Ep #149: Zebra Questions: Exam Strategies for the Unexpected 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. 

Anna: Hello, hello, everyone. Welcome back to another episode.

So, this episode is part of our question mini-series, and it’s going to be our last episode in this series for now, but definitely let us know if you’ve liked these last few episodes, because we can see about doing something similar in the future. And, same as we’ve done the last two episodes, we have Kaitlyn here with us today.

Kaitlyn: Hi, everyone. Happy to be back.

Anna: So remember, in our last couple episodes, if you haven’t checked those out, make sure you do that. But we talked about how to dissect the questions, how to find keywords, and how to use tools like looking at absolute words or opposite answers to help us critically think through questions and narrow down choices. We’re really filling up our little toolbox here with all of the tools that we can use on exam day.

So today we’re going to continue our practice question series, and we’re going to be talking about what to do when you just don’t know. Like when you get to something where you say, what the heck is this? Because I’ve never heard of this before. And before you panic, like take a deep breath. Your exam is bound to have a couple of these. Like it’s just going to happen. But there’s not going to be a ton, especially if you’ve done the right content prep. And today, we’re going to give you some tips and some tricks to work your way through them and move on.

Kaitlyn: Yes. So these are what we call zebra questions. So, like you hear the hooves, you’re usually going to be thinking horses, but sometimes it’s something a little unexpected, like a zebra. So these types of questions are built to make you feel like you’ve never seen this topic before, and maybe you haven’t. But guess what? That’s kind of the point. Boards can throw in a handful of these questions that feel completely out of left field to test how you handle uncertainty. But the good news is that we know how to help you tackle these.

So first off, I want you to tell yourself that many of these are trial questions that really don’t even count towards your score.

Anna: That is literally exactly what I did on my exam because I remember taking it, and then I found a question, and I promise y’all, I’ve never heard of this. I can’t even remember what it was to this day because I had never heard of it before. And so obviously, cue a little stress, but I calmed myself down. I told myself, you know what? This is a trial question. And of course, like I don’t know that for certain, but telling myself that this was one question and this one question is not going to affect my exam, it’s not going to make or break my score, it really, really helped me.

And this is going to sound a little counterintuitive, but the key when you get to these questions isn’t getting them all right. The key is not letting a zebra question affect the rest of your exam. There have been too many times where I have seen somebody get so flustered on one question that they’re then not thinking as clearly, and they begin to miss some of those easier questions or the questions that they really knew that followed that really tough question.

Kaitlyn: Yeah, guilty. I remember I would get questions wrong in practice sets, and then when I went to review them, I could not believe that I didn’t get the right answer. So this is also why it’s so, so, so important to not only have an anxiety plan, but to actually practice that anxiety plan, because when you are reviewing questions and you notice that you missed one that you definitely knew, ask yourself what happened. Was there a really tough question right before, and maybe you were still stressed out, or maybe you were overthinking it, maybe you were rushing. Did you maybe miss a keyword? Were you getting tired? So if you find yourself getting mentally exhausted, that is a great sign to take a quick brain break.

So you don’t have to get up from your seat, just close your eyes, take some deep breaths, every so often, just to reset. And finding this out during your studying, by the way, is much better than having it affect your exam.

Anna: Yes, we want to practice, practice, practice. So find what works for you and practice what works for you. All right, let’s read a question now so that you can get an idea of what we mean by this zebra question.

So let’s say you’re taking your exam, you’re in your groove, and then all of a sudden, this is the next question that pops up:

“A 6-year-old child presents with bright blue skin discoloration, fatigue, and shortness of breath. The parent reports the child recently drank water from a well after heavy rainfall. Which of the following is the most likely diagnosis? A, cystic fibrosis. B, carbon monoxide poisoning. C, Kawasaki disease, or D, methemoglobinemia.”

Okay, one, I don’t even know what that last word I just said was. And then blue skin drinking from a well, I look, what is going on here? Total zebra.

Kaitlyn: Yeah, what in the world? So let’s do our best to break it down and find the right answer. So on these zebras, sometimes just going back to our basics and using process of elimination to make our best guess, I mean, that’s all we can do. So let’s just see where that leads us. So what clues do we have?

So let’s just start with the bright blue skin. That kind of sounds wild, but just pause and think through it. Bright blue skin tells us that something is off with what? Oxygen delivery. So, of course, I’m thinking of cyanosis. So let’s just go through those answers.

A is cystic fibrosis. So this to me has nothing to do with like sudden onset cyanosis, especially not from water exposure that I can think of. And I know CF causes respiratory symptoms, which I’m not seeing in this scenario at all. So while it can affect breathing, I’m not thinking that this is a typical case of CF. So I’m probably eliminating this answer choice. So what do you think about B, Anna, the carbon monoxide poisoning?

Anna: Again, let’s go back to the basics and, well, one, I believe that carbon monoxide poisoning actually causes that, like, cherry red skin, not blue, but even if you didn’t know that, that’s okay. Think, does this question hint at any exposure to carbon monoxide? No, because again, I’m going back and I’m getting stuck on that heavy rainfall and drinking water from a well. And does that cause carbon monoxide poisoning? Nope.

And then same with answer choice C, Kawasaki disease, this makes me think prolonged fever, mucous membrane change, that strawberry tongue, and not whatever this like blue skin well water thing is asking. And so even though I’m still kind of unsure what is happening here, we have just logically eliminated the first three answers. So where does that leave us?

Kaitlyn: Yeah, so that is going to leave us with D, methemoglobinemia. So even if you know nothing about this condition, we have actually just arrived at the correct answer just by process of elimination.

So, another point I do want to mention here before we move on, we have a child who is cyanotic and was drinking well water. So this feels oddly specific. And in healthcare, oddly specific is actually a gift. Well water points to nitrate-contaminated water, especially after rain. So this can cause methemoglobinemia, which is basically this big fancy word for where hemoglobin can’t carry oxygen properly. So even if you didn’t recognize the diagnosis immediately, you totally could have worked your way to the right answer. And that’s the power of strategy. So it’s okay if you didn’t know that or you didn’t get there yet. You can still get to the answer sometimes. But what if you can’t? What if you can eliminate one or two answers but still aren’t sure from there?

Anna: Yeah, that’s a tough one because at a point, right, I mean, we have to pick an answer and move on. And so follow your gut. Your gut is usually correct, right? And you can tell yourself, right, you did all you can to get that question correct. You critically thought through it. You looked at each answer choice and you eliminated what you could so that you have the highest chance of guessing correctly. And then move on.

Another tip we didn’t quite talk about with that last one is breaking down parts of the word. So if you get a condition like methemoglobinemia, I’ll be honest, like I had never heard of that before today. And I can really break that down. It’s my last answer choice left. And so I’m thinking, what does globinemia sound like, right? And I’m thinking something with hemoglobin, something related to anemia. That’s low oxygen carrying capacity. And I can kind of piece a few clues together, and that gives me enough confidence to select that as my answer and move on with that blue skin, and I can’t relate the well water to anything else. And remember, it’s okay to not know it all. Like, you are never going to get 100% of them correct. Even when you start practicing, you are not going to, you should not know it all.

Kaitlyn: Yeah, for sure. And by the way, you actually don’t need 100% to pass the exam. You don’t even need a 90%. And while we don’t know the exact number of questions you need to pass because of the scaled scores, we can still estimate that it’s roughly about a 70% needed. So remind yourself of that when you need to.

Okay, let’s look at one more question. This is not my favorite question. I think I said that about lots of questions on my AANP and ANCC exam, too. So let’s just do this one together:

“A 30-year-old spelunker returns from a weekend exploring underground caves in rural Texas. Three days later, they present to the clinic with fatigue, dry cough, and a headache. On exam, their lungs are clear, and vital signs are stable. A chest x-ray reveals small nodular infiltrate in the right lower lobe. What is the most likely diagnosis?”

Anna: All right, I could tell this was going to be something like super random just based solely on that word spelunker. But we have the caves. We have now the fatigue, the dry cough, the headache, the x-ray findings. All right, what are our answer choices?

Kaitlyn: We have: “A, bacterial pneumonia, B, bronchitis, C, coccidioidomycosis, and D, hantavirus pulmonary syndrome.” And C is, that is a fun word to say.

Anna: Yes, I’m not even going to attempt. And just remember, like with this question, like all questions, don’t panic. Yes, we used the word spelunker, and that just means someone who explores caves. And this question, it is definitely a zebra, my friends. And what do we do when we see a zebra? We take a deep breath. We remind ourselves this is just one question, and then we apply some test-taking strategies.

We have a healthy young adult who has a dry cough and a headache. They were recently exploring some caves, and that, again, is a weirdly specific clue. And these ultra-specific details are almost never random. Now, the question is asking us, what is the most likely diagnosis? So let’s take it one answer at a time.

Answer choice A was bacterial pneumonia. Now, that chest X-ray did make me pause for a minute here, but looking at the whole thing, looking at the big picture, this doesn’t feel like classic bacterial pneumonia, right? I’d expect a productive cough, a fever. I’d expect some lung auscultation where we could hear some rales or even like some consolidation. And yeah, this patient has no fever, clear lungs, like it just doesn’t seem to fit, right?

And then B, that was bronchitis. That wouldn’t give us that nodular infiltrate on imaging. And it’s typically something we could diagnose without needing any imaging. And if we did, the X-ray would be clear or just show like very mild changes. And so what about C and D?

Kaitlyn: So C, coccidioidomycosis. Again, very fun to say. I’ll be honest, most of us are not going to be sure what this is on test day. So let’s just come back to it. D, hantavirus pulmonary syndrome. Yeah, this one just sounds exciting, but it’s definitely not something most of us know much about.

So friends, we have narrowed it down to C and D. 50/50 is much better than 25%. So let’s talk about another strategy and actually talk about what these conditions are. And no, you don’t need to go memorize these or expect to see them on your exam. We purposefully put super random ones in here. You are not expected to know them, but just expect to see something unexpected when you take your test, then you will be as prepared as possible.

So, coccidioidomycosis is actually known as Valley Fever, which is a fungal infection endemic to Texas and the Southwest. So the spores live in dry soil, and they are easily inhaled during activities like digging or cave exploration.

Anna: Huh, learn something new every day.

Kaitlyn: Yeah. Hantavirus can follow rodent exposure in remote areas, but it causes a much more severe, rapidly progressive pulmonary syndrome, often with hypoxia and respiratory failure. So this patient is stable, so it doesn’t really match that profile. But when a question includes an oddly specific detail like specific exposures like spelunking, excavation, desert hiking, don’t brush past that because that detail is going to be your breadcrumb. And it’s probably pointing toward a fungal infection. So just remember, this is one question. You do not need to know all these specific details that I just gave you. So you have got this.

Anna: Yeah, one question, and I will take my 50/50 shot on this question every day. And we talk a lot more about a ton of different test anxiety management strategies, about test-taking strategies in our courses. But just remind yourself as much as you need to throughout your exam that you can do this. You’ve got this. Like you will pass. And yes, you do need to know a lot of content, right? I mean, you’ve been through years of NP school, and reviewing that content, being able to tie those loose ends together, it is half of the equation to being successful. But managing your test anxiety is the other equally important half.

And just remind yourself, like you all deserve to be here. You deserve to be taking this exam. And if you have graduated NP school, you can absolutely pass this exam. And if you need some help getting there on the content, on the anxiety management, on the practice questions, well, you’re in the right place, right? Again, we break down stuff like this on our free channels, like our Instagram at @SMNP_reviews_official, and our YouTube channel, SMNP Reviews. And then our courses and our question banks are packed with exactly what you need to pass your exam and become what we really like to call a real deal NP.

But thank you for joining us the last three episodes for this little mini-series, and I hope you enjoyed these. We’ll be doing more episodes coming up for those of you who are in school, those of you who are getting ready to test, and even those of you who are now the real deal and you’re starting into practice. So keep following along and stay tuned. Until 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.