ERRATUM/Corrections and Updates

FNP Intensive Certification Review book (Sprinter Publishing, New York)
AGNP Intensive Certification Review book (Springer Publishing, New York)
3rd edition
2nd edition



Addison's Disease
Presents with bronze-like skin color (looks like a dark tan) that is especially obvious on the nipples, old scars, etc. Patient will complain of dizziness and weakness. Low serum sodium and high potassium levels. Caused by aldosterone deficiency. 


Mental Health Chapter

Atypical antipsychotics (Zyprexa, Risperdal, Seroquel) to typical antipsychotics (Haldol, Thorazine, etc.)
Increases risk of obesity, type 2 diabetes, and hyperlipidemia. Monitor patients' weight, BMI, fasting blood glucose, and lipid profile.

Do not forget that drugs and new info that was release within the past 12 months will most likely not be included on the exam. Drug doses are not  addressed on the exam, but drug safety issues are. 






WARNING: 
The book is written to review for the ANCC and AANPCP exams so that you can markedly increase your chances of passing your certification exam. It is not written for use on patients in the clinical area. 




JNC 8 Hypertension Treatment Guidelines

BP goals for all races (including preexisting heart disease, diabetes, CKD) is BP < 140/90 until the AGE OF 60 Years. At age of 60 years or older, the SBP goal can be 150/90 or less EXCEPT for diabetes and chronic kidney disease (CKD). For these two diseases, the BP goal is always < 140/90 (lifetime goal).

What is the goal BP for a hypertensive 60 year old Black male who has no history of diabetes 
and kidney disease?   The goal BP is < 150/90 mm Hg

If the above patient has a diagnosis of diabetes (or CKD), what is the goal BP?
The goal BP is < 140/90 mm Hg (lifetime goal)

What is the preferred antihypertensive drug for a diabetic and/or CKD patient?
ACE inhibitors or ARBs. If poor result, add a thiazide diuretic (eg, chlorthalidone or hydrochlorothiazide)

What  medication is more effective for a patient with hypertension who is of African descent?
​Calcium-channel blockers (CCB) and/or thiazide diuretics

What is the preferred drug for isolated systolic hypertension in an elderly patient?
Either low-dose thiazide diuretic (eg, 12.5 -25 mg/day chlortalidone), or long-acting calcium channel blockers/agonist (eg, long-acting dihidropyridone amlodipine/Norvasc, -pine suffix)
​Source: UptoDate 2016

ACC/AHA Guideline on the Treatment of Blood Cholesterol 
The new hyperlipidemia treatment guidelines is pointing us towards using statins alone in different dosages.It is very specific, it gives you not only the statin dose, but also the preferred statins (such as atrovastatin, rosuvastatin, simvastatin, etc.). Combining statins with niacin and fibrates increases the risk of adverse events (liver, muscle breakdown, renal, and drug interactions).

How do I know which statin intensity to "prescribe" a patient? 
Statin intensity doses are determined by presence (or absence) of risk factors and the patient's age group.

The ASCVD 10-year estimated risk of 7.5% is the cutoff. To determine ASCVD risk, use the free ACC/AHA ASCVD risk  estimator tool which is a free app at the Apple store, Google store, or use it directly online. 

According to the ACC and AHA Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD Risk (2013, updated 2014), there are four statin benefit groups. 

Has ASCVD (secondary prevention)
*1. Patients with any form of ASCVD (history of MI, CAD, angina, stroke/TIA, PAD, coronary revascularization)
Younger than 75 yrs: high intensity statin 
Older than 75 yrs (or not candidate for high intensity statin): moderate intensity statin

Does not have ASCVD (primary prevention)
* 2. LDL-C 190 mg/dL or higher:  high intensity statin
3. Diabetics (age 40 to 75 years) with LDL 70-189 mg/dL: moderate intensity statin
4. Without diabetes or ASCVD (age 40 to 75 years) with an estimated 10 -year ASCVD risk of 7.5% or higher: moderate to high intensity statin

Note:
Lack of ASCVD, but adults with 10-year ASCVD risk (between 5% to less than 7.5%), the first line therapy is a heart healthy lifestyle. 

​Statin Intensity Doses
​High Intensity Statins
Atorvastatin (Lipitor)  40 - *80 mg
Rosuvastatin (Crestor) 20 – 40 mg
Moderate Intensity Statins
Atorvastatin 10 -20 mg
Rosuvastatin (Crestor) 5-10 mg
Simvastatin (Zocor) 20-40 mg
Pravastatin (Pravachol) 40-80 mg
Lovastatin (Mevacor) 40 mg

Low Intensity Statins
Simvastatin 10 mg
Pravastatin 10-20 mg
Lovastatin 20 mg
Fluvastatin 20-40 mg



Exam Tip:
I think the best way to study for the test is not to get stuck on specifics. Memorize who gets high-intensity statins. 
There are only two groups (* asterisk by patient group #1 and #2).
The 10-yr ASCVD risk cutoff is 7.5% (age 40-75 yrs).
Egg Allergy and the Flu Vaccine (CDC 2016-2017)

After eating eggs or egg-containing foods, does patient experience only hives?
If YES - administer any influenza vaccine formulation appropriate for patient's age and health status.

After eating eggs or egg-containing foods, dose the patient experience other symptoms such as:
Reaction requiring epinephrine or requiring medical attention, 
If  YES - administer in outpatient or inpatient setting under the supervision of a healthcare provider who is able to recognize and manage severe allergic conditions (CPR, epinephrine, O2, intubation, etc.).

Syphilis (treponema pallidum)
Screening test is either the RPR or VDRL (considered as nontreponemal tests). If positive, order an FTA-ABS (considered a treponemal test). Both the nontreponemal test and the treponemal test must be positive to diagnose syphilis.


ERRATUM - 2nd Edition
Both FNP and AGNP Intensive Certification Review books (2nd ed) are best-sellers and have been published many times since its initial release in 2013. When an error is noted,  it is corrected on the next printing batch. But since it has been reprinted many times, there are older versions out there. 

Endocrine
Somoygi phenomenon is a rebound effect. Due to hypoglycemia early in the morning (about 2 -3 am), the liver secretes glucagon to compensate.  This causes the FBG to become elevated in the morning.  The early am hypoglycemia is caused by evening or bedtime NPH dose too high, skipping snacks, excess physical activity in the afternoon or PM,etc. The "fix" is to eat a carbohydrate snack before bedtime, reduce the intermediate or long-acting insulin dose in the evening, and/or to change the timing of exercise (best to exercise in the morning instead of afternoon/evening).

Dawn phenomenon is physiologic and it occurs in everyone. The body secretes "counter regulatory" hormones such as GH and cortisol in the early am, which causes the FBG to become elevated in the morning. For diabetics, this can cause a problem. The "fix" is to adjust the time (and/or the dose) of the insulin from evening to bedtime, eat fewer carbs in the evening/bedtime, and/or to excercise in the evening (walking).

Antibody Testing (thyroid disease)
Hashimoto Thyroiditis (hypothyroidism) positive for *thyroid peroxidase antibodies (anti-TPO), thyroglobulin antibodies (anti-Tg)
Another name for *thyroid peroxidase antibodies is antimicrosomal antibodies

Graves Disease - thyrotropin (TSH) receptor antibodies or TSH-receptor antibodies (TRAb)

QUESTIONS with corrected answers

19. D) Diuretics (thiazide diuretics)
112. A) Presumptive sign  
162. A) The high vitamin K levels will decrease the bleeding time (or INR goes down). Foods containing vitamin K will decrease the anticoagulation effect of Coumadin (decreases the INR).  Warfarin (Coumadin) is a vitamin K agonist.
191. C) Breastfed infants only require vitamin D supplementation within a few days of birth 
244. B) State legislature has authority to pass the laws (nurse practice act). The BON enforces the laws.
277. D) Elevated creatinine and BUN (EBV does not affect the kidneys).
315. B) Second intercostal space, left sternal border (pulmonic area is best place to auscultate a split S2)
319. B) Basal skin cancer is the most common type of skin cancer. 
338. Can draw a cross at age 4 years. Can ride a bike at age 5 to 6 years.
367. D) Order an AIC level 
372. C) Ranitadine (Zantac) is an H2 blocker, use initially to treat H. pylori negative ulcer instead of starting PPI first.
475. C) Serum folate and B12 level
400. Change question to treatment for a case of uncomplicated chlamydia; answer is C) azithromycin 1 g or doxycline BID x 7 days
But treatment of both gonorrhea and chlamydia is ceftriaxone 250 mg IM plus doxycycline BID x 7 days.
499. See notes above. Somoygi phenomenon is option C) characterized by high fasting BG in morning; Dawn phenomenon is B) physiologic spike...
514. D) Reduction of FEV1 (forced expiratory volume in 1 second) with an increase in  TLC (total lung capacity) and RV (residual volume).





More Notes
Hypertensive Retinopathy: copper wire arterioles, silver wire arterioles, AV nicking
Diabetic Retinopathy: neovascularization, microaneuryms, soft exudates, "dot and blot" hemorrhages

Chest radiographs/xray: you will get a chest film. Memorize right middle lobe pneumonia appearance.  TB chest xray will show cavitations (round black holes) on upper lobes/hila.

Pap/cytology: age less than 21 years, not recommended (even if sexually active, STDs, etc.). Can test for STDs based on sexual history (but no Pap).
CDC Adolescent Mortality Data
The data has changed regarding the 2nd and 3rd leading causes of mortality (death) among adolescents. 

CDC 1999-2006 Aged 12-19 Years (used for 2nd edition of FNP.AGNP Review book)
1. Unintentional injuries (73%)
2. Homicide (13%)
3. Suicide(11%)

CDC 2014 Aged 10-24 Years (used for 3rd edition of FNP/AGNP Review book)
1. Unintentional injuries (39.6%)
2. Suicide (17.4%)
3. Homicide (13.7%)

ERRATUM - 3rd EDITION 
Family Nurse Practitioner Certification Intensive Review: Fast Facts and Practice Questions
Adult Gerontology Nurse Practitioner Certification Intensive Review: Fast Facts and Practice Questions

NEWS:
ANCC
The current ANCC FNP (2016) & AGPCNP (2015) exams are using JNC 8 hypertension guideline. But the new ANCC FNP exam will be released on May 22, 2019 and the AGPCNP will be released on December 2019. It will probably use the new 2017 ACC/AHA hypertension guideline.
Both hypertension guidelines are discussed  below after Erratum section.

AANPCB
Both the AANPCB FNP and AGNP exams were released in early 2018. Their exam will be using both the JNC 8 and the 
​2017 ACC/AHA Hypertension guidelines (see notes below).

Page 70 - 71
Warfarin (Coumadin) is a vitamin K antagonist.

Page 174 (bottom of page)
Warfarin (Coumadin; vitamin K antagonist)

Page 176 (near bottom of page)
Pulsus Paradoxus
Certain pulmonary (pulmonary emboli, severe COPD, tension pneumothorax) and cardiac conditions (moderate to severe cardiac tamponade, pericardial effusions) can cause an exaggerated decrease of the systolic BP of >10 mmHg during inspiration.

Page 179 (middle of page)
Heart 
PAD - peripheral arterial disease
PVD - peripheral vascular disease

Page 185 (top of page)
Action:.. The non-dihydropyridines (diltiazem, verapamil) depress the muscles of the heart (inotropic effect) which affects cardiac conduction and contractility. But they are less potent vasodilators than the dihydropyridines. They are used to treat hypertension, chronic stable angina, cardiac arrhythmias, etc.
The dihydropyridines (amlodipine, nifedipine, felodipine, etc)  are potent vasodilators and have minimal to negative effect on cardiac conduction or cardiac contractility. They are used to treat hypertension and chronic stable angina.

Page 186
Exam Tips
Spironolactone has a side effect of gynecomastia

Page 191 (top of page)
Bacterial Endocarditis
Classic Case
…  Palms and soles may have non-tender red spots on the skin (Janeway lesions). Many have a heart murmur (85%)

Page 300
Treatment Plan
Acute Phase - delete these two sentences from previous guideline  "Give tablet every hour until relief or diarrhea occurs" and "Stop allopurinol during acute phase. Restart 4 to 6 weeks after resolution"
Note: Top 3 bullets -  these sentences are the latest recommendations for gout. 

Practice Questions:
 37. A multigravida who is at 34 weeks gestation wants to know at what level her uterine fundus should be. The best answer is to advise the mother that her fundus is:   D) Change answer to "32 to 36 cm."
Note: Between 20 to 36 weeks gestation, the fundus should be plus or minus 2 cm of the # weeks of gestation. 

509. Option C should be: "Smoking cessation and exercising at least 3 times a week" 
2017 ACC/AHA High Blood Pressure Guidelines 
Normal: < 120/80 mm Hg     
Elevated: SBP between 120-129 mm Hg and DBP < 80 mm Hg
Stage 1: SBP between 130-139  mm Hg or DBP between 80-89 mm Hg
Stage 2: SBP 140 mm Hg or higher or DBP 90 mm Hg or higher

Hypertensive crisis: SBP > 180 mm Hg and/or DBP > 120 mm Hg "with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage". 
Note: This new guideline eliminated the category of "prehypertension"​

​Other changes:
Emphasized importance of proper technique when checking BP
Recommends use of home BP monitoring equipment using validated devices
Watch out for "white-coat hypertension", high chance person has true hypertension
​Most persons with hypertension will need two or more meds (prefer combination meds that is taken once a day - better compliance).
"Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol)".

Pay more attention to "socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient's plan of care".

There is an updated ASCVD Risk Estimator Plus app that reflects the current guidelines. It is available at the iTunes store, Google Play store, and the web. The app should ONLY be used for primary prevention patients (those without ASCVD) only.
Source: https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017

For more information, visit the American College of Cardiology High Blood Pressure in Adults at https://www.acc.org/guidelines/hubs/high-blood-pressure


More to come later....