Ep #148: NP Board Exam Strategies: Absolutes and Opposites 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. So today, we are continuing our mini-series, and we are going to be talking about two different test-taking strategies: absolutes and opposites.

Now, in our last episode, the very first one of this little mini-series that we’re doing, we talked about how to dissect the question, how to find keywords. But this episode is going to focus more so on the answer choices themselves and give you clues when you need help narrowing it down. 

Because we are all about using every strategy you can. And you know what? Sometimes you just have to eliminate some answer choices. Sometimes you just have to narrow it down so that when you do have to guess, your chances of getting it correct go from 25% to maybe up to 50% or 75%.

So, Kaitlyn is here again. She was here in our last episode. So welcome back, Kaitlyn. Thanks for joining.

Kaitlyn: Yeah, hi. So I am in my element. I am loving this series. So just remember everybody, these are general strategies to help you critically think through questions and also to help you narrow down answer choices when you get stuck. So not every strategy will apply to every question. So for example, not every question will have absolute words in there.

Anna: And I love that you are already applying this tip by saying that there are exceptions to even these rules or these strategies. But yes, absolute words. So if you don’t know what we’re talking about, these are words that leave no room for exceptions. They leave no room for gray area. So they’re words like always, never, all. 

So if Kaitlyn said, “Yep, this strategy will work on all questions.” Well, that’d be incorrect, right? Because some questions, they don’t have that absolute word in there. And reflecting on last week, not every question gives you a clinical vignette and a lead-in to dissect. Sometimes you do just get that rote memorization question that you either know it or you don’t.

Kaitlyn: Yeah, exactly. And really, there are so few absolutes in healthcare. There is almost always an exception to the rule, almost. So just some examples I can think of off the top of my head. So never give aspirin to children, right? Unless they have Kawasaki disease. Never use high potency steroids in certain locations, except in cases like lichen sclerosus, so you get the point.

Anna: Yeah, exactly. And since we’re already talking about absolutes and what they are, let’s start with an example or two here. So I’m going to let Kaitlyn read a question and the answer choices, and then we’ll break it down. Now, while she is reading these out loud, see if you can find these buzzwords.

Kaitlyn: Okay, here’s the question. A 21-year-old patient presents to the clinic with a sore throat and fever for two days. They have no cough or rhinorrhea. On exam, their tonsils are erythematous with white exudates and anterior cervical lymphadenopathy is noted. The nurse practitioner knows that: A) amoxicillin is always the first-line therapy, B) azithromycin is the preferred treatment for most patients, C) throat cultures are unnecessary in adults, and D) treatment of this condition can prevent rheumatic fever.

Anna: All right, I definitely caught that word “always” in answer choice A. Amoxicillin is always the first-line therapy. And that one is one of those obvious absolute words, but even answer choice C, if you all caught it, answer choice C said, “Throat cultures are unnecessary in adults.” And that leaves very little room for exceptions, too. Although it doesn’t outright say never to do it. But I automatically in my head can rule those out. But do you want to walk through these answer by answer, Kaitlyn?

Kaitlyn: Yeah, so remember this question, this patient had a sore throat and fever. So sore throat and fever definitely have me thinking that this patient could have something like strep, mono, viral pharyngitis, but the exudates and the anterior cervical lymphadenopathy make me think strep throat is even more likely. So now, what is the question asking us? It just says, “The nurse practitioner knows that blank.” So that means that we have to treat each answer choice like a true or false statement. So, let’s just look at each one.

A, amoxicillin and penicillin VK are indeed both first-line treatment options for strep throat. But this answer choice is a trap, and let me tell you why. It says it is always the first-line therapy, and that absolute language makes this answer wrong. Like I said, there’s very few things in healthcare that are absolute. So even a medication that is technically correct gets knocked out by the word “always.” Because we know that if this patient had hives the last time that they took a penicillin, then amoxicillin is not going to be the first choice.

Anna: Yeah, definitely. And remember you all that the entire answer choice has to be accurate for you to choose that answer. So like Kaitlyn said, amoxicillin is a first-line treatment, but it’s not always the first-line therapy because what if they had allergies like Kaitlyn just mentioned? Or what if they had both strep and mono at the same time? Now, what about answers B, C, and D?

Kaitlyn: Okay, yeah. B, now we know this is wrong because as we just mentioned, amoxicillin and penicillin VK are the preferred treatment for most patients, not azithromycin. By the way, is azithromycin first-line for anything you can think of? It’s actually just one thing: pertussis or whooping cough.

Now, C is incorrect because while rapid tests are common, cultures are still recommended in certain cases. So for example, if this patient in this scenario had a negative strep test, I would definitely be getting that throat culture just to be sure. And then we have D. Of course, this is our correct answer. The biggest reason we treat strep throat beyond just reducing the duration of symptoms is going to be to prevent rheumatic fever, which is a serious post-streptococcal complication that can lead to permanent heart damage.

Anna: Yeah, absolutely. So D, treatment of this condition can prevent rheumatic fever. That is correct, right? Every part of that answer choice is correct, and that is why that is our correct answer. It’s kind of like back in nursing school. It’s the most correct answer.

Now, before I move to the next question, I do want to do a little bonus content check here. And if you have done any of our courses, you know how much I love bonus questions. So earlier, right, I mentioned that amoxicillin wouldn’t be the first line if a patient had both strep and mono. So why is that? Think the answer to yourself, and then ask yourself, what would you use instead? And Kaitlyn, do you want to answer that for our listeners?

Kaitlyn: Sure. So the reason we wouldn’t go with amoxicillin here is that most penicillins can cause a morbilliform rash in patients who have mono. But interestingly, penicillin VK is one of the few that doesn’t usually cause that reaction, so we could use that, or we could go with something like azithromycin instead.

Anna: Thank you. And really you all, the key takeaway here is just generally avoid answers that include those absolutes like always, never, only, or you must do this. Even if the fact seems true, the language just usually means that it’s wrong.

All right, time to do another question. This time we’re going to talk about hypertension. So, here’s our question. A 47-year-old patient presents for evaluation of newly diagnosed hypertension. Their blood pressure readings over the past month have averaged 138/89. They have no known comorbidities and take no medications. Which of the following best reflects evidence-based management?

So we have A) a beta blocker is the first-line treatment for uncomplicated hypertension. B) Anti-hypertensive medications must be started for all patients with elevated readings. C) Cardiovascular risk should guide initial treatment decisions. Or D) lifestyle modification is always ineffective without pharmacologic therapy.

All right, let’s back up a little bit here. Where are you starting, Kaitlyn, when you see this question?

Kaitlyn: So we have a patient with some elevated blood pressure readings, but it’s not like crisis level to me. They don’t have any comorbidities that I can see. So I want to figure out what stage it is so that I can then figure out the best management plan. So listeners, do you know what stage of hypertension we are working with here with that reading of 138/89? So according to ACC/AHA guidelines, it’s going to be Stage 1 hypertension.

Anna: Yeah, absolutely, always a great place to start. I mean, figure out what we think is going on, and then figure out what the question is asking us, right? And it’s not asking us to diagnose or to treat. It’s asking what best reflects evidence-based management. 

So, again, we are going to look at each of these answer choices to decide, is it true or not true? So let’s go through the options. A says beta blockers are first line. Well, I know we can eliminate this one because while beta blockers can lower our blood pressure, they are not one of those four first-line blood pressure medication classes that we think of.

Kaitlyn: Yeah, so moving on to B. Did you catch the absolute there? B says medications must be started for all patients with elevated readings. So this one might sound right, but the word “all” really should give you pause. Management decisions depend on context like risk factors, comorbidities, and cardiovascular risk. So that absolute language makes this one a no.

And D was our other answer with an absolute word. So lifestyle modification is always ineffective without pharmacologic therapy. So boards love our lifestyle modifications. So what word automatically makes this choice incorrect? It’s going to be that word “always.” It’s one of those absolutes that we want to avoid. And we know that lifestyle changes can absolutely work, which is why boards love them, especially in early-stage hypertension.

Anna: Yes, absolutely. And so that leaves us with answer choice C. Cardiovascular risk should guide initial treatment decisions. And that is definitely our winner here, right? According to ACC/AHA, we should use the patient’s 10-year ASCVD risk score to help us decide whether to start meds or try lifestyle changes first. Now, if the risk is under 10% and they don’t have other major issues, then we can stick to just lifestyle changes, no meds first in this scenario. 

All right, I think you all get the point of absolutes. And just remember this trick doesn’t always work, but it’s just another really good tool in your toolbox to start eliminating answers, especially if you’re unsure or you get stuck.

And be sure you are always, and yes, I actually do mean always now, make sure you are always reading the full question and the full answers and you’re critically thinking through them before selecting your answer.

Kaitlyn: Yeah, so at the beginning, you talked about opposites. So I want to move on to one more question and showcase another strategy. This one isn’t used as often, but it can really be valuable. So let’s just go ahead and start with the question before I get into it.

A 59-year-old patient with a COPD exacerbation is being treated with high-dose oral prednisone. Which of the following side effects of prednisone should the nurse practitioner educate the patient about? We’ve got A) bradycardia, B) hyperglycemia, C) hypoglycemia, and D) weight loss. So again, we aren’t jumping to selecting the answer quite yet. So let’s just see how we could walk through this step-by-step in the exam. So Anna, where would you start?

Anna: I immediately notice two things. So first, anytime you see corticosteroids like prednisone, I want your brain to immediately jump to metabolic and endocrine side effects because this med, it does a lot to the body, right? 

Now second, you’re probably sensing a theme here, but I think to myself, what is this question really testing? And initially, you might panic a little because you read it and it says it’s a COPD question and, oh my goodness, the COPD treatment groups is one area that still confuses you, but take a deep breath. This question is just simply checking to see if you know the classic side effects of corticosteroids.

Kaitlyn: Yeah, absolutely. So let’s go through our answer choices now. So A, what do we think about bradycardia? So no, corticosteroids can actually cause restlessness and sometimes even an elevated heart rate. Now for B and C, hyperglycemia and hypoglycemia. So what are you noticing about these?

Yeah, so they’re opposites, right? This is a great test-taking strategy moment. So when opposites show up, one of them is usually the right answer. So in this case, these opposite choices are helping exam writers make sure you don’t just know that corticosteroids affect glucose in general, but that you know how they affect it, right? And we can use that to our advantage at times. 

So let’s say you know nothing about prednisone other than it’s just a type of steroid. So if you get stuck, you can often narrow things down just by identifying, you know, which direction the drug pushes the body. It’s not a diabetes medication, right? So let’s just go ahead and rule out hypoglycemia. That leaves us with hyperglycemia as our correct answer. So prednisone actually ramps up gluconeogenesis and insulin resistance, which in turn causes the blood glucose to rise. And then in turn, answer D was weight loss, but patients on steroids tend to gain weight.

Anna: Yeah, exactly. So just to recap, correct answer here is hyperglycemia. And it’s one of the biggest things that we need to educate patients about when they are on high dose or chronic steroids, especially if they have diabetes.

But that really takes us to the end of this episode. We talked about the absolute words. We talked about if you see those opposite answer choices to really kind of pay attention to them. 

And if you want more like this, follow us on Instagram. It is that @smnpreviewsofficial because we do more practice questions there, and we like to post our favorite test-taking strategies. 

And then check out our courses to learn even more of our no-fluff content with our favorite memory tricks. Those are all in there. Those are at npreviews.com. You can also find our question banks there with so, so many more practice questions to get you ready for your big day. And follow us on this podcast because we are going to do one more of these episodes and we’re going to be looking at a couple more practice questions next time. So I’ll see you then.

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.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.