Certification Exam: Tricks of the Trade

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Certification Exam Tricks of the Trade

• Barbara Resnick, PhD,CRNP
• Ethel Mitty, PhD, RN

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Assisted Living Nurse Certification Exam

• Facts about the Exam, Item Distribution and
  Testing Process

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Facts about the exam

• Based, in part, on AALNA survey conducted in
  early 2005 about knowledge and skills important
  to AL nurses.
• Content is evidence-based, where possible draws
  on current nursing theory and knowledge current
  regulations affecting older adults demographics
  facts on aging etc..
• Examination was vetted and revised pursuant to
  expert and assisted living nurses feedback most
  recently, March, 2009.

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Examination Process

• Administered on-line account creation is done on
  line and requires a specific user name and
  password.
• Takes about 2 hours to complete once started, it
  must be completed.
• Exam can be taken at least two more times in the
  event of failure to pass.
• On passing the exam, the Assisted Living Nurse
  Certification certificate is mailed in
  approximately 14 days.
• Nurse can place on ID badge C-AL (Certified in
  Assisted Living).
• Certification is good for four years.
• To renew the certificate, documentation must be
  provided of at least 20 hours of continuing
  education specific to assisted living nursing or
  healthcare of the older adult approved by the NAB
  or ANCC.

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Testing Domains

• Four areas tested based on the certification
• exams administered by the ANCC (American Nurses
  Credentialing Center)
• Primary care considerations
• Major Health Problems/Review of Systems
• Organization of Health Care Delivery
• Professional Practice

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Primary Care Considerations (approx. 20)

• The Aging Population demographics, normal aging
  changes, attitudes stereotypes, health
  promotion (screening, immunizations, nutrition,
  CAM. Environment (safety, relocation,
  transportation, comm. resources), culture
  ethnicity, spirituality, autonomy, sexuality,
  pharmacology (Beers Criteria)
• contd. next slide

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Primary Care Considerations, contd

• Theories nursing, aging, family, motivational
• Communication includes learning theory
  principles, education, history-taking,
  interviewing and comm. techniques
• Death and Dying hospice/palliative care, beliefs
  and traditions, grieving

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Major Health Problems/Review of Systems (50)

• CV, Resp, GI, GU, Urinary/Repro, Hematology,
  Musculoskeletal, Metabolic Endocrine,
  Immunology, Neuro, Psych, Skin, Sensory, Meds,
  Pain
• Plan of care development and evaluation
• Physical/psychosocial assessment (instruments)

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Organizational Health Policy (15)

• Health care delivery systems interdisc, case
  mgmnt, discharge planning, referrals
• Types the continuum
• Institutional NH, AL, Rehab, acute care/subacute
• Federal regs OAA, ADA, HIPAA, Ombudsman
• Reimbursement SS, SSI, M/are, M/aid, LTCI,
  Managed care, other

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Professional Issues (15)

• Scope and Standards of practice
• Leadership management styles planning and
  decision making, delegation, communicating,
  conflict mgmnt, PE, QI, Staff Dev, Change Theory,
  Policy procedure dev evidence-based practice
• Research Human subject protection, nursing
  research process, research utilization
• contd. next page

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Professional Issues, contd.

• Ethical Legal issues Client elder neglect,
  advocacy, rights, informed consent, advance
  directives, mental capacity issues, organ
  transplant. Nurse ethics values,
  accountability and competency, negligence and
  malpractice, risk mgmnt
• Gerontological nursing trends and issues hx of
  geri nursing, roles, dev, professional orgs

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Test Taking Ability

• How you approach and take the test is critical
• Preparation is critical
• Focus is critical

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General POINTS

• DO NOT ANSWER QUESTIONS BASED ON WHAT YOU DO IN
  REAL WORLD SETTINGS
• In certification exams we make questions and
  answers that can be found in any general
  geriatric test.not your individual site.
• Go with what is evidence based

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Test Taking Skills

• Test Taking
• Read the directions carefully
• If there is time, quickly look through the test
  for an overviewNote key terms, jot down brief
  notes
• Answer questions in a strategic order
• Answer easy questions first
• With objective tests, first eliminate those
  answers you know
• Review make sure you answer all questions look
  for simple/stupid mistakes
• Change answers to questions if you made a
  mistake, or misread the question
• Decide on and adopt study strategies that work
  best

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Tips

• Tips on answering multiple choice questions Read
  the question before you look at the answer.
• Come up with the answer in your head before
  looking at the possible answers, this way the
  choices given on the test won't throw you off or
  trick you.
• Eliminate answers you know aren't right.
• Read all the choices before choosing your answer.
  
• If there is no guessing penalty, always take an
  educated guess and select an answer.
• Don't keep on changing your answer, usually your
  first choice is the right one, unless you misread
  the question.

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Tips

• In "All of the above" and "None of the above"
  choices, if you are certain one of the statements
  is true don't choose "None of the above" or one
  of the statements are false don't choose "All of
  the above".
• In a question with an "All of the above" choice,
  if you see that at least two correct statements,
  then "All of the above" is probably the answer.
• A positive choice is more likely to be true than
  a negative one.
• Usually the correct answer is the choice with the
  most information.

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None of these strategies is infalliblebut

• Responses that use absolute words, such as
  "always" or "never" are less likely to be correct
  than ones that use conditional words like
  "usually" or "probably."
• "Funny" responses are usually wrong.
• "All of the above" is often a correct response.
  If you can verify that more than one of the other
  responses is probably correct, then choose "all
  of the above."
• "None of the above" is usually an incorrect
  response, but this is less reliable than the "all
  of the above" rule. Be very careful not to be
  trapped by double negatives.
• Look for grammatical clues. If the stem ends with
  the indefinite article "an," for example, then
  the correct response probably begins with a
  vowel.

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Cont

• The longest response is often the correct one,
  because the instructor tends to load it with
  qualifying adjectives or phrases.
• Look for verbal associations. A response that
  repeats key words that are in the stem is likely
  to be correct.
• If all else fails, choose response (b) or (c).
  Many instructors subconsciously feel that the
  correct answer is "hidden" better if it is
  surrounded by distractors. Response (a) is
  usually least likely to be the correct one.

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Additional Tips

• Circle or underline important words in the item.
  This will help you focus on the information most
  needed to identify the correct answer choice.

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Additional Tips

• Read all the answer choices before selecting one.
  It is just as likely for the last answer choice
  to be correct as the first.

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Additional Tips

• Cross out answer choices you are certain are not
  correct. This will help you narrow down the
  correct answer choice.

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Additional Tips

• Look for two answer choices that are opposites.
  One of these two answer choices is likely to be
  correct.

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Additional Tips

• Look for hints about the correct answer choice in
  other items on the test. The correct answer
  choice may be part of another item on the test.

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Additional Tips

• Look for answer choices that contain language
  used by your teacher or found in your textbooks.
  An answer choice that contains such language is
  usually correct.

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Additional Tips

• Do not change your initial answer unless you are
  sure another answer choice is correct. More often
  than not, your first choice is correct.

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Additional Tips

• Choose "all of the above" if you are certain all
  other answer choices in the item are correct. Do
  not choose "all of the above" if even just one of
  the other answer choices is not correct.

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Additional Tips

• Choose "none of the above" if you are certain all
  other answer choices in the item are incorrect.
  Do not choose "none of the above" if even just
  one of the other answer choices is correct.

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Tricks of the Trade T/F Questions

• When you do not know the answer. Mark it true!
• There are generally more true questions on
  true-false exams than false questions.
• It is difficult to make a false statement look
  true!
• Specific detail in the statement may also tend to
  make it true. For example, the statement "Babe
  Ruth hit 60 home runs in one season" has specific
  detail and is more likely to be true.
• Look for any factor that will make a statement
  false.
• It is easy to add a false part to an otherwise
  true statement.
• Dont read the question and see some truth and
  quickly assume that the entire statement is true.
  For example, "Water boils at 212 degrees in
  Denver." Water does boil at 212 degrees, but not
  at Denvers altitude.

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Tricks of the Trade T/F Questions

• Look for extreme modifiers that tend to make the
  question false. Extreme modifiers, such as
  always, all, never, or only make it more likely
  that the question is false. Here is a more
  complete list of EXTREME modifiers.
• all
• none
• best
• absolutely
• always
• never
• worst
• absolutely not
• only
• nobody
• everybody
• certainly
• invariably
• no one
• everyone
• certainly not
•  

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Tricks of the Trade T/F Questions

• Qualifying words tend to make a question true.
  Qualifiers (seldom, often, many) increase the
  likelihood that the statement is true. Here is a
  more complete list of QUALIFIERS.
• usually
• frequently
• often
• sometimes
• some
• seldom
• many
• much
• probably
• a majority
• apt to
• most
• might
• a few
• may
• unlikely
•  

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Tricks of the Trade T/F Questions

• BE CAREFUL when there are negative words or
  prefixes
• The prefixes (un-, im-, miss-) will alter the
  meaning of the statement.
• Double negatives make a positive. For example
  "not uncommon" actually means common.  
• Questions that state a reason tend to be false.
• Words in the statement that cause justification
  or reason (since, because, when, if) tend to make
  the statement false.
• Pay close attention, the reason that is given may
  be incorrect or incomplete.  
• Older adults commonly have hip fxs because they
  all have osteoporosis
• Pay close attention, the reason that is given may
  be incorrect or incomplete.
• There is no substitute for the truth.
• Many concentrated hours of study to force facts
  into your memory is the best way to prepare
  true-false questions.
• YOU may, however, have to apply the fact to a
  slightly different situation.

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Tricks of the Trade T/F Questions

• Formulate your own answer before reading the
  options.
• Focus on finding an answer without the help of
  the alternatives.
• This process will increase your concentration.
• Doing this will help you feel more confident
  about your answer .
• Eliminate unlikely answers first.
• Eliminating two alternatives quickly may increase
  your probability to 50/50 or better.
• Use the true-false methods described earlier and
  find the false alternative. 
• Select numbered answers from the middle range,
  not the extremes.
• For example, if the height of a mountain is
  requested, eliminate 20,000 feet (high), and
  3,000 feet (low). Then choose between 8,000 feet
  and 11,000 feet. 
• Select answers that are longer and more
  descriptive.
• Longer (true) answers stand out and contain more
  detail.
• Shorter (false) answers are created quickly as
  throw aways.
• Descriptive detail is given to help you identify
  the truth.  

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Examples of Multiple Choice Questions

• 1. Canada's population is closest to about
• 5 of America's population
• 10 of America's population
• 15 of America's population
• 20 of America's population
• Knowledge
• 2. The permanent set of teeth in a human adult
  including wisdom teeth numbers
• 28
• 30
• 32
• 34
• 32go with the middle range
• 3. Which of the following is not a mammal
• Bat
• horse
• whale
• shark
• Knowledge and eliminate the ridiculous or known

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Multiple Choice Questions

• 4. Which one of these birds does not have
  feathers
• Penguin
• Ostrich
• Eagle
• Robin
• they all have feathers
• DUHknowledge
• 5. A healthy day's food would include all but
• 10-11 servings of the bread and cereals group
• 5-6 servings of the meat group
• 2-3 servings of the dairy group
• 2-3 servings of the fruit and vegetable group
• sweets and oils sparingly
• Knowledge / meat would be unhealthy

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Multiple Choice Questions

• 6. Which of the following is true about hypnosis
  
• It is not real.
• Depth of hypnosis is determined by subjects
  response.
• Most people cannot be hypnotized.
• Weak-minded people are hypnotized easier.
• Knowledgeor eliminate what you do know
• 7. When formulating goals into specific
  activities, one should
• Give priority to activities done easiest.
• Overrule any previously scheduled appointments.
• Make sure activities have a date, time, and place
  to ensure their fulfillment.
• Wait two weeks or until no longer busy to start
  activities.
• Knowledge (date, time and place make sense)

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Multiple Choice Questions

• 8. Drug and alcohol abuse
• is the major cause of racism
• doesn't always lead to death
• are major causes of family breakups
• is coincident with rock and roll
• Doesnt alwaysmakes grammatical sense
• 9. Teachers
• are concerned with the welfare of every student
• can help students by encouraging critical
  thinking
• are unfair
• are all critical thinkers
• Eliminate the absolutes

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Examples of T/F Questions

• 1. All trees except pine trees molt their leaves
  in the fall.
• Falsetoo absolute
• 2. Water is less dense in its liquid state.
• Tjust got to know it!
• 3. Dieting combined with consistent exercise will
  usually aid in weight loss.
• Tusually likely to be true as it is less
  definitive
• 4. More women suffer from anorexia than men
  because men don't worry about appearance as much.
  
• Fexample of a true statement with a because that
  is false
• 5. In car technology the Japanese far exceed the
  Americans. 6. Shakespeare wrote the Bible.
• Ffar exceeds is impossible to achieve

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• 1. According to statistics, which is responsible
  for causing the most disability in persons 85
  years and older?
•  Cardiovascular disease
• Dementia
• Diabetes mellitus
• Hip fracture
•  The leading cause of disability over age 85 is
  dementia. Nearly 20 of persons over age 85 are
  disabled with dementia. Persons with heart
  failure may have the lowest quality of life.
  Diabetes mellitus affects 1 of persons over age
  85. Diabetes mellitus is associated with heart
  disease and stroke which may cause earlier death
  therefore not affecting the over age 85 group as
  much. Hip fracture affects nearly 9 of adults
  over age 85.

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• 2. Normal age-related change in the lungs is
  associated with
• Bronchial hyperreactivity
• Decreased FEV1
• Increased chest wall compliance
• Mucus hypersecretion
• With aging there is a graduate decline in the
  FEV1, increased residual capacity and slight
  decline in the PaO2. There is also decreased
  chest wall compliance the intercostal muscles
  and cartilage are less flexible. Bronchial
  reactivity is unchanged, and hyper reactivity
  would be associated with asthma. Merck Manual
  online.
•  

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• 3. A nurse at an AL has a resident, who is DNH,
  with substernal chest pain, sweaty and nauseated.
  After administration of prn sublingual
  nitroglycerin the next action is to
• Administer oxygen
• Call the primary MD/NP
• Check oxygen saturation via pulse oxymetry
• Give aspirin 160 325 mg
• It is important to prioritize the response.
  Myocardial damage is caused by hypoxia, so oxygen
  should be administered first in anyone who is
  suspected of having a myocardial infarction or
  experiencing angina. If not allergic to aspirin a
  chewable aspirin should be given after starting
  oxygen. While oxygen saturation may be helpful in
  determining response to oxygen, it is more
  important to first administer the treatment
  before monitoring the oxygen level. The third
  component is to control pain, which is not a
  choice given here.  

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• 4. The Patient Self-Determination Act (1991)
  requires that
• a. All patients enrolling in HMOs or admitted to
  hospitals, NHs must complete an Advanced
  Directive.
• b. All patients who are hospitalized be given a
  copy of the hospitals bill of rights.
• c. All patients entering a hospital, HMO, or
  nursing home be informed about their right to
  make an Advanced Directive.
• d. An ombudsman be appointed to inform residents
  in nursing homes of their rights.

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• 5. Which of the following is true about
  decision-making capacity?
• a. It can only be determined by a psychiatrist
• b. It can only be determined by a judge.
• c. It can only be decided using the Folstein
  mini-mental status exam
• d. It can be determined by the primary care
  provider.
• e. It is the same thing as incompetence.

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• 6. Delirium only occurs if the patient already
  has dementia. True or False
• a. True
• b. False

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• 7. Precipitants of delirium include all but one
  of the following
• a. Vitamin supplements
• b. Acute medical illness such as pneumonia
• c. Sedative medicines used for insomnia
• d. Anemia (hct less than 30)
• e. Foley catheter
•  

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• 8. Which of the following statements is true
  about pressure ulcer care?
• a. A moist wound base is desirable.
• b. When you suspect bacterial contamination, you
  should obtain a surface swab culture of the
  wound.
• c. You should always select an absorbent
  dressing.
• d. Dressings should be changed at least every
  day.
• e. Irrigate the wound with an antiseptic
  solution at each dressing change.

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• 9. Consequences of chronic pain include which of
  the following
• a. Decreased socialization
• b. Sleep disturbance
• c. Increased health care utilization and costs
• d. Depression
• e. All of the above

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• You call a provider with concerns about
  increased agitation in a patient with moderate
  dementia. You should provide the following
  critical clinical information
• The residents allergies
• Proxys phone number
• Her weight
• What behavior modification techniques have the
  staff tried

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New Clinical Tidbits CVD

• myocardial ischemia caused by CAD is more
  commonly manifested by dyspnea on exertion than
  by chest pain typical of angina pectoris.
• angina pectoris can present as back or shoulder
  pain or as burning epigastric pain. Substernal
  (below the sternum) anginal pain is less common
  in older adults.
• Angina pectoris pain in older adults can be less
  severe and of shorter duration than presentation
  in a younger individual.
• Myocardial ischemia can cause clinical heart
  failure (HF) and acute pulmonary edema.
• Heart failure generally is associated with
  increased shortness of breath due to fluid
  accumulation throughout the body (legs, lungs,
  abdomen, face).

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New Clinical Tidbits CVD

• Other symptoms associated with acute MI in older
  adults include peripheral gangrene, increased
  claudication (cramping in the calves with
  activity), palpitations, kidney failure,
  weakness, pulmonary embolism, restlessness,
  sweating, and sudden death.
• Older adults with acute MI are more likely than
  younger persons to die from the MI and to have
  pulmonary edema, HF, left ventricular (LV)
  systolic dysfunction (impaired pumping of the
  left ventricle), cardiogenic shock, conduction
  disturbances requiring insertion of a pacemaker,
  atrial fibrillation (AF) or atrial flutter. THEY
  ARE SICK!

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Clinical Tidbits CHF

• Symptoms
• Dyspnea is the most common symptom
• Pulmonary congestion from fluid in the lungs may
  cause coughing and wheezing.
• Decreased cardiac output can cause weakness, a
  feeling of heaviness in the limbs, nocturia,
  oliguria, confusion, insomnia, headache, anxiety,
  memory impairment, bad dreams or nightmares, and,
  rarely, psychotic manifestations.
• Increased fluid in the liver can occur and may
  cause epigastric or right upper quadrant
  heaviness or a dull ache, a sense of fullness
  after eating, anorexia, nausea, and vomiting.
• Right ventricular failure causes edema that
  first occurs in the dependent parts of the body.
• Chest x-ray for residents with suspected HF will
  show pulmonary vascular congestion in those with
  LV failure.

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Clinical Tidbits CHF

• Precipitating causes of HF, such as excess sodium
  ingestion (e.g. pickles, potato chips),
  myocardial ischemia, infection, anemia, fever,
  hypoxia, tachyarrhythmias, bradyarrhythmias,
  hyperthyroidism, hypothyroidism, and obesity must
  be identified and treated.
• THINK IT THRU!

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Sodium

• Sodium intake should be decreased to between
  1500mg to no more than 2400mg/day, equal to about
  1 tsp of salt.
• FOODS?
• Weigh daily and look for 2 pound changes

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Beta Blockers

• Useful if the resident has a nl ejection
  fraction (gt50)
• Reducing the heart rate to lt 90 beats per minute,
  thereby increasing the time the LV has to fill
  and increasing the volume of blood that is pumped
  throughout the body.
• Feeds the heart better
• Prevents more hypertrophy

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Diuretic Tidbits

• Mild HF can be treated with a thiazide diuretic.
• Thiazide is ineffective if the estimated
  glomerular filtration rate (GFR) is lt 30 mL per
  minute
• Older adults with moderate or severe HF should be
  treated with a loop diuretic (e.g., furosemide),
  so named because of where it works in the kidney.
  
• Those with severe HF or concomitant renal
  insufficiency may need metolazone in addition to
  the loop diuretic.
• Aldosterone antagonist diuretics can be used in
  older adults who have a normal estimated GFR and
  a normal serum potassium.

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Atrial Fibrillation

• AF is the most common type of arrhythmia in
  adults it is more common as people age.
• Cardiac conditions associated with the
  development of AF are hypertension, rheumatic
  mitral valve disease, CAD, and HF.
• Noncardiac causes include hyperthyroidism,
  hypoxic pulmonary conditions, surgery, and
  alcohol abuse.
• People with AF may have an irregularly irregular
  heart rate , palpitations and lightheadedness, or
  more vague symptoms, such as malaise.
• Treatment slow rate fix rhythm? Prevent blood
  clots. of AF in older adults with HF requires
  evaluation of their heart rate and rhythm, and
  prevention of a clot.