NR 509 Final Exam WITH ACCURATE
SOLUTIONS /PASS GUIDE 2026 WITH
RATIONALES
Appendicitis - -ANS☑️☑️--1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing
sign, and the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates
to the RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point - -ANS☑️☑️--1. McBurney point lies 2 inches from the
anterior superior spinous process of ilium on a line drawn from that process
to the umbilicus
2. Appendicitis is three times more likely if there is McBurney point
tenderness.
Rovsing sign - -ANS☑️☑️--Press deeply and evenly in the LLQ. Then quickly
withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Psoas Sign - -ANS☑️☑️----Place your hand just above the patient's right knee
and ask the patient to raise that thigh against your hand. Alternatively, ask
,the patient to turn onto the left side. Then extend the patient's right leg at the
hip. Flexion of the leg at the hip makes the psoas muscle contract; extension
stretches it.
--Increased abdominal pain on either maneuver is a positive psoas sign, sug-
gesting irritation of the psoas muscle by an inflamed appendix.
Obturator Sign - -ANS☑️☑️----Less helpful
--Flex the patient's right thigh at the hip, with the knee bent, and rotate the
leg internally at the hip. This maneuver stretches the internal obturator
muscle.
--Right hypogastric pain is a positive obturator sign, from irritation of the
obturator muscle by an inflamed appendix. This sign has very low sensitivity.
Acute Cholecystits - -ANS☑️☑️--RUQ pain
Murphy Sign
Murphy Sign - -ANS☑️☑️--Hook your left thumb or the fingers of your right
hand under the costal margin at the point where the lateral border of the
rectus muscle intersects with the costal margin. Alternatively, palpate the
RUQ with the fingers of your right hand near the costal margin. If the liver is
enlarged, hook your thumb or fingers under the liver edge at a comparable
point. Ask the patient to take a deep breath, which forces the liver and
gallbladder down toward the examining fingers. Watch the patient's breathing
and note the degree of tenderness.
--A sharp increase in tenderness with inspiratory effort is a positive Murphy
sign. When positive, Murphy sign triples the likelihood of acute cholecystitis.
Acute Pancreatitis Process - -ANS☑️☑️--Intrapancreatic trypsinogen
activation to trypsin and other enzymes, result-ing in autodigestion and
inflammation of the pancreas
,Acute Pancreatitis Location - -ANS☑️☑️--Epigastric, may radiate straight to
the back or other areas of the abdomen; 20% with severe sequelae of organ
failure
Acute Pancreatitis Quality - -ANS☑️☑️--Usually steady
Acute PancreatitisTiming - -ANS☑️☑️--Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - -ANS☑️☑️--Lying supine; dyspnea if
pleural effusions from capillary leak syn-drome; selected medications, high
triglycerides may exacerbate
Acute Pancreatitis Relieving factors - -ANS☑️☑️--Leaning forward with trunk
flexed
Acute Pancreatitis Associated Symptoms and Setting - -ANS☑️☑️--Nausea,
vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of
alcohol abuse or gallstones
Peptic Ulcer Disease Process - -ANS☑️☑️--Mucosal ulcer in stomach or duode-
num >5 mm, covered with fibrin, ex-tending through the muscularis mu-cosa;
H. pylori infection present in 90% of peptic ulcers
Peptic Ulcer Disease Location - -ANS☑️☑️--Epigastric, may radiate straight to
the back
Peptic Ulcer Disease Quality - -ANS☑️☑️--Variable: epigastric gnawing or
burning (dyspepsia); may also be boring, aching, or hungerlike
, No symptoms in up to 20%
Peptic Ulcer Disease Timing - -ANS☑️☑️--Intermittent; duodenal ulcer is more
likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient
at night, and (2) occurs intermittently over a few wks, disappears for months,
then recurs
Peptic Ulcer Disease aggravating factors - -ANS☑️☑️--Variable
Peptic Ulcer Disease relieving factors - -ANS☑️☑️--Food and antacids may
bring re-lief (less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - -ANS☑️☑️--Nausea,
vomiting, belching, bloating; heartburn (more common in duodenal ulcer);
weight loss (more common in gastric ulcer); dyspepsia is more com-mon in
the young (20-29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in
those 30-60 yrs
GERD Process - -ANS☑️☑️--Prolonged exposure of esophagus to gastric acid
due to impaired esopha-geal motility or excess relaxations of the lower
esophageal sphincter; Helico-bacter pylori may be present
GERD Location - -ANS☑️☑️--Chest or epigastric
GERD Quality - -ANS☑️☑️--Heartburn, regurgitation
GERD timing - -ANS☑️☑️--After meals, especially spicy foods
SOLUTIONS /PASS GUIDE 2026 WITH
RATIONALES
Appendicitis - -ANS☑️☑️--1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing
sign, and the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates
to the RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point - -ANS☑️☑️--1. McBurney point lies 2 inches from the
anterior superior spinous process of ilium on a line drawn from that process
to the umbilicus
2. Appendicitis is three times more likely if there is McBurney point
tenderness.
Rovsing sign - -ANS☑️☑️--Press deeply and evenly in the LLQ. Then quickly
withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Psoas Sign - -ANS☑️☑️----Place your hand just above the patient's right knee
and ask the patient to raise that thigh against your hand. Alternatively, ask
,the patient to turn onto the left side. Then extend the patient's right leg at the
hip. Flexion of the leg at the hip makes the psoas muscle contract; extension
stretches it.
--Increased abdominal pain on either maneuver is a positive psoas sign, sug-
gesting irritation of the psoas muscle by an inflamed appendix.
Obturator Sign - -ANS☑️☑️----Less helpful
--Flex the patient's right thigh at the hip, with the knee bent, and rotate the
leg internally at the hip. This maneuver stretches the internal obturator
muscle.
--Right hypogastric pain is a positive obturator sign, from irritation of the
obturator muscle by an inflamed appendix. This sign has very low sensitivity.
Acute Cholecystits - -ANS☑️☑️--RUQ pain
Murphy Sign
Murphy Sign - -ANS☑️☑️--Hook your left thumb or the fingers of your right
hand under the costal margin at the point where the lateral border of the
rectus muscle intersects with the costal margin. Alternatively, palpate the
RUQ with the fingers of your right hand near the costal margin. If the liver is
enlarged, hook your thumb or fingers under the liver edge at a comparable
point. Ask the patient to take a deep breath, which forces the liver and
gallbladder down toward the examining fingers. Watch the patient's breathing
and note the degree of tenderness.
--A sharp increase in tenderness with inspiratory effort is a positive Murphy
sign. When positive, Murphy sign triples the likelihood of acute cholecystitis.
Acute Pancreatitis Process - -ANS☑️☑️--Intrapancreatic trypsinogen
activation to trypsin and other enzymes, result-ing in autodigestion and
inflammation of the pancreas
,Acute Pancreatitis Location - -ANS☑️☑️--Epigastric, may radiate straight to
the back or other areas of the abdomen; 20% with severe sequelae of organ
failure
Acute Pancreatitis Quality - -ANS☑️☑️--Usually steady
Acute PancreatitisTiming - -ANS☑️☑️--Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - -ANS☑️☑️--Lying supine; dyspnea if
pleural effusions from capillary leak syn-drome; selected medications, high
triglycerides may exacerbate
Acute Pancreatitis Relieving factors - -ANS☑️☑️--Leaning forward with trunk
flexed
Acute Pancreatitis Associated Symptoms and Setting - -ANS☑️☑️--Nausea,
vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of
alcohol abuse or gallstones
Peptic Ulcer Disease Process - -ANS☑️☑️--Mucosal ulcer in stomach or duode-
num >5 mm, covered with fibrin, ex-tending through the muscularis mu-cosa;
H. pylori infection present in 90% of peptic ulcers
Peptic Ulcer Disease Location - -ANS☑️☑️--Epigastric, may radiate straight to
the back
Peptic Ulcer Disease Quality - -ANS☑️☑️--Variable: epigastric gnawing or
burning (dyspepsia); may also be boring, aching, or hungerlike
, No symptoms in up to 20%
Peptic Ulcer Disease Timing - -ANS☑️☑️--Intermittent; duodenal ulcer is more
likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient
at night, and (2) occurs intermittently over a few wks, disappears for months,
then recurs
Peptic Ulcer Disease aggravating factors - -ANS☑️☑️--Variable
Peptic Ulcer Disease relieving factors - -ANS☑️☑️--Food and antacids may
bring re-lief (less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - -ANS☑️☑️--Nausea,
vomiting, belching, bloating; heartburn (more common in duodenal ulcer);
weight loss (more common in gastric ulcer); dyspepsia is more com-mon in
the young (20-29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in
those 30-60 yrs
GERD Process - -ANS☑️☑️--Prolonged exposure of esophagus to gastric acid
due to impaired esopha-geal motility or excess relaxations of the lower
esophageal sphincter; Helico-bacter pylori may be present
GERD Location - -ANS☑️☑️--Chest or epigastric
GERD Quality - -ANS☑️☑️--Heartburn, regurgitation
GERD timing - -ANS☑️☑️--After meals, especially spicy foods
