Ep #147: Dissecting Practice Questions: How to Read the Lead-In with Kaitlyn D

Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in. 

Hey, hey everyone. Welcome back to another episode and happy back-to-school season. Today, I have Kaitlyn with me. She’s been on a few of our other episodes, but Kaitlyn, I’m going to allow you to introduce yourself and kind of talk about your role here at Blueprint/SMNP Reviews.

Kaitlyn: Hey everyone. I’m Kaitlyn. I am a family nurse practitioner and the FNP content lead here at SMNP Reviews with Blueprint. I have been working as an NP for a few years, but I’ve actually been in the test prep world for much longer, writing and editing tons of content and probably thousands of questions at this point. So I am so excited to be with you all here today.

Anna: Kaitlyn is definitely one of our like test question gurus on the team, and so that is why I’m really excited to have her on here as we’re introducing this like mini-series. So we’re kicking off this like back-to-school season by starting a mini-series over about the next three episodes. And during this series, we’re going to look at breaking down practice questions, and we’ll throw in a few of our favorite test-taking strategies.

So this week, we are going to focus on finding keywords within the question lead-in and just like how important that is, because even one word in the question can change the correct answer entirely. So it is so, so important that we take our time, we read the whole question before jumping to the answers. 

But to start, I want to rewind for a second. I kind of want to talk about how questions are made and what I even meant by lead-in. And Kaitlyn, you said you’ve been doing this a really long time, you’ve been in these questions, writing these questions. So do you want to give a brief description of that?

Kaitlyn: Yeah. So sometimes you’ll see one-sentence questions on the exam where it’s really just like that lead-in that we’ll talk about. And sometimes you’ll get the lengthier questions that have like a whole vignette attached. 

So what is a vignette? This is basically a case scenario. You hear us use this word a lot. So for those longer questions, it’ll include things like their demographics, so their age, where they’re being seen, the office versus the emergency department, and maybe like what their chief concern is. And then sometimes things like patient history, assessments, diagnostic test results.

So the lead-in follows that, and it’s almost always going to be that last sentence, and it’s really what the question is asking you. One of my favorite strategies is to actually read that last sentence first, and then you go back and read the entire question and scenario, including the last sentence again before answering.

Anna: Yeah, I love doing that. That was one of the tricks I used too, and I found that when I did that, it really helped me avoid those times where I’d start reading the scenario and I was like, oh, I know this. Like, I got it. And I just jumped down to the answers because I was like, I expected a certain answer to be there. 

But then when that happens, sometimes you’re going too fast, you look down at the answers, and what you expected isn’t there. Or what you expected is there, but it’s not actually the right answer because the question is asking you something else that you just didn’t read all the way. And that can definitely happen, especially when you’re a little bit more amped up on exam day. And it can cause you to get those questions wrong that you actually really know. And we want to make every single question count on the exam.

Let’s jump into a couple of questions, and we’ll read them out loud, we’ll read the answer choices, and we’re going to apply this. So, Kaitlyn, do you want to start us off?

Kaitlyn: Yes, I would love to. Okay, so before I even get to the question, let’s apply that strategy I mentioned earlier and read just the last sentence. So what is the best next step in management?

Anna: Oh yeah, this is a good one. And those next step type questions love to pop up on the exam. So what really sticks out to you here?

Kaitlyn: I think definitely the words “next step.” So when I read the vignette, I want to be thinking of what has already been done. So what I am thinking of in my list of differentials and what I as the NP would need to do next to either get the information I need, if I need more, or what I would do next for the patient if I’m just ready for that next step.

So here is the whole question now: A 42-year-old patient presents to the clinic reporting sudden severe pain in the left great toe. The physical exam reveals that the toe is erythematous, swollen, and extremely tender to palpation. What is the best next step in management? So A, allopurinol; B, NSAIDs; C, obtain a uric acid level; D, order a synovial fluid analysis.

Anna: Yeah, this is a really, really good example. So I want to break this one down just like step-by-step. So when we read this question, we have to be thinking to ourselves, what is likely going on? And first off, like this is just textbook gout. Alright, we have that sudden sharp pain in one joint, and that big toe is the most famous one. It’s red, it’s swollen, it’s super tender, right? So this combination, it is just screaming gout to me.

Kaitlyn: Oh yeah, yeah. And so once we’ve got that diagnosis in mind, we need to figure out what the question’s really asking. What’s the best next step in management? So you’re going to see this pop up a lot because it is a wonderful critical thinking question. So you’ll notice in our answer choices here, we’ve got a mix of treatment options, and then some tempting diagnostic tests. So we need to really decide if we need to assess further and order more tests, or if we need to go ahead and treat the patient.

Anna: Yeah, and figuring that out will just depend on what the question is, what diagnosis you’re leaning towards, and really all depends on what you already have in the vignette or the case scenario that they gave you. 

But really the key here is that in classic cases of gout like this one, you don’t need to confirm the diagnosis before starting treatment, right? If it walks like a gout duck and it quacks like a gout duck, go ahead and treat it like a gout duck since you are a smart duck-recognizing cost-conscious nurse practitioner. And if we are treating it, you can already strike out two of the four answer choices and just stop looking at them all together.

Kaitlyn, do you want to walk through all of the answer choices real fast though?

Kaitlyn: Yes. So allopurinol is a urate-lowering drug used for long-term management. So it’s not something we ever want to start during a flare. So starting it now could actually make the flare worse. So if they were already on it, they can definitely keep taking it, but we don’t want to assume that because the question doesn’t say that. So we’re not going to start that today.

So we already talked about more tests not being the correct answer, but let’s review the content while we’re here. One answer choice was uric acid levels, and I want you to remember that these are sneaky. They sound helpful, but they’re actually unreliable during a flare. These levels can be normal or even low during a flare, so they’re not really going to be helpful to us here today.

Then we have the synovial fluid analysis, and so this is actually the gold standard for diagnosing gout, but it’s kind of invasive, right? So unless the presentation is – maybe it’s unclear, or you’re worried about something else like septic arthritis, you really don’t need it before starting treatment. And let me just say, on boards, they typically stick to the super classic, obvious presentations for this exact reason. They want to see if you’ll overthink it. So the best move here is NSAIDs to get that inflammation down. So we trust the presentation, go ahead and treat the player.

Anna: Absolutely. Really do not overthink things. Go with that gut answer. And that is the best next step in this case. But we’ve talked about how just a few words can change our answer completely and not to get ahead of yourself when your nerves are running high during the exam. So take a deep breath. Let’s look at that question again, but I am going to change the question slightly.

So this time I’m going to be asking, I’m going to read that last sentence, “What is the best way to confirm the diagnosis?” So now the question would read: a 42-year-old patient presents to the clinic reporting sudden severe pain in the left great toe. Physical exam reveals that the toe is erythematous, swollen, and extremely tender to palpation. What is the best way to confirm the diagnosis? So what do you think now, Kaitlyn?

Kaitlyn: Yeah, well now we have a totally different question, right? So now we’re not being asked what to do next. We’re being asked what test gives us the most definitive answer, and that’s going to shift our thinking. And here’s where we go back to that gold standard we mentioned. The answer would then be a synovial fluid analysis, which is achieved by joint aspiration. And that’s how we confirm gout with certainty by actually seeing those needle-shaped monosodium urate crystals under the microscope.

And so this is such a great example of how just a few words in the stem, like “next step” versus “confirm the diagnosis,” can completely change what the correct answer is going to be. Now, the clinical situation has not changed at all, but the focus of the question has. So always slow down and ask, am I being asked to act or confirm? And that one shift will help you avoid so many traps on test day.

Anna: Yes, absolutely. And again, even in that confirmation, make sure you’re asking yourself, is it asking for an initial test, or is it asking for the gold standard test, the definitive test? Because sometimes that changes the answer, too. But enough with that, enough with gout. That was a really perfect, straightforward example. So should we do one more on a different topic, not gout duck-related, for this episode?

Kaitlyn: Yes, I actually have another one ready. So this one’s lead-in is another common one you’re going to see on the exam. What is the best initial step? Just like Anna said.

Anna: Yep. So a little tip here, do not miss that keyword “initial.” That is a great word to go ahead and highlight using like those fun exam tools that you get so that you don’t forget it. And we offer all those tools like highlighting and striking out that we’ve talked about in our question bank so that you can practice. But okay, let’s read the scenario.

Kaitlyn: A 38-year-old patient presents with intermittent episodes of right upper quadrant discomfort and bloating after meals. Symptoms have been occurring for several months but are not constant. The physical exam is unremarkable. What is the best initial step? So we have A, order an abdominal CT scan; B, order an abdominal ultrasound; C, refer to gastroenterology; or D, schedule a HIDA scan.

Anna: When I break this question down, I read it, or in this case, listen to it, and I immediately heard the words “right upper quadrant pain.” So when I see that, especially in the case of abdominal pain, I look at what quadrant it’s in, and I really think about what lives in this area, because location gives us a really big clue, right? Most of us immediately are thinking gallbladder. So far, so good. Now let’s add in that this pain happens after eating and it’s been intermittent for a few months. So what are you thinking of here, Kaitlyn?

Kaitlyn: Yeah, so that pattern is classic for biliary colic caused by gallstones.

Anna: That – my thoughts exactly. All right, so let’s check again. What is this asking us? Now that we think we know what’s going on, what’s the question actually asking us about it? It’s asking the best initial step. And that word “initial” is so important. It means what is our first move? 

And at first, a few things jump out at me, especially since I’m one of those people and I have the habit of overthinking sometimes. So maybe a GI referral like C could stick out, or even a HIDA scan sometimes jumps out at me because I know that’s related to gallbladder function. But can you break those down and why those are actually not the correct ones to jump to?

Kaitlyn: I can see how C, a GI referral, definitely catches the eye, especially since we do refer a lot in primary care. But just remember, we usually don’t refer as a first step unless, one, it’s an emergency; two, it’s clearly outside of our scope; or three, the patient has already tried multiple treatments and failed. So none of that really applies here. So C is out. So go ahead and strike it out on your exam using that feature if you want. This just helps me stop looking at it and stop second guessing myself.

And then D, HIDA scan, also stands out to me. I agree with you, Anna. And that is because it is actually the gold standard test for evaluating gallbladder function. But “gold standard” does not mean “first step.” We save HIDA scan for later if the ultrasound, ding ding ding, is not helpful.

Anna: You got it. And that is actually our correct answer there. It was B, abdominal ultrasound. And this is the first-line imaging for suspected gallbladder disease, right? It’s non-invasive, it’s accessible, and it’s really sensitive for picking up gallstones, wall thickening, or sludge. So it is going to be our first move here, and that is what the question is asking. Because what can happen if we don’t do that and we jump to a HIDA scan with gallstones present?

Kaitlyn: It could dislodge one, cause a blockage, and lead to a slew of more invasive and costly tests or procedures. And just to be clear about the last answer choice we didn’t talk about, A, an abdominal CT, that is actually better at spotting complications like pancreatitis or appendicitis. It’s really not great for seeing gallstones, and it’s not going to be your first choice in this situation. 

So if you locked in B, an abdominal ultrasound, you nailed it. This is a perfect example of how reading the question stem closely and understanding what “initial” really means can keep you from overthinking or maybe jumping too far ahead in the plan.

Anna: Yeah, absolutely. And I think this is a really good place to stop this episode. We really talked about the importance of one, reading that vignette, trying to figure out what’s going on, but you have to figure out what the question is asking you and pick up on those keywords to be able to get it correct.

Now, if you like practice questions like this, if you like our test-taking strategies, definitely follow us on our Instagram page. It’s @smnpreviews official, because we do some practice questions there. 

And then check out our question banks. If you want to apply these strategies, because that is so important to do before your big day. So you can find that at npreviews.com. And follow us on this podcast to do some more test-taking strategies, some more question breakdown in our next couple of episodes. And we’ll see you next time.

Thanks for listening to another episode of the Real Deal Nurse Practitioner Club. If you want more information about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.