Welcome to Becoming a Stress-Free Nurse Practitioner, a show for new NPs and students that want to pass their board exam the first time and make that transition from RN to NP as seamless as possible. I’m your host Sarah Michelle. Now, let’s dive into today’s episode.

Hey, hey everyone, it’s Anna again. I hope you are doing well and enjoying this wonderful season, I know I certainly am. We have tons of recent graduates gearing up to take their exams, which always gets me excited because I know that means tons of passing posts are coming soon and those are my absolute favorite.

With this popular testing season among us, I thought I would discuss a pretty common question we get from students today. And that is exactly how do I dissect and walk myself through tougher exam questions? I am going to provide you with some example questions today and walk you through them, as well as give some tips and tricks that really helped me get through tricky questions.

I want you going into testing feeling fully prepared to tackle longer information filled questions, especially if you’re taking the AANP as it is notorious for these longer questions. Not to say ANCC can’t have them. So let’s get going.

The first key to dissecting and answering longer or trickier questions is knowing how questions are made. I know this is kind of silly, but knowing how the exams work and how questions are constructed can truly help you get through all of the fluff and to the root of what is being asked. This can also give you a much needed confidence boost. And we know that when you are feeling confident, you are in the best possible place you can be to rock that exam.

With that being said, questions on the AANP and ANCC are constructed in similar manners. Questions, at their core, are made up of a lead-in or a scenario and then stems. Now, these lead-ins or scenarios, they may be longer, they may include patient information, they may be simple just recall stems that are pretty short questions. The more difficult type of question is definitely the ones with the longer lead-ins and stems with those patient scenarios.

Another tip I really, really encourage everyone to use is when these questions come up, read the last part of the question first. I know that seems silly and kind of backwards, but it really can help narrow down what the stem of the question is asking and how we can get to the right answer.

So, for me, when I saw a huge, long question, I took a deep breath. Sometimes even just like put my head down for a moment if I felt like I needed it. And then I got to reading the stem, or that very last sentence first. This allowed me to ask myself, okay, what is this question looking for? What do I need to come up with from this question or the scenario specifically?

Then I would go back, read the entirety of the question. What this did was it allowed my brain to sort through any of the fluff because I already knew what I was looking for.

Another tactic that I like to have in my back pocket is what I call the odd duck rule. The odd duck rule means that you look through the answer choices and see which one or which ones look like odd ducks. By odd ducks, I mean the one that doesn’t belong. The one with the crazy fluffy hair and is swimming in circles.

There’s a saying in healthcare that if you hear hooves, you think horses and not zebras. So we want to try and use this idea to take out any answers that just totally do not belong or are not viable. Even though this seems crazy, it happens more than you think. So often students come back and say, “I was easily able to throw out one to two answers, which really helped me narrow it down.”

So just thinking to ourselves, which answer choice is totally out of left field and definitely not viable can be a really helpful strategy. Not only does this help us focus on our only viable answer choices, but even if we had absolutely no idea at all what the answer might be, it brings our randomly guessing chance from 25% to 33%, which is pretty good. But ideally, we are still able to get ourselves to the correct answer.

Another little tidbit that can be so, so helpful, but is only ANCC specific at this time, is the ability to highlight and cross out selections of the questions. Hopefully AANP updates their testing software to allow for these features as well, but I really suggest that you use them.

Crossing out any of the pieces of information that are not pertinent to you, or crossing out the incorrect answers, or even highlighting the key words and phrases, it can really help your brain only see the important information. When you’re able to do this, it can help you get through that fluff again.

Lastly, look for those key words. The exams are truly not trying to trick you. They use those keys like priority, best and next. These very simple words can help you decide what the question is truly asking. There may be a few answers that are all appropriate, so we look for that key word that differentiates why one answer choice is better than the other.

If you ever get to a question and you think, “Oh, there seems to be two viable answers here,” definitely look for those key words. What would we do next? Or what is the most prioritizing action? They are going to help you truly understand what the question is asking and choose the best answer.

So, how do we know what to read through and arrive at the right answer? Let’s check out an example and work through it together using all of those strategies I just discussed. Here’s a question, and stay with me, re-listen if you need to, this is a long one.

A 30 year old patient is in your office for a visit with complaints of rhinitis, a hacking cough, and some small mucus production when she coughs hard. She is otherwise healthy and does not have any other complaints. She states that she does not have any allergies to food or medicine and denies other complaints.

Upon physical exam you note a temperature of 100.1, respirations of 17. Her pulse is 100 beats per minute, and you auscultate some crackles throughout her lungs. You decided to order some further testing. And her labs reveal a total white blood cell count of 11,000, red blood cell count of 4.22, hemoglobin of 13, hematocrit of 37.8%, platelets of 198, an MCV of 89.9.

A chest X-ray shows some diffuse infiltrates in her left lower and middle lobes of her lung. What is the most likely diagnosis? A, staphylococcus pneumonia. B, mycoplasma pneumonia. C, Legionella pneumonia. Or D, acute bronchitis?

That was a lot. Take a deep breath with me, stick with me, let’s start by backing it up here. Read the last sentence first, what is the most likely diagnosis? Okay, so we know this question is asking about a diagnosis. So that’s what I want to focus on.

I can read through those lab values and physical exam findings to try and help me. So let’s see, we have a slightly elevated white blood cell count. So I’m probably thinking, you know, some sort of infection. Her heart rate and temperature are both elevated, so again, thinking of an infectious process.

She’s young and healthy otherwise, which is a big thing to note. And it doesn’t say that she’s a smoker or that she was exposed to anything that would irritate the lungs. And oh, a big one, the chest X-ray, it shows infiltrates. So to me, we are thinking pneumonia as that is coupled with some crackles on her exam.

So now let’s look at those answer choices. Which one is the odd duck? Definitely acute bronchitis. Bronchitis does not cause these chest X ray findings and is usually more of a dry cough versus this cough with some sputum production that our patient is having. So goodbye answer choice D, cross it out.

The other three choices are all types of pneumonia. So how do we get through these? There is one really, really key piece of evidence from the question that we can use here. Do you know what that might be? Her age. This is a young, healthy adult. So we know that atypical pneumonias are probably unlikely here.

And then we do need to recall a little bit of our clinical knowledge here, which would be that mycoplasma pneumonia is the most common cause in our children and younger adult population.

And I know that this might have felt like a lot, but I promise you the more you practice, the easier these things become. And when you get into your exam, you will be able to fly through these questions because your tools will be second nature to you.

All right let’s practice another question now that our brains are warmed up. This is the second question we’re going to work through. A 68 year old patient is in your office today being seen for a follow-up. Three months ago you started him on amitriptyline or Elavil for some nerve pain related to an accident he was in several years ago.

His past medical history includes osteoarthritis, hypertension, diabetes, obesity, and gout. Besides the amitriptyline or Elavil he is also on Losartan or Cozaar, and metformin or Glucophage. He states that the nerve pain has improved, but he has noticed that he is having a harder time urinating. What should be the priority action at today’s visit?

A, check the patient’s prostate for signs of BPH and a PSA level. Check the patient’s A1C. Stop the patient’s amitriptyline or Elavil. Start the patient on methocarbamol Robaxin for urinary retention.

Let’s walk through this one. So going from the last question up, we see what is the priority action. So we are looking for the most pertinent if we can only choose one.

This patient has a main complaint of urinary retention. So I am now thinking, what is the priority when a patient complains of that? Definitely thinking maybe something with the prostate, maybe a side effect of medication, or maybe they need another medication to help with urination.

And again, we’re looking for the odd duck to toss out. For me, checking the A1C is the odd duck. The question does mention that this patient had diabetes, but this is not going to help us prioritize how to alleviate the urinary retention at today’s visit. So we’re going to throw that one out.

I like the idea of starting a patient potentially on a medication to help relax the muscles, potentially help him urinate, but I don’t think that’s the priority. So we can also throw out option D, start the patient on methocarbamol Robaxin for urinary retention.

So now we have check the patient’s prostate and PSA level or stop the amitriptyline also known as Elavil. And this is a time where in an ideal world, we could do both, but in this question it’s asking for the priority. So the priority is definitely stopping the amitriptyline or Elavil because we know that it has an anticholinergic effect that is likely causing this urinary retention.

Did you follow along for that one? I told you, once you start changing how you think about the questions, it becomes easier and easier.

All right, before I say goodbye, I do want you to know that practicing how to answer questions takes time. Do not be discouraged if you do not get it right away. Practice, practice, practice, and it will all start to become second nature.

We have a great resource with our question bank, so I definitely recommend you all check that out and start using these tips and tricks to help you answer those longer questions.

Talk to you soon, everyone.

As an extra bonus, friends, if you’re looking for support, no matter what phase of your nurse practitioner journey that you’re currently in, I have communities available for both students and new nurse practitioners. In these communities we work to uplift one another and grow this profession together every single day. Links to join will be included for you in the show notes.

Thanks for listening to Becoming a Stress-Free Nurse Practitioner. If you want more information about the different types of support we offer to students and new NPs, visit stressfreenp.com. See you next week.