NSG 550 EXAM 1 2 3 – DIAGNOSTIC REASONING Wilkes University |
Verified Q&A + Rationales (2026-)
Master advanced health assessment frameworks and ace your nurse practitioner
milestones with this complete 2026/2027 Wilkes University NSG 550 study package
covering Exams 1, 2, and 3. This comprehensive test bank features high-yield practice
questions paired with 100% verified answers and detailed clinical rationales exploring
differential diagnosis formulation, screening tool interpretation, and laboratory analysis.
It is an indispensable resource for graduate nursing students looking to optimize study
routines, sharpen diagnostic reasoning skills, and confidently secure an A+ grade.
1. A 68-year-old male with a 45-pack-year smoking history presents with
progressive dyspnea, chronic productive cough, and wheezing. His ABG on room
air shows pH 7.36, PaCO₂ 52 mmHg, PaO₂ 58 mmHg, and HCO₃⁻ 31 mEq/L. This
ABG pattern is MOST consistent with which acid-base disorder?
A) Acute respiratory acidosis without compensation
B) Chronic respiratory acidosis with renal compensation
C) Metabolic alkalosis with respiratory compensation
D) Mixed respiratory and metabolic acidosis
Correct Answer: B) Chronic respiratory acidosis with renal compensation
Rationale: The ABG shows pH 7.36 (compensated, near normal), PaCO₂ 52 mmHg
(elevated, indicating respiratory acidosis), and HCO₃⁻ 31 mEq/L (elevated, indicating renal
compensation). This pattern is classic for chronic respiratory acidosis, commonly seen in
advanced COPD with renal compensation. In acute respiratory acidosis, HCO₃⁻ would be
normal (22-26) with a significantly lower pH .
2. A 72-year-old female presents with acute confusion, urinary incontinence, and
unsteady gait. Her family reports symptom onset over the past 48 hours. She has a
history of hypertension and type 2 diabetes. Her urinalysis shows positive nitrites
and leukocyte esterase. What is the MOST likely diagnosis?
A) Alzheimer's disease
B) Delirium secondary to urinary tract infection
C) Normal pressure hydrocephalus
D) Parkinson's disease
,Correct Answer: B) Delirium secondary to urinary tract infection
Rationale: Delirium is characterized by acute onset, fluctuating course, and identifiable
trigger (UTI). The classic triad of confusion, incontinence, and gait instability in an elderly
patient with acute onset is delirium, not dementia. The positive urinalysis confirms a UTI
as the underlying cause. Delirium is potentially reversible with treatment of the infection .
3. A 55-year-old male presents with a 2-week history of progressive weakness in
his lower extremities, difficulty walking, and urinary retention. He reports a recent
upper respiratory infection. On examination, he has bilateral lower extremity
weakness, hyperreflexia, and a sensory level at T10. What is the MOST appropriate
initial diagnostic test?
A) MRI of the spine with and without contrast
B) CT of the spine without contrast
C) Lumbar puncture
D) EMG/nerve conduction studies
Correct Answer: A) MRI of the spine with and without contrast
Rationale: The presentation of progressive lower extremity weakness, sensory level, and
urinary retention in the setting of a recent respiratory infection suggests transverse
myelitis or spinal cord compression. MRI of the spine is the imaging modality of choice to
evaluate for cord compression, demyelination, or inflammation. A sensory level is a "red
flag" requiring urgent imaging .
4. A 45-year-old female presents with palpitations, heat intolerance, weight loss
despite increased appetite, and fine tremor. Her TSH is <0.01 mIU/L (normal 0.4-
4.0) and free T4 is elevated. What is the MOST likely diagnosis?
A) Primary hypothyroidism
B) Graves' disease (hyperthyroidism)
C) Subclinical hypothyroidism
D) Thyroiditis
Correct Answer: B) Graves' disease (hyperthyroidism)
Rationale: Suppressed TSH with elevated free T4 indicates hyperthyroidism. Symptoms of
palpitations, heat intolerance, weight loss, and tremor are classic for Graves' disease, the
most common cause of hyperthyroidism. The suppressed TSH is due to lack of negative
feedback from elevated thyroid hormone levels. Graves' disease is autoimmune and often
associated with goiter and ophthalmopathy .
,5. A 62-year-old male with a history of coronary artery disease presents with
acute-onset chest pain, shortness of breath, and diaphoresis. His ECG shows ST
elevation in leads II, III, and aVF. Which coronary artery is MOST likely occluded?
A) Left anterior descending artery (LAD)
B) Right coronary artery (RCA)
C) Left circumflex artery (LCx)
D) Left main coronary artery
Correct Answer: B) Right coronary artery (RCA)
Rationale: ST elevation in the inferior leads (II, III, aVF) indicates an inferior wall
myocardial infarction, which is most commonly caused by occlusion of the right coronary
artery (RCA). The LAD supplies the anterior wall (V1-V4), the LCx supplies the lateral wall
(I, aVL, V5-V6), and left main occlusion would cause extensive ST elevation with
hemodynamic instability .
6. A 60-year-old female with a history of diabetes and hypertension presents with
acute-onset right-sided weakness, facial droop, and aphasia. Her symptoms
started 1.5 hours ago. Her blood pressure is 165/95 mmHg. What is the MOST
appropriate immediate diagnostic test before treatment?
A) MRI brain with diffusion-weighted imaging
B) CT head without contrast
C) Carotid Doppler ultrasound
D) CT angiography of the head and neck
Correct Answer: B) CT head without contrast
Rationale: In acute stroke within the thrombolytic window, a non-contrast head CT is the
first and most critical test to rule out intracranial hemorrhage before administering tPA.
The patient is within the 4.5-hour window for tPA, but hemorrhage must be excluded first.
MRI is not typically done emergently. CT angiography is useful for identifying large vessel
occlusion but not as the first test .
7. A 50-year-old female presents with progressive dyspnea on exertion, non-
productive cough, and fatigue. Chest X-ray shows bilateral interstitial infiltrates
with a "ground glass" appearance. Her pulmonary function tests reveal a
restrictive pattern with decreased DLCO. What is the MOST likely diagnosis?
A) COPD (emphysema)
B) Idiopathic pulmonary fibrosis (IPF)
C) Asthma
D) Sarcoidosis
, Correct Answer: B) Idiopathic pulmonary fibrosis (IPF)
Rationale: The combination of progressive dyspnea, non-productive cough, restrictive
pattern on PFTs, decreased DLCO, and bilateral interstitial infiltrates with ground-glass
appearance on CXR is classic for IPF. IPF is a restrictive lung disease with fibrosis and
diffusion impairment. COPD is obstructive with increased lung volumes, not restrictive .
8. A 35-year-old male presents with a 6-month history of progressively worsening
fatigue, joint pain, and a malar rash. He reports photosensitivity and oral ulcers.
His laboratory results show positive ANA, anti-dsDNA, and low complement levels.
What is the MOST likely diagnosis?
A) Rheumatoid arthritis
B) Systemic lupus erythematosus (SLE)
C) Sjögren's syndrome
D) Scleroderma
Correct Answer: B) Systemic lupus erythematosus (SLE)
Rationale: The combination of malar rash, photosensitivity, oral ulcers, joint pain, positive
ANA, positive anti-dsDNA, and low complement levels is diagnostic of SLE. The anti-
dsDNA antibody is highly specific for SLE. Rheumatoid arthritis typically presents with
symmetric joint pain and positive rheumatoid factor, not malar rash. Sjögren's presents
with dry eyes and dry mouth .
9. A 68-year-old male with a history of hypertension and diabetes presents with a
sudden, severe headache described as the "worst headache of my life." He reports
nausea and vomiting. On examination, he has nuchal rigidity. What is the MOST
appropriate initial diagnostic test?
A) Lumbar puncture
B) CT head without contrast
C) MRI brain
D) CT angiography
Correct Answer: B) CT head without contrast
Rationale: A thunderclap headache with nuchal rigidity is suspicious for subarachnoid
hemorrhage (SAH). A non-contrast head CT is the first-line test to detect SAH. If the CT is
negative, a lumbar puncture is performed to evaluate for xanthochromia (blood
breakdown products) to rule out SAH. Lumbar puncture should not be performed without
first ruling out a mass lesion or increased intracranial pressure .
10. A 45-year-old female with a history of asthma presents with acute wheezing,
shortness of breath, and cough. Her peak expiratory flow rate is 45% of predicted.
Verified Q&A + Rationales (2026-)
Master advanced health assessment frameworks and ace your nurse practitioner
milestones with this complete 2026/2027 Wilkes University NSG 550 study package
covering Exams 1, 2, and 3. This comprehensive test bank features high-yield practice
questions paired with 100% verified answers and detailed clinical rationales exploring
differential diagnosis formulation, screening tool interpretation, and laboratory analysis.
It is an indispensable resource for graduate nursing students looking to optimize study
routines, sharpen diagnostic reasoning skills, and confidently secure an A+ grade.
1. A 68-year-old male with a 45-pack-year smoking history presents with
progressive dyspnea, chronic productive cough, and wheezing. His ABG on room
air shows pH 7.36, PaCO₂ 52 mmHg, PaO₂ 58 mmHg, and HCO₃⁻ 31 mEq/L. This
ABG pattern is MOST consistent with which acid-base disorder?
A) Acute respiratory acidosis without compensation
B) Chronic respiratory acidosis with renal compensation
C) Metabolic alkalosis with respiratory compensation
D) Mixed respiratory and metabolic acidosis
Correct Answer: B) Chronic respiratory acidosis with renal compensation
Rationale: The ABG shows pH 7.36 (compensated, near normal), PaCO₂ 52 mmHg
(elevated, indicating respiratory acidosis), and HCO₃⁻ 31 mEq/L (elevated, indicating renal
compensation). This pattern is classic for chronic respiratory acidosis, commonly seen in
advanced COPD with renal compensation. In acute respiratory acidosis, HCO₃⁻ would be
normal (22-26) with a significantly lower pH .
2. A 72-year-old female presents with acute confusion, urinary incontinence, and
unsteady gait. Her family reports symptom onset over the past 48 hours. She has a
history of hypertension and type 2 diabetes. Her urinalysis shows positive nitrites
and leukocyte esterase. What is the MOST likely diagnosis?
A) Alzheimer's disease
B) Delirium secondary to urinary tract infection
C) Normal pressure hydrocephalus
D) Parkinson's disease
,Correct Answer: B) Delirium secondary to urinary tract infection
Rationale: Delirium is characterized by acute onset, fluctuating course, and identifiable
trigger (UTI). The classic triad of confusion, incontinence, and gait instability in an elderly
patient with acute onset is delirium, not dementia. The positive urinalysis confirms a UTI
as the underlying cause. Delirium is potentially reversible with treatment of the infection .
3. A 55-year-old male presents with a 2-week history of progressive weakness in
his lower extremities, difficulty walking, and urinary retention. He reports a recent
upper respiratory infection. On examination, he has bilateral lower extremity
weakness, hyperreflexia, and a sensory level at T10. What is the MOST appropriate
initial diagnostic test?
A) MRI of the spine with and without contrast
B) CT of the spine without contrast
C) Lumbar puncture
D) EMG/nerve conduction studies
Correct Answer: A) MRI of the spine with and without contrast
Rationale: The presentation of progressive lower extremity weakness, sensory level, and
urinary retention in the setting of a recent respiratory infection suggests transverse
myelitis or spinal cord compression. MRI of the spine is the imaging modality of choice to
evaluate for cord compression, demyelination, or inflammation. A sensory level is a "red
flag" requiring urgent imaging .
4. A 45-year-old female presents with palpitations, heat intolerance, weight loss
despite increased appetite, and fine tremor. Her TSH is <0.01 mIU/L (normal 0.4-
4.0) and free T4 is elevated. What is the MOST likely diagnosis?
A) Primary hypothyroidism
B) Graves' disease (hyperthyroidism)
C) Subclinical hypothyroidism
D) Thyroiditis
Correct Answer: B) Graves' disease (hyperthyroidism)
Rationale: Suppressed TSH with elevated free T4 indicates hyperthyroidism. Symptoms of
palpitations, heat intolerance, weight loss, and tremor are classic for Graves' disease, the
most common cause of hyperthyroidism. The suppressed TSH is due to lack of negative
feedback from elevated thyroid hormone levels. Graves' disease is autoimmune and often
associated with goiter and ophthalmopathy .
,5. A 62-year-old male with a history of coronary artery disease presents with
acute-onset chest pain, shortness of breath, and diaphoresis. His ECG shows ST
elevation in leads II, III, and aVF. Which coronary artery is MOST likely occluded?
A) Left anterior descending artery (LAD)
B) Right coronary artery (RCA)
C) Left circumflex artery (LCx)
D) Left main coronary artery
Correct Answer: B) Right coronary artery (RCA)
Rationale: ST elevation in the inferior leads (II, III, aVF) indicates an inferior wall
myocardial infarction, which is most commonly caused by occlusion of the right coronary
artery (RCA). The LAD supplies the anterior wall (V1-V4), the LCx supplies the lateral wall
(I, aVL, V5-V6), and left main occlusion would cause extensive ST elevation with
hemodynamic instability .
6. A 60-year-old female with a history of diabetes and hypertension presents with
acute-onset right-sided weakness, facial droop, and aphasia. Her symptoms
started 1.5 hours ago. Her blood pressure is 165/95 mmHg. What is the MOST
appropriate immediate diagnostic test before treatment?
A) MRI brain with diffusion-weighted imaging
B) CT head without contrast
C) Carotid Doppler ultrasound
D) CT angiography of the head and neck
Correct Answer: B) CT head without contrast
Rationale: In acute stroke within the thrombolytic window, a non-contrast head CT is the
first and most critical test to rule out intracranial hemorrhage before administering tPA.
The patient is within the 4.5-hour window for tPA, but hemorrhage must be excluded first.
MRI is not typically done emergently. CT angiography is useful for identifying large vessel
occlusion but not as the first test .
7. A 50-year-old female presents with progressive dyspnea on exertion, non-
productive cough, and fatigue. Chest X-ray shows bilateral interstitial infiltrates
with a "ground glass" appearance. Her pulmonary function tests reveal a
restrictive pattern with decreased DLCO. What is the MOST likely diagnosis?
A) COPD (emphysema)
B) Idiopathic pulmonary fibrosis (IPF)
C) Asthma
D) Sarcoidosis
, Correct Answer: B) Idiopathic pulmonary fibrosis (IPF)
Rationale: The combination of progressive dyspnea, non-productive cough, restrictive
pattern on PFTs, decreased DLCO, and bilateral interstitial infiltrates with ground-glass
appearance on CXR is classic for IPF. IPF is a restrictive lung disease with fibrosis and
diffusion impairment. COPD is obstructive with increased lung volumes, not restrictive .
8. A 35-year-old male presents with a 6-month history of progressively worsening
fatigue, joint pain, and a malar rash. He reports photosensitivity and oral ulcers.
His laboratory results show positive ANA, anti-dsDNA, and low complement levels.
What is the MOST likely diagnosis?
A) Rheumatoid arthritis
B) Systemic lupus erythematosus (SLE)
C) Sjögren's syndrome
D) Scleroderma
Correct Answer: B) Systemic lupus erythematosus (SLE)
Rationale: The combination of malar rash, photosensitivity, oral ulcers, joint pain, positive
ANA, positive anti-dsDNA, and low complement levels is diagnostic of SLE. The anti-
dsDNA antibody is highly specific for SLE. Rheumatoid arthritis typically presents with
symmetric joint pain and positive rheumatoid factor, not malar rash. Sjögren's presents
with dry eyes and dry mouth .
9. A 68-year-old male with a history of hypertension and diabetes presents with a
sudden, severe headache described as the "worst headache of my life." He reports
nausea and vomiting. On examination, he has nuchal rigidity. What is the MOST
appropriate initial diagnostic test?
A) Lumbar puncture
B) CT head without contrast
C) MRI brain
D) CT angiography
Correct Answer: B) CT head without contrast
Rationale: A thunderclap headache with nuchal rigidity is suspicious for subarachnoid
hemorrhage (SAH). A non-contrast head CT is the first-line test to detect SAH. If the CT is
negative, a lumbar puncture is performed to evaluate for xanthochromia (blood
breakdown products) to rule out SAH. Lumbar puncture should not be performed without
first ruling out a mass lesion or increased intracranial pressure .
10. A 45-year-old female with a history of asthma presents with acute wheezing,
shortness of breath, and cough. Her peak expiratory flow rate is 45% of predicted.
