upper lobe. Which next step in the diagnostic
workup is most appropriate according to current lung cancer screening and incidental nodule
guidelines?
A. Repeat chest X-ray in 3 months to assess for interval growth
B. Obtain a low-dose CT chest without contrast for further characterization ✓ CORRECT
C. Proceed directly to PET-CT for metabolic staging
D. Schedule bronchoscopy with transbronchial biopsy
Correct Answer: B
Rationale: A spiculated nodule greater than 8 mm in a high-risk patient requires further
characterization with CT, which provides better detail on margins, calcification, and solid
versus subsolid components than plain radiography. PET-CT is not the appropriate next step
for an uncharacterized nodule, and bronchoscopy is premature without first obtaining
cross-sectional imaging to guide the approach. In primary care, you will frequently see
incidental nodules on X-ray; the first rule is to get a diagnostic CT before any invasive
procedure, as this determines whether the Fleischner criteria or the more aggressive lung
cancer pathway applies.
Question 4 of 50
, A 42-year-old female kindergarten teacher presents with a 6-month history of intermittent
palpitations, heat intolerance, and a 15-pound unintentional weight loss despite increased
appetite. On exam, her resting heart rate is 112 bpm, she has a fine tremor in her outstretched
hands, and her thyroid is diffusely enlarged without nodules. Laboratory studies show a
suppressed TSH at 0.01 mIU/L and elevated free T4 at 2.8 ng/dL. Which physical exam finding
would be most specific for confirming the underlying etiology of her hyperthyroidism?
A. Exophthalmos with lid lag and periorbital edema ✓ CORRECT
B. A bruit audible over the carotid arteries bilaterally
C. Tenderness to palpation over the anterior neck
D. A single firm nodule palpable in the right thyroid lobe
Correct Answer: A
Rationale: Exophthalmos with lid lag is pathognomonic for Graves disease, which is the most
common cause of hyperthyroidism in this demographic and perfectly matches her diffuse
goiter and constitutional symptoms. Carotid bruits suggest atherosclerotic vascular disease,
thyroid tenderness points toward subacute thyroiditis, and a solitary nodule would indicate a
toxic adenoma rather than diffuse autoimmune disease. When you see the triad of
hyperthyroidism, diffuse goiter, and eye findings in a middle-aged woman, you can be highly
confident in Graves disease before antibody results return.
Question 5 of 50
A 71-year-old woman with hypertension and type 2 diabetes is brought to the clinic by her
daughter, who reports that her mother has become increasingly forgetful over the past 18
months, repeating questions and misplacing items daily. The daughter notes that her mother
got lost driving home from the grocery store last week. On mental status exam, the patient
scores 18/30 on the MoCA, with particular deficits in delayed recall, orientation, and
executive function. Her physical and neurological exams are otherwise unremarkable. Which
finding on further workup would be most consistent with a diagnosis of Alzheimer disease
rather than another dementia subtype?
A. MRI showing confluent periventricular white matter hyperintensities
B. CSF analysis demonstrating elevated beta-amyloid with decreased tau protein
C. MRI revealing progressive cortical atrophy disproportionate to white matter changes ✓
CORRECT
D. PET scan showing reduced dopamine transporter uptake in the striatum
Correct Answer: C
Rationale: Alzheimer disease is characterized by progressive cortical atrophy, particularly in
the medial temporal lobes and parietal regions, with relatively preserved white matter
compared to vascular dementia. Confluent white matter changes are more typical of vascular
cognitive impairment, and reduced dopamine transporter uptake is the hallmark of dementia
with Lewy bodies or Parkinson disease dementia. In advanced practice, when you see a
