AANP Exam Pearls Discussion And Answers 2022//2023.

Discussion On the ANCC exam, expect to see several colored photographs of skin conditions and a few on the eye/fundi. In the future, there may be pictures from other organ systems. The stem of the question usually will ask for the possible diagnosis, differential diagnosis, or type of treatment. If you plan to take the ANCC exam, you need to memorize how a skin condition or eye finding appears in colored photos/pictures. It is a good idea to use a search engine (e.g., Google, Bing, Yahoo) to look for the images. For example, you want to become familiar with skin cancers, such as basal cell and melanoma, and with funduscopic findingsin diabetes and hypertension. II. Example The nurse practitioner (NP) is performing a routine physical exam on a 54-year-old White male farmer who is an immigrant from Australia. The NP notices a shiny round, ulcerated round skin lesion on the patient’s head. It has a firm texture with indurated edges and telangiectasia. See Figure 2.1. The patient reports that the lesion does not itch, but it 27 has slowly enlarged over the past few years. Which of the following conditions is most 42 42 likely in this patient? A) Nodular melanoma B) Squamous cell carcinoma C) Basal cell carcinoma D) Actinic keratosis Figure 2.1 Sample exam photograph. This image can be found in color in the app. Source: Courtesy of National Cancer Institute. III. Correct Answer: Option C C) Basal cell carcinoma IV. Question Dissection Best Clues Notice that the skin lesion has a pearly or wax-like (shiny) appearance with telangiectasia, on the edges and mild crusting, which is “classic” for basal cell carcinoma; some lesions may show central ulceration Patient hasrisk factors for skin cancer, such aslight-colored skin, and he isfrom Australia, which has high rates of skin cancer The skin lesion islocated on a sun-exposed area (forehead) It is probably not nodular melanoma, which usually has pigment such as brown or black color with irregular borders Actinic keratosis is a precancer of squamous cell carcinoma and is usually located on the scalp (males), face, and the back of the hands (dorsum); they appear as a crusty/scaly growth that slowly enlarges overtime The gold-standard test for skin cancer isthe skin biopsy MULTIPLE-CHOICE QUESTIONS WITH MORE THAN ONE CORRECT RESPONSE I. Discussion 43 43 Expect to see some multiple-choice questions with five to six answer options in both the ANCC and American Academy of Nurse Practitioners Certification Board (AANPCB) exams. The question will ask for two to three correct answers. For example, you may be asked to pick two or three differential diagnoses for a case of skin rash. The clues are given in the presentation of the signs and symptoms. II. Example A 75-year-old woman with mild dementia, hyperlipidemia, and emphysema is brought in by her middle-aged daughter as a walk-in patient in a community clinic with a complaint of the sudden onset of red rashes on her left lower arm and hand. During the skin exam, the NP notes that there are a few blisters. When the NP touches one of the blisters, it ruptures and drains clear serousfluid. Which of the following three conditions should the NP consider in the differential diagnosis? A) Contact dermatitis B) Erysipelas C) Psoriasis D) Impetigo E) Thermal burn III. Correct Answer: Options A, D, and E 28 A) Contact dermatitis D) Impetigo E) Thermal burn IV. Question Dissection Best Clues Easily ruptured blisters (fragile) is a classic finding for bullousimpetigo, an acute bacterial skin infection caused by Staphylococcus or Streptococcus. Contact dermatitis can present with just red skin or red skin with blisters. The rash can be located anywhere on the body and it may have a pattern (like a belt) or no pattern. The timing of the rash is very important. Is it acute or chronic? Rule out option C (psoriasis), which is a chronic skin disease. Erysipelas is a type of cellulitis caused by strep. It resembles a bright-red, warm, raised rash (plaque-like) with discrete borders usually located on the face or the shins. Blistering is not present. A thermal burn is a burn caused by heat (fire, heat). Consider a second-degree burn in the differential diagnosis because of its acute onset. Also, the patient has mild dementia, which puts her at a higher risk for accidents. DIAGNOSTIC IMAGING I. Discussion 44 44 Questions about diagnostic imaging tests may appear on the exam. You may get a multiplechoice question alone or a question that is accompanied by a chest x-ray film. I recommend that you use a search engine (Google, Bing, Yahoo) to search for images of chest films with lobar consolidation due to community-acquired pneumonia (CAP), right middle lobe pneumonia, pulmonary tuberculosis (TB) infection, and emphysema/chronic obstructive pulmonary disease [COPD]). II. Example A 34-year-old male smoker presents in an urgent care clinic complaining of a productive cough, chest congestion, fever, chills, and poor appetite for 1 week. Cough is productive of greenish sputum, which is sometimestinged with a small amount of blood. Vital signs are temperature of 101.2°F, pulse of 100 beats/min, respirations of 24 breaths/min, and BP 122/88 mmHg. A radiograph of the chest is obtained (see Figure 2.2). What is the most likely diagnosis in this patient? Figure 2.2 Sample exam photo. Source: Wikimedia. A) Acute bronchitis 29 B) Right middle lobe pneumonia C) Right lower lobe pneumonia D) Legionella pneumonia III. Correct Answer: Option B B) Right middle lobe pneumonia IV. Question Dissection Best Clues Presence of signs and symptoms of CAP such asfever, cough productive of green sputum with small amount of blood (or rust-colored sputum). Rust-colored sputum is associated with Streptococcus pneumoniae infection. 45 45 Most of the middle lobe of the right lung isin the anterior chest by the right nipple area. Notice that lobar consolidation islocated in the same area. Patients with acute bronchitis may have chest congestion but not fever, chills, or productive cough with purulent sputum. Legionella pneumonia (Legionnaire’s disease) is uncommon in primary care. Look for a history of exposure to “nebulized” watersources such as air conditioners, fountains, etc. Presents with pneumonia signs/symptoms that are accompanied by GI symptoms (diarrhea, nausea/vomiting). CULTURE I. Discussion There will be several questions on the ANCC exam that address culture. The questions will address knowledge of cultural practices that influence health-seeking behavior. Some of the cultures that may be included in the ANCC exam are Hispanic/Latino, Muslim, Chinese, Native American (Navajo), and Southeast Asian (Vietnamese, Hmong, Filipinos, and others). II. Example An elderly woman immigrant from Vietnam who recently has been diagnosed with hypertension is returning for a 4-week follow-up visit. The patient is on a prescription of hydrochlorothiazide 12.5 mg daily. Her blood pressure during the visit is 150/94 mmHg. The NP queriesthe patient whether she is taking her medication. The patient looks down at the floor and does not directly answer the question. Which of the following statements regarding the health behaviors of Southeast Asians isincorrect? A) The patient may have difficulty verbalizing questions about his or her treatment B) The patient may ask to consult with an older family member about major health decisions C) If the patient is not compliant with taking medications, he or she will not directly communicate it with the health provider D) The patient will directly verbalize his or her disagreement in a loud voice III. Correct Answer: Option D D) The patient will directly verbalize his or her disagreement in a loud voice. IV. Question Dissection Best Clues The patient’s behavior (aggressive, loud) is considered rude in most Asian cultures 30 Notes 46 46 1. The Hmong ethnic group that immigrated to the United States came from several countries (e.g., Laos, Vietnam, Thailand). A traditional household has a male (i.e., father) who is the head of the household. The family identifies with a clan group, which is headed by an older male. 2. For major health decisions, the head of the family is always involved in the health decision. If the father is dead, then another older male relative (e.g., uncle) may be consulted. 3. Most Asians have high regard for physicians (and college education). Because of this cultural value, they may not directly disagree or question the health care provider. 4. Asian Americans and Pacific Islanders are eight to 13 times more likely to develop liver cancer than other groups due to higher rates of chronic hepatitis B infection. LAB RESULTS AND DIAGNOSTIC TESTS I. Discussion Laboratory tests, such as hemoglobin and hematocrit, mean corpuscular volume (MCV), total white blood cell (WBC) count, percentage of neutrophils in the WBC differential, thyroid-stimulating hormone (TSH), prostate-specific antigen (PSA), and urinalysis (UA), are commonly encountered in the exams. Learn the significance of the abnormal results and the follow-up teststhat are needed to evaluate them further. The AANPCB exam doeslist the norms for some of the common laboratory tests. They will appear only when needed to answer a question (such as an anemia question). It is important that you copy the lab norm that is given (on your scratch paper) because it will be listed only once. In contrast, the ANCC does not list any of the normal results in its certification exams. Therefore, if you plan to take the ANCC exam, it is important that you memorize the normal results of these laboratory tests. Be warned that lab results are also used as distractors; the labs listed may not be necessary to solve the exam question correctly. The normal results for these labs are also included in the pertinent review chapters of this book (e.g., TSH will be found in Chapter 9. II. Example An elderly man of Mediterranean descent has a routine CBC done for an annual physical. The following are his lab test results: hemoglobin is 12.0 g/dL, hematocrit is 39%, and MCV is 72 fL. His PSA result is 3.2 ng/mL. UA shows no leukocytes and few epithelial cells. Which of the following laboratory tests are indicated for this patient? A) Serum iron, serum ferritin, total iron-binding capacity (TIBC), and the red cell distribution width (RDW) B) Serum vitamin B12 and folate level with a peripheralsmear C) CBC with white cell differential and UA 47 47 D) Urine culture and sensitivity with microscopic exam of the urine (Tables 2.1 and 2.2) III. Correct Answer: Option A A) Serum iron, serum ferritin, total iron-binding capacity (TIBC), and the red cell distribution width (RDW) Table 2.1 List of Laboratory Norms 31 CBC Reference Ranges Hemoglobin Males 13.0–17.5 g/dL Females 12.0–16 g/dL Hematocrit Males 40%–50% Females 36%–45% MCV 80–100 fL RDW 14.5% Platelet count 150,000/mm3 (increased risk of bleeding, disseminated intravascular coagulation) 0.5%–1.5% of red cells (↑ acute bleeding,starting treatment for Reticulocytes vitamin deficiencies (iron, B , folate), acute hemolytic episodes 12 Total WBC count 4,500–11,000/mm3 (↑ bacterial infections) Neutrophils (or segs) 50% (↑ bacterial infections) Band forms (immature WBCs) 6% (↑ severe bacterial infections) Also called “shift to the left” Eosinophils 3% (↑ allergies, parasitic diseases, cancer) CBC, complete blood count; MCV, mean corpuscular volume;RDW, red cell distribution width; WBC, white blood cell. Table 2.2 List of Blood Chemistries LaboratoryTest Reference Ranges TSH 5.0 mU/L (hypothyroidism) 0.4 mU/L (hyperthyroidism) PSA 4.0 ng/mL (benign prostatic hyperplasia [BPH, prostate cancer) Ferritin 15 mcg/L (iron-deficiency anemia) Men 0–22 mm/hr ESR;sed rate Women 0–29 mm/hr Elevated (giant cell arteritis, rheumatoid arthritis [RA], lupus, inflammation) CRP Elevated (inflammation, autoimmune diseases, a risk factor for heart disease) cTnT Elevated in myocardial infarction, heart damage, heart failure Sensitive test for myocardial cell damage 48 48 B-type natriuretic peptide Elevated (elevated in heart failure) Potassium 3.0 or 5.5 mEq/L (risk of arrhythmia) CRP, c-reactive protein; cTnT, cardiac troponins; ESR, erythrocyte sedimentation rate; PSA, prostate-specific antigen; TSH, thyroid-stimulating hormone. IV. Question Dissection Best Clues Low hemoglobin and hematocrit for gender (male) and age (abnormal CBC result) An MCV of 72 fL, which isindicative of microcytic anemia (assessment) The ethnic background of the patient (demographics) Ignore the UA and PSA tests because they are not necessary to solve the problem 32 Notes 1. You must go through three steps to answer this question correctly: First step: A hemoglobin of less than 13.5 g/dL in males(but not in females) is indicative of anemia. An MCV of 72 fL is indicative of microcytic anemia (norm 80–100 fL). Second step: The MCV will direct you in the differential diagnosis (microcytic, normocytic, or macrocytic). Third step: The differential diagnosis for microcytic anemia is iron deficiency and alpha/beta thalassemia trait or minor for the exams. 2. In iron-deficiency anemia, the following results are found: • Decreased (serum ferritin and serum iron levels) • Elevated (TIBC and RDW) 3. In alpha or beta thalassemia trait or minor, the following results are found: • Normal to high (serum ferritin and serum iron levels) • Normal (TIBC) 4. The gold-standard test to diagnose any anemia involving abnormal hemoglobin (thalassemia, sickle cell, etc.) isthe hemoglobin electrophoresis. 5. The RDW is a measure of the variability in size of RBCs (or anisocytosis). An elevated RDW is one of the earliest indicators of iron-deficiency anemia. 6. In clinical practice,rule out iron-deficiency anemia first (most common anemia in the world for all ages/races/gender) before ordering a hemoglobin electrophoresis. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) I. Discussion One common topic that is frequently included in the certification exam is the HIPAA of 1996. The questions are designed to determine whether you know how to apply HIPAA regulations in primary care practice. Your job is to determine whether the activity is 49 49 compliant (or not) with HIPAA regulations. II. Example According to the HIPAA of 1996, which of the following examples demonstrates noncompliance? A) The sign-in sheet on the front desk is covered so that other patients’ names are not visible to new patients B) The medical assistant calls the patient who is in the waiting room using his or her first name C) A patient’s chart that is hanging on the door of the exam room isturned backward D) The NP calls the daughter of an elderly diabetic patient and leaves a detailed message on the answering machine regarding her mother’s lab results III. Correct Answer: Option D D) The NP calls the daughter of an elderly diabetic patient and leaves a detailed message on the answering machine regarding her mother’s lab re