AANP: Exam Pearls Exam Format • AANP FNP exam contains very few nonclinical questions • Certification tests are designed for entry-level practice • AANP has 15 pilot questions which are not graded [there is NO WAY to identify the pilot test questions from the graded questions] • New clinical info [treatment and/or guidelines] released in the last 10 months won’t be on the exam • Questions will be on primary care disorders – if you are guessing, AVOID PICKING EXOTIC DIAGNOSIS AS AN ANSWER Labs • Normal lab results pertinent to a question WILL ONLY BE LISTED ONCE. Use your scratch sheet of paper to jot down these values if given. • Follow the LAB NORMS GIVEN BY AANP not what you learned in NP school • Learn the significance of abnormal lab values AND type of follow-up needed [i.e. elderly gentleman with c/o scalp tenderness + indurated temporal artery, NP suspects temporal arteritis. Screening test is sed rate – which is expected to be MUCH HIGHER than normal value] Good to Know • Expect one question related to dental injury [i.e. completely avulsed permanent tooth should be reimplanted ASAP! It can be transported to dentist in cold milk (not frozen milk) • May be a question on epidemiologic terms (i.e. sensitivity is defined as the ability of a test to detect a person who has the disease. Specificity is defined as the ability of a test to detect a person who is healthy or detect the person without the disease) • Learn definition of some research study designs: cohort follows a group of people who share some common characteristics to observe the development of a disease over time – Framingham nurses health study • Emergent conditions that will present in primary care clinics will be on the exam: navicular fracture, MI, cauda equina syndrome, anaphylaxis, angioedema, meningococcal meningitis • Know some anatomic areas: trauma to Kiesselbach’s plexus = anterior nosebleed • Some questions ask about “gold-standard test” or the “diagnostic test for the condition”: sickle cell anemia, G6PD anemia, and alpha/beta thalassemia = hgb electrophoresis • Disease states are usually presented in their “full-blown classic” textbook presentation: acute mononucleosis, teen will have classic triad of sore throat, prolonged fatigue, and enlarged cervical nodes. If patient is older with same signs/symptoms, it is still mononucleosis reactivated type • Ethic background may provide clues to disease: alpha thal = southeast Asia / Filipinos; beta thal = Mediterranean • NO ASYMPTOMATIC or BORDERLINE CASES OF DISEASE STATES WILL BE ON THE EXAM: IDA in “real life” don’t present often with pica or spoon-shaped nails, on the exam they will have these clinical findings • Be familiar with lupus and SLE: malar rash (butterfly) = lupus. Instruct patient to avoid / minimize sun exposure r/t photosensitivity. • Be familiar with polymyalgia rheumatica (PRM): 1st line tx is long-term steroids. Long-term, low-dose steroids are commonly used to control symptoms (pain, severe stiffness in shoulders / hip girdle). PMR patients are at HIGH RISK FOR TEMPORAL ARTERITIS. AANP EXAM PEARLS • Gold standard exam for temporal arteritis: biopsy + refer patient to optho for management. • Learn the disorders for which maneuvers are used and what a positive report means: o Finkelstein’s test—positive in De Quervain’s tenosynovitis o Anterior drawer maneuver and Lachman maneuver—positive if anterior cruciate ligament (ACL) of the knee is damaged. The knee may also be unstable. o McMurray’s sign—positive in meniscus injuries of the knee • Conditions that NEED a radiologic test: damaged joints – order Xray 1st (but MRI is the gold standard) • Abnormal eye findings in DM (diabetic retinopathy) and HTN (hypertensive retinopathy) should be MEMORIZED and learn to distinguish each one: o Diabetic retinopathy = neovascularization, cotton wool spots, microaneurysms o Hypertensive retinopathy = AV nicking, silver and/or copper wire arterioles • Become knowledgeable about physical exam “normal” and “abnormal” findings: o Checking DTRs in patient w/severe sciatica or diabetic peripheral neuropathy: ankle jerk reflex (Achilles reflex) may be absent or hypoactive. Scoring absent (0), hypoactive (1), normal (2), hyperactive (3), and clonus (4). • ONLY A FEW QUESTIONS WILL BE ON BENIGN or PHYSIOLOGIC VARIANTS: benign S4 heart sounds may be auscultated in some elderly pt. Torus palantinus and fishtail uvula may be seen during the oral exam in a few patients. • If the question is asking for the initial or screening lab test, it will probably be a “cheap” and readily available test: CBC (complete blood count (CBC) to screen for anemia • There are some questions on theories and conceptual models: Stages of change or “decision” theory (Prochaska) includes concepts such as precontemplation, contemplation, preparation, action, and maintenance. • Other health theorists who have been included on the exams in the past are (not inclusive): o Alfred Bandura (self-efficacy), Erik Erikson, Sigmund Freud, Elisabeth Kübler-Ross (grieving), and others o If a small child expresses a desire to marry a parent of the opposite sex: the child is in the oedipal stage (Freud). Child’s age is about 5 to 6 years (preschool to kindergarten). o Starting at the age of about 11 years, most children can understand abstract concepts (early abstract thinking) and are better at logical thinking. o When performing the Mini-Mental State Exam, when the NP is asking about “proverbs,” the nurse is assessing the patient’s ability to understand abstract concepts. • Keep these good communication rules in mind: Ask open-ended questions, do not reassure patients, avoid angering the patient, and respect the patient’s culture. • There may be two to three questions relating to abuse: child abuse, domestic abuse, elderly abuse Antibiotics & Medications • Know the difference between 1st and 2nd line abx: AOM in 7 yr old treated with amoxicillin returns in 48hr without improvement (continued ear pain, bulging TM). Next step is to d/c amox and start child on 2nd line abx Augmentin BID x10 days • Be familiar with alternative abx for PCN-allergic patients: If patient has gram+ infection, prescribe macrolides, clinda, quinolones = levo or moxi • Patient responds well to macrolides but thinks they’re allergic to erythromycin (nausea, GI upset): inform patient she had an adverse rx, not a true allergic (hives/angioedema): switch pt from erythromycin to azithromycin (z-pack) • Fails to respond to initial medication: add another medication per treatment guidelines (i.e. COPD pt prescribed Atrovent for dyspnea. On follow-up, patient complains symptoms are not relieved. Next step is to prescribe albuterol (Ventolin) or combo inhaler) • Commonly used drugs with rare (potentially fatal) adverse effects: ACE-I = angioedema. Common side effect of ACEIs = dry cough (up to 10%) • Learn the preferred and/or 1st line drug to tx some diseases: ACEI/ARB is preferred for HTN in DM and patients with mild-mod renal disease = renal protective properties • When meds are used in answer options, they will be listed either by name (generic and brand name) or by drug class alone: ipratropium (Atrovent) or an anticholinergic • Most of the drugs mentioned in the exam are the well-recognized drugs: o Penicillin: Amoxicillin (broad-spectrum penicillin), penicillin VK o Macrolide: Erythromycin, azithromycin (Z-Pack), or clarithromycin (Biaxin) o Cephalosporins: First-generation (Keflex), second-generation (Cefaclor, Ceftin, Cefzil), third generation (Rocephin, Suprax, Omnicef) o Quinolones: Ciprofloxacin (Cipro), ofloxacin (Floxin) o Quinolones with gram-positive coverage: Levofloxacin (Levaquin), moxifloxacin (Avelox), gatifloxacin (Tequin) o Sulfa: Trimethoprim-sulfamethoxazole (Bactrim, Septra), nitrofurantoin (Macrobid) o Tetracyclines: Tetracycline, doxycycline, minocycline (Minocin) o Nonsteroidal anti-inflammatory drug (NSAID): Ibuprofen, naproxen (Aleve, Anaprox) o COX-2 inhibitor: Celecoxib (Celebrex) • Category B drugs are ALLOWED for pregnant or lactating women: Pain relief, pick acetaminophen (Tylenol) instead of NSAIDs such as ibuprofen (Advil) or naproxen (Aleve, Anaprox). Avoid nitrofurantoin and sulfa drugs during the third trimester (these increase risk of hyperbilirubinemia). • Preferred tx for cutaneous anthrax: ciprofloxacin 500 mg orally BID for 60 days or for 8 weeks. If the patient is allergic to ciprofloxacin, use doxycycline 100 mg BID. Cutaneous anthrax is not contagious; it comes from touching fur or animal skins that are contaminated with anthrax spores. Follow national treatment guidelines for certain disorders: • Asthma: National Asthma Education and Prevention Program (NAEPP) • COPD: Global Initiative for Chronic Obstructive Lung Disease (GOLD Guidelines) • Diabetes: American Diabetes Association Clinical Practice Recommendations (ADA) • Ethics: Guide to the Code of Ethics for Nurses with Interpretive Statements: Development, Interpretation, and Application • Healthy People: Office of Disease Promotion and Health Prevention • Health Promotion: The Guide to Clinical Preventive Services 2014: Recommendations of the U.S. Preventive Services Task Force (USPSTF) • Hyperlipidemia: (ACC/AHA) • Hypertension: (JNC 8) • Mental Health: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (APA) • Pediatrics: American Academy of Pediatrics. (AAP – Bright Futures) • Sexually Transmitted Diseases (CDC) Maximize Your Score 1. The FIRST ANSWER that pops in your head: it’s usually the correct answer 2. If you are GUESSING: pick an answer at random and DO NOT CHANGE IT unless you are sure. a. Click mark command: this will allow you to return to the question later when you complete the exam. b. AVOID changing too many answers (no more than 3): If you are not sure, then leave the answer alone. c. AVOID choosing exotic diseases as answers if you are guessing: Remember, these are tests for primary care conditions. d. Methods of Guessing i. Look for a pattern and pick the answer that does not fit the pattern. ii. Pick the answer that you are most “attracted” to – go with your gut and DO NOT CHANGE the answer unless you are very sure. 3. READ SLOWLY and carefully throughout the test: Make sure that you understand the stem of the question (usually the last sentence of a question) 4. If you are having issues choosing / understanding the answer options: try to read them from the bottom up (from option D to A, or from 4 to 1). 5. Only eliminate wrong answers AFTER you read all the answer choices 6. If an answer option contains all-inclusive words “all,” “none,” “every,” “never,” “none”: IT IS PROBABLY WRONG. Be careful with certain words such as “always,” “exactly,” “often,” “sometimes,” and “mostly.” 7. Assume each question has enough information to answer it correctly: Questions and answers are carefully designed. Take the facts at face value. 8. The first few questions are usually harder to solve: This is a common test design. Do not let it shake your confidence. (Guess the answer and “mark” it so that you can return to it later.) 9. Read the last sentence or stem of long questions and case scenarios first: this saves you time and mental strain. Then, read the question again from the beginning. This “backwards technique” allows you to know ahead of time what the question is asking for so when you read it again, it becomes easier to recognize important clues that will help you answer the question. 10. Just because a statement or an answer is true does not mean that it is the correct answer: If it does not answer the stem of the question, then it is the wrong answer. 11. Design and memorize your “scratch paper” BEFORE YOU TAKE THE EXAM: Choose what you want on it wisely. Remember to keep it brief. a. Use the “free” computer tutorial time to write down the facts you memorized for your scratch paper (If you run out of time, skip this step) b. Suggested facts to write down: lab results (hemoglobin, hematocrit, MCV, platelets, WBC count, neutrophil percentage, potassium, urinalysis, etc.). Other popular choices are the murmurs, mnemonics, and cranial nerves. 12. NEVER LEAVE QUESTIONS UNANSWERED: there is NO penalty for guessing. Questions that are left blank are marked as errors (0 points). If you have only 30 minutes left and you are not done, quickly answer the remaining questions at random. 13. DO NOT SPEND MORE THAN 60 SECONDS ON A QUESTION: doing so, wastes time. Answer it at random and then “mark” it so that you can return to it later (after you finish the entire test). 14. Consider a quick break (if you have enough time) if you get too mentally fatigued: Solving 200 questions is pretty intense. If you feel “fuzzy” or tired, go to the bathroom and get a drink of water, and splash cold water on your face. This can take less than 5 minutes. You can bring bottled water, but you have to leave it outside the testing area. 15. COUNTDOWN CLOCK does NOT stop for breaks: Do not use more than 5 mins for your quick bathroom break. 16. Do not panic or let your anxiety take over: Learn to use a calming technique (controlled breathing) to calm yourself quickly before you take the exam. 17. MOST IMPORTANT ADVICE: Aim for at least 7 to 8 hours of sleep the night before the exam!
