THE ULTIMATE ANCC FNP BOARD
EXAM PREP: HIGH-YIELD QUESTIONS
WITH RATIONALES ACROSS ALL
PRACTICE DOMAINS
Question 1
A 4-month-old infant is brought to the clinic with episodes of sudden,
inconsolable crying, drawing the knees to the abdomen, and vomiting. The
episodes last 15-20 minutes and are followed by periods of lethargy. On
exam, the abdomen is soft between episodes, but a sausage-shaped mass
is palpable in the right upper quadrant. Stool is guaiac-positive. What is the
most likely diagnosis?
A) Volvulus
B) Pyloric stenosis
C) Intussusception
D) Incarcerated inguinal hernia
Answer: C) Intussusception
Rationale: Intussusception classically presents in infants 3-12 months with
intermittent, colicky abdominal pain, vomiting, "currant jelly" stool (guaiac-
positive), and a palpable "sausage-shaped" mass in the RUQ (Dance sign).
Prompt diagnosis and air/contrast enema reduction are critical to prevent
bowel ischemia. Volvulus presents with bilious vomiting and acute distress.
,Pyloric stenosis features projectile vomiting without bloody stools. An
incarcerated hernia would show a visible, tender bulge .
Question 2
A 2-year-old boy presents with a 3-day history of low-grade fever, barking
cough, and inspiratory stridor that worsens at night. He has no drooling
and appears comfortable between coughing episodes. What is first-line
management?
A) Nebulized racemic epinephrine and oral dexamethasone
B) Intramuscular ceftriaxone and hospital admission
C) Nebulized albuterol and chest physiotherapy
D) Emergent intubation and ENT consultation
Answer: A) Nebulized racemic epinephrine and oral dexamethasone
Rationale: Croup (laryngotracheobronchitis) is managed with a single dose
of oral dexamethasone (0.15-0.6 mg/kg) and nebulized racemic
epinephrine for moderate to severe cases. Most cases are viral and self-
limited. The absence of drooling and comfort between episodes helps
distinguish croup from epiglottitis, which requires more emergent
management .
Question 3
A 28-year-old woman presents with a 2-week history of fatigue, sore throat,
and generalized lymphadenopathy. Physical exam reveals posterior cervical
lymphadenopathy and splenomegaly. CBC shows atypical lymphocytes
(15%). What is the most likely diagnosis?
A) Streptococcal pharyngitis
B) Infectious mononucleosis
C) Acute lymphoblastic leukemia
D) Acute HIV infection
,Answer: B) Infectious mononucleosis
Rationale: Infectious mononucleosis (EBV) presents with the classic triad of
fever, pharyngitis, and lymphadenopathy, with atypical lymphocytosis >10%
and splenomegaly. Avoid amoxicillin/ampicillin due to risk of rash.
Streptococcal pharyngitis typically does not cause significant splenomegaly
or posterior cervical lymphadenopathy .
Question 4
A 6-month-old infant presents with a 2-day history of rhinorrhea, low-
grade fever, and wheezing. On exam, there is tachypnea, nasal flaring,
intercostal retractions, and diffuse wheezes and crackles. RSV testing is
positive. What is the most appropriate next step in management?
A) Initiate palivizumab prophylaxis
B) Administer nebulized albuterol and oral corticosteroids
C) Provide supportive care with hydration and nasal suctioning
D) Admit for IV antibiotics and chest physiotherapy
Answer: C) Provide supportive care with hydration and nasal
suctioning
Rationale: RSV bronchiolitis is managed supportively with hydration, nasal
suctioning, and oxygen as needed. Bronchodilators and corticosteroids are
not routinely recommended per AAP guidelines. Palivizumab is for
prophylaxis in high-risk infants, not acute treatment .
Question 5
A 45-year-old man presents with sudden-onset severe headache described
as "the worst headache of my life," accompanied by nausea and
photophobia. On exam, he has nuchal rigidity and a positive Brudzinski
sign. CT head is pending. What is the most likely diagnosis?
, A) Migraine with aura
B) Subarachnoid hemorrhage
C) Acute bacterial meningitis
D) Tension headache
Answer: B) Subarachnoid hemorrhage
Rationale: A thunderclap headache with meningeal signs is classic for
subarachnoid hemorrhage. Non-contrast CT is the initial imaging of choice,
followed by lumbar puncture if CT is negative. Migraine typically has a more
gradual onset, and meningitis usually presents with fever and may have a
more subacute course .
Question 6
A 3-year-old girl is brought in with a fever of 103°F, irritability, and a stiff
neck. She has a purpuric rash on her lower extremities. Kernig and
Brudzinski signs are positive. What is the most appropriate immediate
management?
A) Oral amoxicillin and observation
B) Immediate IV ceftriaxone and hospitalization
C) Oral acyclovir and outpatient follow-up
D) IV vancomycin and ceftriaxone after CT head
Answer: D) IV vancomycin and ceftriaxone after CT head
Rationale: This presentation suggests bacterial meningitis with possible
meningococcal infection (purpuric rash). Empiric antibiotics (vancomycin +
ceftriaxone) should be initiated after blood cultures and STAT CT head to
rule out increased ICP. Corticosteroids (dexamethasone) should also be
considered. Do not delay antibiotics for LP if CT is delayed .
EXAM PREP: HIGH-YIELD QUESTIONS
WITH RATIONALES ACROSS ALL
PRACTICE DOMAINS
Question 1
A 4-month-old infant is brought to the clinic with episodes of sudden,
inconsolable crying, drawing the knees to the abdomen, and vomiting. The
episodes last 15-20 minutes and are followed by periods of lethargy. On
exam, the abdomen is soft between episodes, but a sausage-shaped mass
is palpable in the right upper quadrant. Stool is guaiac-positive. What is the
most likely diagnosis?
A) Volvulus
B) Pyloric stenosis
C) Intussusception
D) Incarcerated inguinal hernia
Answer: C) Intussusception
Rationale: Intussusception classically presents in infants 3-12 months with
intermittent, colicky abdominal pain, vomiting, "currant jelly" stool (guaiac-
positive), and a palpable "sausage-shaped" mass in the RUQ (Dance sign).
Prompt diagnosis and air/contrast enema reduction are critical to prevent
bowel ischemia. Volvulus presents with bilious vomiting and acute distress.
,Pyloric stenosis features projectile vomiting without bloody stools. An
incarcerated hernia would show a visible, tender bulge .
Question 2
A 2-year-old boy presents with a 3-day history of low-grade fever, barking
cough, and inspiratory stridor that worsens at night. He has no drooling
and appears comfortable between coughing episodes. What is first-line
management?
A) Nebulized racemic epinephrine and oral dexamethasone
B) Intramuscular ceftriaxone and hospital admission
C) Nebulized albuterol and chest physiotherapy
D) Emergent intubation and ENT consultation
Answer: A) Nebulized racemic epinephrine and oral dexamethasone
Rationale: Croup (laryngotracheobronchitis) is managed with a single dose
of oral dexamethasone (0.15-0.6 mg/kg) and nebulized racemic
epinephrine for moderate to severe cases. Most cases are viral and self-
limited. The absence of drooling and comfort between episodes helps
distinguish croup from epiglottitis, which requires more emergent
management .
Question 3
A 28-year-old woman presents with a 2-week history of fatigue, sore throat,
and generalized lymphadenopathy. Physical exam reveals posterior cervical
lymphadenopathy and splenomegaly. CBC shows atypical lymphocytes
(15%). What is the most likely diagnosis?
A) Streptococcal pharyngitis
B) Infectious mononucleosis
C) Acute lymphoblastic leukemia
D) Acute HIV infection
,Answer: B) Infectious mononucleosis
Rationale: Infectious mononucleosis (EBV) presents with the classic triad of
fever, pharyngitis, and lymphadenopathy, with atypical lymphocytosis >10%
and splenomegaly. Avoid amoxicillin/ampicillin due to risk of rash.
Streptococcal pharyngitis typically does not cause significant splenomegaly
or posterior cervical lymphadenopathy .
Question 4
A 6-month-old infant presents with a 2-day history of rhinorrhea, low-
grade fever, and wheezing. On exam, there is tachypnea, nasal flaring,
intercostal retractions, and diffuse wheezes and crackles. RSV testing is
positive. What is the most appropriate next step in management?
A) Initiate palivizumab prophylaxis
B) Administer nebulized albuterol and oral corticosteroids
C) Provide supportive care with hydration and nasal suctioning
D) Admit for IV antibiotics and chest physiotherapy
Answer: C) Provide supportive care with hydration and nasal
suctioning
Rationale: RSV bronchiolitis is managed supportively with hydration, nasal
suctioning, and oxygen as needed. Bronchodilators and corticosteroids are
not routinely recommended per AAP guidelines. Palivizumab is for
prophylaxis in high-risk infants, not acute treatment .
Question 5
A 45-year-old man presents with sudden-onset severe headache described
as "the worst headache of my life," accompanied by nausea and
photophobia. On exam, he has nuchal rigidity and a positive Brudzinski
sign. CT head is pending. What is the most likely diagnosis?
, A) Migraine with aura
B) Subarachnoid hemorrhage
C) Acute bacterial meningitis
D) Tension headache
Answer: B) Subarachnoid hemorrhage
Rationale: A thunderclap headache with meningeal signs is classic for
subarachnoid hemorrhage. Non-contrast CT is the initial imaging of choice,
followed by lumbar puncture if CT is negative. Migraine typically has a more
gradual onset, and meningitis usually presents with fever and may have a
more subacute course .
Question 6
A 3-year-old girl is brought in with a fever of 103°F, irritability, and a stiff
neck. She has a purpuric rash on her lower extremities. Kernig and
Brudzinski signs are positive. What is the most appropriate immediate
management?
A) Oral amoxicillin and observation
B) Immediate IV ceftriaxone and hospitalization
C) Oral acyclovir and outpatient follow-up
D) IV vancomycin and ceftriaxone after CT head
Answer: D) IV vancomycin and ceftriaxone after CT head
Rationale: This presentation suggests bacterial meningitis with possible
meningococcal infection (purpuric rash). Empiric antibiotics (vancomycin +
ceftriaxone) should be initiated after blood cultures and STAT CT head to
rule out increased ICP. Corticosteroids (dexamethasone) should also be
considered. Do not delay antibiotics for LP if CT is delayed .
