NR509 /NR 509 Final Exam (Latest 2024 /2025) Advanced Physical Assessment - Chamberlain

NR 509 Final Exam 1. A 35-year-old female with a history of migraines pre- Take a further hissents to the clinic with worsening symptoms for the tory and perform a past few weeks. She reports waking up at night with very careful neuroheadaches and nausea. Her only medication history is logical exam oral contraceptive pills (OCPs). Otherwise, she states she is healthy. Which of the following actions if taken by the NP is the best next step?

2. A grandmother is accompanying her 9-year-old grand- IV daughter during a routine physical examination. She asks you privately if her granddaughter has started puberty yet. During the examination, the NP notes asymmetric projection of the areola and nipple of the right chest to form a secondary mound above the level of the breast. The left breast is underdeveloped.

These assessment findings are consistent with which Tanner Stage of development?

3. Primary prevention is defined as which of the follow- Interventions deing? signed to prevent disease 4. Based on the U.S. Preventive Services Task Force Mammography is (USPSTF) recommendations, which of the following recommended statements is true about screening for breast cancer every 2 years for in average-risk women? women aged 50-74 with insufficient evidence for screening women over the age of 75.

5. Which of the following statements is true regarding Target blood presrecommendations by the eighth Joint National Com- sure should be mittee (JNC8) for adults aged 60 and older? Select all </= 150/90 mmHg that apply. but notes that if treatment results in SBP <140 and is "well tolerated 1 / 21

NR 509 Final Exam and without adverse effects to health or quality of live, treatment does not need to be adjusted."

In those aged 80 or older, blood pressure targets of 140 to <150/70 to 80 appear optimal for notable reductions in stroke, cardiovascular events, and all-cause mortality.

6. Which of the following is a useful strategy when ex- Have the paramining young children between the ages of 1 and 4? ent facilitate the exam (e.g., removing clothes, holding the child on lap).

"It often takes the 7. The NP is completing the review of systems on a 4-month-old female during a routine encounter. Which baby more than 30 minutes to finish a statement from the parent may indicate a cardiac bottle." problem in the infant and require a more thorough subjective history?

8. A 16-year-old male presents to the clinic with a history CNIII of a congenital right upper eyelid drooping as represented in this image. He has no complaints and denies injury or trauma. Which cranial nerve (CN) is involved in this condition?

Patient with eyelid drooping 9.

CN IX 2 / 21

NR 509 Final Exam Which cranial nerve (CN) innervates the muscles of the pharynx and provides sensory fibers to portions of the tympanic membrane, auditory canal, pharynx, and the posterior third of the tongue?

10. The NP should suspect injury to which cranial nerve CNIII (CN) if a patient presents with complaints of photosensitivity and uneven pupils after being struck in the eye with a baseball?

11. Which of the following statements is true regarding Obesity doubles risks and rapid recognition of suspected stroke? Se- the risk of stroke lect all that apply even without associated glucose intolerance Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke 12. The combination of both receptive and expressive aphasia is a characteristic of which type of speech disorder?

global aphasia

13. The NP is assessing a 42-year-old female who preDo you have any sents to the clinic with recurring headaches. What is aura prior to the an effective question to ask the patient? headaches?

14. A 55-year-old female presents to the clinic with a The patient reheadache. During the interview, which of the following ports fever, night symptoms should prompt the NP to be concerned and sweats, and thinks investigate further? she lost weight.

15. When grading muscle strength on a scale of 1 to 5, a Active movement grade of 3 indicates which of the following? against gravity 16. Which musculoskeletal disorder is paired correctly with the associated systemic manifestations?

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Lyme disease and expanding erythe-

NR 509 Final Exam matous targetoid patch in early illness 17. A 62-year-old female has a diagnosis of rheumatoid Swelling of the arthritis (RA). Which of the following are expected synovial tissue in assessment findings consistent with the diagnosis? joints and tendon sheaths.

18. A 58-year-old male complains of pain in his knees, hips, hands, wrists, neck, and lower back. Based on the joints involved, the NP suspects that the patient most likely has which condition?

Osteoarthritis

19. A 55-year-old male has a diagnosis of lumbar spinal Flexed forward stenosis. Which sign should the NP expect to find on posture with lowexamination that is most consistent with the diagno- er extremity weaksis? ness 20. What is the action(s) of the erector spinae muscle group?

Extension of the spine

Compare the 21. A 17-year-old male presents to the clinic for a follow-up appointment. He fractured his left arm 8 weeks strength of the ago and remains in a cast. Upon inspection, the NP trapezius muscles finds that his shoulder heights are unequal and there is winging of the scapula. The NP suspects contralateral weakness and muscle wasting as the etiology for the winged scapula. Which of the following physical assessment maneuvers should the NP perform to confirm the suspension?

22. A 31-year-old female presents to the clinic with a Torticollis worsening stiff, painful neck. On inspection, the patient's head is laterally deviated toward the shoulder and rotated. Given this specific physical assessment finding, what condition should the NP suspect as a differential diagnosis?

23.

Sacrospinalis 4 / 21

NR 509 Final Exam During an evaluation of an athletic 30-year-old female, the NP conducts an active range of motion evaluation at the neck. All of the following muscles are being assessed when the patient is asked to extend, flex, and rotate the neck, EXCEPT? 24. A 58-year-old male complains of lower back pain for ankylosing many years. He denies a recent injury. On examina- spondylitis tion, the NP finds that the patient has tenderness to palpation over the sacroiliac joint. Which of the following conditions is most consistent with this physical sign?

25. Which of the following statements is true regarding prostate cancer screening?

Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on balancing

26. A 53-year-old African American male presents for This patient is at discussion of his prostate cancer risk and possible an elevated risk screening for this disease. His father was diagnosed of prostate cancer at age 82 years with prostate cancer but died recently due to his famat age 87 years from a myocardial infarction before the ily history; thus, disease progressed. Family history also reveals that screening modalihis mother died of ovarian cancer when he was age ties should be dis10 years, and two of his maternal aunts had breast cussed between cancer. Which of the following is true about prostate the patient and cancer risk for this patient and subsequent screen- provider. ing?

27. A 34-year-old female presents to primary care for Inflammatory bowfollow-up regarding anal pain with defecation. A re- el disease cent referral to GI for anoscopic examination revealed anal fissures that appear to be her source of pain.

In addition, today she reports that she has developed episodic abdominal discomfort and sores in her mouth. Which of the following underlying conditions is the NP most likely to find?

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NR 509 Final Exam 28. A 45-year-old female presents to the primary care clin- recent onset ic. She complains of recently experiencing a change of small-caliber in the patterns of her bowel movements. Her PMH is stools significant for bleeding ulcers as well as Crohn's disease. Her family medical history includes a maternal aunt who died of colon cancer at age 49 years. Which of the following historical elements would be most concerning for colon cancer in this patient?

29. A 67-year-old female presents to the office for an These findings annual check-up. She retired as a police captain at suggest osage 66. Now she enjoys gardening and water aeroteoarthritis bics several days a week. She states, "staying active keeps me limber". After a careful history and physical examination, the NP documents the following musculoskeletal system findings: Full range of motion in all joints. Hands with Heberden nodes at the DIP joints, Bouchard nodes at PIP joints. Mild pain with flexion, extension, and rotation of both hips. Full range of motion in the knees, with moderate crepitus. No effusion but bony enlargement along the tibiofemoral joint line bilaterally. Both feet with hallux valgus at the first MTP joints. Which of the following is the most accurate interpretation of these findings?

30. A 50-year-old male presents to the office for a rouThese findings tine physical examination. He has no complaints. His suggest no abdPMH is significant for non-alcoholic fatty liver disease normalities and high cholesterol for which he is taking fenofibrate. On the social history intake form, he reported consuming 8 ounces of malt liquor daily for 20 years. After a careful history and physical examination, the NP documents the following nervous system findings: Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Speech is fluent, follows commands.

Detailed cognitive testing deferred. Cranial Nerves: I—not tested; II through XII intact. Motor: Normal mus6 / 21

NR 509 Final Exam cle bulk and tone. Strength 5/5 throughout. No pronator drift. Cerebellar—Rapid alternating movements (RAMs), finger-to-nose (F’N), heel-to-shin (H’S) intact.

Gait with normal stance and stride. Sensory: Pinprick, light touch, position, and vibration intact. Romberg— maintains balance with eyes closed. Reflexes: 2+ and symmetric with plantar reflexes downgoing. Which of the following is the most accurate interpretation of these findings?

31. Which cranial nerve (CN) is being assessed by the CNXI examiner in this image? ADA Description: Examiner's hands placed on anterior shoulders while patient shrugs both shoulders upward against hands.

32. What assessment test is being performed in this im- Weber test age? ADA Description: Tuning fork on top of the head.

33. A 74-year-old man presents to the clinic for a sched- Cotton wool spots uled annual examination. He has a history of hypertension and diabetes, both controlled with medication. He denies any complaints. The NP performed a fundoscopic examination. Identify the abnormal assessment findings in this image. ADA Description: Accumulations of axoplasmic debris within adjacent bundles of unmyelinated ganglion cell axons of the retina.

34. A 66-year-old female presents to the office for a Deny her request, focused visit to discuss hypertension management inform the pastrategies. During the interview, the patient asks the tient that she has NP if she could be screened today for cervical can- had three negative cer/HPV. Review of her medical record reveals she screenings in the was screened at ages 57, 60, and 63, with no abnormal last 10 years and findings, and no history of cancer. What is the best no longer requires action the NP should take regarding the patient's re- screening, and foquest for screening? cus on the reason for the visit.

35.35.

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NR 509 Final Exam Of the following statements, which is true regarding the human papillomavirus (HPV) vaccine?

The vaccine can protect against anogenital lesions

36. A 21-year-old female presents for her first annual Raised friable or exam. She reports concern because her female part- lobed lesions ner was recently diagnosed with condyloma acuminata and wonders if she could also be infected. If true, what physical assessment findings would the NP expect to find during the speculum examination?

37. An 18-year-old female presents to the clinic complain- Cervical os ing of a thick and yellow vaginal discharge along with recent pelvic pain. Her history is significant for pelvic inflammatory disease (PID). During the speculum examination, the NP would expect to find purulent discharge in the following area(s) which is consistent with the diagnosis of PID? 38. A 23-year-old female presents to the clinic. She has She is on her decided to discontinue using condoms and would like menses a different birth control option. Her last pelvic exam was 2 years ago when she had a negative Pap smear and STI screening. Her LMP was 2 days ago, and she is still spotting. She last had sex with her boyfriend 1 week ago. Condoms were used. The NP elects to postpone her speculum exam during this office encounter. What is the best evidence-based rationale for the decision to postpone her exam?

39. A 24-year-old female presents to the clinic for an an- Transformation nual exam. The NP proceeds to perform a Pap smear zone and understands that the most important area on the cervix to obtain cells for the Pap smear is where?

40. A 45-year-old female presents to the clinic for heavy These findings periods and pelvic pain during her menses. She suggest uterine fireached menarche at age 13 years and has had reg- broids ular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her hus8 / 21

NR 509 Final Exam band has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her LMP was 1 week ago. On a bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27.

Which of the following is the most likely interpretation of these findings?

41. A 48-year-old female presents to the clinic with com- These findings plaints of heavy vaginal discharge and severe itching suggest candida for 1 week. On visualization of the vulva, a thick, white, vaginitis curdy discharge is seen at the introitus. On speculum examination, there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae. Which of the following is the most accurate interpretation of these findings?

42. Cervical motion tenderness and/or adnexal tenderness are hallmarks of all the following conditions, EXCEPT?

Bacterial vaginosis

43. A 30-year-old female presents to the clinic with com- These findings plaints of a bad-smelling vaginal discharge with some suggest bacterial mild itching for about 3 weeks. She denies pain with vaginosis urination or with sexual intercourse. She also reports that the smell increased after intercourse and during her period last week. After a careful history and physical assessment, the NP documents the following pelvic and anorectal examination findings: Bilateral shotty inguinal adenopathy. External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with thin white homogeneous discharge with a mild fishy odor. After swabbing the cervix, no discharge is visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood. pH of vaginal discharge

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NR 509 Final Exam >4.5. Which of the following is the most accurate interpretation of these findings?

44. The NP knows it is possible to palpate multiple struc- Internal inguinal tures in relation to the inguinal canal and related rings hernias while performing a physical examination on male patients. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region?

45. What are the most predominant risk factors for prostate cancer?

Age Ethnicity Family history

46. A patient presents with right-upper quadrant (RUQ) Murphy Sign pain but does not have any tenderness on palpation in the RUQ. The NP is suspicious of acute cholecystitis. The NP knows to perform which assessment test next?

47. Pain in the right-lower quadrant (RLQ) during deep, Blumberg sign even palpation of the left-lower quadrant (LLQ) then quickly withdrawing your fingers indicates what positive assessment finding?

48. The NP suspects a patient has appendicitis. Identify McBurney Sign the physical examination maneuver done by applying pressure halfway between the umbilicus and the anterior spine of the ilium?

49. Which assessment finding would be most suggestive Associated right of a diagnosis of biliary colic? shoulder pain 50. Which of the following physical assessment finding Pressing down is most suggestive of peritonitis secondary to a rup- onto the abdomen tured appendix? firmly and quickly withdrawals the hand produces pain 10 / 21

NR 509 Final Exam 51. A 76-year-old female presents to the office for an an- Do not screen rounual physical. Upon reviewing her history, she had a tinely positive FOBT on one occasion at age 66 years. Subsequent colonoscopy revealed internal hemorrhoids and sigmoid diverticuli only. She has no firstdegree relatives with a history of colorectal cancer or adenomatous polyps. What is the U.S. Preventive Services Task Force (USPSTF) screening recommendation for this particular patient?

52. A 30-year-old male is admitted to the hospital for ab- These findings dominal pain. He reports steady, aching pain that be- suggest acute gan suddenly around his naval and now involves the peritonitis lower abdomen. He also reports a decreased appetite with nausea but no vomiting. After a careful history and physical examination, the NP documents the following abdominal findings: The abdomen is flat, firm, and rigid, with increased tenderness and guarding in the right lower quadrant. No bowel sounds heard.

Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses. No CVA tenderness. Psoas sign positive.

Blumberg sign positive. Which of the following is the most accurate interpretation of these findings?

53. The NP student is precepting with a provider in a The tool asgeriatric-based clinic. The provider asks the student sesses for funcif he is familiar with the 10-Minute Geriatric Screener. tional deficits Which of the following statements best demonstrates which are strong that the NP understands this assessment tool? predictors of patient outcomes in the elderly.

54. The NP conducted a physical assessment on a The patient has 79-year-old male who lives independently in subsi- chronic allergies dized housing. The documentation for the Head, Eyes, Ears, Nose, Throat (HEENT) findings are as follows: Scalp without lesions. Skull NC/AT. Conjunctiva pink, sclera muddy. Pupils 2 mm constricting to 1 mm, 11 / 21

NR 509 Final Exam round, regular, equally reactive to light and accommodation. Extraocular movements intact. Disc margins sharp, without hemorrhages or exudates. Mild arteriolar narrowing. TMs with good cone of light. Weber midline. AC > BC. Nasal mucosa erythematous, septum deviated to the right, turbinates mildly enlarged.

No sinus tenderness. Oral mucosa pink. Dentition fair.

Caries present. Tongue midline, slight beefy redness.

Pharynx is mildly erythematous with cobblestoning.

Which of the following is the most accurate interpretation of the findings?

55. The staff NP in a nursing home is conducting a phys- Actinic purpura ical assessment on an 84-year-old male resident who is pleasant, active, and cooperative. The skin findings in this image are observed during the examination.

The staff and patient deny any known injury or trauma.

The NP should document these findings as consistent with which of the following?

ADA Description: Extensor surface of the right forearm with emphasis on well-demarcated vividly purple macules and patches 56. An 80-year-old woman who lives alone at home pre- Perform a compresents with concerns about maintaining her indepen- hensive assessdent living status. She continues to drive and care for ment of fall risk herself and her pet dog but reports two falls over the and plan prevenpast 4 months. During one fall, she struck her head, tive interventions causing a contusion over the right eye. She attributes these episodes to environmental factors. Once she tripped over a rug, and once she misjudged the depth of the curb while crossing the street. Which of the following would be the best approach to this patient?

57. Concerning alcohol consumption in older adults, which of the following is true?

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The CAGE screening for alcohol abuse retains the same sensitiv-

NR 509 Final Exam ity and specificity it has for younger populations 58. Which of the following statements are true about the Older patients are presentation of pain and pain assessment in the older less likely to readult? Select all that apply port pain symptoms than younger patients The American Geriatrics Society (AGS) prefers the term "persistent pain" over the term "chronic pain".

59. Which of the following physical assessment findings A net increase regarding blood pressure is consistent with the nor- in pulse pressure mal aging process and not a sign of cardiovascular with an increase in systolic presdisease? sure and a decrease in diastolic pressure 60. Which of the following statements best demonstrates I will evaluate geriatric conditions in that the NP understands their role in caring for the terms of functionaging population? ality and quality of life rather than via traditional disease models.

61. Which of the following physiologic and psychologic changes are expected assessment findings with the normal aging process? Select all that apply 62. A 25-year-old female presents to the clinic after a pos- Ask open-ended itive home pregnancy test. She confides in you that questions, allow her live-in, male partner has been verbally threatening her to make de13 / 21

her. She denies interest in involving law enforcement. cisions that she Additionally, she reports that she has a 3- year-old feels are best for daughter who lives in the home. What is the appropri- herself given the ate next step by the NP? circumstance, and provide immediate or long-term referrals to domestic violence resources 63. A 42-year-old female is at 39-weeks gestation. She re- A diastolic murports no major issues except swelling in her feet and mur during pregshortness of breath which she assumed is normal for nancy is likely pregnancy. On exam, the NP notes a diastolic murmur. pathological; furWhich of the following is true about her presentation ther investigation and the appropriate next step by the NP? and work-up is warranted 64. A 32-year-old primigravid woman is at 27 weeks gesta- Iron supplemention. She presents with nausea, vomiting, urinary fre- tation, hormonal quency, discomfort in the lower abdomen, tenderness changes, slowed over the suprapubic area, and severe constipation. intestinal transit, Which of the following is true regarding these preg- physical pressure nancy symptoms? from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women.

65. A 24-year-old female presents to the clinic concerned an internal cervithat she may be pregnant. Her LMP was 7-weeks ago, cal os closed to the and the urine human chorionic gonadotropin (HCG) width of a fingertip test is positive. What can the NP expect to find on physical examination, assuming a normal pregnancy? a bluish hue to the Select all that apply cervix 66. A 20-year-old female presents to the clinic with symp- 3/27/22 toms of fatigue, nausea, and an increase in urination. She is sexually active, and her male partner 14 / 21

uses condoms occasionally. A urine pregnancy test is positive. Her last menstrual period was 3 months ago (6/20/2021). Using the Naegele rule, what is the estimated date of delivery (EDD, or due date)?

67. The NP is conducting a physical assessment on a Facial edema woman in her 26th week of pregnancy. Which of the examination finding is worrisome for a potential, emergent condition?

68. The NP is documenting the obstetric history of a pa- G6P3024 tient. Her history includes two spontaneous miscarriages at 16- and 24-weeks' gestation, four living children (one set of twins) who were delivered at term, and a current pregnancy. How would this be documented?

69. An 11-month-old infant male is accompanied to the Erythematous, clinic by his father. The father is concerned about patches and the skin rash on this son's arms represented in this plaques involving image. Family history is significant for a 4-year-old the extensor sibling with atopic dermatitis and asthma. Which of surfaces of the the following is the best documentation of the integu- bilateral ment findings? antecubital fossa.

Mild, secondary excoriations present with serous exudate.

No streaking.

Scant purulent drainage 70. A mother brings her 15-day-old female infant to the miliaria rubra outpatient clinic for evaluation of a rash that appeared suddenly after visiting family in Florida. It is August and the house did not have air conditioning. The infant is afebrile, eating and drinking well, and does not appear to be in distress. The physical assessment findings are represented in this image. Based on the history and examination findings, what is the likely 15 / 21

etiology? ADA Description: Infant with a red, facial rash.

71. The NP assesses for the Moro Reflex as part of an infant routine physical examination. The NP should suspect a neurologic disease if the reflex has not disappeared by what specific timeframe?

16 weeks

72. A 2-month-old female is accompanied by her parThe infant's growth ents for her first visit to the practice. When reviewchart with coning the hospital medical records of her birth, the NP cern for height and notes documentation regarding significantly edema- length. tous hands and feet present at birth. Upon physical examination of the infant, the NP finds skin folds that The infant's abilirun along the sides of the neck down to the shoulders. ty to properly latch Which of the following should be assessed and moni- during breastfeedtored by the NP and parents related to these findings? ing.

Select all that apply.

The infant's fluid gain or loss.

73. The NP is observing a female pediatric patient during 4 years a routine physical. She can jump in place and balance on one foot. She speaks in full sentences and her mother states that she can feed herself. Based on your observations and the history, determine her developmental age 74. The NP is observing a full-term infant male. He can 12 months pull to a stand, use "mama" and "dada" specifically, and indicates his wants by vocalization and pointing.

Based on your observations, determine his developmental age.

75. Of the following statements, which is accurate regard- All charts include ing growth and assessment charts published by the height, weight, National Center for Health Statistics? Select all that and head circumapply. ference for children up to 36 months.

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Growth charts are available for children with specific conditions such as Down syndrome or Turner syndrome.

Growth charts are available for use in infants born prematurely.

76. A 25-year-old male presents to the clinic with a com- These findings plaint of severe rectal pain during defecation. The pain suggest infectious proctitis is so severe he waits several days before having a bowel movement. He has a history of ulcerative colitis (UC). He also reports being in an active sexual new relationship with a male partner. After conducting a history and physical exam, the NP documents the following anorectal findings: Perirectal area inflamed; no ulcerations, open sores, fissures, or verruca. Scant, whiteyellow, mucoid, rectal discharge noted. Unable to examine external sphincter, rectal vault, or prostate because of spasm of the external sphincter and marked inflammation and tenderness of anal canal. Which of the following is the most accurate interpretation of these findings?

77. A 54-year-old female with a history of migraines since Migraine childhood presents to the clinic with chronic intermit- Tension tent, progressive pulsatile headaches which are similar in nature to prior attacks and precipitated by current life stressors. The headaches are accompanied by nausea and vomiting. She denies constitutional symptoms. On examination, she has elevated blood pressure but otherwise a normal cardiovascular, neurologic, and fundoscopic examination. Based on the history and physical examination findings, which di17 / 21

agnoses are appropriate for the differential diagnosis (DDx) list? Select all that apply.

78. A 50-year-old female presents to the clinic for eval- These findings uation of neck stiffness and aching pain. She was a suggest cervical restrained driver in a low-speed, rear-end, motor vehi- strain cle collision 1 day ago. The pain started several hours after the accident. On physical examination, you note muscle spasms over the paraspinous muscles on the left side of the neck, as well as pain reported during active range of motion of the cervical spine. No neurological deficits are noted. Which of the following is the most accurate interpretation of these findings?

79. Which muscle(s) are being assessed during active rotation of the neck?

Sternocleidomastoid

80. A 34-year-old female presents to the office with left lateral epicondylielbow pain following rigorous training for a tennis tis match. Tenderness is noted with palpation in the area on the image marked by the red circle. What correlative diagnosis does this assessment finding indicate?

ADA Description: Left elbow with emphasis on the small, tuberculated eminence, curved a little forward, about 1 cm from the joint.

81. A 35-year-old male presents to the clinic for a routine These findings physical examination. His only complaint is a feeling suggest testicular of heaviness in his scrotum. He denies injury or trau- cancer ma. After conducting a history and physical, the NP documents the following genitourinary (GU) findings: Uncircumcised penis; prepuce easily retractable. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally; right testicle smooth; 1 × 1 cm firm, fixed, nontender, nodule on the left lateral testicle. Epididymis nontender. No inguinal or femoral hernias. Negative CVA tenderness. Which of the following is the most accurate interpretation of these findings?

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82. A 26-year-old female presents to the Emergency De- Ruptured ectopic partment with intense abdominal pain for 6 hours, pregnancy light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a history of gallstones and is concerned that she is having another gallbladder attack. She denies nausea and vomiting, and her last normal bowel movement was this morning. She reports that her LMP was 10 weeks ago. Vital signs: pulse 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. A ²-human chorionic gonadotropin (²hCG) blood test is pending. The NP performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. Which of the following is the most likely etiology for these assessment findings?

83. A 42-year-old female presents to the office for her These findings annual well-woman examination. She has a history suggest a cyst of fibrocystic breast changes since her mid-20s, so she did not report any new issues except that her right breast feels "heavier" than usual. After a careful history and physical examination, the NP documents the following breast findings: Breasts pendulous with diffuse fibrocystic changes. Single firm 1 × 1 cm mass, mobile, and nontender, with overlying peau d'orange appearance in the right breast, upper outer quadrant at 11 o'clock, 2 cm from the nipple. Which of the following is the most accurate interpretation of these findings?

84. An NP student conducted a clinical breast examina- rubbery, mobile, tion on a 27-year-old female with a history of fibroade- nontender mass nomas. The NP palpated a rubbery, mobile, nontender located in the mass in the right breast. The mass was located 3 cm right breast, in proximal to and 3 cm to the left of the nipple. Which the 10:30 position of the following would be the most appropriate way to from the nipple document the physical assessment findings?

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85. A 24-year-old male presents to the office for evalu- Breast cancer ation of a lump under his left nipple. He reports no other symptoms, denies trauma or injury, and reports no known family history of a first-degree relative with breast cancer. On examination, the NP notes a firm, 2-cm mass under his areola. What is the most likely etiology for these findings?

86. A 34-year-old female arrives at the clinic for a prenatal, If a pregnant pasecond-trimester appointment. During the interview, tient does not inher behavior is concerning for intoxication, and she tend to quit tobacsmells of alcohol and cigarettes. She reveals a history co, cutting down of intravenous drug use "10-years ago". How should is still considthe NP counsel this patient? Select all that apply ered beneficial to the pregnancy and should be encouraged.

Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use 87. A 27-year-old female presents to the outpatient clinic Ectopic pregnanct with acute abdominal pain and uterine bleeding. Her last menstrual period was 6-weeks ago. She and her husband have been trying to conceive for almost one year. On physical examination, the NP palpates an ill-defined, adnexal mass in the left lower quadrant.

The urine pregnancy test results are pending. Based on the history and examination findings, what is the most likely etiology?

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88. The NP knows measurement of growth is one of the Beyond 2 standard most important indicators of infant health. Deviations deviations for age may provide an early indication of an underlying prob- range lem. What is the minimum variation that indicates a more detailed evaluation is needed?

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