NSG 6020 - 3P Exam Study
Advanced Pathophysiology | Advanced Pharmacology | Advanced Physical Assessment
South University | 2026/2027 Academic Year
100 Questions with Comprehensive Rationales
Section 1: Advanced Physical Assessment and Diagnostic Reasoning
(Q1-Q30)
Q1. A 55-year-old patient presents for a comprehensive health assessment. The NP uses the OLDCARTS
mnemonic during history taking. Which component of OLDCARTS refers to identifying what makes the
symptom better or worse?
A. Onset
B. Duration
C. Aggravating/Alleviating factors [CORRECT]
D. Timing
Correct Answer: C
Rationale: The 'A' in OLDCARTS stands for Aggravating and Alleviating factors. This component explores what worsens or
improves the patient's symptom, providing critical diagnostic clues. Onset refers to when the symptom began, Duration addresses
how long it lasts, and Timing refers to when the symptom occurs (e.g., morning vs. evening). Understanding aggravating and
alleviating factors is essential for differential diagnosis and guides both physical examination maneuvers and initial
management strategies.
Q2. A patient presents with a suspicious skin lesion on the forearm. The NP applies the ABCDE criteria for
melanoma assessment. Which finding is most concerning for malignant transformation?
A. Diameter of 4 mm
B. Border irregularity with notching [CORRECT]
C. Uniform brown color throughout
D. Symmetrical shape
Correct Answer: B
Rationale: Border irregularity with notching is a hallmark sign of melanoma according to the ABCDE criteria. Melanomas
typically exhibit irregular, scalloped, or poorly defined borders in contrast to benign lesions that have smooth, well-defined
edges. While diameter greater than 6 mm is concerning, border irregularity is one of the earliest and most reliable indicators of
malignancy. Uniform color and symmetrical shape are reassuring findings suggestive of benign lesions such as benign nevi.
Q3. A patient undergoes Snellen visual acuity testing and reads the 20/40 line with the left eye but only
20/200 with the right eye. How should the NP interpret the right eye finding?
, A. The patient can read at 20 feet what a person with normal vision can read at 200 feet [CORRECT]
B. The patient can read at 200 feet what a person with normal vision can read at 20 feet
C. The patient has 200% of normal visual acuity
D. The patient requires a 200-foot distance for accurate testing
Correct Answer: A
Rationale: Snellen visual acuity of 20/200 means the patient can read at 20 feet what a person with normal vision can read at
200 feet. This represents significant visual impairment. The numerator (20) represents the testing distance, while the
denominator (200) indicates the distance at which a person with normal vision could read the same line. Legal blindness is
defined as corrected visual acuity of 20/200 or worse in the better eye. This finding warrants urgent ophthalmologic referral
for further evaluation and potential intervention.
Q4. During cardiac auscultation of a 68-year-old patient with a history of hypertension, the NP hears a
low-frequency extra sound immediately preceding S1. This sound is best described as:
A. S3 gallop
B. S4 gallop [CORRECT]
C. Aortic stenosis murmur
D. Pericardial friction rub
Correct Answer: B
Rationale: An S4 gallop is a low-frequency sound heard immediately before S1 (presystolic) and is caused by atrial contraction
forcing blood into a stiff, noncompliant ventricle. It is associated with conditions that reduce ventricular compliance, such as
hypertension, hypertrophic cardiomyopathy, and coronary artery disease. An S3 gallop occurs after S2 (early diastolic) and is
associated with heart failure. Aortic stenosis produces a systolic ejection murmur, and a pericardial friction rub produces a
scratching sound in both systole and diastole.
Q5. A 42-year-old patient has a crescendo-decrescendo systolic murmur heard best at the right upper
sternal border that radiates to the carotids. The murmur is graded III/VI. What does a Grade III/VI murmur
indicate?
A. Barely audible with special positioning
B. Quiet but heard immediately with the stethoscope
C. Loud without a thrill [CORRECT]
D. Loud with a palpable thrill
Correct Answer: C
Rationale: A Grade III/VI murmur is loud and easily heard with the stethoscope but is not associated with a palpable thrill.
Murmurs are graded on a I-VI scale: Grade I is barely audible, Grade II is quiet but immediately heard, Grade III is loud
without thrill, Grade IV is loud with a palpable thrill, Grade V is very loud with a thrill, and Grade VI is loud enough to be
heard with the stethoscope slightly off the chest. A crescendo-decrescendo systolic murmur at the right upper sternal border
radiating to carotids is classic for aortic stenosis.
Q6. While performing a respiratory assessment on a patient with pneumonia, the NP auscultates fine,
discontinuous, high-pitched popping sounds heard primarily during inspiration. These adventitious sounds
are best documented as:
A. Rhonchi
B. Wheezes
C. Fine crackles (rales) [CORRECT]
, D. Pleural friction rub
Correct Answer: C
Rationale: Fine crackles (formerly called rales) are discontinuous, high-pitched, popping sounds heard primarily during
inspiration. They are caused by the explosive opening of collapsed small airways and alveoli and are associated with pulmonary
edema, pneumonia, pulmonary fibrosis, and interstitial lung disease. Rhonchi are low-pitched, continuous snoring sounds
caused by secretions in large airways. Wheezes are continuous, high-pitched musical sounds indicating narrowed airways. A
pleural friction rub is a grating or rubbing sound caused by inflamed pleural surfaces rubbing together.
Q7. A 35-year-old patient presents with right upper quadrant abdominal pain. The NP performs deep
palpation and asks the patient to take a deep breath while pressing under the right costal margin. The patient
abruptly stops breathing due to pain. This positive sign is known as:
A. Murphy's sign [CORRECT]
B. Rovsing's sign
C. McBurney's point tenderness
D. Obturator sign
Correct Answer: A
Rationale: Murphy's sign is positive when the patient abruptly stops breathing during deep inspiration as the inflamed
gallbladder contacts the examiner's hand during deep palpation under the right costal margin. This is a classic finding in acute
cholecystitis and is highly specific for gallbladder inflammation. Rovsing's sign suggests appendicitis (palpation of the left lower
quadrant produces pain in the right lower quadrant). McBurney's point tenderness is also associated with appendicitis. The
obturator sign tests for appendicitis with internal rotation of the flexed right thigh.
Q8. During abdominal examination of a patient with suspected peritonitis, the NP performs rebound
tenderness testing. Which technique is correct for eliciting rebound tenderness?
A. Slowly release pressure after deep palpation and observe for increased pain [CORRECT]
B. Press deeply and maintain steady pressure for 30 seconds
C. Tap the abdomen lightly and observe the patient's response
D. Compress the abdomen rapidly with both hands
Correct Answer: A
Rationale: Rebound tenderness is elicited by slowly releasing pressure after deep palpation. A positive sign occurs when the
patient experiences increased, sharp pain upon release rather than during compression. This suggests parietal peritoneal
irritation, commonly seen in conditions such as appendicitis, peritonitis, and perforated viscus. Rebound tenderness is a more
specific but less sensitive indicator of peritoneal inflammation compared to voluntary guarding. When positive, it signals the
need for urgent surgical evaluation.
Q9. A patient presents with shoulder pain and limited range of motion. The NP performs the Neer
impingement test by passively flexing the patient's internally rotated arm overhead. A positive result
reproduces pain, suggesting pathology of which structure?
A. Rotator cuff tendons [CORRECT]
B. Biceps brachii tendon
C. Acromioclavicular joint
D. Glenoid labrum
Correct Answer: A
, Rationale: The Neer impingement test is performed by passively flexing the patient's internally rotated arm overhead, which
compresses the rotator cuff tendons (particularly the supraspinatus) against the anterior acromion. A positive result,
characterized by pain reproduction, suggests rotator cuff impingement syndrome. This is one of the most common causes of
shoulder pain in adults. The Hawkins-Kennedy test is another impingement test that flexes the shoulder and elbow to 90 degrees
and then internally rotates the arm.
Q10. During cranial nerve assessment, the NP asks the patient to stick out the tongue and observes
deviation to the right side. Which cranial nerve is affected?
A. CN IX - Glossopharyngeal
B. CN X - Vagus
C. CN XII - Hypoglossal [CORRECT]
D. CN XI - Spinal Accessory
Correct Answer: C
Rationale: The hypoglossal nerve (CN XII) controls tongue movement. Damage to CN XII causes the tongue to deviate toward
the side of the lesion due to unopposed action of the genioglossus muscle on the unaffected side. A rightward deviation indicates
a right CN XII lesion. CN IX (glossopharyngeal) and CN X (vagus) are tested by gag reflex and palatal elevation. CN XI (spinal
accessory) is tested by shoulder shrug (trapezius) and head turning (sternocleidomastoid). Tongue deviation is a specific finding
for hypoglossal nerve dysfunction.
Q11. A patient's deep tendon reflexes are graded as 3+ bilaterally. How should the NP interpret this
finding?
A. Absent reflexes
B. Diminished reflexes
C. Brisk or hyperactive reflexes, possibly upper motor neuron lesion [CORRECT]
D. Normal reflexes
Correct Answer: C
Rationale: Deep tendon reflexes (DTRs) are graded on a 0-4 scale: 0 = absent, 1+ = diminished, 2+ = normal, 3+ = brisk or
increased (may indicate upper motor neuron lesion), 4+ = markedly hyperactive with clonus. A 3+ finding bilaterally may
indicate upper motor neuron pathology such as spinal cord compression, multiple sclerosis, or stroke. However, it can also be a
normal variant in some healthy individuals. Unilateral hyperreflexia is more clinically significant than bilateral findings.
Asymmetric reflexes (more than one grade difference between sides) are more concerning.
Q12. The NP performs the Babinski reflex test on an adult patient by stroking the lateral aspect of the foot
from heel to toe. The patient's great toe extends and the other toes fan outward. This finding is documented
as:
A. A normal Babinski response
B. A positive Babinski sign [CORRECT]
C. A negative Babinski sign
D. Clonus
Correct Answer: B
Rationale: A positive Babinski sign (upper motor neuron sign) occurs when stimulation of the lateral sole produces great toe
extension (dorsiflexion) with fanning of the other toes. In adults, a positive Babinski sign indicates upper motor neuron
pathology affecting the corticospinal tract, such as stroke, spinal cord injury, multiple sclerosis, or brain tumor. A normal
(negative) Babinski response in adults is toe flexion (plantar flexion). Note that a positive Babinski is a normal finding in infants
under 12 months due to incomplete myelination of the corticospinal tract.
Advanced Pathophysiology | Advanced Pharmacology | Advanced Physical Assessment
South University | 2026/2027 Academic Year
100 Questions with Comprehensive Rationales
Section 1: Advanced Physical Assessment and Diagnostic Reasoning
(Q1-Q30)
Q1. A 55-year-old patient presents for a comprehensive health assessment. The NP uses the OLDCARTS
mnemonic during history taking. Which component of OLDCARTS refers to identifying what makes the
symptom better or worse?
A. Onset
B. Duration
C. Aggravating/Alleviating factors [CORRECT]
D. Timing
Correct Answer: C
Rationale: The 'A' in OLDCARTS stands for Aggravating and Alleviating factors. This component explores what worsens or
improves the patient's symptom, providing critical diagnostic clues. Onset refers to when the symptom began, Duration addresses
how long it lasts, and Timing refers to when the symptom occurs (e.g., morning vs. evening). Understanding aggravating and
alleviating factors is essential for differential diagnosis and guides both physical examination maneuvers and initial
management strategies.
Q2. A patient presents with a suspicious skin lesion on the forearm. The NP applies the ABCDE criteria for
melanoma assessment. Which finding is most concerning for malignant transformation?
A. Diameter of 4 mm
B. Border irregularity with notching [CORRECT]
C. Uniform brown color throughout
D. Symmetrical shape
Correct Answer: B
Rationale: Border irregularity with notching is a hallmark sign of melanoma according to the ABCDE criteria. Melanomas
typically exhibit irregular, scalloped, or poorly defined borders in contrast to benign lesions that have smooth, well-defined
edges. While diameter greater than 6 mm is concerning, border irregularity is one of the earliest and most reliable indicators of
malignancy. Uniform color and symmetrical shape are reassuring findings suggestive of benign lesions such as benign nevi.
Q3. A patient undergoes Snellen visual acuity testing and reads the 20/40 line with the left eye but only
20/200 with the right eye. How should the NP interpret the right eye finding?
, A. The patient can read at 20 feet what a person with normal vision can read at 200 feet [CORRECT]
B. The patient can read at 200 feet what a person with normal vision can read at 20 feet
C. The patient has 200% of normal visual acuity
D. The patient requires a 200-foot distance for accurate testing
Correct Answer: A
Rationale: Snellen visual acuity of 20/200 means the patient can read at 20 feet what a person with normal vision can read at
200 feet. This represents significant visual impairment. The numerator (20) represents the testing distance, while the
denominator (200) indicates the distance at which a person with normal vision could read the same line. Legal blindness is
defined as corrected visual acuity of 20/200 or worse in the better eye. This finding warrants urgent ophthalmologic referral
for further evaluation and potential intervention.
Q4. During cardiac auscultation of a 68-year-old patient with a history of hypertension, the NP hears a
low-frequency extra sound immediately preceding S1. This sound is best described as:
A. S3 gallop
B. S4 gallop [CORRECT]
C. Aortic stenosis murmur
D. Pericardial friction rub
Correct Answer: B
Rationale: An S4 gallop is a low-frequency sound heard immediately before S1 (presystolic) and is caused by atrial contraction
forcing blood into a stiff, noncompliant ventricle. It is associated with conditions that reduce ventricular compliance, such as
hypertension, hypertrophic cardiomyopathy, and coronary artery disease. An S3 gallop occurs after S2 (early diastolic) and is
associated with heart failure. Aortic stenosis produces a systolic ejection murmur, and a pericardial friction rub produces a
scratching sound in both systole and diastole.
Q5. A 42-year-old patient has a crescendo-decrescendo systolic murmur heard best at the right upper
sternal border that radiates to the carotids. The murmur is graded III/VI. What does a Grade III/VI murmur
indicate?
A. Barely audible with special positioning
B. Quiet but heard immediately with the stethoscope
C. Loud without a thrill [CORRECT]
D. Loud with a palpable thrill
Correct Answer: C
Rationale: A Grade III/VI murmur is loud and easily heard with the stethoscope but is not associated with a palpable thrill.
Murmurs are graded on a I-VI scale: Grade I is barely audible, Grade II is quiet but immediately heard, Grade III is loud
without thrill, Grade IV is loud with a palpable thrill, Grade V is very loud with a thrill, and Grade VI is loud enough to be
heard with the stethoscope slightly off the chest. A crescendo-decrescendo systolic murmur at the right upper sternal border
radiating to carotids is classic for aortic stenosis.
Q6. While performing a respiratory assessment on a patient with pneumonia, the NP auscultates fine,
discontinuous, high-pitched popping sounds heard primarily during inspiration. These adventitious sounds
are best documented as:
A. Rhonchi
B. Wheezes
C. Fine crackles (rales) [CORRECT]
, D. Pleural friction rub
Correct Answer: C
Rationale: Fine crackles (formerly called rales) are discontinuous, high-pitched, popping sounds heard primarily during
inspiration. They are caused by the explosive opening of collapsed small airways and alveoli and are associated with pulmonary
edema, pneumonia, pulmonary fibrosis, and interstitial lung disease. Rhonchi are low-pitched, continuous snoring sounds
caused by secretions in large airways. Wheezes are continuous, high-pitched musical sounds indicating narrowed airways. A
pleural friction rub is a grating or rubbing sound caused by inflamed pleural surfaces rubbing together.
Q7. A 35-year-old patient presents with right upper quadrant abdominal pain. The NP performs deep
palpation and asks the patient to take a deep breath while pressing under the right costal margin. The patient
abruptly stops breathing due to pain. This positive sign is known as:
A. Murphy's sign [CORRECT]
B. Rovsing's sign
C. McBurney's point tenderness
D. Obturator sign
Correct Answer: A
Rationale: Murphy's sign is positive when the patient abruptly stops breathing during deep inspiration as the inflamed
gallbladder contacts the examiner's hand during deep palpation under the right costal margin. This is a classic finding in acute
cholecystitis and is highly specific for gallbladder inflammation. Rovsing's sign suggests appendicitis (palpation of the left lower
quadrant produces pain in the right lower quadrant). McBurney's point tenderness is also associated with appendicitis. The
obturator sign tests for appendicitis with internal rotation of the flexed right thigh.
Q8. During abdominal examination of a patient with suspected peritonitis, the NP performs rebound
tenderness testing. Which technique is correct for eliciting rebound tenderness?
A. Slowly release pressure after deep palpation and observe for increased pain [CORRECT]
B. Press deeply and maintain steady pressure for 30 seconds
C. Tap the abdomen lightly and observe the patient's response
D. Compress the abdomen rapidly with both hands
Correct Answer: A
Rationale: Rebound tenderness is elicited by slowly releasing pressure after deep palpation. A positive sign occurs when the
patient experiences increased, sharp pain upon release rather than during compression. This suggests parietal peritoneal
irritation, commonly seen in conditions such as appendicitis, peritonitis, and perforated viscus. Rebound tenderness is a more
specific but less sensitive indicator of peritoneal inflammation compared to voluntary guarding. When positive, it signals the
need for urgent surgical evaluation.
Q9. A patient presents with shoulder pain and limited range of motion. The NP performs the Neer
impingement test by passively flexing the patient's internally rotated arm overhead. A positive result
reproduces pain, suggesting pathology of which structure?
A. Rotator cuff tendons [CORRECT]
B. Biceps brachii tendon
C. Acromioclavicular joint
D. Glenoid labrum
Correct Answer: A
, Rationale: The Neer impingement test is performed by passively flexing the patient's internally rotated arm overhead, which
compresses the rotator cuff tendons (particularly the supraspinatus) against the anterior acromion. A positive result,
characterized by pain reproduction, suggests rotator cuff impingement syndrome. This is one of the most common causes of
shoulder pain in adults. The Hawkins-Kennedy test is another impingement test that flexes the shoulder and elbow to 90 degrees
and then internally rotates the arm.
Q10. During cranial nerve assessment, the NP asks the patient to stick out the tongue and observes
deviation to the right side. Which cranial nerve is affected?
A. CN IX - Glossopharyngeal
B. CN X - Vagus
C. CN XII - Hypoglossal [CORRECT]
D. CN XI - Spinal Accessory
Correct Answer: C
Rationale: The hypoglossal nerve (CN XII) controls tongue movement. Damage to CN XII causes the tongue to deviate toward
the side of the lesion due to unopposed action of the genioglossus muscle on the unaffected side. A rightward deviation indicates
a right CN XII lesion. CN IX (glossopharyngeal) and CN X (vagus) are tested by gag reflex and palatal elevation. CN XI (spinal
accessory) is tested by shoulder shrug (trapezius) and head turning (sternocleidomastoid). Tongue deviation is a specific finding
for hypoglossal nerve dysfunction.
Q11. A patient's deep tendon reflexes are graded as 3+ bilaterally. How should the NP interpret this
finding?
A. Absent reflexes
B. Diminished reflexes
C. Brisk or hyperactive reflexes, possibly upper motor neuron lesion [CORRECT]
D. Normal reflexes
Correct Answer: C
Rationale: Deep tendon reflexes (DTRs) are graded on a 0-4 scale: 0 = absent, 1+ = diminished, 2+ = normal, 3+ = brisk or
increased (may indicate upper motor neuron lesion), 4+ = markedly hyperactive with clonus. A 3+ finding bilaterally may
indicate upper motor neuron pathology such as spinal cord compression, multiple sclerosis, or stroke. However, it can also be a
normal variant in some healthy individuals. Unilateral hyperreflexia is more clinically significant than bilateral findings.
Asymmetric reflexes (more than one grade difference between sides) are more concerning.
Q12. The NP performs the Babinski reflex test on an adult patient by stroking the lateral aspect of the foot
from heel to toe. The patient's great toe extends and the other toes fan outward. This finding is documented
as:
A. A normal Babinski response
B. A positive Babinski sign [CORRECT]
C. A negative Babinski sign
D. Clonus
Correct Answer: B
Rationale: A positive Babinski sign (upper motor neuron sign) occurs when stimulation of the lateral sole produces great toe
extension (dorsiflexion) with fanning of the other toes. In adults, a positive Babinski sign indicates upper motor neuron
pathology affecting the corticospinal tract, such as stroke, spinal cord injury, multiple sclerosis, or brain tumor. A normal
(negative) Babinski response in adults is toe flexion (plantar flexion). Note that a positive Babinski is a normal finding in infants
under 12 months due to incomplete myelination of the corticospinal tract.
