AANPCB FNP Exam Questions

Correct answer: HPV 16 and HPV 18

HPV is a small DNA virus with more than 120 known types, which usually infects the epithelium via direct contact with a person who has HPV, whether or not signs and symptoms of the infection are present. A variety of benign and malignant diseases are caused by HPV infection. Anal, penile, and cervical carcinomas are largely the consequences of HPV infection, and almost all cases (over 99%) of cervical cancer are caused by HPV. HPV has also been implicated in causing up to 70% of oropharyngeal cancers. 

HPV strains 16 and 18 are oncogenic/carcinogenic. Primary prevention of HPV disease is available through immunization with Gardasil 9, which protects against HPV strains 16 and 18 as well as various others. 

HPV strains 6, 11, 40, 42, 43, and 44 are largely benign and often self-limiting HPV infections with more than 90% of genital warts being caused by HPV types 6 and 11. 

Correct answer: Topical miconazole

Cheilosis is known by several names, including angular cheilitis, perleche, and angular stomatitis. It most commonly affects older adults who wear dentures, particularly when the dentures do not fit correctly. The condition may also be caused by vitamin B deficiencies, autoimmune diseases such as lupus or Sjögren's syndrome, irritant dermatitis, squamous cell carcinoma, and hypersalivation. Cheiolosis may also occur in children as a result of thumb or pacifier sucking and licking of the lips. Patients typically present with painful cracking and ulceration at the corners of the mouth or scaling and erythema at the corners of the mouth. 

Cheilosis may be acute or chronic; improper treatment of acute cheilosis can result in a chronic case. The lesions of cheilosis can become secondarily infected with Candida. First-line treatment for cheilosis includes the administration of a topical azole such as miconazole, or nystatin. If the condition does not fully resolve with the use of topical antifungal medication and microscopy has confirmed the presence of yeast, oral treatment with fluconazole may be indicated. Cheilosis may also become secondarily infected with Staphylococcus, which should be treated with mupirocin. If a vitamin B deficiency is suspected, lab studies should be ordered and the patient should be treated accordingly. 

Applying zinc oxide cream or petroleum jelly to the corners of the mouth once the condition has been resolved can help prevent the recurrence of cheilosis.

Correct answer: The child should be kept out of daycare for 24 hours after initiation of antibiotic therapy.

Impetigo is a contagious skin infection that usually consists of discrete purulent lesions. During treatment of impetigo, it is important to minimize the risk of infectious transmission. In terms of preventing transmission in a daycare or school setting, this is accomplished by keeping the child at home for 24 hours after starting antibiotic therapy. Family members should also be checked for lesions.

Waiting for the lesions to form crusts, become less irritated, or for the child to become afebrile are not indicated measures.

Correct answer: Tachypnea at rest, confusion

As with other infectious diseases, elderly patients often experience fewer symptoms and may present with an elevated resting respiratory rate and a general feeling of illness. Altered mental status is also often seen in older adults with pneumonia.

Fever, shaking chills, pleuritic chest pain, fatigue, and anorexia are symptoms typically seen in the adult with CAP. 

Correct answer: Computerized tomography of the abdomen

Abdominal Computerized Tomography (CT) usually provides a diagnostic view of the inflamed pancreas seen in acute pancreatitis.

An abdominal Magnetic Resonance Imaging (MRI) scan is used to help differentiate between other pancreatic disorders, including pancreatic pseudocyst and pancreatic cancer. Abdominal CT may also be used in this case.

An abdominal x-ray is not a routine procedure in emergency examinations for diagnosing diseases of the abdomen.

An abdominal ultrasound is useful in diagnosing gallbladder disease but is not helpful in evaluating the pancreas due to limited views of the pancreas.

Correct answer: Prescribe nasal packing or a topical antifibrinolytic agent (thrombin)

If the application of pressure is not effective after 10 minutes, the next line of treatment is nasal packing or cautery. Topical antifibrinolytic agents (thrombin) may also be used. 

Application of an ice pack to the nose is an ineffective treatment for epistaxis.

Nasal cautery is occasionally performed but only in recurrent or refractory epistaxis. 

Referral to otolaryngology for surgical intervention is reserved for refractory cases that do not respond to second-line therapy.

Correct answer: "It will shorten the time you feel ill by one day."

Anti-viral medications such as oseltamivir (Tamiflu) can be used to treat influenza A and B infections caused by susceptible viral strains. If the medication is administered within the first 48 hours of developing symptoms, the time a person feels ill is shortened by one day. 

Although these select antiviral medications carry indications for the postexposure prevention of influenza, all have a less favorable adverse reaction profile than the influenza vaccine. These products are also significantly more expensive, with a greater risk for treatment failure. Active immunization against influenza A and B is the preferred method of disease prevention. 

Influenza, or "the flu," is solely a respiratory illness and does not have any gastrointestinal (GI) components. Lay people often mistakenly refer to a cluster of GI symptoms as "the stomach flu."

Correct answer: 1.2 mg initially, then 0.6 mg one hour later, followed by 0.6 mg once or twice daily

Because colchicine (Colcrys) is often poorly tolerated, the suggested dosing is 1.2 mg initially, then 0.6 mg one hour later, followed by 0.6 mg once or twice daily. The total recommended dose of colchicine in a 24-hour period is limited to 2.4 milligrams.

A short course of a systemic corticosteroid, such as oral prednisone, is a helpful alternative to colchicine. 

Correct answer: Irritability, hypervigilance

Irritability and hypervigilance are classic signs seen with PTSD. Other signs include detachment, flashbacks, nightmares, and numbing of emotions.

Fatigue, hypersomnia, and sadness are signs of depression. Back pain and headaches are often somatic symptoms related to anxiety. Aggressive behavior can be related to several mental health disorders, including anxiety, delirium or dementia, bipolar disorder, schizophrenia, or conduct disorder.

Correct answer: Etonogestrel-containing subdermal contraceptive implant (Nexplanon)

Various methods are used to treat primary dysmenorrhea with the choice of agent used in treating the dysmenorrhea based on each patient's unique medical history and their current lifestyle needs. Basic treatment for the patient presenting for the first time with a complaint of dysmenorrhea may include rest, application of heat, using simple teas, or an over-the-counter analgesic. However, typically a patient who is seeking treatment for dysmenorrhea will have already unsuccessfully tried these potential remedies.

In this scenario, the teenage patient has already been offered COCs and failed to be able to take them consistently enough to provide relief of her symptoms. Because the patient is engaging in regular non-penetrative sexual activity with a stable partner, the nurse practitioner should consider and discuss with the patient the possibility of engaging in intercourse and the concern of possible unplanned pregnancy.

In consideration of the patient's inability to be consistent with remembering to take pills and her possible need for a birth control method, the ibuprofen regimen, which has been found to improve dysmenorrhea in 80% of women, and Vitamin E, while excellent options for treatment of dysmenorrhea, are not the best options in this scenario. 

The LevoNorGestrel IntrauUerine Devices (LNG-IUDs) are not indicated for treatment of dysmenorrhea, despite that they typically contribute to a gradual decrease in menstrual bleeding or even cessation of menses, which in theory should also result in improvement of dysmenorrhea. Observation data of users of levonorgestrel IUD devices were observed to report a 60% incidence of dysmenorrhea prior to IUD insertion, which decreased to 29% after three years of treatment with IUD. Furthermore, the IUD devices are ideally inserted during the first few days of menstrual bleeding, which is when cramping tends to be worse. IUD insertion causes menstrual cramping and may cause prolonged cramping at times in individuals who suffer from dysmenorrhea.

In this scenario, the etonogestrel subdermal contraceptive implant (Nexplanon) is the best option for this patient, as this implantable device has been shown to decrease dysmenorrhea in users of the device through its mechanism on ovulation and menstrual suppression. Seventy-seven percent of women who used an etonogestrel contraceptive implant reported complete cessation of dysmenorrhea with the device in place. In addition, this device provides an excellent method of contraception in which the user does not need to be responsible for ensuring use of the device to be effective (there is no need for daily pills). 

Correct answer: Two years

Giant cell arteritis most often affects older patients (average age at the time of diagnosis is >76 years) who often have a related, co-existing diagnosis of polymyalgia rheumatica (PMR, 50% to 70%). Females are affected more frequently than males, with individuals with Northern European heritage being at the greatest risk of being diagnosed with either GCA or PMR. 

Because patients who are diagnosed with GCA are at a high risk of developing blindness due to ischemic optic neuropathy, immediate treatment with high-dose oral steroids (prednisone) is indicated. This also helps alleviate the pain of GCA. Prednisone doses of up to 80 mg to 100 mg per day should be continued until symptoms begin to abate and the disease process appears to be under control. The prednisone dose should then be tapered down to the lowest dose that continues to provide alleviation of symptoms. This dose should then be maintained for at least 6 months, with most patients requiring prednisone treatment for 2 years. 

Correct answer: The hippocampus

Positron emission tomography (PET) scans of individuals experiencing recurrent major depression or depression prior to the age of 21 years have found the hippocampus has a smaller volume than that of patients who have not experienced recurrent major depression or those patients whose depression was in remission. It is unclear whether recurrent major depression contributes to atrophy or shrinking of the hippocampus or if individuals with a smaller hippocampus are more likely to experience depression. The hippocampus is associated with memory formation and emotions.

Other brain structure changes associated with recurrent major depression include an increase in the size/volume of the lateral ventricles, an increase in the cerebrospinal fluid volume, and decreases in size of the basal ganglia, thalamus, frontal lobe, orbitofrontal cortex, and the gyrus rectus.

Correct answer: After she has given birth to the baby

The MMR vaccine contains live but weakened (attenuated) virus and requires two immunizations during childhood to provide immunity against the diseases. If an adult has not received the recommended vaccines during childhood, they should be completed during adulthood. 

Pregnant women should not receive the MMR vaccine regardless of their vaccine status because of the theoretical but unproven risk of congenital rubella syndrome from the live virus contained in the vaccine. The MMR vaccine is safe to use during lactation and should be administered to the woman, regardless of her infant's feeding status, as soon after delivery as possible.

Correct answer: A reaction to bed bug bites

Bed bugs (Cimex lectularius) are parasitic insects that have been implicated in increasing numbers of infestations worldwide. They are found everywhere, from the most unkempt homes to pristine 5-star hotels. They require only a warm host and hiding places to flourish.

Repeated exposure to bed bug bites can lead to skin reactions, which can include macules, wheals, vesicles, bullae, nodules, and papules with a darker red spot in the center. A bed bug bite closely resembles a flea or mosquito bite and often appears in a "breakfast, lunch, and dinner" pattern, in that the parasite will bite in one location, then move laterally to bite again, and repeat the action for a third bite (hence the zig-zag pattern). The bites are most often found on exposed skin of the arms, legs, neck, and shoulders. The rash is pruritic and self-limited, and should resolve without treatment in 1-2 weeks.

Atopic dermatitis is characterized by pruritic, lichenified lesions. Herpes zoster is characterized by painful, pruritic vesicular lesions in a linear pattern that do not cross the midline. Lyme disease is characterized by a single painless annular lesion.

Correct answer: Central obesity with a waist circumference of ≥ 80 cm (31.5 in) in women of Japanese ancestry

The International Diabetes Federation uses an ethnic-specific waist circumference of central obesity as one facet of criteria in diagnosing metabolic syndrome. Central obesity measurements must be as follows to meet the definition:

• European, sub-Saharan African, Eastern Mediterranean, Middle Eastern (Arabic) ancestry
  • Women ≥ 80 cm (31.5 in)
  • Men ≥ 94 cm (37 in)
• South Asian, Chinese, ethnic South and Central American ancestry
  • Women ≥ 80 cm (31.5 in)
  • Men ≥ 90 cm (35.5 in)
• Japanese ancestry
  • Women ≥ 80 cm (31.5 in)
  • Men ≥ 90 cm (35.5 in)

In addition to meeting the definition of central obesity, patients must also have two or more of the following findings to be diagnosed with metabolic syndrome:

• Abnormal triglycerides ≥ 150 mg/dL
• HDL cholesterol < 40 mg/dL in men or < 50 mg/dL in women
• Blood pressure readings of ≥130 Hg systolic or ≥ 85 Hg diastolic or treatment of previously diagnosed hypertension
• Fasting glucose ≥ 100 mg/dL or previous diagnosis of type 2 diabetes or impaired glucose tolerance

Correct answer: Digital rectal examination

Prostate size and contour can be assessed in an initial Digital Rectal Examination (DRE), but additional diagnostic procedures are needed to rule out or confirm infection or other conditions, such as an enlarged prostate, that are causing symptoms. DRE can be misleading, as a prostate that is apparently small on examination can cause significant symptoms. Since diagnosis of BPH is based on multiple components, use of a validated tool such as the American Urological Association (AUA) Symptom Index for Benign Prostatic Hyperplasia increases the likelihood of an accurate diagnosis as well as a urinalysis and/or urine culture to rule out infection.

Diagnostic procedures that are used to confirm presence of an enlarged prostate include a urinary flow test, transrectal ultrasound, and post-void residual urine volume test. 

Correct answer: Cardiovascular history, family medical history, and cardiovascular physical exam

The screening process in a preparticipation sports screening examination should involve three essential parts, including cardiovascular history, family medical history, and cardiovascular physical examination.

The cardiovascular history should include the following questions:

• Prior occurrence of exertional chest pain/discomfort or syncope/near syncope
• Excessive, unexpected, and unexplained shortness of breath or fatigue associated with exercise
• Past detection of a heart murmur or high blood pressure

Family history should assess for history of premature death (sudden or otherwise), significant disability from cardiovascular disease in one or more close relatives younger than age 50, or specific knowledge of the occurrence of certain conditions (hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan syndrome, or clinically important dysrhythmias).

The cardiovascular exam should include the following:

• Precordial auscultation in the supine and standing positions to identify heart murmurs consistent with dynamic left ventricular outflow obstruction
• Assessment of the femoral artery pulses to exclude coarctation of the aorta
• Recognition of the physical stigmata of Marfan syndrome
• Blood pressure measurement in the sitting and standing positions

A generalized past medical history, sports-specific history, urinalysis, height and weight, and complete blood count (CBC), while helpful at painting an overall picture of the patient's health, are not essential components of a preparticipation sports screening examination.

Correct answer: Vitamin B₁₂

While patients who are deficient in vitamin B₁₂ are rarely so due to nutritional deficiency alone, it is possible to experience a deficiency of vitamin B₁₂ if a strict vegan or plant-based diet is adhered to for upwards of three to five years. This vitamin is found in quantity in animal proteins (meat, dairy products, eggs, etc.) and less so in plant sources such as nutritional yeast, mushrooms, algae, and fortified grain products. Excess dietary vitamin B₁₂ is stored in the liver for future use in Red Blood Cell (RBC) production, and as only small amounts are utilized during RBC production, the liver typically holds enough vitamin B₁₂ stores to last for over three to five years. Most patients with pernicious anemia (vitamin B₁₂ deficiency) receive supplementation using a parenteral form of the vitamin dosed at 1,000 mcg/day Intramuscularly (IM) for one week, then decreasing to administering the same dose once per week for one month, and then the same dose again administered every one to three months for life. This IM dose likely represents an over-dosing of vitamin B₁₂, as the body is unable to absorb this hefty dose, resulting in the excretion of the excess via the kidneys. An IM dose of 100 mcg is most likely adequate.

Vitamin B₁₂ is also available in an oral format. Dosing for this form requires higher dosing (1,000 mcg/day). The vitamin is also available in nasal gel and nasal spray formulas that are administered once per week; these forms are dosed at 500 mcg/week. 

Correct answer: Painful, slightly raised lesions in the mouth

Inhaled CorticoSteroids (ICS) are the preferred controller treatment for all levels of persistent asthma. Local adverse effects include a sore throat, oral candidiasis, and hoarseness. Oral candidiasis, or thrush, is characterized by the presence of creamy white lesions primarily on the tongue and inner cheeks. Lesions may also be seen on the palate, gums, and tonsils. Lesions may be slightly raised with a cottage cheese-like appearance, and slight bleeding may occur if the lesions are rubbed or scraped. Rinsing the mouth after use of these medications and the use of a spacer can help reduce these effects.

Dry mouth is not a sign of thrush but may encourage its development with ICS use. A sore throat and hoarseness are local adverse effects of ICS therapy along with, but are not symptoms of, oral candidiasis.

Correct answer: Increase the omeprazole (Prilosec) dosing schedule to twice per day

Reflux esophagitis is present in 40% of patients with GastroEsophageal Reflux Disease (GERD). Patients who have been treated for bothersome reflux symptoms or those patients with known complications related to GERD should receive treatment with a Proton Pump Inhibitor (PPI) administered once daily. If symptoms do not improve or resolve within 2 to 4 weeks, the nurse practitioner should increase the PPI dosing to twice per day for 8 weeks.

If, after 8 weeks of twice per day dosing, the patient's symptoms do not improve, the patient should be referred to gastroenterology for further evaluation, including upper GI endoscopy. The nurse practitioner may elect to change the PPI based on endoscopy results but should continue twice per day dosing with the new PPI. The PPIs are preferred over H2-receptor antagonists, such as famotidine, because of their superiority.