NU 577 / AANP
g g g
ExamPearls
g g
LatestExam g g
Prep
,NU 577 / AANP Exam Pearls
g g g g g
AANP: Exam Pearls
g g
Exam Format g
• AANPgFNPgexamgcontainsg verygfewgnonclinicalgquestions
• Certificationgtestsgareg designedgforgentry-levelg practice
• AANPghasg 15gpilotgquestionsg whichgaregnotggradedg [theregisgNOgWAYgtogidentifygthegpilo
tgtestgquestionsgfromgtheggradedgquestions]
• Newgclinicalginfog[treatmentgand/orgguidelines] greleasedgingtheglastg10gmonthsg won’tgbegongthe
exam
• Questionsgwillgbegong primarygcaregdisordersg–
gifgyougaregguessing,gAVOID gPICKINGgEXOTIC gDIAGNOSISgASgANgANSWER
Labs
• Normalglabgresultsgpertinentgtogagquestiong WILLgONLYgBEgLISTEDgONCE.gUsegyourgsc
ratchgsheetgofgpapergtogjotgdowngthesegvaluesgifggiven.
• FollowgthegLABgNORMSgGIVENgBYgAANPg notgwhatgyouglearnedgingNPgschool
• LearngthegsignificancegofgabnormalglabgvaluesgANDgtypegofgfollow-
upgneededg[i.e.gelderlyggentlemangwithgc/ogscalpgtendernessg+ginduratedgtemporalgartery,
gNPgsuspectsgtemporalgarteritis.gScreeninggtestgisgsedgrateg–
gwhich gisg expected gtogbe gMUCHgHIGHER gthangnormalgvalue]
GoodtoKnow
g g
• Expectg onegquestiongrelatedgtogdentalginjury
[i.e.gcompletelygavulsedgpermanentgtooth
gshouldgbeg reimplantedgASAP!g Itgcangbegtransportedgtogdentistgingcoldgmilkg(notgfrozen
gmilk)
• Maygbegagquestiongong epidemiologicgtermsg (i.e.gsensitivityg isgdefinedgasgthegabilitygofgagt
estgtogdetectgagpersongwhoghasgthegdisease.g Specificityg isgdefinedgasgthegabilitygofgagtestgt
ogdetectgagpersongwhogisghealthygorgdetectgthegpersongwithoutgthegdisease)
• Learng definitiongofgsomegresearchgstudygdesigns g :gcohortgfollowsgaggroupgofgpeoplegwho
sharegsomegcommongcharacteristicsgtogobservegthegdevelopment gofgagdiseasegovergtimeg–
gFraminghamg nursesg healthg study
• Emergentgconditionsg thatgwillgpresentgingprimarygcaregclinicsgwillgbegongthegexam:gnavicular
fracture,gMI,gcaudagequinagsyndrome,ganaphylaxis,gangioedema,gmeningococcalgmeningitis
• Knowgsomeg anatomicgareasg:gtraumagtogKiesselbach’sgplexusg=ganteriorgnosebleed
• Somegquestionsgaskgaboutg “gold-
standardgtest”g orgtheg“diagnosticgtestgforgthegcondition”:gsicklegcellganemia,gG6PDgane
mia,gandgalpha/betagthalassemiag=ghgbgelectrophoresis
• Diseasegstatesgaregusuallyg presentedgingtheirg“full-blowngclassic”gtextbookgpresentation:
acutegmononucleosis,gteengwillghavegclassicgtriadgofgsoregthroat,gprolongedgfatigue,gandg enl
argedgcervicalgnodes.gIfgpatientgisgoldergwithgsamegsigns/symptoms,gitgis
stillgmononucleosi
sgreactivatedgtype
• Ethicgbackgroundgmaygprovidegcluesgtogdisease:galphagthalg=gsoutheastgAsiag/gFilipinos;g
betagthalg=gMediterranean
• NOgASYMPTOMATICgorgBORDERLINEgCASESgOF gDISEASEgSTATESgWILLgBEgONgTHE
EXAM:g IDAging“realglife”gdon’tgpresentgoftengwithgpicagorgspoon-shapedgnails,gongthegexamgthey
,NUg577g/gAANPgExamgPearl
s
willghavegthesegclinicalgfindings
• Begfamiliargwithg lupusgandgSLE:g malargrashg(butterfly)g=glupus.gInstructgpatientgtogav
oidg/gminimizegsungexposuregr/tgphotosensitivity.
• Begfamiliargwithg polymyalgiagrheumaticag(PRM):g g 1stglinegtxgisglong-termgsteroids.gLong-term,
low-dosegsteroidsgaregcommonlygusedgtogcontrolgsymptomsg(pain,gseveregstiffnessgingshoulders
/ghipggirdle).gPMRgpatientsgaregatgHIGHgRISKgFORgTEMPORALgARTERITIS.
, NUg577g/gAANPgExamgPearl
s
• Goldgstandard gexamgforgtemporalgarteritis: biopsyg+grefergpatientgtogopthogforgmanagement.
• Learngtheg disordersgforgwhichgmaneuversgaregusedg andgwhatgagpositivegreportgmeansg:
o Finkelstein’sgtest—positivegingDegQuervain’sgtenosynovitis
o AnteriorgdrawergmaneuvergandgLachmangmaneuver—
positivegifganteriorgcruciategligamentg(ACL)gofgthegkneegisgdamaged.gThegkn
eegmaygalsogbegunstable.
o McMurray’sgsign—positivegingmeniscusginjuriesgofgthegknee
• Conditionsgthatg NEEDgagradiologicgtestg:gdamaged gjointsg–
gordergXrayg1g stg(butgMRIgisgtheg goldgstandard)
• AbnormalgeyegfindingsgingDMg(diabeticgretinopathy)gandgHTNg(hypertensivegretinopathy)
shouldgbegMEMORIZED gandglearngtogdistinguishgeachgone:
o Diabeticgretinopathyg=gneovascularization, gcottongwoolgspots,gmicroaneurysms
o Hypertensivegretinopathyg=gAVgnicking,gsilvergand/orgcoppergwiregarterioles
• Becomegknowledgeablegaboutgphysicalgexamg“normal”gandg“abnormal”gfindings:
o Checking gDTRsgingpatientgw/severegsciaticagorgdiabeticgperipheralgneuropathy:gankle
jerkgreflexg(Achillesgreflex)gmaygbeg absentgorghypoactive.g Scoringgabsentg(0),ghypoac
tiveg(1),gnormalg(2),ghyperactiveg(3),gandgclonusg(4).
• ONLYgAgFEWgQUESTIONSgWILLgBEgONgBENIGNgorgPHYSIOLOGICgVARIANTS:g benigngS4
heartgsoundsgmaygbegauscultated gingsomegelderlygpt.gTorusgpalantinusgandgfishtailguvulagmay
gbegseengduringgthegoralgexamgingagfewgpatients.
• Ifgthegquestiongisgaskinggforgtheg initialgorgscreeningglabgtestg ,gitgwillgprobablygbegag“gcheapg”gand
readilygavailablegtestg:gCBCg(completegbloodgcountg(CBC)gtogscreengforganemia
• Theregaregsomegquestionsgong theoriesgandgconceptualgmodelsg :gStagesgofgchange
gorg“decision”gtheoryg(Prochaska)gincludes gconceptsgsuchgasgprecontemplation, gcontemp
lation,gpreparation,gaction,gandgmaintenance.
• Otherghealthgtheoristsgwhoghavegbeengincluded gongthegexamsgingthegpastgareg(g g notginclusiveg):
o AlfredgBandurag(self-efficacy),gErikgErikson,gSigmundgFreud,gElisabethgKübler-
Rossg(grieving),gandgothers
o Ifgagsmallgchildgexpressesgagdesiregtogmarrygagparentgofgthegoppositegsexg:gthegc
hildgisgingthegoedipalgstageg(Freud).gChild’sgagegisgaboutg5gtog6gyearsg(preschoolgto
kindergarten).
o Startinggatgtheg agegofgaboutg11gyearsg,gmostgchildrengcang understandgabst
ractgconceptsg (earlygabstractgthinking)gandgareg bettergatglogicalgthinking
g.
o Whengperforminggtheg Mini-
MentalgStategExamg ,gwhengthegNPgisgaskinggaboutg“proverbs,”gthegnursegisgasses
singgthegpatient’sgabilitygtogunderstandgabstractgconcepts.
• Keepgtheseg goodgcommunicationgrulesgingmindg:gAskgopen-endedgquestions,gdognotgreassure
patients,gavoidgangeringgthegpatient,gandgrespectgthegpatient’sgculture.
• Theregmaygbegtwogtogthreegquestionsgrelating gtog abuseg:gchildgabuse,gdomesticgabuse,gel
derlygabuse
Antibiotics & Medications
g g
• Knowgtheg differencegbetweeng1g stgandg2gndglinegabxg:gAOMging7gyrgoldgtreatedgwithgamo
xicillingreturnsging48hrgwithoutgimprovementg(continuedgeargpain,gbulginggTM).gNextgstepgis
gtogd/cgamoxgand gstartgchildgong2g ndglinegabxgAugmentingBIDgx10gdays
• Begfamiliargwithg alternativegabxgforgPCN-
allergicgpatients:g Ifgpatientghasggram+ginfection,gprescribeg macrolides, gclinda,gquinol
onesg=glevogorgmoxi
• Patientgrespondsgwellgtogmacrolidesgbutg thinksgthey’regallergicgtogerythromycin g(nau
sea,gGIgupset):ginformgpatientgsheghadgangadversegrx,gnotgagtruegallergicg(hives/angioedem
a):gswitch
g g g
ExamPearls
g g
LatestExam g g
Prep
,NU 577 / AANP Exam Pearls
g g g g g
AANP: Exam Pearls
g g
Exam Format g
• AANPgFNPgexamgcontainsg verygfewgnonclinicalgquestions
• Certificationgtestsgareg designedgforgentry-levelg practice
• AANPghasg 15gpilotgquestionsg whichgaregnotggradedg [theregisgNOgWAYgtogidentifygthegpilo
tgtestgquestionsgfromgtheggradedgquestions]
• Newgclinicalginfog[treatmentgand/orgguidelines] greleasedgingtheglastg10gmonthsg won’tgbegongthe
exam
• Questionsgwillgbegong primarygcaregdisordersg–
gifgyougaregguessing,gAVOID gPICKINGgEXOTIC gDIAGNOSISgASgANgANSWER
Labs
• Normalglabgresultsgpertinentgtogagquestiong WILLgONLYgBEgLISTEDgONCE.gUsegyourgsc
ratchgsheetgofgpapergtogjotgdowngthesegvaluesgifggiven.
• FollowgthegLABgNORMSgGIVENgBYgAANPg notgwhatgyouglearnedgingNPgschool
• LearngthegsignificancegofgabnormalglabgvaluesgANDgtypegofgfollow-
upgneededg[i.e.gelderlyggentlemangwithgc/ogscalpgtendernessg+ginduratedgtemporalgartery,
gNPgsuspectsgtemporalgarteritis.gScreeninggtestgisgsedgrateg–
gwhich gisg expected gtogbe gMUCHgHIGHER gthangnormalgvalue]
GoodtoKnow
g g
• Expectg onegquestiongrelatedgtogdentalginjury
[i.e.gcompletelygavulsedgpermanentgtooth
gshouldgbeg reimplantedgASAP!g Itgcangbegtransportedgtogdentistgingcoldgmilkg(notgfrozen
gmilk)
• Maygbegagquestiongong epidemiologicgtermsg (i.e.gsensitivityg isgdefinedgasgthegabilitygofgagt
estgtogdetectgagpersongwhoghasgthegdisease.g Specificityg isgdefinedgasgthegabilitygofgagtestgt
ogdetectgagpersongwhogisghealthygorgdetectgthegpersongwithoutgthegdisease)
• Learng definitiongofgsomegresearchgstudygdesigns g :gcohortgfollowsgaggroupgofgpeoplegwho
sharegsomegcommongcharacteristicsgtogobservegthegdevelopment gofgagdiseasegovergtimeg–
gFraminghamg nursesg healthg study
• Emergentgconditionsg thatgwillgpresentgingprimarygcaregclinicsgwillgbegongthegexam:gnavicular
fracture,gMI,gcaudagequinagsyndrome,ganaphylaxis,gangioedema,gmeningococcalgmeningitis
• Knowgsomeg anatomicgareasg:gtraumagtogKiesselbach’sgplexusg=ganteriorgnosebleed
• Somegquestionsgaskgaboutg “gold-
standardgtest”g orgtheg“diagnosticgtestgforgthegcondition”:gsicklegcellganemia,gG6PDgane
mia,gandgalpha/betagthalassemiag=ghgbgelectrophoresis
• Diseasegstatesgaregusuallyg presentedgingtheirg“full-blowngclassic”gtextbookgpresentation:
acutegmononucleosis,gteengwillghavegclassicgtriadgofgsoregthroat,gprolongedgfatigue,gandg enl
argedgcervicalgnodes.gIfgpatientgisgoldergwithgsamegsigns/symptoms,gitgis
stillgmononucleosi
sgreactivatedgtype
• Ethicgbackgroundgmaygprovidegcluesgtogdisease:galphagthalg=gsoutheastgAsiag/gFilipinos;g
betagthalg=gMediterranean
• NOgASYMPTOMATICgorgBORDERLINEgCASESgOF gDISEASEgSTATESgWILLgBEgONgTHE
EXAM:g IDAging“realglife”gdon’tgpresentgoftengwithgpicagorgspoon-shapedgnails,gongthegexamgthey
,NUg577g/gAANPgExamgPearl
s
willghavegthesegclinicalgfindings
• Begfamiliargwithg lupusgandgSLE:g malargrashg(butterfly)g=glupus.gInstructgpatientgtogav
oidg/gminimizegsungexposuregr/tgphotosensitivity.
• Begfamiliargwithg polymyalgiagrheumaticag(PRM):g g 1stglinegtxgisglong-termgsteroids.gLong-term,
low-dosegsteroidsgaregcommonlygusedgtogcontrolgsymptomsg(pain,gseveregstiffnessgingshoulders
/ghipggirdle).gPMRgpatientsgaregatgHIGHgRISKgFORgTEMPORALgARTERITIS.
, NUg577g/gAANPgExamgPearl
s
• Goldgstandard gexamgforgtemporalgarteritis: biopsyg+grefergpatientgtogopthogforgmanagement.
• Learngtheg disordersgforgwhichgmaneuversgaregusedg andgwhatgagpositivegreportgmeansg:
o Finkelstein’sgtest—positivegingDegQuervain’sgtenosynovitis
o AnteriorgdrawergmaneuvergandgLachmangmaneuver—
positivegifganteriorgcruciategligamentg(ACL)gofgthegkneegisgdamaged.gThegkn
eegmaygalsogbegunstable.
o McMurray’sgsign—positivegingmeniscusginjuriesgofgthegknee
• Conditionsgthatg NEEDgagradiologicgtestg:gdamaged gjointsg–
gordergXrayg1g stg(butgMRIgisgtheg goldgstandard)
• AbnormalgeyegfindingsgingDMg(diabeticgretinopathy)gandgHTNg(hypertensivegretinopathy)
shouldgbegMEMORIZED gandglearngtogdistinguishgeachgone:
o Diabeticgretinopathyg=gneovascularization, gcottongwoolgspots,gmicroaneurysms
o Hypertensivegretinopathyg=gAVgnicking,gsilvergand/orgcoppergwiregarterioles
• Becomegknowledgeablegaboutgphysicalgexamg“normal”gandg“abnormal”gfindings:
o Checking gDTRsgingpatientgw/severegsciaticagorgdiabeticgperipheralgneuropathy:gankle
jerkgreflexg(Achillesgreflex)gmaygbeg absentgorghypoactive.g Scoringgabsentg(0),ghypoac
tiveg(1),gnormalg(2),ghyperactiveg(3),gandgclonusg(4).
• ONLYgAgFEWgQUESTIONSgWILLgBEgONgBENIGNgorgPHYSIOLOGICgVARIANTS:g benigngS4
heartgsoundsgmaygbegauscultated gingsomegelderlygpt.gTorusgpalantinusgandgfishtailguvulagmay
gbegseengduringgthegoralgexamgingagfewgpatients.
• Ifgthegquestiongisgaskinggforgtheg initialgorgscreeningglabgtestg ,gitgwillgprobablygbegag“gcheapg”gand
readilygavailablegtestg:gCBCg(completegbloodgcountg(CBC)gtogscreengforganemia
• Theregaregsomegquestionsgong theoriesgandgconceptualgmodelsg :gStagesgofgchange
gorg“decision”gtheoryg(Prochaska)gincludes gconceptsgsuchgasgprecontemplation, gcontemp
lation,gpreparation,gaction,gandgmaintenance.
• Otherghealthgtheoristsgwhoghavegbeengincluded gongthegexamsgingthegpastgareg(g g notginclusiveg):
o AlfredgBandurag(self-efficacy),gErikgErikson,gSigmundgFreud,gElisabethgKübler-
Rossg(grieving),gandgothers
o Ifgagsmallgchildgexpressesgagdesiregtogmarrygagparentgofgthegoppositegsexg:gthegc
hildgisgingthegoedipalgstageg(Freud).gChild’sgagegisgaboutg5gtog6gyearsg(preschoolgto
kindergarten).
o Startinggatgtheg agegofgaboutg11gyearsg,gmostgchildrengcang understandgabst
ractgconceptsg (earlygabstractgthinking)gandgareg bettergatglogicalgthinking
g.
o Whengperforminggtheg Mini-
MentalgStategExamg ,gwhengthegNPgisgaskinggaboutg“proverbs,”gthegnursegisgasses
singgthegpatient’sgabilitygtogunderstandgabstractgconcepts.
• Keepgtheseg goodgcommunicationgrulesgingmindg:gAskgopen-endedgquestions,gdognotgreassure
patients,gavoidgangeringgthegpatient,gandgrespectgthegpatient’sgculture.
• Theregmaygbegtwogtogthreegquestionsgrelating gtog abuseg:gchildgabuse,gdomesticgabuse,gel
derlygabuse
Antibiotics & Medications
g g
• Knowgtheg differencegbetweeng1g stgandg2gndglinegabxg:gAOMging7gyrgoldgtreatedgwithgamo
xicillingreturnsging48hrgwithoutgimprovementg(continuedgeargpain,gbulginggTM).gNextgstepgis
gtogd/cgamoxgand gstartgchildgong2g ndglinegabxgAugmentingBIDgx10gdays
• Begfamiliargwithg alternativegabxgforgPCN-
allergicgpatients:g Ifgpatientghasggram+ginfection,gprescribeg macrolides, gclinda,gquinol
onesg=glevogorgmoxi
• Patientgrespondsgwellgtogmacrolidesgbutg thinksgthey’regallergicgtogerythromycin g(nau
sea,gGIgupset):ginformgpatientgsheghadgangadversegrx,gnotgagtruegallergicg(hives/angioedem
a):gswitch
