by Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC
The NP certification exams test the broad knowledge base needed for practice. Highly developed skills in clinical assessment and intervention are critical to NP practice. You should expect that the certification exam will reflect this content. Here are a few hints about how to be prepared for the exam and nurse practitioner practice.
Know that the health history forms the primary database necessary to arrive at a diagnosis.
A 38 year-old woman presents with a 12-hour history of sudden onset vomiting, diarrhea and cramping abdominal pain with three episodes of emesis and six episodes of watery, brown stools. Which of the following health history questions is most relevant to this clinical situation?
A. Have you had an appendectomy?
B. Are you sexually active?
C. Has anyone else in your home or workplace had similar problems?
D. When was your last menstrual period?
The correct response is C. While the information given about this patient is scant, the scenario is most consistent with viral gastroenteritis. This diagnosis is supported by report of contact with others who have recently had the same illness. While obtaining the information that would be gleaned by asking questions A, B and D is unlikely to be useful, since this clinical scenario is not consistent with the typical presentation of appendicitis, pelvic inflammatory disease or pregnancy-related gastrointestinal upset.
Patient assessment starts with the health history, and there should be few surprises when you get to the physical exam. Increasing your skill in obtaining an accurate health history in a timely manner will help you in your NP practice and enhance your certification exam performance.
Know which pathogens cause which diseases.
One of the most common causative pathogens for community-acquired pneumonia in the older adult is:
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Legionella species
D. Pseudomonas aeruginosa
The correct response is A. The newly graduated NP often comes to outpatient practice with experience providing inpatient care as an RN. In hospitals, care is provided to the sickest of the sick, and these often are patients who have not improved with outpatient care or have multiple health problems that complicate every illness, no matter how minor. In contrast, the majority of NP practice is delivered in the ambulatory care setting. The organisms that cause community-acquired pneumonia can differ from those of nosocomial or hospital-acquired pneumonia. If the NP sitting for certification knows only the pneumonia pathogens that commonly cause inpatient cases of pneumonia, she may give an incorrect exam response.
The most common outpatient pathogen responsible for community-acquired pneumonia in older patients is S. pneumoniae. Haemophilus influenzae, the atypical pathogens (M. pneumoniae, C. pneumoniae and Legionella species) and viruses are less common causes of pneumonia in community-dwelling patients. Pneumonia caused by pathogens such as P. aeruginosa or S. aureus is more likely to be nosocomial in origin and quite unlikely to be found in the older adult with community-acquired pneumonia.
Know why and when to use different types of history-taking questions.
A 65-year-old man presents with a chief complaint of “having no pep for the past few months.” You start the interview by asking:
A. Exactly when did this start?
B. Tell me what you mean by having “no pep.”
C. Are you taking any medications?
D. Have you had this problem in the past?
The correct answer is B. Choice B is an example of an open-ended question. This question usually starts with a statement such as “Tell me …” The benefit of asking a question this way is that you hear the patient’s perception of the problem. The drawback can be the quality and quantity of information gathered.
Responses A, C and D are closed-ended questions that ask the patient to provide a specific response, providing you with focused information. Patient responses are usually short and precise. Another example of a closed-ended question is, “How many days have you had no pep?” If the examiner only asks closed-ended questions in a clinical scenario, the patient information will be limited to quantifiable measures, such as location, severity and duration of a problem. What will be missed is the impact of the problem on the person’s life as well as the patient’s hunch about what has contributed to or caused the problem.
Know the difference between a symptoms and a sign.
A common symptom in early appendicitis is:
B. vague periumbilical or epigastric pain
C. rebound tenderness
The correct answer is B. A symptom is the patient’s description of a problem, while a sign is an objective finding. Since fever, rebound tenderness and leukocytosis are objective findings or signs, these options are incorrect. By the way, fever and rebound tenderness are late rather than early findings in appendicitis.
Know how to quantify tobacco use.
Tamara is a 28-year-old woman who started to smoke cigarettes at age 13. Until around age 23, she smoke an average of one pack of cigarettes per day (PPD), and since then has smoked about two PPD. She has a ___ pack-year history.
The correct answer is C. A pack-year cigarette smoking history is calculated by multiplying the number of years as a smoker by the number of packs-per-day (PPD x years smoking). Tamara smoked one PPD X 10 years (10 pack-years) followed by two PPD X 5 years (another 10 pack-years), yielding 20 pack-years.
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This article originally appeared in my quarterly certification column in Advance for Nurse Practitioners and is made available here by the courtesy of Advance. For other articles of interest to Nurse Practitioners, be sure to subscribe to this outstanding journal.