NR 509 Final Advanced Physical Assessment Review
NR 509 Final Advanced Physical Assessment Review
Comprehensive Review Examination | Advanced Physical Assessment
Q1: A 58-year-old male presents with shortness of breath on exertion and lower extremity edema. On auscultation, the
nurse practitioner hears an S3 gallop at the apex. This finding is most consistent with which condition?
A. Aortic stenosis
B. Mitral valve prolapse
C. Ventricular dysfunction and heart failure [CORRECT]
D. Pericardial effusion
Correct Answer: C
Rationale: Correct because an S3 gallop is produced by rapid ventricular filling into a stiff, noncompliant ventricle and is a classic
indicator of ventricular dysfunction and heart failure. This matches the clinical presentation of exertional dyspnea and bilateral lower
extremity edema.
Q2: When performing tactile fremitus, the nurse practitioner asks the patient to say 'ninety-nine' while palpating the chest
wall. Increased fremitus would most likely be found in which condition?
A. Pneumothorax
B. Consolidation from lobar pneumonia [CORRECT]
C. COPD with hyperinflation
D. Pleural effusion
Correct Answer: B
Rationale: Correct because increased tactile fremitus occurs when vibrations travel more easily through consolidated or dense lung tissue,
as seen in lobar pneumonia. This matches the pathophysiologic principle that solid or fluid-filled tissue transmits sound vibrations more
effectively than air-filled tissue.
Q3: During abdominal assessment, the nurse practitioner notes a positive Murphy sign. Which of the following describes
the correct technique and interpretation?
A. Pain on release of deep palpation in the right lower quadrant, suggesting appendicitis
B. Inspiratory arrest during deep palpation of the right upper quadrant, suggesting cholecystitis [CORRECT]
C. Rebound tenderness in the epigastric area, suggesting pancreatitis
D. Tenderness at McBurney point during coughing, suggesting peritonitis
Correct Answer: B
Rationale: Correct because Murphy sign is elicited by asking the patient to take a deep breath while the examiner performs deep
palpation in the right upper quadrant; abrupt cessation of inspiration due to pain suggests acute cholecystitis. This matches the
anatomical relationship of the gallbladder to the diaphragm and liver.
Q4: A 72-year-old patient presents with a shuffling gait, masked facies, and resting tremor. The nurse practitioner
observes that the patient has difficulty initiating movement. Which neurotransmitter system is most likely affected?
A. Serotonin deficiency in the brainstem
B. Dopamine depletion in the basal ganglia [CORRECT]
C. Acetylcholine excess at the neuromuscular junction
D. Norepinephrine reduction in the cerebral cortex
Correct Answer: B
Rationale: Correct because Parkinson disease is characterized by degeneration of dopaminergic neurons in the substantia nigra pars
compacta of the basal ganglia, leading to the classic triad of resting tremor, rigidity, and bradykinesia. This matches the presentation of
shuffling gait, masked facies, and difficulty with movement initiation.
Q5: Which component of the health history is most useful for identifying risk factors for cardiovascular disease that may
not be apparent during the physical examination?
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, NR 509 Final Advanced Physical Assessment Review
A. Chief complaint
B. Review of systems
C. Past medical history and family history [CORRECT]
D. General survey
Correct Answer: C
Rationale: Correct because the past medical history reveals conditions such as hypertension, diabetes, and hyperlipidemia, while the
family history identifies hereditary predispositions such as early coronary artery disease. This matches the purpose of a comprehensive
history in uncovering risk factors that are not visible on physical examination.
Q6: A nurse practitioner assesses a pressure injury on the sacrum of a bedridden patient. There is a full-thickness tissue
loss with subcutaneous fat visible but no exposed bone, tendon, or muscle. How should this be staged?
A. Stage 1
B. Stage 2
C. Stage 3 [CORRECT]
D. Stage 4
Correct Answer: C
Rationale: Correct because a Stage 3 pressure injury involves full-thickness skin loss with visible subcutaneous fat, without exposure of
bone, tendon, or muscle. This matches the National Pressure Injury Advisory Panel staging system classification criteria.
Q7: When assessing cranial nerve VII (facial nerve), which technique is most appropriate for evaluating motor function?
A. Ask the patient to identify familiar odors with eyes closed
B. Ask the patient to raise eyebrows, close eyes tightly, and smile [CORRECT]
C. Assess the gag reflex by touching the posterior pharynx
D. Have the patient say 'ah' and observe palatal elevation
Correct Answer: B
Rationale: Correct because cranial nerve VII innervates the muscles of facial expression, and testing includes asking the patient to raise
the eyebrows, close the eyes against resistance, and smile to assess both the temporal and zygomatic branches. This matches the standard
cranial nerve examination technique for facial motor function.
Q8: A 45-year-old female presents for a routine physical examination. She reports no symptoms. On auscultation, a grade
2/6 systolic ejection murmur is heard at the right second intercostal space that does not radiate. The murmur decreases
with Valsalva maneuver. What is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic sclerosis [CORRECT]
C. Hypertrophic cardiomyopathy
D. Ventricular septal defect
Correct Answer: B
Rationale: Correct because aortic sclerosis produces a grade 1-2 systolic ejection murmur at the right second intercostal space that does
not radiate and decreases with Valsalva, distinguishing it from the murmur of hypertrophic cardiomyopathy which intensifies with
Valsalva. This matches the classic presentation of an asymptomatic mid-systolic murmur in older adults.
Q9: In the SOAP documentation format, which section contains the objective findings obtained during the physical
examination and diagnostic testing?
A. Subjective
B. Objective [CORRECT]
C. Assessment
D. Plan
Correct Answer: B
Rationale: Correct because the Objective section of the SOAP note contains all measurable and observable data including vital signs,
physical examination findings, and results of diagnostic tests. This matches the standardized documentation framework used in clinical
practice.
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, NR 509 Final Advanced Physical Assessment Review
Q10: While auscultating the lungs of a patient with pneumonia, the nurse practitioner hears bronchial breath sounds in the
right middle lobe. This finding indicates which of the following?
A. Air trapping distal to an obstructed bronchus
B. Consolidation of lung tissue allowing sound transmission [CORRECT]
C. Pleural fluid accumulation in the right hemithorax
D. Collapsed alveoli with reduced ventilation
Correct Answer: B
Rationale: Correct because bronchial breath sounds heard over the peripheral lung fields indicate consolidation, as the solid or
fluid-filled tissue transmits sounds from the larger airways more efficiently than normal air-filled alveoli. This matches the
pathophysiology of lobar pneumonia where alveoli fill with exudate.
Q11: When performing a knee examination, which test is used to assess the integrity of the anterior cruciate ligament?
A. McMurray test
B. Lachman test [CORRECT]
C. Phalen test
D. Tinel test
Correct Answer: B
Rationale: Correct because the Lachman test is the most sensitive and specific clinical test for evaluating anterior cruciate ligament
integrity, performed by applying an anterior force to the tibia with the knee in 20-30 degrees of flexion. This matches orthopedic
examination standards for knee ligament assessment.
Q12: A 68-year-old patient is being evaluated for cognitive impairment. When asked to recall three objects after 5 minutes,
the patient can only remember one. This deficit is most accurately described as impairment in which cognitive domain?
A. Attention
B. Language
C. Executive function
D. Short-term memory [CORRECT]
Correct Answer: D
Rationale: Correct because the ability to register and recall information after a delay of 3-5 minutes is a direct measure of short-term
memory function. This matches the Mini-Mental State Examination and Montreal Cognitive Assessment testing methodology for
memory assessment.
Q13: A patient's blood pressure is 168/102 mmHg in the right arm and 142/88 mmHg in the left arm. A 32 mmHg systolic
difference between arms is most suggestive of which condition?
A. Coarctation of the aorta
B. Subclavian artery stenosis or aortic dissection [CORRECT]
C. Essential hypertension with poor control
D. Bilateral carotid artery disease
Correct Answer: B
Rationale: Correct because a systolic blood pressure difference greater than 20 mmHg between arms is clinically significant and suggests
arterial obstruction such as subclavian artery stenosis, aortic dissection, or thoracic aortic aneurysm. Priority is to investigate potentially
serious vascular pathology before attributing the difference to measurement error.
Q14: During abdominal percussion, the nurse practitioner notes dullness in the left upper quadrant at the 9th to 11th
intercostal space in the midscapular line. This finding most likely represents which structure?
A. Liver edge
B. Spleen [CORRECT]
C. Descending colon
D. Left kidney
Correct Answer: B
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, NR 509 Final Advanced Physical Assessment Review
Rationale: Correct because the spleen is located in the left upper quadrant and produces a dull percussion note at the 9th to 11th
intercostal space in the midscapular line during full inspiration. This matches the standard technique for percussing splenic enlargement.
Q15: A 12-month-old infant is brought for a well-child visit. The nurse practitioner observes that the infant can pull to
stand, crawl forward, use a pincer grasp, and say 'mama' and 'dada' with meaning. These developmental milestones are
most consistent with which age range?
A. 6-8 months
B. 9-11 months
C. 12-15 months [CORRECT]
D. 18-24 months
Correct Answer: C
Rationale: Correct because pulling to stand, independent crawling, pincer grasp, and speaking two meaningful words are expected
developmental milestones for a 12-month-old infant. This matches the Denver II developmental screening norms for gross motor, fine
motor, and language development at this age.
Q16: A nurse practitioner examines a skin lesion that is 8 mm in diameter, flat, and displays varying shades of brown,
black, and red with irregular borders. Which type of lesion is this?
A. Seborrheic keratosis
B. Basal cell carcinoma
C. Melanoma [CORRECT]
D. Actinic keratosis
Correct Answer: C
Rationale: Correct because the ABCDE criteria including Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm,
and Evolving characteristics are used to identify potential melanoma. This lesion meets multiple criteria including color variation,
irregular borders, and size greater than 6 mm. This matches clinical guidelines for melanoma screening and early detection.
Q17: A 65-year-old male with a history of hypertension presents with chest discomfort, diaphoresis, and dyspnea. On
examination, his jugular venous pressure is elevated at 10 cm above the sternal angle, and bilateral crackles are heard at
the lung bases. Which hemodynamic parameter is most directly responsible for the elevated JVP?
A. Decreased systemic vascular resistance
B. Increased right atrial pressure [CORRECT]
C. Left ventricular ejection fraction above 60%
D. Reduced pulmonary capillary wedge pressure
Correct Answer: B
Rationale: Correct because jugular venous pressure reflects right atrial pressure, and elevation of JVP indicates increased central venous
pressure, which in this clinical context of heart failure is caused by impaired right ventricular function and venous congestion. This
matches the pathophysiologic relationship between right atrial pressure and jugular venous distension.
Q18: When assessing the Babinski reflex in an adult patient, which response is considered a normal finding?
A. Dorsiflexion of the great toe with fanning of the other toes
B. Plantar flexion of the toes [CORRECT]
C. No movement of the toes
D. Withdrawal of the entire lower extremity
Correct Answer: B
Rationale: Correct because in adults, a normal Babinski response is plantar flexion of the toes, indicating intact upper motor neuron
pathways. Dorsiflexion of the great toe with fanning (a positive Babinski sign) suggests upper motor neuron lesion in adults. This matches
standard neurological examination principles.
Q19: A patient with chronic obstructive pulmonary disease has diminished breath sounds throughout with prolonged
expiratory phase and wheezing. Which pathophysiologic mechanism best explains the diminished breath sounds?
A. Consolidation of alveolar spaces with exudate
Page 4
NR 509 Final Advanced Physical Assessment Review
Comprehensive Review Examination | Advanced Physical Assessment
Q1: A 58-year-old male presents with shortness of breath on exertion and lower extremity edema. On auscultation, the
nurse practitioner hears an S3 gallop at the apex. This finding is most consistent with which condition?
A. Aortic stenosis
B. Mitral valve prolapse
C. Ventricular dysfunction and heart failure [CORRECT]
D. Pericardial effusion
Correct Answer: C
Rationale: Correct because an S3 gallop is produced by rapid ventricular filling into a stiff, noncompliant ventricle and is a classic
indicator of ventricular dysfunction and heart failure. This matches the clinical presentation of exertional dyspnea and bilateral lower
extremity edema.
Q2: When performing tactile fremitus, the nurse practitioner asks the patient to say 'ninety-nine' while palpating the chest
wall. Increased fremitus would most likely be found in which condition?
A. Pneumothorax
B. Consolidation from lobar pneumonia [CORRECT]
C. COPD with hyperinflation
D. Pleural effusion
Correct Answer: B
Rationale: Correct because increased tactile fremitus occurs when vibrations travel more easily through consolidated or dense lung tissue,
as seen in lobar pneumonia. This matches the pathophysiologic principle that solid or fluid-filled tissue transmits sound vibrations more
effectively than air-filled tissue.
Q3: During abdominal assessment, the nurse practitioner notes a positive Murphy sign. Which of the following describes
the correct technique and interpretation?
A. Pain on release of deep palpation in the right lower quadrant, suggesting appendicitis
B. Inspiratory arrest during deep palpation of the right upper quadrant, suggesting cholecystitis [CORRECT]
C. Rebound tenderness in the epigastric area, suggesting pancreatitis
D. Tenderness at McBurney point during coughing, suggesting peritonitis
Correct Answer: B
Rationale: Correct because Murphy sign is elicited by asking the patient to take a deep breath while the examiner performs deep
palpation in the right upper quadrant; abrupt cessation of inspiration due to pain suggests acute cholecystitis. This matches the
anatomical relationship of the gallbladder to the diaphragm and liver.
Q4: A 72-year-old patient presents with a shuffling gait, masked facies, and resting tremor. The nurse practitioner
observes that the patient has difficulty initiating movement. Which neurotransmitter system is most likely affected?
A. Serotonin deficiency in the brainstem
B. Dopamine depletion in the basal ganglia [CORRECT]
C. Acetylcholine excess at the neuromuscular junction
D. Norepinephrine reduction in the cerebral cortex
Correct Answer: B
Rationale: Correct because Parkinson disease is characterized by degeneration of dopaminergic neurons in the substantia nigra pars
compacta of the basal ganglia, leading to the classic triad of resting tremor, rigidity, and bradykinesia. This matches the presentation of
shuffling gait, masked facies, and difficulty with movement initiation.
Q5: Which component of the health history is most useful for identifying risk factors for cardiovascular disease that may
not be apparent during the physical examination?
Page 1
, NR 509 Final Advanced Physical Assessment Review
A. Chief complaint
B. Review of systems
C. Past medical history and family history [CORRECT]
D. General survey
Correct Answer: C
Rationale: Correct because the past medical history reveals conditions such as hypertension, diabetes, and hyperlipidemia, while the
family history identifies hereditary predispositions such as early coronary artery disease. This matches the purpose of a comprehensive
history in uncovering risk factors that are not visible on physical examination.
Q6: A nurse practitioner assesses a pressure injury on the sacrum of a bedridden patient. There is a full-thickness tissue
loss with subcutaneous fat visible but no exposed bone, tendon, or muscle. How should this be staged?
A. Stage 1
B. Stage 2
C. Stage 3 [CORRECT]
D. Stage 4
Correct Answer: C
Rationale: Correct because a Stage 3 pressure injury involves full-thickness skin loss with visible subcutaneous fat, without exposure of
bone, tendon, or muscle. This matches the National Pressure Injury Advisory Panel staging system classification criteria.
Q7: When assessing cranial nerve VII (facial nerve), which technique is most appropriate for evaluating motor function?
A. Ask the patient to identify familiar odors with eyes closed
B. Ask the patient to raise eyebrows, close eyes tightly, and smile [CORRECT]
C. Assess the gag reflex by touching the posterior pharynx
D. Have the patient say 'ah' and observe palatal elevation
Correct Answer: B
Rationale: Correct because cranial nerve VII innervates the muscles of facial expression, and testing includes asking the patient to raise
the eyebrows, close the eyes against resistance, and smile to assess both the temporal and zygomatic branches. This matches the standard
cranial nerve examination technique for facial motor function.
Q8: A 45-year-old female presents for a routine physical examination. She reports no symptoms. On auscultation, a grade
2/6 systolic ejection murmur is heard at the right second intercostal space that does not radiate. The murmur decreases
with Valsalva maneuver. What is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic sclerosis [CORRECT]
C. Hypertrophic cardiomyopathy
D. Ventricular septal defect
Correct Answer: B
Rationale: Correct because aortic sclerosis produces a grade 1-2 systolic ejection murmur at the right second intercostal space that does
not radiate and decreases with Valsalva, distinguishing it from the murmur of hypertrophic cardiomyopathy which intensifies with
Valsalva. This matches the classic presentation of an asymptomatic mid-systolic murmur in older adults.
Q9: In the SOAP documentation format, which section contains the objective findings obtained during the physical
examination and diagnostic testing?
A. Subjective
B. Objective [CORRECT]
C. Assessment
D. Plan
Correct Answer: B
Rationale: Correct because the Objective section of the SOAP note contains all measurable and observable data including vital signs,
physical examination findings, and results of diagnostic tests. This matches the standardized documentation framework used in clinical
practice.
Page 2
, NR 509 Final Advanced Physical Assessment Review
Q10: While auscultating the lungs of a patient with pneumonia, the nurse practitioner hears bronchial breath sounds in the
right middle lobe. This finding indicates which of the following?
A. Air trapping distal to an obstructed bronchus
B. Consolidation of lung tissue allowing sound transmission [CORRECT]
C. Pleural fluid accumulation in the right hemithorax
D. Collapsed alveoli with reduced ventilation
Correct Answer: B
Rationale: Correct because bronchial breath sounds heard over the peripheral lung fields indicate consolidation, as the solid or
fluid-filled tissue transmits sounds from the larger airways more efficiently than normal air-filled alveoli. This matches the
pathophysiology of lobar pneumonia where alveoli fill with exudate.
Q11: When performing a knee examination, which test is used to assess the integrity of the anterior cruciate ligament?
A. McMurray test
B. Lachman test [CORRECT]
C. Phalen test
D. Tinel test
Correct Answer: B
Rationale: Correct because the Lachman test is the most sensitive and specific clinical test for evaluating anterior cruciate ligament
integrity, performed by applying an anterior force to the tibia with the knee in 20-30 degrees of flexion. This matches orthopedic
examination standards for knee ligament assessment.
Q12: A 68-year-old patient is being evaluated for cognitive impairment. When asked to recall three objects after 5 minutes,
the patient can only remember one. This deficit is most accurately described as impairment in which cognitive domain?
A. Attention
B. Language
C. Executive function
D. Short-term memory [CORRECT]
Correct Answer: D
Rationale: Correct because the ability to register and recall information after a delay of 3-5 minutes is a direct measure of short-term
memory function. This matches the Mini-Mental State Examination and Montreal Cognitive Assessment testing methodology for
memory assessment.
Q13: A patient's blood pressure is 168/102 mmHg in the right arm and 142/88 mmHg in the left arm. A 32 mmHg systolic
difference between arms is most suggestive of which condition?
A. Coarctation of the aorta
B. Subclavian artery stenosis or aortic dissection [CORRECT]
C. Essential hypertension with poor control
D. Bilateral carotid artery disease
Correct Answer: B
Rationale: Correct because a systolic blood pressure difference greater than 20 mmHg between arms is clinically significant and suggests
arterial obstruction such as subclavian artery stenosis, aortic dissection, or thoracic aortic aneurysm. Priority is to investigate potentially
serious vascular pathology before attributing the difference to measurement error.
Q14: During abdominal percussion, the nurse practitioner notes dullness in the left upper quadrant at the 9th to 11th
intercostal space in the midscapular line. This finding most likely represents which structure?
A. Liver edge
B. Spleen [CORRECT]
C. Descending colon
D. Left kidney
Correct Answer: B
Page 3
, NR 509 Final Advanced Physical Assessment Review
Rationale: Correct because the spleen is located in the left upper quadrant and produces a dull percussion note at the 9th to 11th
intercostal space in the midscapular line during full inspiration. This matches the standard technique for percussing splenic enlargement.
Q15: A 12-month-old infant is brought for a well-child visit. The nurse practitioner observes that the infant can pull to
stand, crawl forward, use a pincer grasp, and say 'mama' and 'dada' with meaning. These developmental milestones are
most consistent with which age range?
A. 6-8 months
B. 9-11 months
C. 12-15 months [CORRECT]
D. 18-24 months
Correct Answer: C
Rationale: Correct because pulling to stand, independent crawling, pincer grasp, and speaking two meaningful words are expected
developmental milestones for a 12-month-old infant. This matches the Denver II developmental screening norms for gross motor, fine
motor, and language development at this age.
Q16: A nurse practitioner examines a skin lesion that is 8 mm in diameter, flat, and displays varying shades of brown,
black, and red with irregular borders. Which type of lesion is this?
A. Seborrheic keratosis
B. Basal cell carcinoma
C. Melanoma [CORRECT]
D. Actinic keratosis
Correct Answer: C
Rationale: Correct because the ABCDE criteria including Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm,
and Evolving characteristics are used to identify potential melanoma. This lesion meets multiple criteria including color variation,
irregular borders, and size greater than 6 mm. This matches clinical guidelines for melanoma screening and early detection.
Q17: A 65-year-old male with a history of hypertension presents with chest discomfort, diaphoresis, and dyspnea. On
examination, his jugular venous pressure is elevated at 10 cm above the sternal angle, and bilateral crackles are heard at
the lung bases. Which hemodynamic parameter is most directly responsible for the elevated JVP?
A. Decreased systemic vascular resistance
B. Increased right atrial pressure [CORRECT]
C. Left ventricular ejection fraction above 60%
D. Reduced pulmonary capillary wedge pressure
Correct Answer: B
Rationale: Correct because jugular venous pressure reflects right atrial pressure, and elevation of JVP indicates increased central venous
pressure, which in this clinical context of heart failure is caused by impaired right ventricular function and venous congestion. This
matches the pathophysiologic relationship between right atrial pressure and jugular venous distension.
Q18: When assessing the Babinski reflex in an adult patient, which response is considered a normal finding?
A. Dorsiflexion of the great toe with fanning of the other toes
B. Plantar flexion of the toes [CORRECT]
C. No movement of the toes
D. Withdrawal of the entire lower extremity
Correct Answer: B
Rationale: Correct because in adults, a normal Babinski response is plantar flexion of the toes, indicating intact upper motor neuron
pathways. Dorsiflexion of the great toe with fanning (a positive Babinski sign) suggests upper motor neuron lesion in adults. This matches
standard neurological examination principles.
Q19: A patient with chronic obstructive pulmonary disease has diminished breath sounds throughout with prolonged
expiratory phase and wheezing. Which pathophysiologic mechanism best explains the diminished breath sounds?
A. Consolidation of alveolar spaces with exudate
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