AANPCB FNP Exam Questions

Correct answer: 1.25 to 1.50 grams of protein per kilogram of body weight

For a healthy adult, the daily nutritional requirement of protein needed to heal a wound is approximately 1.25 to 1.50 grams of protein and 30 to 35 calories per kilogram of body weight. These requirements are increased in the presence of sizable wounds. Inadequate protein-calorie nutrition, even after just a few days, can impair normal wound-healing mechanisms.

Correct answer: Drug eruption

Morbilliform drug eruption is the disorder that most commonly mimics a viral morbilliform exanthem. Even to the trained eye, the morbilliform rash of a drug eruption can be clinically indistinguishable from a viral morbilliform exanthem. While a number of drugs can cause a morbilliform eruption, antibiotics are the most common culprits behind this rash. 

A morbilliform drug eruption is most common in adults who have started taking a medication in the last one to two weeks or who have completed medication treatment within the most recent week. The rash may also be accompanied by low-grade fever and pruritus.

Rubeola virus (measles) is less likely in this scenario due to the patient's recent history of antibiotic usage, the presence of a low-grade versus high-grade fever, and lack of other systemic symptoms typically associated with rubeola virus.

Early guttate psoriasis may also cause a morbilliform rash and typically occurs two to three weeks after streptococcal infection or tonsilitis; however, in this condition, the rash typically starts on the extremities or trunk and then may spread to the face, ears, or scalp.

In adults infected with rubella virus, the exanthem typically starts on the face as discrete macules and then spreads downward over the neck, trunk, and extremities. Individuals infected with rubella virus also may experience fever, sore throat, and rhinitis.

Correct answer: A grade 1 harsh systolic murmur in a crescendo-decrescendo pattern

The murmur heard with aortic stenosis is defined as a grade 1 to 4/6 harsh systolic murmur, usually in a crescendo-decrescendo pattern, and is best heard at the second right intercostal space with radiation to the carotids. This type of murmur softens with standing.

Systolic murmurs are graded on a 1 to 6 scale from barely audible to audible with the stethoscope off the chest. A grade 3 murmur is about as loud as S1 or S2, whereas a grade 2 murmur is slightly softer; a grade 1 murmur is difficult to hear. Grade 4 murmurs are usually accompanied by a thrill or a feel of turbulent blood flow.

Diastolic murmurs are usually graded on the same scale but abbreviated to grades 1 through 4 because these murmurs are not loud enough to reach grades 5 and 6.

A grade 1 to 4/6 high-pitched blowing systolic murmur, which radiates to the axilla and often extends beyond S2 and laterally displaces the Point of Maximal Impulse (PMI), is associated with aortic regurgitation. 

A grade 1 to 3/6 early to midsystolic murmur heard best at left sternal border, no radiation beyond precordium, softens or disappears with standing and increases in intensity with activity, fever, or anemia. A Point of Maximal Impulse (PMI) normal is characteristic of a physiological murmur (also known as innocent or functional murmur).

A grade 1 to 3/6 late-systolic crescendo murmur with a honking quality is heard best at apex; a murmur that follows midsystolic click is associated with mitral valve prolapse.

Correct answer: "I can drink two glasses of red wine each evening."

Recommended lifestyle modifications related to hypertension include limiting consumption of alcohol. In women, < 1 alcoholic drink per day is recommended. One drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof whiskey.

A diet rich in fruits, vegetables, and lowfat dairy products is recommended. A bottle or can of beer typically holds 12 ounces, which meets the recommendation.

Correct answer: Imiquimod

Men who have sex with men (MSM) are more at risk for contracting anogenital warts through sexual contact than are heterosexual males. The condyloma typically appear around the anus and the surrounding anogenital skin and may also be present within the rectum, necessitating a digital rectal examination when assessing for the full extent of the infection.

While very small or low numbers of small warts located on the anogenital area may be treated with application of TCA in the office setting, when greater numbers of condyloma are present or they are somewhat larger in size, treatment with imiquimod is more appropriate. Imiquimod is an immune system modulator that serves to stimulate the patient's immune system to "ramp up" to suppress the Human Papilloma Virus (HPV) causing the condyloma. While treatment with imiquimod allows the patient to perform treatment in the privacy of his own home, patients may be less compliant with completing the full treatment due to the necessary longer treatment time (16 weeks) and the breaks between application (applied only twice per week). Removal of the condyloma through chemical or physical methods only serves to remove the visible reminders of HPV; their absence after removal does not indicate that the patient's immune system is actively working to suppress the virus.

While small condyloma may be managed through scissors removal in the office, typically a shave biopsy is not indicated for lesions of the anogenital region.

Liquid nitrogen cryotherapy can be used to manage condylomata acuminata. However, in a scenario where the nurse practitioner has identified multiple lesions, some of which are medium sized, the better option is to manage the infection with use of the topical immune system modulator. The nurse practitioner may elect to selectively treat the small lesions with cryotherapy and then prescribe a full course of imiquimod for the patient to complete at home.

Correct answer: Sertraline

Premenstrual dysphoric disorder is considered to be a severe form of premenstrual syndrome (PMS) that can result in debilitating symptoms for the patient, severely interfering with her ability to perform day-to-day functions. Patients often present with mood symptoms including extreme irritability (most common) or anger, feeling hopeless or depressed, feeling overwhelmed, anxiety, food cravings, and mood swings, as well as physical symptoms such as insomnia or hypersomnia, breast pain and tenderness, bloating, headaches, swelling, and joint or muscle pain. 

The first line of treatment for PMDD is a selective serotonin reuptake inhibitor (SSRI) such as sertraline. Pharmacologic management of PMDD should be combined with non-pharmacologic treatment strategies, such as cognitive-behavioral therapy, relaxation techniques, light therapy, sleep deprivation therapy, and diet and exercise changes. 

Correct answer: Morning stiffness is minimal.

OA is the most common joint disease in North America. OA is a condition that manifests without systemic manifestations or acute inflammation. The Distal Interphalangeal Joint (DIP) is the most common OA site, and the most problematic joint involvement is in the hip and knee. With OA, discomfort typically increases as the day progresses and there is minimal morning stiffness; in contrast, with RA, morning stiffness is usually most problematic.

Both OA and RA can affect small and large joints. Fatigue, general malaise, and swollen joints are characteristic of RA.

Correct answer: Endocervical polyp, remove the lesion with a ring forceps

Endocervical polyps are benign growths which most commonly occur in women between the ages of 40-60 years and may cause symptoms such as painless post-coital spotting or copious leukorrhea. Often, they are asymptomatic and are found incidentally during routine gynecologic examination. Endocervical polyps are typically removed by twisting off the lesion by use of a ring forceps; smaller lesions may be removed by using a punch biopsy. In this scenario, the lesion is too large to be removed in entirety through use of punch biopsy.

Microglandular hyperplasia occurs most often in women who are taking an oral contraceptive or are using depo-medroxyprogesterone acetate as a result of the exogenous progesterone exposure. Unable to be visualized on speculum examination, it is identified by use of the Pap test.

Correct answer: Individuals diagnosed with primary RP should receive treatment based on an individualized treatment plan.

Raynaud's Phenomenon (RP), also referred to as Raynaud's disease, is a painful vasospastic disorder that affects the fingers and toes (primarily). The disorder may be autoimmune and associated with underlying autoimmune conditions such as Systemic Lupus Erythematosus (SLE) or Systemic Sclerosis (SSc) (also referred to as scleroderma) or may be diagnosed as a stand-alone disorder. Individuals with RP typically present with symptoms of spasm-like pain to the fingertips and/or toes (also nose, and nipples in breastfeeding women) associated with pallor of the skin that is followed by cyanosis (caused by venous pooling) and then rubor (due to rebounding blood flow). Ninety percent of individuals who present with symptoms consistent with Raynaud's will ultimately receive a diagnosis of primary disease, with the other 10% going on to be diagnosed with associated/underlying autoimmune disorders. Females are affected more frequently than males, with the age range of diagnosis between 15 to 30 years of age. Individuals diagnosed with primary RP should receive an individualized treatment plan based on the severity of their presenting symptoms. Since RP episodes tend to be triggered by cold exposure, initial treatment should be aimed at managing the patient's exposure to cold, including the use of heated vests and hats, gloves, socks, and layering of clothing. Lifestyle methods of decreasing the sympathetic tone (which is increased in response to stress) include teaching the use of deep sigh breathing techniques and mild exercise coupled with meditative-like practices (prayer, etc.). Some individuals may require medication to improve circulation to the periphery and prevent damage to the tissues. 

Secondary RP is most frequently identified with a diagnosis of Systemic Sclerosis (SSc)/scleroderma, and is in fact, considered a hallmark sign of SSc. It may also be associated with Systemic Lupus Erythematosus (SLE). These individuals are at risk of experiencing systemic vascular damage as well as peripheral vascular damage due to RP. 

Correct answer: Aspiration of the joint

Aspiration of a bursa suspected to be affected by bursitis is necessary prior to injecting the area with a corticosteroid to alleviate pain and allow the bursa to reapproximate. Whether or not the nurse practitioner suspects infection, bursal fluid must first be aspirated and septic bursitis excluded before therapeutic injection may be administered. 

Plain film radiographs, bone scan, and CBC with differential may all be indicated in diagnosing septic bursitis but do not eliminate the need to aspirate the bursal fluid.

Correct answer: Nortriptyline

IBS is most commonly diagnosed in females (80%) during their young adult or middle-aged years. The condition is chronic and is marked by cramping abdominal pain affecting the left lower quadrant, bloating, flatulence, and a stool pattern marked by alteration of constipation and diarrhea (mixed IBS), predominantly diarrhea (IBS-D), or predominantly constipation (IBS-C). Mucus may be present in the stools, but bleeding is not typical with IBS. IBS tends to run in families; patients may experience spontaneous remission of symptoms only to re-experience symptoms months or years later. Stress may exacerbate symptoms. 

Treatment is based on alleviating symptoms by adding fiber to the diet and avoiding foods that may be problematic (gluten, lactose) or gas-causing (cabbage, beans, onions, high-fructose corn syrup, artificial sweeteners). Prebiotics and probiotics may be beneficial in treating IBS; more research is needed in this area. Medications for treating IBS symptoms should be based on the presenting symptoms; patients who are primarily diarrhea-prone may be treated with an antidiarrheal medication such as loperamide, or the antibiotic rifaximin that has been approved for the treatment of IBS-D. Prescription of a tricyclic antidepressant such as nortriptyline is also indicated for alleviating the pain associated with IBS and can help decrease diarrhea associated with IBS-D. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and sertraline can also be prescribed to help alleviate pain; SSRIs are most effective for patients with IBS-C. The use of an osmotic laxative such as PEG-350 (Miralax) or magnesium hydroxide (Milk of Magnesia) can be beneficial for patients with IBS-C. 

Correct answer: The kidney both contributes to the development of essential hypertension and is a target of the disease.

Hypertension is a complex disorder, and the etiology of the development of essential hypertension may be multifactorial. Genetics, the sympathetic nervous system, a high dietary salt intake, obesity, and the renin-angiotensin-aldosterone system all contribute to the development of essential, or primary, hypertension. 

The kidneys are known to both contribute to the development of essential hypertension, as well as become the target of hypertensive disease. The renal nerves play a significant role in control of blood pressure, as well as in the development of hypertension. De-innervation of the renal nerves in animal studies has been found to profoundly affect blood pressure in a positive manner.

Essential hypertension begins sometime within the first decade of life to the third decade of life and progresses to an established or complicated hypertension by the time the individual reaches the fifth decade.

Correct answer: The first symptoms of menopause take place

Perimenopause, by definition, is the time surrounding menopause. Its average age of onset is 40 to 45 years (this occurs earlier in women who are cigarette smokers). It is said to have begun when the first symptoms of menopause are experienced—vasomotor symptoms, sleep disturbances, changes in menstrual bleeding or the menstrual bleeding pattern—and ends when menopause truly begins with cessation of the menses. Menstrual irregularities become more common, ovulation becomes erratic, and the vasomotor symptoms of hot flashes and night sweats take place in 65 to 75% of women. The shifting levels of multiple biological substances is likely the cause of perimenopause.

A woman is in menopause when she has had no naturally occurring menstrual period for 12 months. 

Correct answer: Prescribe oral amoxicillin with clavulanate to be taken two times per day

As 80% of cat bites become infected, antimicrobial therapy should begin immediately. The primary medication recommended is amoxicillin with clavulanate. Alternative antibiotics include cefuroxime or doxycycline.

As cat bites are typically deep puncture wounds, topical ointments are not effective. Doxycycline is an optional medication but cannot be given intramuscularly. Rabies risk with pet bites is typically negligible, so rabies prophylaxis is not usually indicated.

Correct answer: Uric acid stones

Uric acid stones form when urine is persistently acidic. These stones form in people who do not drink enough fluids or who lose too much fluid, eat a high-protein diet, or who have gout. The Institute of Medicine (IOM) recommends a total fluid intake of 13 cups (3 liters) a day for adult males. The recommendation for adult females is 9 cups (2.2 liters) daily.

Calcium oxalate stones are caused by high calcium and oxalate excretion. Oxalate is a substance that occurs naturally in some fruits and vegetables as well as nuts and chocolate. Calcium phosphate stones are caused by high levels of urine calcium and alkaline urine. Struvite stones result from kidney infections.

Correct answer: Prescribe topical application of silver sulfadiazine (Silvadene)

Topical application of silver sulfadiazine (Silvadene) or mafenide acetate (Sulfamylon) is an effective therapy for infection prophylaxis. Oral antibiotics are not as effective as topical medication for prevention of infection.

Generally, smaller first- or second-degree burns can be effectively treated on an outpatient basis, not requiring hospitalization or referral to a burn unit.

Correct answer: Refer the patient to the emergency department for I & D

Unless the Family Nurse Practitioner (FNP) has received specialized training in Incision and Drainage (I&D) of a peritonsillar abscess, this is best left to the emergency department. A peritonsillar abscess, while often associated with the progression of streptococcal tonsillitis, is observed year-round, while strep tonsillitis has a far more seasonal pattern of occurrence. The development of a peritonsillar abscess may be associated with infectious mononucleosis and is more commonly diagnosed in teenage or college-aged individuals. Patients with a peritonsillar abscess typically present as being acutely ill and complain of a severe sore throat, dysphagia, a muffled voice (often referred to as a "hot potato" voice), and pain or difficulty upon opening the jaw (trismus). A unilateral area of edema of the affected tonsillar area with extension into the superior soft palate area is commonly noted, and the uvula is often displaced due to the abscess. While prescribing broad-spectrum antibiotics to ensure coverage of both Group A Streptococcus (GAS) and oral anaerobes is indicated for the treatment of a peritonsillar abscess, single treatment using penicillin is also acceptable, but I&D of the abscess is the first-line treatment of a peritonsillar abscess. Oral corticosteroids added to the post-I&D treatment regimen can aid in shortening the recovery time. Prompt identification and treatment of a peritonsillar abscess are necessary to prevent the development of airway obstruction, an extension of the infection into the deep tissues of the neck, or aspiration of the abscess contents in the case of a ruptured abscess. 

Correct answer: Rifampin (Rifadin, Rimactane)

When levothyroxine (Synthroid, Levothroid, Levoxyl) is taken with rifampin (Rifadin, Rimactane), phenobarbital, phenytoin (Dilantin), and carbamazepine (Tegretol), its metabolism can be increased with a resulting reduction of free T4, indicating a decrease in the effectiveness of levothyroxine. Levothyroxine should be taken at the same time every day on an empty stomach with water only. If the dose is taken upon arising, no food should be taken for ideally 1 hour after the levothyroxine dose. 

Research data reveals H₂ receptor antagonists, such as cimetidine (Tagamet) and ranitidine (Zantac) or glucocorticoids, such as dexamethasone (Maxidex, Ozurdex, Baycadron), do not alter the effectiveness of levothyroxine.

Correct answer: Individuals of advanced age

Peripheral Arterial Occlusive Disease (PAOD), a subset of the greater group of peripheral vascular diseases, typically presents with claudication (a reproducible ischemic calf muscle pain), which worsens with exertion and improves with cessation of the activity that triggered the symptoms. It is typically diagnosed in individuals with risk factors such as diabetes mellitus, extensive atherosclerosis, hypertension, and hyperlipidemia. Tobacco smokers are particularly at risk. 

In the absence of these risk factors, PAOD is rarely diagnosed, except in individuals of advanced age; the condition is found in 10% of older adults.  

Ethnicity, family history, and sedentary lifestyle are not risk factors for the development of PAOD.

Correct answer: Acute bacterial prostatitis

Acute bacterial prostatitis is an infection of the prostate gland. It is caused by gram-negative bacteria such as E. Coli or Pseudomonas species in men 35 and older. In younger men, causative factors include sexually-transmitted infections such as gonorrhea or chlamydia and, less often, gram-positive organisms such as enterococci. Other risk factors include a history of prostatitis, bladder or urethral infection, pelvic trauma, dehydration, or urinary catheter use.

Chronic bacterial prostatitis lasts more than 3 months, most commonly affects men 36 to 50 years of age, and is primarily caused by Enterobacteriaceae species. Symptoms include irritative voiding symptoms with low back and perineal pain, along with a history of urinary tract infections. The prostate will be tender, indurated, and boggy (sponge-like). About 5% of patients with acute bacterial prostatitis will progress to the chronic form.

Epididymoorchitis is characterized by fever and painful swelling of the epididymis and scrotum. Benign prostatic hyperplasia (BPH) rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60, and about half will do so by age 80.