AANPCB FNP Exam Questions

Correct answer: Intraspinal surgery within the past two months

Intracranial or intraspinal surgery within the past two months is an absolute contraindication to fibrinolysis. Before giving a thrombolytic agent such as tissue plasminogen activator or streptokinase, the prescriber must be aware of absolute and relative contraindications to thrombolytic therapy (fibrinolysis). Other absolute contraindications include any prior intracranial hemorrhage, known structural cerebral vascular lesion, known malignant intracranial neoplasm, ischemic stroke within 3 months except acute ischemic stroke within 4.5 hours, suspected aortic dissection, active bleeding or bleeding diathesis (excluding menses), significant closed-head or facial trauma within 3 months, severe uncontrolled hypertension (unresponsive to emergency therapy), and for streptokinase, prior treatment within the previous 6 months.

A history of chronic, severe, or poorly controlled hypertension; major surgery within the past three weeks; and pregnancy (evidenced by a positive quantitative human chorionic gonadotropin test) are all relative, not absolute, contraindications to fibrinolysis.

Correct answer: Cutaneous T-cell lymphoma; large-bore punch biopsy

Cutaneous T-Cell Lymphoma (CTCL) is a rare type of cancer that begins in the white blood cells and attacks the skin. It is one of several types of lymphoma collectively called non-Hodgkin's lymphoma. CTCL usually occurs in the older adult (>65 years) and may progress and affect the lymph nodes, blood, and the internal organs. 

The nurse practitioner who is seeing a patient in the office setting and who has a concern of CTCL should perform a large-bore punch biopsy of the rashy area to ensure a generous sample that extends down into the subcutaneous fat. 

The rash of SLE typically affects sun-exposed skin, often first presenting as an erythematous malar rash. Discoid lesions often appear on the sun-exposed areas and are plaque-like. Photosensitivity also occurs. SLE is diagnosed through use of a punch biopsy, not a shave biopsy.

Allergic contact dermatitis typically occurs in an area that has been in contact with an allergen-producing agent. In its acute phase, it is characterized by pruritic papules and vesicles on an erythematous base; in its chronic phase, lichenified pruritic plaques occur. While punch biopsy may be used to aid in the diagnosis of allergic contact dermatitis, the patch test is the gold standard of diagnosis.

Tinea corporis is characterized by erythematous, scaly, plaque-like lesions that may quickly worsen and spread followed by gradual resolution of the central area of the lesions resulting in an annular shape.

Correct answer: Noncoronary atherosclerosis

Atherosclerosis may affect the heart as well as noncoronary arteries. Noncoronary atherosclerosis can affect the large vessels of the central nervous system, the peripheral vascular system, and the vasculature of the gastrointestinal system as well as targeting specific organs.

Patients who have atherosclerosis of the carotid arteries may present with decreased carotid artery pulses and carotid artery bruits and may complain of focal neurological deficits such as one-sided weakness of an extremity; vision, speech, or hearing deficits; facial weakness (drooping); paralysis; loss of muscle control; paresthesias; and numbness or decreased sensation. 

Cervical spinal stenosis and TIA may also contribute to one-sided weakness or other focal neurological deficits, but in this scenario, the nurse practitioner also needs to take into consideration the findings of carotid bruit and decreased carotid pulses to make a diagnosis.

The patient's symptoms and examination findings are not expected changes associated with aging.

Correct answer: "I noticed my uncle is taking quite a few medications for his blood pressure and to help him sleep. Can we review his medications and see if it's possible to discontinue any of them or change them to another medication with less risk?"

Falls are common in the elderly population and serve as a significant source of morbidity and mortality among this age group. There are many risk factors for falls, both modifiable and non-modifiable. Polypharmacy, including the use of antihypertensive medications which may induce hypotension, is one fall risk category that can often be modified. For example, alpha-blockers pose a significant risk for orthostatic hypotension and could possibly be replaced. 

Other fall risks that can be modified include removing throw rugs in the home and providing chairs with elevated seat height; adding physical therapy is helpful, but the goal of physical therapy, in this case, should not be to remove the patient's need for a walker, as it is providing stability.

Making sure the individual at risk for falls is left home alone as little as possible can be a viable way to prevent falls; however, alcohol use can both put the patient at risk of falling and potentiate sedating effects of medications, again increasing the risk of falling.

Proper footwear is an important, modifiable means of decreasing the risk of falls. Individuals should avoid slippers, sandals, and soft-soled jogging shoes such as sneakers in favor of a tie shoe with an enclosed toe and semirigid sole.

Correct answer: The scrotal appearance is similar to a "bag of worms"

Varicocele is an abnormal dilation of the spermatic veins within the scrotum. These varicose veins in the scrotum give it an appearance similar to a "bag of worms." Varicocele usually starts to develop at puberty and is found in approximately 15% of healthy men and up to 35% of men with primary infertility.

A varicocele is most often found in the left scrotum rather than the right.

 Varicocele is present while the man is standing. It disappears when he is in the supine position.

Correct answer: Punch biopsy

DH is a chronic immunodermatologic condition associated with a gluten-sensitive enteropathy. Individuals with DH may also have celiac disease or may have evidence of disease in the small intestine. DH is characterized by the presence of intensely itchy herpetiform blisters that typically occur bilaterally affecting the forearms near the elbows, the knees, and the buttocks. The dermatitis results from dietary gluten intake; an occasional patient who has been diagnosed with DH will report gastrointestinal symptoms such as bloating, cramping, and diarrhea. The disease affects men twice as often as women, is more common among individuals of Northern European ethnicity, and typically presents between the third and fourth decades of life.

The condition is diagnosed by use of a punch biopsy of a lesion. The tissue sample is then exposed to a fluorescent dye that identifies granular deposits of IgA. 

Patch testing is used to diagnose allergic dermatitis. Endoscopic biopsy is used to diagnose celiac disease; some patients with DH may show evidence of disease on endoscopic biopsy, but this is not a diagnostic tool for DH. Serum amylase and lipase levels are used to help diagnose acute pancreatitis; they are not used to diagnose DH.

Correct answer: A 55-year-old Caucasian male

According to the National Institute of Health (NIH), approximately 20% of Americans have been diagnosed with GERD. Reflux occurs when the tone of the lower esophageal sphincter (LES) is decreased, allowing gastric contents to reflux into the esophagus. Many individuals who experience reflux do not initially have symptoms or evidence of damage to the esophageal tissue. It is only when the individual becomes symptomatic or has proof of esophageal tissue damage that GERD is diagnosed. Patients with GERD may present with classic gastrointestinal (GI) symptoms of the disease, such as dyspepsia, chest pain (when resting), and postprandial fullness. Others may present with non-GI symptoms including a chronically hoarse voice, sore throat, coughing at night, and wheezing. 

Males are at a significantly greater risk of being diagnosed with GERD, as are smokers (or those regularly exposed to second-hand smoke), pregnant women, individuals who are obese, and individuals who take certain medications. Patients who have chronic GERD are at risk of developing esophageal strictures and Barrett's esophagus. Caucasians are at the most significant risk of developing Barrett's esophagus, followed by Hispanics. African Americans and Asians are rarely diagnosed with Barrett's esophagus. 

Correct answer: The patient is a package handler for a package delivery service.

Most commonly, medial epicondylitis results from repetitive daily activity such as lifting, using certain tools, or playing sports involving a tight grip (racket sports). Recurrences can be prevented by the use of devices such as using a tennis elbow band, using proper body mechanics, developing flexibility and strength of the involved musculature, and lifting with palms upward. Older age is a risk factor in the development of both lateral and medial epicondylitis.

A history of osteoarthritis is not a risk factor for the development of epicondylitis. Ethnicity is not a factor in the development of medial epicondylitis. The development of carpal tunnel syndrome is commonly associated with protracted use of a computer keyboard.

Correct answer: Mild edema in the ankle area seen at the end of the day

Mild edema in the ankle area, particularly during warm weather and/or at the end of the day, is a common occurrence in patients with varicose veins.

In uncomplicated varicose veins, lifestyle modification usually helps minimize the symptoms and disease progression. When palpated, the affected vein compresses easily and without pain. The degree of discomfort with varicose veins is poorly correlated with the number and appearance of the affected veins.

Correct answer: Combined hormonal contraceptives (CHCs)

The USMEC guidelines were created to decrease the number of unintended pregnancies by removing unnecessary barriers in accessing and using contraceptives. They were revised in 2016 with specific changes being made to eligibility criteria for breastfeeding women as well as several other categories of women. For breastfeeding women who are between 30 and 42 days postpartum and who have a BMI >30, use of the Combined Hormonal Contraceptives (CHCs) is classified as category 3 drugs, "a condition for which the theoretical or proven risks usually outweigh the advantages of using the method." For breastfeeding women who have a BMI <30 and who are between 30 to 42 days postpartum, the CHCs are considered a category 2 drug, "a condition for which the advantages of using the method generally outweigh the theoretical or proven risks." 

Obese women in the early postpartum weeks are at an increased risk of experiencing Venous ThromboEmbolism (VTE), the risk of which is exacerbated by the use of CHCs. Thus, CHCs are not an appropriate method of contraception for this particular patient. 

The POPs, LNG IUDs, and the etonogestrel contraceptive implant are all categorized as category 1 drugs and appropriate for use in this patient.

Correct answer: Schnitzler Syndrome (SS)

All individuals with autoinflammatory disorders (problems with innate immunity) are at risk of developing sarcoidosis due to deposits of inflammatory proteins in the organ tissues. While the protein deposits may occur in any organ, the kidneys are most commonly affected, ultimately resulting in kidney failure. Individuals with FMF are at the highest risk of developing amyloidosis, with over 75% of affected individuals developing amyloidosis before colchicine was utilized to treat FMF. Individuals with FMF who do go on to develop amyloidosis benefit from hemodialysis; peritoneal dialysis can worsen peritoneal attacks of the disease. TRAPS results in amyloidosis in up to 25% of affected individuals, with a strong family preference for amyloidosis being noted, and as many as 33% of individuals with CAPS will ultimately develop amyloidosis if not treated or treated inadequately. It is unclear why certain patients will progress to the development of amyloidosis, as individuals with the same (or similar) level and chronicity of inflammation do not all go on to develop amyloidosis. 

Schnitzler syndrome carries a very low risk of amyloidosis. 

Correct answer: Dyspnea after a few minutes of walking on a level surface and increased fatigue 

The spirometry results provided indicate Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) Stage 3 level of chronic obstructive pulmonary disease (COPD), severe COPD. The patient with GOLD Stage 3 disease will experience dyspnea after a few minutes of walking on a level surface, increased fatigue, and a significant decrease in quality of life.

Dyspnea when hurrying across level surfaces or when walking on a slight incline is seen with GOLD Stage 1 disease (mild COPD). Dyspnea during everyday activities, such as dressing and undressing, is associated with the most severe level, GOLD Stage 4. Dyspnea when walking on level surfaces or walking more slowly than expected for age is associated with GOLD Stage 2 (moderate COPD). 

It should be noted that a cough, with or without sputum production, may or may not be present in any stage of COPD. 

Correct answer: Prevnar 13 (PCV 13) followed by Pneumovax (PPSV23) in one year

Patients with COPD are at increased risk of contracting several vaccine-preventable illnesses. Patients who are older than 65 who have not received a pneumococcal vaccine should receive vaccination with Prevnar 13 (PCV 13), followed by vaccination with Pneumovax (PPSV23) one year later.

Shingrix is a recombinant vaccine for prevention of herpes zoster infection (shingles). It is recommended for immunocompetent adults 50 years and older, and is given in two doses separated by 2 to 6 months. It is not specifically recommended for persons with a COPD diagnosis.

MMR vaccine is recommended for adults who do not have evidence of immunity, but not specifically those with COPD. Adults born in 1957 or earlier are considered immune as a result of having had these diseases because vaccines against them were unavailable until the 1960s.

Patients with COPD should receive seasonal influenza vaccination using either trivalent or quadrivalent inactivated vaccine. LAIV should be avoided in individuals with airway disease.

Correct answer: Tremor of the upper limbs when the patient is at rest

There is no radiologic test, a biopsy sample, genetic testing, or serum marker testing that can be completed to provide a diagnosis of Parkinson's Disease (PD). Diagnosis of PD must be made using a clinical assessment of the patient as the basis for determining a diagnosis. The presence of two of the four key features associated with PD is necessary for obtaining a PD diagnosis: tremor at rest, rigidity, slowness of movement, and postural instability. The fourth feature, postural instability, does not typically appear until later in the disease process, so this sign is not required to be evident when first diagnosing the patient (two of the remaining three signs must be present for a positive diagnosis to be made). Most frequently, a PD patient experiences resting tremor of the upper extremities as the initial sign of PD. Patients may also frequently experience non-motor symptoms of PD, such as loss of smell, excessive salivation, forgetfulness, constipation, and urinary retention as early symptoms of PD.  

Correct answer: Colchicine

A diagnosis of Familial Mediterranean Fever (FMF) is a clinical diagnosis that is arrived at by the use of a validation tool referred to as the Tel Hashomer Criteria for the Diagnosis of FMF. Patients who are suspected of experiencing symptoms as a result of FMF must possess at least one major criterion—three attacks with fever >38 Celsius coupled with abdominal symptoms OR pleural symptoms OR monoarthritis OR a single symptom of fever >38 Celsius—and at least two (or more) minor criteria—leg pain with exertion, a history of an incomplete attack with monoarthritis, or a favorable response to colchicine. Colchicine was first used for the treatment of FMF in the 1970s, and it continues to be the first-line treatment for FMF today. Despite 50 years of use in treating FMF, it is unclear how colchicine works to prevent an FMF attack and prevent the development of amyloidosis. All patients with an FMF diagnosis should be treated with colchicine regardless of the severity of their disease or frequency of FMF attacks due to its effectiveness against the development of potentially fatal amyloidosis. Patients typically are prescribed 1.0 to 1.5 mg/day, up to 3 mg/day if tolerated (and needed to produce a response). Patients who are unresponsive to colchicine should continue to receive colchicine treatment with the addition of anti-interleukin-1 treatment, such as interferon-alpha. 

Prednisone may be warranted to treat severe, persistent myalgia with fever.

NSAIDs such as diclofenac may be prescribed to manage spondyloarthropathy.

Correct answer: Imiquimod

Verruca vulgaris lesions are commonly known as warts and are caused by any number of different strains of Human PapillomaViruses (HPVs), most causing nongential warts. Patients typically become infected with HPV through direct skin contact or, more uncommonly, through contact with the virus on inanimate objects. Warts on the hands are caused by a non-high-risk HPV and, while unsightly, do not typically pose a problem. "Watch and wait" therapy, where no treatment is prescribed, is appropriate, as most warts will self-resolve within 12 to 24 months. There are also a number of treatment options available, either provided in a clinic setting or at home, through use of: 

• Keratolytic agents
• Liquid nitrogen cryotherapy
• Podophyllum resin (podofilox)
• Tretinoin
• Laser therapy

Imiquimod is an immune system modulator drug indicated for treatment of anogenital warts, or external condylomata acuminata. It has more recently been used off-label for treatment of common verruca, but the evidence supporting this off-label usage is lacking. It may rarely be indicated for treatment of common verruca located in areas with concern for scarring, such as the face.

Correct answer: Dizziness and syncope

Dizziness and syncope are signs of respiratory compromise and pending cardiovascular collapse, which are the most frequent causes of death from anaphylaxis.

Anaphylactic shock begins with generalized itching followed by a urticarial-type (hives) rash, which gradually extends over the entire body. Next, angioedema affecting deeper tissues develops quickly, leading to shortness of breath related to narrowing airways. Nausea and abdominal pain generally follow the previous symptoms. Within a few minutes, the arterial blood pressure falls, the heart rate accelerates, and syncope can occur. The allergens usually responsible for an anaphylactic reaction are food, medicines, anesthetics, latex, and wasp or bee stings.

While headache, nausea, or urticaria can occur during allergic reactions, they are not life-threatening complications.

Correct answer: At the secondary stage of infection

Syphilis is a complex, multiorgan Sexually Transmitted Infection (STI) caused by a spirochete (Treponema pallidum). There are four stages of infection: primary, secondary, latent, and tertiary. 

Primary syphilis occurs 3 to 90 days after initial exposure and is characterized by the development of a chancre, a firm, round, painless genital and/or anal ulcer(s) with a clean base and indurated margins, accompanied by localized lymphadenopathy. This stage lasts for about 3 weeks. Given the chancre is painless and will resolve without therapy (heals in 6 to 9 weeks if not treated), many patients do not seek care at this stage. 

It is during the secondary stage that the disease is most contagious. Secondary syphilis occurs 4 to 10 weeks after initial infection. It presents as a diffuse nonpruritic, maculopapular skin rash involving the palms and soles (as well as mucous membrane lesions), generalized lymphadenopathy, low-grade fever, malaise, arthralgias, myalgia, and headache. Resolution without treatment is possible at this stage. 

Latent stage syphilis occurs when secondary syphilis resolves though the patient remains seroreactive (asymptomatic but positive titers). 

Tertiary syphilis occurs 3 to 15 years after initial infections and primarily affects the cardiovascular system and CNS. It presents with gumma, aortic insufficiency, aortic aneurysm, Argyll Robertson pupil (a pupil that does not react to light), and seizures.

Correct answer: A wound with a sinus tract located on the buttocks 

Alginate dressing materials are a highly absorbent dressing material that is most appropriate for wounds that are highly exudative or have copious drainage. Alginate is derived from a seaweed extract and provides a tensile material with excellent absorptive capability. Alginate rope is particularly useful in packing wounds with sinus tracts.

A diabetic foot ulcer that has been refractory to treatment with becaplermin should be re-evaluated frequently and then continue treatment with becaplermin.

A dry necrotic pressure ulcer benefits from debridement followed by treatment with a debriding agent such as hypertonic saline gel, collagenase, or other enzymatic debriding agents.

A clean, granulating wound on the forearm benefits from treatment with a foam or polyurethane foam wound dressing.

Correct answer: Vitamin C

For patients who prefer not to utilize traditional pharmacological treatment for their migraines, there are several effective non-pharmacological migraine treatment options.

Evidence supports the use of certain herbal preparations, vitamins, and minerals for the prevention of migraine headaches. The strongest evidence supports the use of Petasites (butterbur), a butterbur shrub extract, for migraine prevention. In clinical trials, coenzyme Q10 (CoQ10) was found to decrease migraine frequency (although the evidence is weaker to support its use). Feverfew has been extensively studied for use in the treatment of migraine headaches and has been found to be helpful in preventing migraines in some individuals. In addition, riboflavin and magnesium can also be helpful. 

Vitamin C in large doses may contribute to migraine headaches.