1|Page
NR 509 FINAL ACTUAL EXAM PREP 2026 ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ALREADY A
GRADED WITH EXPERT FEEDBACK |NEW AND
REVISED
1. A 55-year-old male presents with a 2-week history of progressive
shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. On
physical examination, you note jugular venous distention, crackles at the
lung bases, and 2+ pitting edema in the lower extremities. Which of the
following is the most likely underlying pathophysiologic mechanism?
A. Right-sided heart failure
B. Left-sided heart failure
C. Pulmonary embolism
D. Chronic obstructive pulmonary disease
Rationale: Left-sided heart failure leads to pulmonary congestion
(crackles, dyspnea, orthopnea) and forward failure (fatigue). The
findings of JVD and peripheral edema indicate right-sided heart
failure as well, but the pulmonary symptoms point to left-sided failure
as the primary pathology. Pulmonary embolism typically presents
acutely with pleuritic chest pain and hypoxia.
2. A 45-year-old female presents with a 3-day history of fever,
productive cough, and pleuritic chest pain. On auscultation, you note
crackles in the right lower lobe. Which of the following is the most
appropriate next step in the physical examination?
,2|Page
A. Assess for egophony
B. Assess for tactile fremitus
C. Assess for bronchophony
D. Assess for whispered pectoriloquy
Rationale: Tactile fremitus is increased in consolidation (pneumonia)
due to enhanced transmission of vocal vibrations through the
consolidated lung tissue. Egophony, bronchophony, and whispered
pectoriloquy are also findings of consolidation, but tactile fremitus is
the most direct physical assessment finding and should be assessed
systematically.
3. A 68-year-old male presents with a 6-month history of progressive
weakness in his right arm and leg. He also reports difficulty with speech
and swallowing. On neurological examination, you note hyperreflexia in
the right upper and lower extremities, a positive Babinski sign on the
right, and muscle atrophy in the right hand. Which of the following is
the most likely diagnosis?
A. Amyotrophic lateral sclerosis (ALS)
B. Multiple sclerosis
C. Parkinson's disease
D. Stroke
Rationale: ALS presents with both upper motor neuron (hyperreflexia,
Babinski) and lower motor neuron (muscle atrophy, fasciculations)
signs. The progressive nature, combined upper and lower motor
neuron findings, and bulbar symptoms (speech, swallowing) point to
ALS rather than MS (which has relapsing-remitting pattern) or stroke
(sudden onset).
,3|Page
4. A 32-year-old female presents with a 3-month history of fatigue, joint
pain, and a malar rash that worsens with sun exposure. On physical
examination, you note erythematous plaques on the cheeks and bridge of
the nose, sparing the nasolabial folds. You also note painless oral ulcers.
Which of the following is the most appropriate next step?
A. Referral for dermatologic evaluation
B. Laboratory testing including ANA and anti-dsDNA
C. Skin biopsy of the malar rash
D. Topical corticosteroid therapy
Rationale: The malar rash sparing the nasolabial folds,
photosensitivity, oral ulcers, and arthralgias are classic features of
systemic lupus erythematosus. Laboratory testing including ANA and
anti-dsDNA is the appropriate next step to confirm the diagnosis.
While the rash itself may be biopsied, systemic evaluation should be
prioritized.
5. A 72-year-old female presents with a 2-week history of pain and
stiffness in her shoulders, hips, and neck. She reports that the stiffness is
worse in the morning and lasts for more than an hour. She also reports
fatigue and a low-grade fever. On physical examination, you note
limited active range of motion in the shoulders and hips but no joint
swelling or erythema. Which of the following is the most likely
diagnosis?
A. Rheumatoid arthritis
B. Polymyalgia rheumatica
C. Osteoarthritis
D. Fibromyalgia
Rationale: Polymyalgia rheumatica presents with bilateral pain and
stiffness in the shoulders, hips, and neck, worse in the morning,
lasting >1 hour. The absence of joint swelling and erythema
, 4|Page
distinguishes it from rheumatoid arthritis. ESR and CRP are typically
markedly elevated.
6. A 55-year-old male with a 30-pack-year smoking history presents
with a 3-month history of hoarseness and a sensation of a lump in his
throat. On physical examination, you note a firm, fixed mass in the left
anterior neck. Which of the following is the most appropriate next step?
A. Thyroid ultrasound
B. CT of the neck
C. Laryngoscopy
D. Fine needle aspiration
Rationale: Hoarseness and a neck mass in a smoker raise concern for
laryngeal or hypopharyngeal malignancy. Laryngoscopy is the
appropriate next step to visualize the larynx and hypopharynx. While
thyroid ultrasound and CT may be useful, direct visualization of the
larynx is essential.
7. A 28-year-old male presents with a 2-week history of headache, fever,
and nuchal rigidity. On physical examination, you note Kernig's sign and
Brudzinski's sign. Which of the following is the most appropriate next
step?
A. Head CT without contrast
B. Head CT with contrast
C. MRI of the brain
D. Lumbar puncture
Rationale: The combination of fever, headache, nuchal rigidity,
Kernig's and Brudzinski's signs is highly suggestive of meningitis.
Lumbar puncture is the diagnostic procedure of choice. Head CT
NR 509 FINAL ACTUAL EXAM PREP 2026 ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ALREADY A
GRADED WITH EXPERT FEEDBACK |NEW AND
REVISED
1. A 55-year-old male presents with a 2-week history of progressive
shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. On
physical examination, you note jugular venous distention, crackles at the
lung bases, and 2+ pitting edema in the lower extremities. Which of the
following is the most likely underlying pathophysiologic mechanism?
A. Right-sided heart failure
B. Left-sided heart failure
C. Pulmonary embolism
D. Chronic obstructive pulmonary disease
Rationale: Left-sided heart failure leads to pulmonary congestion
(crackles, dyspnea, orthopnea) and forward failure (fatigue). The
findings of JVD and peripheral edema indicate right-sided heart
failure as well, but the pulmonary symptoms point to left-sided failure
as the primary pathology. Pulmonary embolism typically presents
acutely with pleuritic chest pain and hypoxia.
2. A 45-year-old female presents with a 3-day history of fever,
productive cough, and pleuritic chest pain. On auscultation, you note
crackles in the right lower lobe. Which of the following is the most
appropriate next step in the physical examination?
,2|Page
A. Assess for egophony
B. Assess for tactile fremitus
C. Assess for bronchophony
D. Assess for whispered pectoriloquy
Rationale: Tactile fremitus is increased in consolidation (pneumonia)
due to enhanced transmission of vocal vibrations through the
consolidated lung tissue. Egophony, bronchophony, and whispered
pectoriloquy are also findings of consolidation, but tactile fremitus is
the most direct physical assessment finding and should be assessed
systematically.
3. A 68-year-old male presents with a 6-month history of progressive
weakness in his right arm and leg. He also reports difficulty with speech
and swallowing. On neurological examination, you note hyperreflexia in
the right upper and lower extremities, a positive Babinski sign on the
right, and muscle atrophy in the right hand. Which of the following is
the most likely diagnosis?
A. Amyotrophic lateral sclerosis (ALS)
B. Multiple sclerosis
C. Parkinson's disease
D. Stroke
Rationale: ALS presents with both upper motor neuron (hyperreflexia,
Babinski) and lower motor neuron (muscle atrophy, fasciculations)
signs. The progressive nature, combined upper and lower motor
neuron findings, and bulbar symptoms (speech, swallowing) point to
ALS rather than MS (which has relapsing-remitting pattern) or stroke
(sudden onset).
,3|Page
4. A 32-year-old female presents with a 3-month history of fatigue, joint
pain, and a malar rash that worsens with sun exposure. On physical
examination, you note erythematous plaques on the cheeks and bridge of
the nose, sparing the nasolabial folds. You also note painless oral ulcers.
Which of the following is the most appropriate next step?
A. Referral for dermatologic evaluation
B. Laboratory testing including ANA and anti-dsDNA
C. Skin biopsy of the malar rash
D. Topical corticosteroid therapy
Rationale: The malar rash sparing the nasolabial folds,
photosensitivity, oral ulcers, and arthralgias are classic features of
systemic lupus erythematosus. Laboratory testing including ANA and
anti-dsDNA is the appropriate next step to confirm the diagnosis.
While the rash itself may be biopsied, systemic evaluation should be
prioritized.
5. A 72-year-old female presents with a 2-week history of pain and
stiffness in her shoulders, hips, and neck. She reports that the stiffness is
worse in the morning and lasts for more than an hour. She also reports
fatigue and a low-grade fever. On physical examination, you note
limited active range of motion in the shoulders and hips but no joint
swelling or erythema. Which of the following is the most likely
diagnosis?
A. Rheumatoid arthritis
B. Polymyalgia rheumatica
C. Osteoarthritis
D. Fibromyalgia
Rationale: Polymyalgia rheumatica presents with bilateral pain and
stiffness in the shoulders, hips, and neck, worse in the morning,
lasting >1 hour. The absence of joint swelling and erythema
, 4|Page
distinguishes it from rheumatoid arthritis. ESR and CRP are typically
markedly elevated.
6. A 55-year-old male with a 30-pack-year smoking history presents
with a 3-month history of hoarseness and a sensation of a lump in his
throat. On physical examination, you note a firm, fixed mass in the left
anterior neck. Which of the following is the most appropriate next step?
A. Thyroid ultrasound
B. CT of the neck
C. Laryngoscopy
D. Fine needle aspiration
Rationale: Hoarseness and a neck mass in a smoker raise concern for
laryngeal or hypopharyngeal malignancy. Laryngoscopy is the
appropriate next step to visualize the larynx and hypopharynx. While
thyroid ultrasound and CT may be useful, direct visualization of the
larynx is essential.
7. A 28-year-old male presents with a 2-week history of headache, fever,
and nuchal rigidity. On physical examination, you note Kernig's sign and
Brudzinski's sign. Which of the following is the most appropriate next
step?
A. Head CT without contrast
B. Head CT with contrast
C. MRI of the brain
D. Lumbar puncture
Rationale: The combination of fever, headache, nuchal rigidity,
Kernig's and Brudzinski's signs is highly suggestive of meningitis.
Lumbar puncture is the diagnostic procedure of choice. Head CT
