AANPCB FNP Exam Questions

Correct answer: Tapping over the median nerve results in tingling in the hand

This describes Tinel's sign, a maneuver to detect irritated nerves, which is performed by lightly tapping over the median nerve (as it passes through the carpal tunnel area) to elicit a sensation of abnormal tingling or "pins and needles" in the distribution of the nerve. A positive Tinel's sign is associated with CTS. Though this test is still commonly used in the diagnosis of CTS, it is associated with low specificity and sensitivity. 

Tapping the brachioradialis tendon with the reflex hammer resulting in flexion of the lower arm at the elbow and supination of the hand is a normal reflex. Having the patient grip your index fingers with a pincer grip is a test of strength in the hands, not related to CTS. Having the patient hold a piece of paper between the thumb and index finger that results in flexion of the interphalangeal joint of the thumb indicates ulnar nerve palsy.

Correct answer: Eating a green smoothie made using spinach every day for breakfast

Dietary modifications to limit purine intake is recommended for individuals who experience gouty arthritis. High-purine foods include some seafood such as scallops and mussels and meats such as organ and game meats. Vegetable-sources of purine include spinach, asparagus, and beans (legumes), and while more readily tolerated in individuals who have gout, they may need to be avoided to prevent flare-ups or worsening of symptoms.

Oatmeal is moderately high in purines but may occasionally be eaten. Eggs, chocolate, cocoa, peanut butter, and nuts are low in purines and are safe to include in the diet. Other acceptable foods include green vegetables and tomatoes; fruits; breads and cereals that are not whole-grain; butter; buttermilk; cheese; eggs; and coffee, tea, and carbonated beverages. Low-fat or nonfat milk and low-fat yogurt may lower the risk of gout.

Correct answer: Should be changed: discontinue both the dihydroergotamine mesylate (Migranal, D.H.E.45) and naproxen sodium (Aleve, Anaprox) and start the combination medication caffeine/butalbital/acetaminophen (Fioricet)

Migraine treatment can be complicated, and having other health conditions can complicate treatment further. Patients with CAD, angina, and uncontrolled hypertension are often limited by what medications they are able to take to stave off painful migraine symptoms. The use of triptans, the ergotamines (dihydroergotamine mesylate, ergotamine tartrate), and some NSAID drugs is contraindicated in people who have CAD or angina because of the potential vasoconstrictive effect.

An appropriate substitute would be the use of caffeine/butalbital/acetaminophen (Fioricet). Frequent or excessive use of the product should be discouraged due to the potential for barbiturate dependency and analgesic rebound headache.

Correct answer: Abdominal CT with contrast 

A history of diverticulosis is necessary for a patient to experience an episode of acute diverticulitis. Most individuals with diverticulosis are not aware that they have diverticula (out-pouching of the intestinal walls, most commonly the sigmoid colon or descending colon), which occurs as a natural consequence of aging. More than 50% of Americans have diverticulosis. There is some debate as to the general cause of diverticulosis. For many years, it was believed that a low-fiber diet comprised heavily of processed foods contributed to the development of diverticulosis. Risk factors for diverticulosis include a family history of diverticulosis, connective tissue disorders, and Marfan syndrome. Cases of acute diverticulitis may be mild or severe; mild cases can be managed on an outpatient basis, but severe cases should be referred to the hospital, as these are considered to be life-threatening. 

Severe cases of acute diverticulitis may present with symptoms of acute abdomen, a positive Rovsing's sign (pain in the right lower quadrant when the left lower quadrant is palpated), rebound tenderness, and a boardlike abdomen. Patients typically complain of nausea, vomiting, diarrhea or constipation, and minimal appetite for several days, as well as left lower quadrant pain. They are typically febrile, and lab studies (CBC with differential) show leukocytosis, neutrophilia (with >70% neutrophils), and a shift to the left (band forms), indicating a severe bacterial infection. A positive fecal occult blood test may be positive if the patient has experienced perforation or rupture of the infected diverticula. Acute diverticulitis is best diagnosed with abdominal computed tomography with contrast. Plain abdominal films may be useful for identifying free air, signifying diverticular perforation in mild cases. Colonoscopy and barium enema should not be utilized during acute diverticulitis; colonoscopy should be reserved for follow-up visits once the acute phase has resolved. 

Correct answer: Once a baseline for the liver enzymes has been established, it is not necessary to recheck levels routinely, as this will not prevent liver damage from statins.

Before starting a patient on statin medication, it is necessary to check liver enzyme levels to establish a baseline for liver function. Historically, the standard practice was for routine monitoring of liver enzymes after initiating statins out of concern for significant liver damage, but this concern has been proven to be untrue. 

Higher dosages of statins can cause a minimal to moderate increase in liver enzyme results (resulting in borderline liver enzyme results) that is seen over time, but routine monitoring of the liver enzymes is not useful in preventing any damage that may occur as a result of statin usage. The association of statins with elevated liver enzymes is sporadic and cannot be predicted, even when higher dosages of statins are prescribed. 

Correct answer: Qsymia

Many prescription weight loss medications are considered safe for use and are currently available to patients who desire to lose weight. Weight loss drugs are important to consider when providing care for obese or overweight patients who are embarking on a weight loss program, as some of the drugs can also aid in the absorption of dietary fats and, when combined with lifestyle changes, can result in an overall increase in weight loss. 

According to data published by the Centers for Disease Control and Prevention (CDC) in 2020, a similar percentage of both men and women in the US are obese, but women are more likely than men to be severely obese. While many of the weight-loss medications currently available are safe for use in most patients, some medications require more discretion in prescribing. Qsymia, a combination of phentermine and topiramate, should not be prescribed for women who are planning to become pregnant or who are at risk of becoming pregnant. Topiramate is known to cause cleft lip and palate defects in a developing fetus; this risk occurs early during the first few weeks of pregnancy, often before a woman even knows she is pregnant. Its use during pregnancy is also linked to autism spectrum disorders and learning disabilities in infants/children. If Qsymia^R is to be prescribed to a sexually active woman of childbearing age, the patient must take a pregnancy test before starting the medication and must agree to monthly pregnancy testing while taking Qsymia. 

Contrave should not be prescribed to patients who are already taking another form of bupropion, as it may cause increases in blood pressure and heart rate. The patient's blood pressure and heart rate should be monitored at each visit to assess for changes.

Saxenda is contraindicated for patients who have a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.

Orlistat should not be prescribed for patients who have known malabsorption issues. 

All weight-loss medications carry a warning against use during pregnancy, as there is no benefit of weight loss during pregnancy for the pregnant woman, and weight loss during pregnancy may result in harm to the fetus. 

Correct answer: Mitral valve prolapse

Mitral valve prolapse is characterized by a grade 1-3/6 late systolic crescendo honking murmur following a mid-systolic click.

Aortic stenosis presents with a grade 1-4/6 harsh systolic murmur, heard at the second right intercostal space. 

Mitral regurgitation is characterized by a grade 1-4/6 high-pitched blowing murmur, heard at the right lower scapular border. 

Aortic regurgitation presents as a high-pitched diastolic murmur, heard best at the third intercostal space by the left sternal border (Erb's point) if it is due to a diseased aortic valve or at the right upper sternal border (aortic area) if it is due to an abnormal aortic root.

Correct answer: Presence of coagulopathy

Coagulopathy, a condition in which the blood's ability to coagulate is impaired, is not involved in the development of thrombophlebitis.

Thrombophlebitis, the presence of coagulated blood or thrombus in a vein that leads to inflammation, can occur in superficial or deep veins. It is found most often in the lower extremities. Its development is caused by a combination of factors referred to as Virchow's triad: venous (blood) stasis, injury to the vascular intima, and abnormal coagulation leading to clot formation. 

The condition is more likely to occur after trauma to the area, prolonged rest/travel, presence of varicose veins, having a history of prior thrombophlebitis, and the use of estrogen-containing compounds such as contraceptives or hormone replacement therapy during the menopausal years.

Correct answer: Snellen test

The Family Nurse Practitioner (FNP) should be well-versed in completing basic testing to evaluate vision. Near vision should be evaluated by asking the patient to read a flyer or leaflet (or another similar item) with a small print, while distance vision should be evaluated using the Snellen test. (Illiterate patients should be tested using the Tumbling E chart). The patient should be asked to stand approximately 20 feet away from the Snellen chart and asked to cover one eye at a time and read from the chart. Patients with glasses should be assessed with the glasses on. Visual deficits are noted if the patient is unable to read at least four out of the six letters in a line or if there is a greater than two-line difference between the two eyes. Patients with visual deficits should be referred to an optometrist for full visual testing. The peripheral vision should also be tested by using the "visual fields of confrontation" exam. This requires the patient to stare at the examiner's nose while the examiner holds up a finger (or fingers) in each of the four visual quadrants. It is considered an abnormal finding if the patient is unable to visualize the finger (or fingers) in one of the quadrants or is unable to correctly identify the number of fingers being displayed. Color blindness is assessed through the use of the Ishihara chart. The Ishihara chart is a booklet comprised of several pseudoisochromatic plates bearing numbers (typically) or tracing lines which are used to evaluate for the presence of color blindness. 

Both the Weber test and the Rinne test are utilized to evaluate for hearing loss. 

Correct answer: Acyclovir (Zovirax) 400 mg by mouth twice per day (PO BID)

Herpes virus suppressive therapy is indicated in individuals experiencing frequent recurrent outbreaks, reducing the frequency of outbreaks by 70-80%. It can also be effectively utilized in individuals experiencing less frequent outbreaks and confers the advantage of decreasing risk of virus transmission to susceptible partners. 

For individuals experiencing ≥ 10 outbreaks per year, suppressive therapy utilizing acyclovir (Zovirax) 400 mg PO BID is one of the most effective treatment regimens. Other effective treatments include famciclovir (Favier) 250 mg PO BID or valacyclovir (Valtrex) 1 gram PO qd. 

Dosing valacyclovir (Valtrex) at 500 mg PO qd is less effective than these previous regimens for treating individuals experiencing ≥ 10 outbreaks per year (frequent recurrences). Acyclovir (Zovirax) 800 mg PO TID is prescribed for two days during episodic recurrent outbreaks that total > 10 outbreaks per year. Famciclovir (Favier) 250 mg PO TID is prescribed for 7-10 days during primary infection.

Correct answer: Lactic acidosis

Patients who are scheduled for surgery are instructed to withhold metformin (Glumetza, Riomet, Glucophage, Fortamet) on the day of surgery due to an increased risk of lactic acidosis.

Metformin improves insulin-mediated glucose uptake and metabolic parameters such as fibrinolysis. The anticipated A1C reduction with intensified or maximum safe and tolerated metformin dose is about 1% to 2%. It does carry a rare risk of lactic acidosis, a potentially fatal illness (approximately 3 in every 100,000 patients treated). This condition most often occurs with impaired renal function, hypovolemia, low perfusion state, and age greater than 80 years. However, with radiocontrast use, surgery, or other conditions that can potentially alter hydration status, it should be omitted the day of and reintroduced when hydration status and renal function are back to baseline. 

Metformin carries very little risk of hypoglycemia when used as a solo product and does not lead to hyperglycemia or hemorrhage.

Correct answer: "I'm going to write you a prescription for folic acid supplementation, 4 mg tablets. I would like you to take one tablet every day for three months before trying to become pregnant."

Neural tube defects are caused by a deficiency of folic acid, frequently due to dietary deficiencies or as a result of taking medications that interfere with the absorption of folate, such as phenytoin (Dilantin^R), methotrexate, metformin (Glucophage^R), and trimethoprim-sulfate (Bactrim^R). More recently, it has been discovered that genetic factors impacting the body's ability to metabolize/use dietary folic acid may contribute to an increased risk of neural tube defects during pregnancy. Women who have given birth to an infant with a neural tube defect or experienced the loss of an infant during any stage of pregnancy due to a neural tube defect are at a heightened risk of giving birth to another child with a neural tube defect. These patients should be counseled to delay becoming pregnant until they have been treated with folic acid supplementation of 4 mg/day for three months. Once pregnancy has been achieved, this folic acid dose should be continued until at least through the first 12 weeks of the pregnancy, when the risk of neural tube defect has passed. 

Any woman of childbearing age who has the potential to become pregnant should be counseled to take a daily dose of 400 mg of folic acid in case she becomes pregnant. Pregnant women should receive folic acid supplementation of 800 mcg to 1 mg/day throughout their pregnancy. Women who present to their provider already pregnant should be counseled to begin immediate folic acid supplementation and continue it through the first seven weeks of the pregnancy.

Correct answer: The patient has been treated with TMP-SMX (Bactrim DS).

The symptoms described are characteristic of Stevens-Johnson syndrome, a severe immune-complex-mediated hypersensitivity reaction involving the skin and the mucous membranes that occurs as a delayed reaction to medications such as sulfonamides (including TMP-SMX), allopurinol, anticonvulsants, and oxicam NonSteroidal Anti-Inflammatory Drugs (NSAIDs).

Multiple lesions that appear like a target (or a "bull's eye") start erupting abruptly and can include hives, blisters (bullae), petechiae, purpura, and necrosis and sloughing of the epidermis. There is extensive mucosal surface involvement (eyes, nose, mouth, esophagus, and bronchial tree), and there could be a prodrome or fever with flu-like symptoms 1 to 3 days before the rashes appear.  

Stevens-Johnson syndrome is not typically triggered by beta-lactams such as amoxicillin (Moxatag), cephalosporins such as ceftriaxone (Rocephin), or macrolides such as azithromycin (Zithromax, AzaSite, Zmax).

Correct answer: Transferrin

Transferrin is a protein produced by the liver and is necessary for the transport of iron. Transferrin binds with iron and transports it through the blood to the bone marrow and wherever else it is needed in the body, and as well, aids in the uptake of iron into the cells. When iron levels are low, the liver produces and releases more transferrin in an attempt to increase iron-binding, making for elevated unbound serum transferrin levels in Iron-Deficiency Anemia (IDA). The transferrin level is measured by evaluating the Total Iron-Binding Capacity (TIBC) level.

Ferritin is measured by evaluating the serum ferritin level, decreased in IDA.

The iron level is measured by evaluating serum iron levels, also decreased in IDA.

Ferrous sulfate is a form of oral iron supplementation.

Correct answer: Symptoms persist after an 8-week course of a proton-pump inhibitor (PPI) such as omeprazole (Prilosec)

An 8-week course of PPI therapy is usually adequate to heal acute esophageal inflammation noted with ongoing GERD. If symptoms continue after 8 weeks, a referral to gastroenterology for further evaluation is indicated.

Most cases of mild gastroesophageal reflux disease (GERD) respond to the use of lifestyle modifications and antacids. If symptoms continue, the next step is the prescription of a histamine-2 receptor antagonist (H2RA), such as ranitidine (Zantac) or cimetidine (Tagamet), for a maximum of 6 weeks. If there is no improvement within 6 weeks, long-term H2RA therapy is unlikely to be helpful. If H2RA therapy has failed, a PPI can be prescribed for 8 weeks prior to referral to gastroenterology.

Correct answer: Group A streptococci

Impetigo is a highly contagious skin condition. It usually occurs on the face, neck, and hands of young children and infants. Children who wear diapers also tend to get it around the diaper area. Impetigo occurs more rarely in adults, usually following another skin condition or an infection.

Nonbullous impetigo is a bacterial infection caused by Streptococcus pyogenes (gram-positive Group A streptococci), Staphylococcus aureus, or a combination of both. S. aureus is the primary causative bacteria of bullous impetigo and is responsible for a substantial portion of nonbullous infections as well. Recommended treatment often depends on which bacteria are causing the infection.

While other serogroups (e.g., Groups B, C, and G streptococci) are occasionally observed, they are not considered a primary cause of impetigo.

Correct answer: An abdominal computed tomography (CT) scan

If a patient with acute diverticulitis fails to respond to conservative treatment within 2 to 3 days or becomes significantly worse during that time, particularly if peritoneal signs develop, an abdominal CT scan and specialty surgical consultation should be obtained. With recurrent diverticulitis episodes, particularly with a complicated course, surgical intervention with partial colectomy is an option to remove the problematic portion of the intestines.

A barium enema for x-rays is contraindicated during an acute episode of diverticular disease due to the risk for complications. 

Nuclear medicine studies, such as a SPECT scan, have a limited role in the evaluation of diverticulitis. 

Abdominal ultrasound is not useful as a diagnostic test for diverticulitis.

Correct answer: The average American male has an approximate 3% risk of dying from prostate cancer.

The average American male has a 40% lifetime risk of developing latent prostate cancer, a 10% risk of developing clinically significant disease, and a 3% risk of dying from prostate cancer. Studies show that the absolute risk reduction of prostate cancer deaths with screening is very small. 

Screening for prostate cancer by use of the Digital Rectal Exam (DRE) is advised but has limitations. The DRE may reveal a discrete, painless prostate lesion in individuals with prostate cancer but may also be normal until the disease is advanced.

Transrectal ultrasound is not indicated as a first-line screening tool for prostate cancer due to its low sensitivity and specificity but can be useful when coupled with Prostate-Specific Antigen (PSA) results and DRE findings. Watchful waiting is often a reasonable option for older men with local disease. 

Correct answer: Levofloxacin 750 mg PO BID  metronidazole 500 mg PO Q6 hours

Mild cases of diverticulitis—inflammation of diverticula (outpouchings of the sigmoid or descending colon) with likely micro-perforation of the diverticula—may be recurrent in patients who have a long-standing history of diverticulosis despite attempts to manage the disorder. Daily use of a fiber supplement such as psyllium or methylcellulose in addition to a high-fiber diet, ample fluid intake, and daily aerobic activity should be recommended to individuals with known diverticulosis. Most cases of diverticulosis are discovered incidentally, such as during routine colonoscopy, and are asymptomatic. Diverticulitis is believed to occur as a result of fecal particles settling in the diverticula, resulting in inflammation, distention, and obstruction of the diverticula. Mild cases of diverticulitis may be safely managed on an outpatient basis; despite research failing to find an improvement in mild diverticulitis when antibiotic therapy is administered, the current management of the disorder includes the administration of oral antibiotics for 7 to 10 days. The patient should also be counseled to avoid solid foods until symptoms have resolved to ensure adequate bowel rest. 

Primary antibiotic treatment of mild diverticulitis may include trimethoprim-sulfamethoxazole DS PO BID, ciprofloxacin 750 mg PO BID plus metronidazole 500 mg PO Q6 hours, or levofloxacin 750 mg PO QD plus metronidazole 500 mg PO Q6 hours. Alternate antibiotic treatment regimens that may be prescribed include amoxicillin-clavulanate 875/125 mg PO BID, amoxicillin-clavulanate ER 1,000/62.5 mg 2 tablets PO BID, or moxifloxacin 400 mg Q24 hours. 

Patients should be instructed to return to the clinic if there is no improvement in their symptoms in 48 to 72 hours or to go to the emergency department if symptoms worsen.

Correct answer: Return for colposcopy

Per current cervical cancer screening recommendations of the American Society for Colposcopy and Cervical Pathology (ASCCP), a Pap test result of LSIL, HPV positive requires follow-up by colposcopy. Typically, biopsies are obtained at the time of colposcopy.

Co-testing for HPV has already been obtained for this patient and is positive. Had the co-testing generated a negative result, repeat co-testing in one year would be appropriate.

Loop Electrosurgical Excision Procedure (LEEP) is indicated for the treatment of cervical cancer or in the case of a high-grade Pap abnormality, or occasionally for treatment of persistent lower grade abnormalities.