NR-509 – Advanced Physical Assessment Graduate
Nursing Assessment Study Guide, Advanced
Examination Skills, Diagnostic Reasoning, Clinical
Evaluation, and Practice Questions
Question 1
A 68-year-old male presents with a complaint of progressive dyspnea on exertion
and orthopnea. On cardiovascular examination, the nurse practitioner notes a
sustained, displaced apical impulse at the 6th intercostal space anterior axillary line
and an S3 gallop. Jugular venous pressure is estimated at 12 cm H₂O with the
patient positioned at 45 degrees. Which of the following is the most likely
diagnosis?
A) Mitral stenosis
B) Aortic stenosis
C) Dilated cardiomyopathy with heart failure
D) Pericardial effusion
Answer: C) Dilated cardiomyopathy with heart failure
Rationale: The findings of a displaced, sustained apical impulse (indicating left
ventricular dilation), S3 gallop (indicating reduced ventricular compliance and
elevated filling pressures), elevated jugular venous pressure, and dyspnea with
orthopnea are classic for dilated cardiomyopathy with heart failure. JVP >3-4 cm
above the sternal angle at 45 degrees indicates elevated right atrial pressure. Mitral
stenosis would present with a diastolic rumble, and aortic stenosis with a systolic
ejection murmur. Pericardial effusion would cause muffled heart sounds and a
paradoxical pulse.
Question 2
A 45-year-old female presents with acute onset of severe headache, nausea, and
photophobia. On examination, you note nuchal rigidity and a positive Brudzinski's
sign. Which of the following is the most appropriate next step?
,A) Administer a triptan for suspected migraine
B) Perform a non-contrast head CT followed by lumbar puncture if negative
C) Order a stat MRI of the brain
D) Administer high-dose corticosteroids
Answer: B) Perform a non-contrast head CT followed by lumbar puncture if
negative
Rationale: The classic triad of severe headache, fever, and nuchal rigidity is
concerning for meningitis. Brudzinski's sign (involuntary flexion of hips and knees
with neck flexion) indicates meningeal irritation. In adults with suspected
meningitis, the recommended approach is to first obtain a non-contrast head CT to
rule out increased intracranial pressure or mass lesion, followed by lumbar
puncture for CSF analysis if imaging is negative.
Question 3
A nurse practitioner is examining a patient with suspected peripheral arterial
disease (PAD). Which of the following physical examination findings is most
consistent with this diagnosis?
A) Bilateral lower extremity edema with pitting
B) Cool, pale feet with diminished or absent pedal pulses and hair loss
C) Warm, erythematous legs with bounding pulses
D) Brownish discoloration of the skin around the ankles
Answer: B) Cool, pale feet with diminished or absent pedal pulses and hair
loss
Rationale: PAD is characterized by diminished arterial blood flow, leading to
cool, pale extremities, diminished or absent pulses, and chronic skin changes
including hair loss, thin, shiny skin, and thickened nails. Venous insufficiency
(Options A and D) presents with edema, warmth, and brownish stasis dermatitis.
Option C suggests infection or inflammation.
Question 4
During a cardiac examination, a nurse practitioner auscultates a high-pitched,
blowing diastolic decrescendo murmur heard best at the left upper sternal border
,with the patient leaning forward and exhaling. This murmur is most consistent
with:
A) Aortic stenosis
B) Mitral regurgitation
C) Aortic regurgitation
D) Pulmonic stenosis
Answer: C) Aortic regurgitation
Rationale: Aortic regurgitation produces a high-pitched, blowing, diastolic
decrescendo murmur best heard at the left upper sternal border (Erb's point) with
the patient leaning forward and exhaling. Aortic stenosis is a systolic ejection
murmur. Mitral regurgitation is a holosystolic murmur heard best at the apex with
radiation to the axilla. Pulmonic stenosis is a systolic ejection murmur at the left
upper sternal border.
Question 5
A 72-year-old female presents with a complaint of "feeling like the room is
spinning" when she turns her head quickly. She also reports hearing loss and
tinnitus in the left ear. Which of the following is the most likely diagnosis?
A) Benign paroxysmal positional vertigo (BPPV)
B) Ménière's disease
C) Vestibular neuritis
D) Cerebellar stroke
Answer: B) Ménière's disease
Rationale: Ménière's disease is characterized by the classic triad of episodic
vertigo, sensorineural hearing loss, and tinnitus, often with a sensation of aural
fullness. BPPV causes brief episodes of vertigo with head position changes but
does not typically include hearing loss. Vestibular neuritis causes acute, severe
vertigo without hearing loss. Cerebellar stroke would present with additional
neurological deficits (ataxia, dysarthria, nystagmus).
, Question 6
A nurse practitioner is assessing a patient's abdomen. Which of the following is the
correct order for abdominal examination techniques?
A) Inspection, Palpation, Percussion, Auscultation
B) Inspection, Auscultation, Percussion, Palpation
C) Palpation, Percussion, Auscultation, Inspection
D) Auscultation, Inspection, Palpation, Percussion
Answer: B) Inspection, Auscultation, Percussion, Palpation
Rationale: For abdominal assessment, the correct order is Inspection,
Auscultation, Percussion, and Palpation because palpation and percussion can alter
bowel sounds. Inspection should be performed first to observe for scars, distension,
and visible masses. Auscultation should be performed before percussion and
palpation to avoid altering bowel sounds.
Question 7
A 55-year-old male with a history of smoking presents with a chronic cough and
hemoptysis. On examination, you note clubbing of the fingernails and decreased
breath sounds in the right upper lobe. Which of the following is the most likely
underlying condition?
A) Bronchiectasis
B) Lung cancer
C) Tuberculosis
D) Pneumonia
Answer: B) Lung cancer
Rationale: The combination of chronic cough, hemoptysis, smoking history,
clubbing, and focal decreased breath sounds suggests a mass lesion such as lung
cancer. While bronchiectasis can cause clubbing and cough, hemoptysis is less
characteristic. Tuberculosis would present with night sweats and weight loss.
Pneumonia would present with fever and acute onset.
Nursing Assessment Study Guide, Advanced
Examination Skills, Diagnostic Reasoning, Clinical
Evaluation, and Practice Questions
Question 1
A 68-year-old male presents with a complaint of progressive dyspnea on exertion
and orthopnea. On cardiovascular examination, the nurse practitioner notes a
sustained, displaced apical impulse at the 6th intercostal space anterior axillary line
and an S3 gallop. Jugular venous pressure is estimated at 12 cm H₂O with the
patient positioned at 45 degrees. Which of the following is the most likely
diagnosis?
A) Mitral stenosis
B) Aortic stenosis
C) Dilated cardiomyopathy with heart failure
D) Pericardial effusion
Answer: C) Dilated cardiomyopathy with heart failure
Rationale: The findings of a displaced, sustained apical impulse (indicating left
ventricular dilation), S3 gallop (indicating reduced ventricular compliance and
elevated filling pressures), elevated jugular venous pressure, and dyspnea with
orthopnea are classic for dilated cardiomyopathy with heart failure. JVP >3-4 cm
above the sternal angle at 45 degrees indicates elevated right atrial pressure. Mitral
stenosis would present with a diastolic rumble, and aortic stenosis with a systolic
ejection murmur. Pericardial effusion would cause muffled heart sounds and a
paradoxical pulse.
Question 2
A 45-year-old female presents with acute onset of severe headache, nausea, and
photophobia. On examination, you note nuchal rigidity and a positive Brudzinski's
sign. Which of the following is the most appropriate next step?
,A) Administer a triptan for suspected migraine
B) Perform a non-contrast head CT followed by lumbar puncture if negative
C) Order a stat MRI of the brain
D) Administer high-dose corticosteroids
Answer: B) Perform a non-contrast head CT followed by lumbar puncture if
negative
Rationale: The classic triad of severe headache, fever, and nuchal rigidity is
concerning for meningitis. Brudzinski's sign (involuntary flexion of hips and knees
with neck flexion) indicates meningeal irritation. In adults with suspected
meningitis, the recommended approach is to first obtain a non-contrast head CT to
rule out increased intracranial pressure or mass lesion, followed by lumbar
puncture for CSF analysis if imaging is negative.
Question 3
A nurse practitioner is examining a patient with suspected peripheral arterial
disease (PAD). Which of the following physical examination findings is most
consistent with this diagnosis?
A) Bilateral lower extremity edema with pitting
B) Cool, pale feet with diminished or absent pedal pulses and hair loss
C) Warm, erythematous legs with bounding pulses
D) Brownish discoloration of the skin around the ankles
Answer: B) Cool, pale feet with diminished or absent pedal pulses and hair
loss
Rationale: PAD is characterized by diminished arterial blood flow, leading to
cool, pale extremities, diminished or absent pulses, and chronic skin changes
including hair loss, thin, shiny skin, and thickened nails. Venous insufficiency
(Options A and D) presents with edema, warmth, and brownish stasis dermatitis.
Option C suggests infection or inflammation.
Question 4
During a cardiac examination, a nurse practitioner auscultates a high-pitched,
blowing diastolic decrescendo murmur heard best at the left upper sternal border
,with the patient leaning forward and exhaling. This murmur is most consistent
with:
A) Aortic stenosis
B) Mitral regurgitation
C) Aortic regurgitation
D) Pulmonic stenosis
Answer: C) Aortic regurgitation
Rationale: Aortic regurgitation produces a high-pitched, blowing, diastolic
decrescendo murmur best heard at the left upper sternal border (Erb's point) with
the patient leaning forward and exhaling. Aortic stenosis is a systolic ejection
murmur. Mitral regurgitation is a holosystolic murmur heard best at the apex with
radiation to the axilla. Pulmonic stenosis is a systolic ejection murmur at the left
upper sternal border.
Question 5
A 72-year-old female presents with a complaint of "feeling like the room is
spinning" when she turns her head quickly. She also reports hearing loss and
tinnitus in the left ear. Which of the following is the most likely diagnosis?
A) Benign paroxysmal positional vertigo (BPPV)
B) Ménière's disease
C) Vestibular neuritis
D) Cerebellar stroke
Answer: B) Ménière's disease
Rationale: Ménière's disease is characterized by the classic triad of episodic
vertigo, sensorineural hearing loss, and tinnitus, often with a sensation of aural
fullness. BPPV causes brief episodes of vertigo with head position changes but
does not typically include hearing loss. Vestibular neuritis causes acute, severe
vertigo without hearing loss. Cerebellar stroke would present with additional
neurological deficits (ataxia, dysarthria, nystagmus).
, Question 6
A nurse practitioner is assessing a patient's abdomen. Which of the following is the
correct order for abdominal examination techniques?
A) Inspection, Palpation, Percussion, Auscultation
B) Inspection, Auscultation, Percussion, Palpation
C) Palpation, Percussion, Auscultation, Inspection
D) Auscultation, Inspection, Palpation, Percussion
Answer: B) Inspection, Auscultation, Percussion, Palpation
Rationale: For abdominal assessment, the correct order is Inspection,
Auscultation, Percussion, and Palpation because palpation and percussion can alter
bowel sounds. Inspection should be performed first to observe for scars, distension,
and visible masses. Auscultation should be performed before percussion and
palpation to avoid altering bowel sounds.
Question 7
A 55-year-old male with a history of smoking presents with a chronic cough and
hemoptysis. On examination, you note clubbing of the fingernails and decreased
breath sounds in the right upper lobe. Which of the following is the most likely
underlying condition?
A) Bronchiectasis
B) Lung cancer
C) Tuberculosis
D) Pneumonia
Answer: B) Lung cancer
Rationale: The combination of chronic cough, hemoptysis, smoking history,
clubbing, and focal decreased breath sounds suggests a mass lesion such as lung
cancer. While bronchiectasis can cause clubbing and cough, hemoptysis is less
characteristic. Tuberculosis would present with night sweats and weight loss.
Pneumonia would present with fever and acute onset.
