1
Midterm Exam: NR 509/ NR509 Advanced Physical
Assessment Actual Exam 2026/2027 Midterm Exam
Questions with Verified Answers (Latest 2026/2027
Actual Exam)- Chamberlain
Item ID: NR509-MID-001
Item Type: NGN: (Prioritization)
Scenario: A 68-year-old male presents with a new complaint of "some dizziness"
and fatigue. Past medical history is significant only for controlled hypertension.
During the cardiovascular assessment, you note the following: BP 138/86 mmHg,
HR 52 bpm, regular rhythm. JVP is elevated to 5 cm above the sternal angle (7 cm
total). Auscultation reveals a Grade III/VI crescendo-decrescendo systolic murmur
heard best at the right upper sternal border (RUSB), radiating to the neck/carotids.
S2 is diminished and split is paradoxically closed with expiration. The apical
impulse is sustained and slightly displaced laterally.
Question: Based on the advanced physical assessment findings, which two clinical
actions should the FNP prioritize for this patient before initiating routine diagnostic
workup?
Options:
A. Immediately order a complete lipid panel and A1C.
B. Initiate a stat consultation with Cardiology for urgent intervention planning.
C. Order a transthoracic echocardiogram (TTE) for definitive structural
assessment.
D. Place the patient on continuous cardiac monitoring and obtain a 12 -lead ECG.
(Correct Choices: B & D)
Rationale (Verified):
• Correct Answer: B & D.
• Advanced Assessment Analysis: The physical exam findings are classic for
severe aortic stenosis (AS): The Grade III/VI crescendo-decrescendo
, 2
systolic murmur at the RUSB radiating to the carotids, diminished S2, and
sustained apical impulse (suggesting left ventricular hypertrophy/strain) all
point strongly to severe AS. The elevated JVP indicates right -sided volume
overload or failing heart/increased end-diastolic pressure. The associated
symptoms (dizziness/fatigue) and bradycardia (HR 52 bpm) combined with
the severe AS findings place the patient at high risk for syncope, sudden
cardiac death, or acute decompensation. Urgent consultation (B) is needed
for rapid definitive management (TTE and intervention planning).
Immediate cardiac monitoring (D) is critical to detect and manage high-
grade AV block or life-threatening arrhythmias associated with severe AS
and bradycardia, preventing sudden death.
• Distractor Breakdown:
o A: Routine labs (lipids/A1C) are necessary but are not the immediate
priority over emergent cardiac risk stratification and management for
severe symptomatic AS.
o C: TTE is necessary for definitive diagnosis and quantification but
consultation (B) and monitoring (D) must precede the TTE result
due to the high-risk presentation. The assessment findings themselves
are enough to justify the consult and monitoring.
Item ID: NR509-MID-002
Item Type: Complex MCQ
Scenario: A 32-year-old female presents with a 4-week history of fatigue, weight
loss, and an intermittent low-grade fever. Upon general assessment, she appears
thin with mild scleral icterus. Abdominal assessment reveals a firm, non -tender
spleen palpable 3 cm below the left costal margin (LCM). The liver is also slightly
enlarged and tender to palpation. Capillary refill is brisk, and no lymphadenopathy
is noted in the neck or axillae.
Question: Which advanced assessment technique should the FNP perform next to
specifically evaluate the most likely underlying etiology suggested by the physical
exam findings?
Options:
A. Percuss Traube's space to confirm splenic enlargement.
B. Perform an advanced mental status exam (e.g., Mini-Cog) to check for hepatic
encephalopathy.
, 3
C. Assess for asterixis (flapping tremor) and measure abdominal girth for ascites.
D. Palpate for supraclavicular and epitrochlear lymphadenopathy.
Rationale (Verified):
• Correct Answer: D.
• Advanced Assessment Analysis: The triad of fever, splenomegaly, and
lymphadenopathy (even if not yet found in common sites) is a classic
presentation for systemic illnesses, particularly infectious mononucleosis
(though less likely in this age with weight loss), hematologic malignancies
(e.g., lymphoma, leukemia), or chronic systemic infections (e.g., HIV, TB).
Splenomegaly (3 cm below LCM) with systemic symptoms (fever, weight
loss) warrants a meticulous search for all signs of systemic disease.
Supraclavicular and epitrochlear lymphadenopathy (D) are highly
suggestive of systemic malignancy (e.g., lymphoma) or advanced
infection/autoimmune disease and must be specifically sought out in the
presence of unexplained splenomegaly and B-symptoms (fever, weight loss,
night sweats).
• Distractor Breakdown:
o A: Percussing Traube's space confirms the finding but doesn't advance
the differential diagnosis. Palpation already established the
splenomegaly.
o B: Hepatic encephalopathy is a late-stage complication of liver
failure; while the liver is enlarged/tender, the immediate concern is
identifying the cause of the splenomegaly and systemic symptoms.
o C: Ascites and asterixis are signs of advanced portal
hypertension/cirrhosis, which is less likely to present with fever and
prominent splenomegaly without a known history of chronic liver
disease.
Item ID: NR509-MID-003
Item Type: NGN: (Interpretation)
Scenario: A 4-year-old child presents with a high-pitched, barking cough that is
worse at night. Respiratory rate is 28 breaths/min, and oxygen saturation is 98% on
room air. The child appears anxious. During the lung assessment, you note
inspiratory stridor that is louder with agitation. The child is retracting slightly at
the suprasternal notch. Breath sounds are clear to auscultation bilaterally.
, 4
Question: Match the specific physical exam finding to its most likely anatomical
source of obstruction in a pediatric patient.
Options: (Match the finding on the left to the source on the right)
1. Barking cough
2. Inspiratory stridor louder with agitation
3. Suprasternal retractions
A. Intrathoracic airways (bronchi/bronchioles)
B. Lower airway (trachea below the sternal notch)
C. Extrathoracic airways (larynx/upper trachea)
D. Pulmonary parenchyma (alveoli/interstitium)
(Correct Choices: 1-C, 2-C, 3-C)
Rationale (Verified):
• Correct Answer: 1-C, 2-C, 3-C.
• Advanced Assessment Analysis: This is the classic presentation of
laryngotracheitis (Croup), which involves inflammation and edema of the
extrathoracic airways (larynx/upper trachea) (C).
o Barking cough (1) is specifically due to inflammation/edema around
the vocal cords in the larynx.
o Inspiratory stridor (2) occurs when air attempts to pass through a
narrowed extrathoracic (above the sternal notch) airway. It is louder
with agitation/effort because the negative inspiratory pressure
increases.
o Suprasternal retractions (3) are a visible sign of using accessory
muscles to overcome the obstruction in the upper/extrathoracic
airway. Obstruction lower in the chest would cause intercostal or
subcostal retractions.
• Distractor Breakdown: A, B, and D describe lower airway or lung tissue
issues (e.g., asthma, bronchiolitis, pneumonia), which would typically
present with wheezing, rales, or expiratory difficulty/retractions, not the
classic croup findings of barking cough and primarily inspiratory stridor.
Item ID: NR509-MID-004
Midterm Exam: NR 509/ NR509 Advanced Physical
Assessment Actual Exam 2026/2027 Midterm Exam
Questions with Verified Answers (Latest 2026/2027
Actual Exam)- Chamberlain
Item ID: NR509-MID-001
Item Type: NGN: (Prioritization)
Scenario: A 68-year-old male presents with a new complaint of "some dizziness"
and fatigue. Past medical history is significant only for controlled hypertension.
During the cardiovascular assessment, you note the following: BP 138/86 mmHg,
HR 52 bpm, regular rhythm. JVP is elevated to 5 cm above the sternal angle (7 cm
total). Auscultation reveals a Grade III/VI crescendo-decrescendo systolic murmur
heard best at the right upper sternal border (RUSB), radiating to the neck/carotids.
S2 is diminished and split is paradoxically closed with expiration. The apical
impulse is sustained and slightly displaced laterally.
Question: Based on the advanced physical assessment findings, which two clinical
actions should the FNP prioritize for this patient before initiating routine diagnostic
workup?
Options:
A. Immediately order a complete lipid panel and A1C.
B. Initiate a stat consultation with Cardiology for urgent intervention planning.
C. Order a transthoracic echocardiogram (TTE) for definitive structural
assessment.
D. Place the patient on continuous cardiac monitoring and obtain a 12 -lead ECG.
(Correct Choices: B & D)
Rationale (Verified):
• Correct Answer: B & D.
• Advanced Assessment Analysis: The physical exam findings are classic for
severe aortic stenosis (AS): The Grade III/VI crescendo-decrescendo
, 2
systolic murmur at the RUSB radiating to the carotids, diminished S2, and
sustained apical impulse (suggesting left ventricular hypertrophy/strain) all
point strongly to severe AS. The elevated JVP indicates right -sided volume
overload or failing heart/increased end-diastolic pressure. The associated
symptoms (dizziness/fatigue) and bradycardia (HR 52 bpm) combined with
the severe AS findings place the patient at high risk for syncope, sudden
cardiac death, or acute decompensation. Urgent consultation (B) is needed
for rapid definitive management (TTE and intervention planning).
Immediate cardiac monitoring (D) is critical to detect and manage high-
grade AV block or life-threatening arrhythmias associated with severe AS
and bradycardia, preventing sudden death.
• Distractor Breakdown:
o A: Routine labs (lipids/A1C) are necessary but are not the immediate
priority over emergent cardiac risk stratification and management for
severe symptomatic AS.
o C: TTE is necessary for definitive diagnosis and quantification but
consultation (B) and monitoring (D) must precede the TTE result
due to the high-risk presentation. The assessment findings themselves
are enough to justify the consult and monitoring.
Item ID: NR509-MID-002
Item Type: Complex MCQ
Scenario: A 32-year-old female presents with a 4-week history of fatigue, weight
loss, and an intermittent low-grade fever. Upon general assessment, she appears
thin with mild scleral icterus. Abdominal assessment reveals a firm, non -tender
spleen palpable 3 cm below the left costal margin (LCM). The liver is also slightly
enlarged and tender to palpation. Capillary refill is brisk, and no lymphadenopathy
is noted in the neck or axillae.
Question: Which advanced assessment technique should the FNP perform next to
specifically evaluate the most likely underlying etiology suggested by the physical
exam findings?
Options:
A. Percuss Traube's space to confirm splenic enlargement.
B. Perform an advanced mental status exam (e.g., Mini-Cog) to check for hepatic
encephalopathy.
, 3
C. Assess for asterixis (flapping tremor) and measure abdominal girth for ascites.
D. Palpate for supraclavicular and epitrochlear lymphadenopathy.
Rationale (Verified):
• Correct Answer: D.
• Advanced Assessment Analysis: The triad of fever, splenomegaly, and
lymphadenopathy (even if not yet found in common sites) is a classic
presentation for systemic illnesses, particularly infectious mononucleosis
(though less likely in this age with weight loss), hematologic malignancies
(e.g., lymphoma, leukemia), or chronic systemic infections (e.g., HIV, TB).
Splenomegaly (3 cm below LCM) with systemic symptoms (fever, weight
loss) warrants a meticulous search for all signs of systemic disease.
Supraclavicular and epitrochlear lymphadenopathy (D) are highly
suggestive of systemic malignancy (e.g., lymphoma) or advanced
infection/autoimmune disease and must be specifically sought out in the
presence of unexplained splenomegaly and B-symptoms (fever, weight loss,
night sweats).
• Distractor Breakdown:
o A: Percussing Traube's space confirms the finding but doesn't advance
the differential diagnosis. Palpation already established the
splenomegaly.
o B: Hepatic encephalopathy is a late-stage complication of liver
failure; while the liver is enlarged/tender, the immediate concern is
identifying the cause of the splenomegaly and systemic symptoms.
o C: Ascites and asterixis are signs of advanced portal
hypertension/cirrhosis, which is less likely to present with fever and
prominent splenomegaly without a known history of chronic liver
disease.
Item ID: NR509-MID-003
Item Type: NGN: (Interpretation)
Scenario: A 4-year-old child presents with a high-pitched, barking cough that is
worse at night. Respiratory rate is 28 breaths/min, and oxygen saturation is 98% on
room air. The child appears anxious. During the lung assessment, you note
inspiratory stridor that is louder with agitation. The child is retracting slightly at
the suprasternal notch. Breath sounds are clear to auscultation bilaterally.
, 4
Question: Match the specific physical exam finding to its most likely anatomical
source of obstruction in a pediatric patient.
Options: (Match the finding on the left to the source on the right)
1. Barking cough
2. Inspiratory stridor louder with agitation
3. Suprasternal retractions
A. Intrathoracic airways (bronchi/bronchioles)
B. Lower airway (trachea below the sternal notch)
C. Extrathoracic airways (larynx/upper trachea)
D. Pulmonary parenchyma (alveoli/interstitium)
(Correct Choices: 1-C, 2-C, 3-C)
Rationale (Verified):
• Correct Answer: 1-C, 2-C, 3-C.
• Advanced Assessment Analysis: This is the classic presentation of
laryngotracheitis (Croup), which involves inflammation and edema of the
extrathoracic airways (larynx/upper trachea) (C).
o Barking cough (1) is specifically due to inflammation/edema around
the vocal cords in the larynx.
o Inspiratory stridor (2) occurs when air attempts to pass through a
narrowed extrathoracic (above the sternal notch) airway. It is louder
with agitation/effort because the negative inspiratory pressure
increases.
o Suprasternal retractions (3) are a visible sign of using accessory
muscles to overcome the obstruction in the upper/extrathoracic
airway. Obstruction lower in the chest would cause intercostal or
subcostal retractions.
• Distractor Breakdown: A, B, and D describe lower airway or lung tissue
issues (e.g., asthma, bronchiolitis, pneumonia), which would typically
present with wheezing, rales, or expiratory difficulty/retractions, not the
classic croup findings of barking cough and primarily inspiratory stridor.
Item ID: NR509-MID-004
