NR 509 FINAL EXAM QUESTIONS AND
ANSWERS 100% GUARANTEED
DISTINCTION 2025/2026
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
ANSWERS 100% GUARANTEED
DISTINCTION 2025/2026
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
