Midterm Exam: NR 569 / NR569
Differential Diagnosis in Acute Care Practicum
Exam Questions & Answers — 100% Correct — Grade A
Total Questions: 150 | 9 Sections | Multiple Choice (A–D)
Latest Update — Aligned with AHA/ACC, Surviving Sepsis, GOLD, & Neurocritical Care Guidelines
Section 1: Acute Care Clinical Reasoning and Diagnostic Strategy (Q1–Q16)
Q1: A 62-year-old presents with acute substernal chest pressure, diaphoresis, and dyspnea. Which
diagnostic strategy is MOST appropriate for the acute care provider to apply FIRST?
A. Order a comprehensive metabolic panel and wait for results before forming a hypothesis
B. Generate a prioritized differential including ACS, PE, aortic dissection, and pneumothorax, then
immediately obtain ECG and troponin [CORRECT]
C. Treat with acetaminophen and re-evaluate in 4 hours
D. Discharge with reassurance if vitals are stable
Correct Answer: B
Rationale: Hypothesis-driven diagnosis in acute care requires generating a prioritized differential focused on
time-sensitive, life-threatening etiologies (ACS, PE, aortic dissection, pneumothorax) and immediately initiating parallel
diagnostic workup (ECG within 10 minutes, troponin, CXR). Waiting for non-urgent labs (A) delays critical intervention.
Acetaminophen (C) and discharge (D) ignore the high-risk presentation. NR 569 emphasizes parallel processing in
time-sensitive differentials.
Q2: Which principle BEST characterizes the SNAPPY approach to acute care differential diagnosis?
A. Sequential evaluation of one diagnosis at a time before considering alternatives
B. Simultaneous consideration of multiple life-threatening diagnoses with parallel diagnostic workup
and empiric treatment of time-critical conditions [CORRECT]
C. Deferring diagnosis until all lab results return
D. Focusing only on the most likely diagnosis based on initial impression
Correct Answer: B
Rationale: SNAPPY (Simultaneous/Narrowed/Analyze/Parallel/Plan/Yield) emphasizes parallel diagnostic processing
— considering multiple life-threatening etiologies simultaneously rather than serial evaluation. This prevents anchoring
bias and missed diagnoses in time-sensitive scenarios. Choices A, C, and D describe serial, delayed, or anchoring
approaches that NR 569 explicitly identifies as high-risk reasoning pitfalls in acute care.
Q3: A 55-year-old presents with syncope, HR 35 (sinus bradycardia), BP 78/45. Which is the IMMEDIATE
priority action?
A. Order a stat head CT to rule out intracranial cause
B. Administer IV atropine 1 mg and prepare for transcutaneous pacing if no response [CORRECT]
C. Administer a beta-blocker to prevent further syncope
D. Place the patient in Trendelenburg and reassess in 30 minutes
,Correct Answer: B
Rationale: Symptomatic bradycardia with hemodynamic compromise requires immediate atropine 1 mg IV push (repeat
q3–5 min to max 3 mg) and transcutaneous pacing if unresponsive. ACS, electrolyte, and drug-induced causes are
evaluated simultaneously. Choice A delays resuscitation — CT is performed after stabilization. Choice C (beta-blocker)
worsens bradycardia. Choice D delays definitive intervention. NR 569 follows ACLS guidelines for symptomatic
bradycardia management.
Q4: Which finding is MOST concerning for a time-sensitive, life-threatening diagnosis requiring
immediate escalation?
A. Heart rate of 95 bpm in a comfortable patient
B. Respiratory rate of 32 with SpO2 88% on room air and altered mental status [CORRECT]
C. Blood pressure of 138/82 mmHg in a chronic hypertensive
D. Temperature of 99.4°F without other symptoms
Correct Answer: B
Rationale: Tachypnea (RR 32), hypoxemia (SpO2 88%), and altered mental status are red-flag findings indicating
respiratory failure with neurologic compromise — a time-sensitive emergency requiring immediate airway/breathing
support, ABG, and rapid evaluation. Choice A, C, D represent stable or non-emergent findings. NR 569 emphasizes
early recognition of respiratory deterioration as a primary determinant of escalation timing.
Q5: When prioritizing differential diagnoses in acute care, which framework BEST supports identifying
time-sensitive conditions?
A. Bayesian analysis focusing on most statistically probable diagnosis
B. Worst-first hypothesis generation — consider the most life-threatening etiologies first and rule
them out rapidly [CORRECT]
C. Occam's razor — prefer the single most unifying diagnosis
D. Hickam's dictum — assume multiple independent diagnoses
Correct Answer: B
Rationale: Worst-first hypothesis generation prioritizes life-threatening conditions (STEMI, PE, aortic dissection, septic
shock, tension pneumothorax) for rapid identification and treatment, recognizing that missing these causes preventable
mortality. Choice A (Bayesian) may anchor to common, less dangerous diagnoses. Choices C and D are cognitive
heuristics useful in chronic but not acute care. NR 569 emphasizes worst-first reasoning in time-sensitive scenarios.
Q6: A 70-year-old presents with confusion, BP 88/52, HR 118, lactate 4.2 mmol/L, and pyuria. Which
diagnosis is MOST likely and what is the IMMEDIATE priority?
A. Delirium from UTI; oral antibiotics and reorientation
B. Septic shock from urosepsis; STAT IV fluids, broad-spectrum antibiotics, and lactate monitoring
per Surviving Sepsis bundle [CORRECT]
C. Hypovolemic shock from dehydration; oral rehydration only
D. Cardiogenic shock; IV furosemide
Correct Answer: B
Rationale: Confusion plus hypotension, tachycardia, lactate ≥2 mmol/L, and a presumed infection source (pyuria)
meets sepsis criteria with septic shock physiology (hypotension requiring vasopressors and lactate >2 despite fluids). The
Surviving Sepsis 2021 Hour-1 bundle requires lactate, blood cultures, broad-spectrum antibiotics, 30 mL/kg crystalloid,
, and vasopressors if hypotensive. Choices A, C, D delay bundle delivery or misidentify shock type. NR 569 emphasizes
rapid sepsis recognition.
Q7: Which laboratory finding warrants the MOST urgent intervention in an acute care patient?
A. Sodium of 132 mEq/L in an asymptomatic patient
B. Potassium of 7.1 mEq/L with peaked T waves and wide QRS [CORRECT]
C. Glucose of 240 mg/dL in a known diabetic
D. BUN of 28 mg/dL in a stable patient
Correct Answer: B
Rationale: Potassium 7.1 mEq/L with peaked T waves and wide QRS indicates severe hyperkalemia with cardiac
toxicity — immediate IV calcium gluconate for membrane stabilization, insulin/glucose, albuterol, and consideration of
dialysis. Choice A is mild, asymptomatic hyponatremia. Choice C requires management but is not immediately
life-threatening. Choice D is mild azotemia. NR 569 tests ECG-based hyperkalemia recognition as a time-critical
diagnosis.
Q8: A 68-year-old presents with acute onset tearing chest pain radiating to the back, BP 185/110 in the
right arm and 140/85 in the left arm. Which is the PRIORITY action?
A. Administer sublingual nitroglycerin for suspected ACS
B. Obtain a stat CT angiogram of the chest and initiate IV beta-blockade for suspected aortic
dissection [CORRECT]
C. Administer IV morphine and reassess pain
D. Begin IV thrombolytics for suspected STEMI
Correct Answer: B
Rationale: Tearing chest pain radiating to the back with blood pressure differential (>20 mmHg between arms) is
classic for aortic dissection — immediate CTA for diagnosis and IV beta-blockade to reduce shear force (target HR
<60, SBP 100–120). Nitroglycerin (A) without beta-blockade can worsen dissection by increasing dP/dt. Morphine (C)
delays diagnosis. Thrombolytics (D) are catastrophic in dissection. NR 569 tests recognition of aortic emergencies
requiring specific management distinct from ACS.
Q9: Which diagnostic test is the GOLD standard for confirming pulmonary embolism in a
hemodynamically stable patient?
A. D-dimer alone
B. CT pulmonary angiography (CTPA) [CORRECT]
C. Ventilation-perfusion (V/Q) scan as first-line in all patients
D. Lower extremity Doppler ultrasound
Correct Answer: B
Rationale: CTPA is the gold standard for PE diagnosis in hemodynamically stable patients due to high
sensitivity/specificity and ability to identify alternative diagnoses. D-dimer (A) has high negative predictive value but is
non-specific. V/Q scan (C) is preferred in patients with contrast allergy, renal failure, or pregnancy (with radiation
concerns). Doppler ultrasound (D) diagnoses DVT but not PE directly. NR 569 tests risk-stratified PE diagnostic
strategy.
, Q10: A 45-year-old presents with sudden severe headache, neck stiffness, and photophobia. CT shows no
hemorrhage. Which is the NEXT appropriate step?
A. Discharge with NSAIDs for tension headache
B. Perform lumbar puncture to evaluate for subarachnoid hemorrhage or meningitis [CORRECT]
C. Begin IV antibiotics for presumed bacterial meningitis without further workup
D. Order an MRI brain and wait for results
Correct Answer: B
Rationale: Sudden severe headache (thunderclap) with meningeal signs warrants lumbar puncture after a negative CT
to detect SAH (xanthochromia, RBCs) or meningitis (CSF analysis). CT sensitivity for SAH is ~100% in first 6 hours but
declines; LP remains essential. Choice A is dangerous — misses life-threatening diagnoses. Choice C is appropriate if
meningitis is suspected but LP should still be attempted before or shortly after antibiotics. Choice D delays diagnosis. NR
569 tests the CT-LP sequence in suspected SAH.
Q11: Which ECG finding is MOST concerning for acute myocardial infarction requiring immediate
reperfusion therapy?
A. PR interval of 200 ms
B. ST-segment elevation of ≥1 mm in two contiguous leads with reciprocal changes [CORRECT]
C. Sinus arrhythmia with HR of 70
D. First-degree AV block with HR of 65
Correct Answer: B
Rationale: ST-segment elevation ≥1 mm in two contiguous leads with reciprocal changes indicates STEMI requiring
immediate reperfusion (PCI within 90 min of first medical contact or thrombolytics within 30 min if PCI unavailable).
Choice A (1° AV block), C (sinus arrhythmia), and D (1° AV block) are benign ECG findings. NR 569 tests STEMI
recognition and the 90-minute door-to-balloon standard per AHA/ACC guidelines.
Q12: Which assessment finding BEST differentiates septic shock from cardiogenic shock?
A. Both present with hypotension; differentiation requires SVR and cardiac output assessment, with
septic shock showing high CO/low SVR (warm extremities) and cardiogenic shock showing low
CO/high SVR (cool extremities) [CORRECT]
B. Septic shock always has bradycardia; cardiogenic shock always has tachycardia
C. Septic shock has dry warm skin; cardiogenic shock has wet cool skin
D. Both have identical clinical presentations
Correct Answer: A
Rationale: Both shock types present with hypotension, but their hemodynamic profiles differ: septic shock (distributive)
typically shows high cardiac output, low systemic vascular resistance, and warm extremities early; cardiogenic shock
shows low CO, high SVR, cool clammy extremities. Choice B is incorrect — both typically present with tachycardia.
Choice C is incomplete. Choice D is incorrect. NR 569 tests shock type differentiation by hemodynamic profile.
Q13: A patient with COPD presents with respiratory rate 32, SpO2 88% on room air, and ABG showing
pH 7.28, PaCO2 70, PaO2 55. Which is the MOST appropriate interpretation?
A. Mild hypoxemia; discharge with home oxygen
B. Acute hypercapnic respiratory failure (Type II) with respiratory acidosis requiring noninvasive
ventilation (BiPAP) [CORRECT]
Differential Diagnosis in Acute Care Practicum
Exam Questions & Answers — 100% Correct — Grade A
Total Questions: 150 | 9 Sections | Multiple Choice (A–D)
Latest Update — Aligned with AHA/ACC, Surviving Sepsis, GOLD, & Neurocritical Care Guidelines
Section 1: Acute Care Clinical Reasoning and Diagnostic Strategy (Q1–Q16)
Q1: A 62-year-old presents with acute substernal chest pressure, diaphoresis, and dyspnea. Which
diagnostic strategy is MOST appropriate for the acute care provider to apply FIRST?
A. Order a comprehensive metabolic panel and wait for results before forming a hypothesis
B. Generate a prioritized differential including ACS, PE, aortic dissection, and pneumothorax, then
immediately obtain ECG and troponin [CORRECT]
C. Treat with acetaminophen and re-evaluate in 4 hours
D. Discharge with reassurance if vitals are stable
Correct Answer: B
Rationale: Hypothesis-driven diagnosis in acute care requires generating a prioritized differential focused on
time-sensitive, life-threatening etiologies (ACS, PE, aortic dissection, pneumothorax) and immediately initiating parallel
diagnostic workup (ECG within 10 minutes, troponin, CXR). Waiting for non-urgent labs (A) delays critical intervention.
Acetaminophen (C) and discharge (D) ignore the high-risk presentation. NR 569 emphasizes parallel processing in
time-sensitive differentials.
Q2: Which principle BEST characterizes the SNAPPY approach to acute care differential diagnosis?
A. Sequential evaluation of one diagnosis at a time before considering alternatives
B. Simultaneous consideration of multiple life-threatening diagnoses with parallel diagnostic workup
and empiric treatment of time-critical conditions [CORRECT]
C. Deferring diagnosis until all lab results return
D. Focusing only on the most likely diagnosis based on initial impression
Correct Answer: B
Rationale: SNAPPY (Simultaneous/Narrowed/Analyze/Parallel/Plan/Yield) emphasizes parallel diagnostic processing
— considering multiple life-threatening etiologies simultaneously rather than serial evaluation. This prevents anchoring
bias and missed diagnoses in time-sensitive scenarios. Choices A, C, and D describe serial, delayed, or anchoring
approaches that NR 569 explicitly identifies as high-risk reasoning pitfalls in acute care.
Q3: A 55-year-old presents with syncope, HR 35 (sinus bradycardia), BP 78/45. Which is the IMMEDIATE
priority action?
A. Order a stat head CT to rule out intracranial cause
B. Administer IV atropine 1 mg and prepare for transcutaneous pacing if no response [CORRECT]
C. Administer a beta-blocker to prevent further syncope
D. Place the patient in Trendelenburg and reassess in 30 minutes
,Correct Answer: B
Rationale: Symptomatic bradycardia with hemodynamic compromise requires immediate atropine 1 mg IV push (repeat
q3–5 min to max 3 mg) and transcutaneous pacing if unresponsive. ACS, electrolyte, and drug-induced causes are
evaluated simultaneously. Choice A delays resuscitation — CT is performed after stabilization. Choice C (beta-blocker)
worsens bradycardia. Choice D delays definitive intervention. NR 569 follows ACLS guidelines for symptomatic
bradycardia management.
Q4: Which finding is MOST concerning for a time-sensitive, life-threatening diagnosis requiring
immediate escalation?
A. Heart rate of 95 bpm in a comfortable patient
B. Respiratory rate of 32 with SpO2 88% on room air and altered mental status [CORRECT]
C. Blood pressure of 138/82 mmHg in a chronic hypertensive
D. Temperature of 99.4°F without other symptoms
Correct Answer: B
Rationale: Tachypnea (RR 32), hypoxemia (SpO2 88%), and altered mental status are red-flag findings indicating
respiratory failure with neurologic compromise — a time-sensitive emergency requiring immediate airway/breathing
support, ABG, and rapid evaluation. Choice A, C, D represent stable or non-emergent findings. NR 569 emphasizes
early recognition of respiratory deterioration as a primary determinant of escalation timing.
Q5: When prioritizing differential diagnoses in acute care, which framework BEST supports identifying
time-sensitive conditions?
A. Bayesian analysis focusing on most statistically probable diagnosis
B. Worst-first hypothesis generation — consider the most life-threatening etiologies first and rule
them out rapidly [CORRECT]
C. Occam's razor — prefer the single most unifying diagnosis
D. Hickam's dictum — assume multiple independent diagnoses
Correct Answer: B
Rationale: Worst-first hypothesis generation prioritizes life-threatening conditions (STEMI, PE, aortic dissection, septic
shock, tension pneumothorax) for rapid identification and treatment, recognizing that missing these causes preventable
mortality. Choice A (Bayesian) may anchor to common, less dangerous diagnoses. Choices C and D are cognitive
heuristics useful in chronic but not acute care. NR 569 emphasizes worst-first reasoning in time-sensitive scenarios.
Q6: A 70-year-old presents with confusion, BP 88/52, HR 118, lactate 4.2 mmol/L, and pyuria. Which
diagnosis is MOST likely and what is the IMMEDIATE priority?
A. Delirium from UTI; oral antibiotics and reorientation
B. Septic shock from urosepsis; STAT IV fluids, broad-spectrum antibiotics, and lactate monitoring
per Surviving Sepsis bundle [CORRECT]
C. Hypovolemic shock from dehydration; oral rehydration only
D. Cardiogenic shock; IV furosemide
Correct Answer: B
Rationale: Confusion plus hypotension, tachycardia, lactate ≥2 mmol/L, and a presumed infection source (pyuria)
meets sepsis criteria with septic shock physiology (hypotension requiring vasopressors and lactate >2 despite fluids). The
Surviving Sepsis 2021 Hour-1 bundle requires lactate, blood cultures, broad-spectrum antibiotics, 30 mL/kg crystalloid,
, and vasopressors if hypotensive. Choices A, C, D delay bundle delivery or misidentify shock type. NR 569 emphasizes
rapid sepsis recognition.
Q7: Which laboratory finding warrants the MOST urgent intervention in an acute care patient?
A. Sodium of 132 mEq/L in an asymptomatic patient
B. Potassium of 7.1 mEq/L with peaked T waves and wide QRS [CORRECT]
C. Glucose of 240 mg/dL in a known diabetic
D. BUN of 28 mg/dL in a stable patient
Correct Answer: B
Rationale: Potassium 7.1 mEq/L with peaked T waves and wide QRS indicates severe hyperkalemia with cardiac
toxicity — immediate IV calcium gluconate for membrane stabilization, insulin/glucose, albuterol, and consideration of
dialysis. Choice A is mild, asymptomatic hyponatremia. Choice C requires management but is not immediately
life-threatening. Choice D is mild azotemia. NR 569 tests ECG-based hyperkalemia recognition as a time-critical
diagnosis.
Q8: A 68-year-old presents with acute onset tearing chest pain radiating to the back, BP 185/110 in the
right arm and 140/85 in the left arm. Which is the PRIORITY action?
A. Administer sublingual nitroglycerin for suspected ACS
B. Obtain a stat CT angiogram of the chest and initiate IV beta-blockade for suspected aortic
dissection [CORRECT]
C. Administer IV morphine and reassess pain
D. Begin IV thrombolytics for suspected STEMI
Correct Answer: B
Rationale: Tearing chest pain radiating to the back with blood pressure differential (>20 mmHg between arms) is
classic for aortic dissection — immediate CTA for diagnosis and IV beta-blockade to reduce shear force (target HR
<60, SBP 100–120). Nitroglycerin (A) without beta-blockade can worsen dissection by increasing dP/dt. Morphine (C)
delays diagnosis. Thrombolytics (D) are catastrophic in dissection. NR 569 tests recognition of aortic emergencies
requiring specific management distinct from ACS.
Q9: Which diagnostic test is the GOLD standard for confirming pulmonary embolism in a
hemodynamically stable patient?
A. D-dimer alone
B. CT pulmonary angiography (CTPA) [CORRECT]
C. Ventilation-perfusion (V/Q) scan as first-line in all patients
D. Lower extremity Doppler ultrasound
Correct Answer: B
Rationale: CTPA is the gold standard for PE diagnosis in hemodynamically stable patients due to high
sensitivity/specificity and ability to identify alternative diagnoses. D-dimer (A) has high negative predictive value but is
non-specific. V/Q scan (C) is preferred in patients with contrast allergy, renal failure, or pregnancy (with radiation
concerns). Doppler ultrasound (D) diagnoses DVT but not PE directly. NR 569 tests risk-stratified PE diagnostic
strategy.
, Q10: A 45-year-old presents with sudden severe headache, neck stiffness, and photophobia. CT shows no
hemorrhage. Which is the NEXT appropriate step?
A. Discharge with NSAIDs for tension headache
B. Perform lumbar puncture to evaluate for subarachnoid hemorrhage or meningitis [CORRECT]
C. Begin IV antibiotics for presumed bacterial meningitis without further workup
D. Order an MRI brain and wait for results
Correct Answer: B
Rationale: Sudden severe headache (thunderclap) with meningeal signs warrants lumbar puncture after a negative CT
to detect SAH (xanthochromia, RBCs) or meningitis (CSF analysis). CT sensitivity for SAH is ~100% in first 6 hours but
declines; LP remains essential. Choice A is dangerous — misses life-threatening diagnoses. Choice C is appropriate if
meningitis is suspected but LP should still be attempted before or shortly after antibiotics. Choice D delays diagnosis. NR
569 tests the CT-LP sequence in suspected SAH.
Q11: Which ECG finding is MOST concerning for acute myocardial infarction requiring immediate
reperfusion therapy?
A. PR interval of 200 ms
B. ST-segment elevation of ≥1 mm in two contiguous leads with reciprocal changes [CORRECT]
C. Sinus arrhythmia with HR of 70
D. First-degree AV block with HR of 65
Correct Answer: B
Rationale: ST-segment elevation ≥1 mm in two contiguous leads with reciprocal changes indicates STEMI requiring
immediate reperfusion (PCI within 90 min of first medical contact or thrombolytics within 30 min if PCI unavailable).
Choice A (1° AV block), C (sinus arrhythmia), and D (1° AV block) are benign ECG findings. NR 569 tests STEMI
recognition and the 90-minute door-to-balloon standard per AHA/ACC guidelines.
Q12: Which assessment finding BEST differentiates septic shock from cardiogenic shock?
A. Both present with hypotension; differentiation requires SVR and cardiac output assessment, with
septic shock showing high CO/low SVR (warm extremities) and cardiogenic shock showing low
CO/high SVR (cool extremities) [CORRECT]
B. Septic shock always has bradycardia; cardiogenic shock always has tachycardia
C. Septic shock has dry warm skin; cardiogenic shock has wet cool skin
D. Both have identical clinical presentations
Correct Answer: A
Rationale: Both shock types present with hypotension, but their hemodynamic profiles differ: septic shock (distributive)
typically shows high cardiac output, low systemic vascular resistance, and warm extremities early; cardiogenic shock
shows low CO, high SVR, cool clammy extremities. Choice B is incorrect — both typically present with tachycardia.
Choice C is incomplete. Choice D is incorrect. NR 569 tests shock type differentiation by hemodynamic profile.
Q13: A patient with COPD presents with respiratory rate 32, SpO2 88% on room air, and ABG showing
pH 7.28, PaCO2 70, PaO2 55. Which is the MOST appropriate interpretation?
A. Mild hypoxemia; discharge with home oxygen
B. Acute hypercapnic respiratory failure (Type II) with respiratory acidosis requiring noninvasive
ventilation (BiPAP) [CORRECT]
