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
...
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.• 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!25
2
Question Dissection and Analysis*
EVIDENCE-BASED MEDICINE (EBM)
I. Discussion
Questions about EBM are typically designed in “drag-and-drop” format on the American
Nurses Credentialing Center exam. They are presented as two boxes with three sections
each. The example that follows illustrates this format. On the left side, three types of article
summaries (or research studies) are marked A, B, or C (in the exam, they will appear as
yellow boxes). On the right side, you will see the rankings from 1 to 3 (in the exam, they
will be blue boxes). You “drag” one of the articles from the left-hand box into the correct
ranking or hierarchy in the right-hand box. Your job is to rank the three research article
summaries as 1, 2, or 3 (best evidence, moderate evidence, weakest evidence).
II. Example
Article Summaries Strength of Evidence (strongest to
weakest)
A) A meta-analysis on Medline and Cochrane databases that found 53
RCTs about gingko biloba use in patients with early dementia 1.
B) A specialty society opinion paper regarding the effectiveness of
gingko biloba supplementation in dementia 2.
C) An experimental study on 500 patients with early dementia who
were given gingko biloba daily for 6 months versus the control
group, which given placebo pills
3.
RCTs, randomized controlled trials.
III. Correct Answer:
Article A is ranked 1, Article C is ranked 2, and Article B is ranked 3.
4027
26
IV. Question Dissection
Best Clues
I teach a three-step system to students in my review courses.
First, identify the research study that has the highest/best level of evidence (#1
ranking). An easy way to do this is by searching for keywords in the question such
as “meta-analysis,” “systematic review” or “randomized controlled trials” combined
with “Cochrane database,” “Medline database,” and/or Cumulative Index to Nursing
and Allied Health Literature (“CINAHL”).
Next, look for the research study that has the weakest evidence (#3 ranking). It usually
contains keywords such as “expert opinion” or “specialty society.”
Therefore, view the study that is leftover as having the middle ranking (#2 ranking). In
addition, keep in mind that if the choices do not include a meta-analysis or systemic
review, then the study with the highest ranking would be an RCT or an experimental
study. The ANCC exams usually have several of this type of question. Further
discussion about EBM appears in the chapter on Evidence-Based Medicine and
Epidemiology later in this book.
The levels of evidence rankings are:
• Meta-analysis and/or systematic reviews (Cochrane/Medline/CINAHL/PubMed)
• RCTs (used for testing medical treatment effectiveness, subjects assigned at random
to either a control or treatment group)
• Experimental studies (control group, intervention group, randomization)
• Cohort/case control studies
• Retrospective chart reviews
• Expert/specialty society opinions
PHOTOGRAPHS
I. Discussion
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