ANCC study guide for PMHNP certification exam
2025
What is the ACC/AHA ASCVD risk score cutoff recommendation to initiate antihypertensive
medication? > 10% diabetes mellitus, post-kidney transplantation, known cardiovascular disease, heart
failure, and/or peripheral arterial disease.
Hypertension management is highly individualized. It is widely accepted by clinicians and organizations
including the ACC and the AHA.
ACC and the AHA
Normal blood pressure is defined as < 120/80 mm Hg.
An elevated blood pressure is between 120/80 and 129/80 mm Hg.
Stage 1 hypertension is defined as a systolic blood pressure of 130–139 mm Hg or a diastolic
blood pressure of 80–90 mm Hg
Stage 2 hypertension is defined as anything ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic.
This can be accomplished by ordering a lipid profile, complete blood count, fasting blood glucose, serum
creatinine, glomerular filtration rate, electrocardiogram, thyroid-stimulating hormone, and urinalysis.
Patients who are at low risk (e.g., < 65 years, low ASCVD risk score) should be started on
antihypertensive medications if their blood pressure is ≥ 140/90 mm Hg. First-line medications used in
the treatment of hypertension include thiazide diuretics, dihydropyridine calcium channel blockers,
angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. Patients started on a
new antihypertensive should follow up with the clinician in 3–6 months.
Patients with bilateral renal artery stenosis should not take ACE inhibitors, and those with preexisting
chronic kidney disease may need a lower starting dose.
ACE inhibitors should have their kidney function monitored regularly.
If a patient’s glomerular filtration rate (GFR) drops 30% or more from their baseline or the GFR
is under 30 mL/min/1.73m2, the ACE inhibitor should be discontinued.
drug-induced hepatitis. The abdominal pain coupled with the jaundiced sclera are clues that his high-
intensity statin is causing acute hepatitis. Liver function tests like aspartate aminotransferase (AST) and
alanine aminotransferase (ALT) would be imperative to move forward with how to best treat this
patient.
, Signs and symptoms of acute hepatitis
jaundice, fatigue, nausea, vomiting, myalgias, abdominal pain, fever, headaches, and arthralgias. viral-
like illness with extrahepatic manifestations that may suggest some drug hypersensitivity. right upper
quadrant pain. Some patients may be asymptomatic. may report dark urine or clay-colored stools
before obvious jaundice appears. The physical examination may also reveal a rash, tender
hepatomegaly, ascites, and signs of encephalopathy.
Treatment of drug-induced hepatitis is immediate discontinuation of the offending medication, followed
by close monitoring.
Clinical manifestations of acute kidney failure include decreased urine output, fatigue, confusion, and
signs of electrolyte imbalances.
Clinical manifestations of rhabdomyolysis include muscle pain, dark urine, and weakness.
What would the nurse practitioner expect to see on an ECG that reveals atrial fibrillation? lack of P
waves and variable intervals between QRS complexes
In a properly functioning heart, the sinoatrial node generates an electrical signal that causes the
atria of the heart to contract, called depolarization. This signal travels into the atrioventricular
node and then down into the ventricles and causes them to contract. In Afib, the electrical
signals do not initiate in the sinoatrial node, which causes the atria to fibrillate. This sends
uncoordinated signals to the ventricles, which causes irregular contractions.
Afib is classified as paroxysmal, persistent, long-standing persistent, or permanent. Paroxysmal
Afib self-resolves within 7 days. Persistent Afib lasts > 7 days, and long-standing persistent Afib
lasts for 12 months or longer. Permanent Afib is a term used when no further interventions are
pursued to attempt restoration of sinus rhythm.
Inverted T waves on ECG typically suggest ischemia.
P waves embedded in the QRS complexes on ECG are characteristic of supraventricular
tachycardia.
Wide QRS complexes suggest ventricular dysrhythmia.
Gynecomastia is a benign condition in which the breast gland tissue cells multiply and cause masses to
grow from the nipples. It occurs in male patients.
Gynecomastia is diagnosed on physical examination. It is usually bilateral but can present as unilateral,
and it is typically tender. A common side effect of spironolactone use is the development of
gynecomastia. It works by blocking and displacing androgens, such as testosterone, which allows
estrogen levels to increase.
If a patient presents with breast swelling, breast cancer should be ruled out. It generally presents as
unilateral, fixed, and nontender. Breast cancer may also present with surrounding lymph node
enlargement in the axilla. Another differential diagnosis is pseudogynecomastia, which is the growth of
fatty breast tissue instead of glandular tissue.
Diagnostic tests used to help confirm a diagnosis can include mammogram or breast ultrasound. If the
cause of gynecomastia is determined to be a medication, it will typically resolve by stopping the
medication.
,A 55-year-old man presents to the clinic with fatigue, shortness of breath, and dizziness for 1 day. He
has a history of hypertension. The patient’s electrocardiogram reveals a second-degree
atrioventricular block. Which of the following medications should be immediately discontinued if the
patient is currently taking it? Nondihydropyridine calcium channel blockers, such as diltiazem.
Symptoms of a second-degree atrioventricular (AV) heart block include fatigue, dyspnea, chest pain,
syncope, and even sudden cardiac arrest. Nondihydropyridine calcium channel blockers, such as
diltiazem (C), are contraindicated in patients with second-degree AV heart blocks, as they alter the
conduction through the AV node. Other medications that should be avoided in these patients include
digoxin and beta-blockers.
AV block is defined as an interruption or delay in the transmission of an impulse from the atria to the
ventricles due to dysfunction in the conduction system. This impulse disruption can be transient or
permanent. A first-degree AV block occurs when there is delayed conduction from the atrium to the
ventricle without full interruption in atrial to ventricular conduction (i.e., a prolonged PR interval). A
second-degree AV block occurs when there is intermittent atrial conduction to the ventricle in a regular
pattern (e.g., 2:1 or 3:2), or there can be higher degrees of block that are classified into Mobitz type I
and II. A third-degree AV block occurs when there are no atrial impulses to conduct to the ventricle.
Patients with firstdegree AV block typically have no signs or symptoms. Patients with a symptomatic AV
block typically have at least a second-degree AV block. Patients found to have second- or third-degree
heart block should be immediately hospitalized.
An abdominal aortic aneurysm (AAA) is defined as a widened area of the aorta. It is most commonly
infrarenal in location, which means it occurs below the kidneys. They are typically asymptomatic until
they are close to rupture or with an active rupture. An expanding AAA at risk of rupture can cause back,
flank, and abdominal pain. It can also cause a pulsatile sensation in the abdomen. AAA rupture is a
medical emergency that is fatal without immediate repair. It causes severe pain, often described as
ripping in nature, and extensive blood loss. AAA rupture requires immediate endovascular or open
surgical repair, which is why you should advise this patient to call 911 immediately (A).
A typical infrarenal aorta is 2 cm wide, and any location > 3 cm wide is considered an aneurysm. AAA can
be palpable with physical examination if it is 5 cm wide or larger. Guidelines recommend screening for
AAA in men aged 65–75 years old who have smoked 100 cigarettes or more. The screening is a one-time
recommendation and is completed by ultrasound. Risk factors for developing AAA include male sex,
older age, smoking, and family history of AAA. Cardiovascular conditions such as high blood pressure,
high cholesterol, and coronary artery disease are also risk factors.
The nurse practitioner is reviewing a patient’s comprehensive metabolic panel results. Which of the
following assessments would support a result of hypocalcemia? Carpal spasm or flexion of the wrist
and metacarpophalangeal joints with hyperextension of the fingers upon occlusion of the brachial
artery with a sphygmomanometer is descriptive of a positive Trousseau sign and is a common symptom
of severe hypocalcemia.
Sarcoidosis (D) is not a type of obstructive lung disease. It is a chronic condition that causes collections
of inflammatory tissue, which are called granulomas. Sarcoidosis is a systemic disease and can present
in multiple body systems but most commonly occurs in the lungs. This is considered a type of restrictive
lung disease, which is characterized by reduced lung expansion and decreased amount of air in the lungs
held with inspiration.
, restrictive lung disease include
pulmonary fibrosis,
interstitial lung disease
pleural effusion
The most common symptoms are dyspnea and dry cough. The gold standard diagnostic tool for
diagnosis of restrictive lung disease is a pulmonary function test (PFT). This test measures airflow, gas
exchange, lung volume, and lung capacity. Common PFT results in restrictive lung disease are decreased
lung volume and total lung capacity.
type of obstructive lung disease
Asthma
chronic bronchitis cystic fibrosis are examples of obstructive lung disease, which is
characterized by difficulty with exhalation from obstruction in the airways and lung alveoli.
Hormonal contraception is not recommended for patients with a current breast cancer diagnosis or a
history of breast cancer. A copper intrauterine device (IUD) (B) is the most appropriate type of
contraception for the nurse practitioner to recommend to this patient, as it is an effective and
nonhormonal option.
The nurse practitioner should reasonably exclude pregnancy prior to initiating contraception in female
patients. Routine Pap smears are advised, as warranted. A copper IUD is inserted at any time during the
menstrual cycle and is approved for use for up to 10 years. The efficacy of a copper IUD is comparable to
surgical sterilization. It may cause heavier menstrual bleeding and spotting in between periods, so it
should not be recommended to patients who experience difficulty with these symptoms.
An otherwise healthy 6-month-old girl is brought to the clinic by a parent, who states the patient has
been extremely fussy for the past 2 days and developed a fever of 100.4°F today. On physical exam,
the nurse practitioner observes a well-appearing infant. A screening urinalysis and urine culture are
obtained. Urinalysis results indicate a urinary tract infection. Urine culture results are pending. This is
the infant’s first urinary tract infection. What plan of care is most appropriate for this patient?
prescribing antibiotics to empirically treat the infection and ordering a kidney and bladder ultrasound
Management of febrile urinary tract infection (UTI) in infants consists of prescribing antibiotics to
empirically treat the infection and ordering a kidney and bladder ultrasound (C). Given that this infant
otherwise appears well and has no named kidney anomalies or preexisting kidney disease, amoxicillin or
amoxicillin-clavulanate is a reasonable first-line empiric therapy. Amoxicillin can be flavored by a
pharmacy, making it more palatable for infants and young children. In cases of high risk for antibiotic
resistance to Escherichia coli, the most common organism responsible for UTIs in children, second- or
third-generation cephalosporin therapy may be necessary. Next, the American Academy of Pediatrics
recommends obtaining a kidney and bladder ultrasound for all infants and children aged 2 to 24 months
with a febrile UTI. This test will evaluate for possible predisposing urologic abnormalities, such as
vesicoureteral reflux. Among boys, posterior urethral valves are the most common proximate cause of
recurring UTIs.
Most immunocompetent children ≥ 2 months diagnosed with UTI can be safely managed in an
outpatient setting with close follow-up. The nurse practitioner should follow up once the urine culture
results are available to ensure the patient is being treated with the correct antibiotic for the causative
2025
What is the ACC/AHA ASCVD risk score cutoff recommendation to initiate antihypertensive
medication? > 10% diabetes mellitus, post-kidney transplantation, known cardiovascular disease, heart
failure, and/or peripheral arterial disease.
Hypertension management is highly individualized. It is widely accepted by clinicians and organizations
including the ACC and the AHA.
ACC and the AHA
Normal blood pressure is defined as < 120/80 mm Hg.
An elevated blood pressure is between 120/80 and 129/80 mm Hg.
Stage 1 hypertension is defined as a systolic blood pressure of 130–139 mm Hg or a diastolic
blood pressure of 80–90 mm Hg
Stage 2 hypertension is defined as anything ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic.
This can be accomplished by ordering a lipid profile, complete blood count, fasting blood glucose, serum
creatinine, glomerular filtration rate, electrocardiogram, thyroid-stimulating hormone, and urinalysis.
Patients who are at low risk (e.g., < 65 years, low ASCVD risk score) should be started on
antihypertensive medications if their blood pressure is ≥ 140/90 mm Hg. First-line medications used in
the treatment of hypertension include thiazide diuretics, dihydropyridine calcium channel blockers,
angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. Patients started on a
new antihypertensive should follow up with the clinician in 3–6 months.
Patients with bilateral renal artery stenosis should not take ACE inhibitors, and those with preexisting
chronic kidney disease may need a lower starting dose.
ACE inhibitors should have their kidney function monitored regularly.
If a patient’s glomerular filtration rate (GFR) drops 30% or more from their baseline or the GFR
is under 30 mL/min/1.73m2, the ACE inhibitor should be discontinued.
drug-induced hepatitis. The abdominal pain coupled with the jaundiced sclera are clues that his high-
intensity statin is causing acute hepatitis. Liver function tests like aspartate aminotransferase (AST) and
alanine aminotransferase (ALT) would be imperative to move forward with how to best treat this
patient.
, Signs and symptoms of acute hepatitis
jaundice, fatigue, nausea, vomiting, myalgias, abdominal pain, fever, headaches, and arthralgias. viral-
like illness with extrahepatic manifestations that may suggest some drug hypersensitivity. right upper
quadrant pain. Some patients may be asymptomatic. may report dark urine or clay-colored stools
before obvious jaundice appears. The physical examination may also reveal a rash, tender
hepatomegaly, ascites, and signs of encephalopathy.
Treatment of drug-induced hepatitis is immediate discontinuation of the offending medication, followed
by close monitoring.
Clinical manifestations of acute kidney failure include decreased urine output, fatigue, confusion, and
signs of electrolyte imbalances.
Clinical manifestations of rhabdomyolysis include muscle pain, dark urine, and weakness.
What would the nurse practitioner expect to see on an ECG that reveals atrial fibrillation? lack of P
waves and variable intervals between QRS complexes
In a properly functioning heart, the sinoatrial node generates an electrical signal that causes the
atria of the heart to contract, called depolarization. This signal travels into the atrioventricular
node and then down into the ventricles and causes them to contract. In Afib, the electrical
signals do not initiate in the sinoatrial node, which causes the atria to fibrillate. This sends
uncoordinated signals to the ventricles, which causes irregular contractions.
Afib is classified as paroxysmal, persistent, long-standing persistent, or permanent. Paroxysmal
Afib self-resolves within 7 days. Persistent Afib lasts > 7 days, and long-standing persistent Afib
lasts for 12 months or longer. Permanent Afib is a term used when no further interventions are
pursued to attempt restoration of sinus rhythm.
Inverted T waves on ECG typically suggest ischemia.
P waves embedded in the QRS complexes on ECG are characteristic of supraventricular
tachycardia.
Wide QRS complexes suggest ventricular dysrhythmia.
Gynecomastia is a benign condition in which the breast gland tissue cells multiply and cause masses to
grow from the nipples. It occurs in male patients.
Gynecomastia is diagnosed on physical examination. It is usually bilateral but can present as unilateral,
and it is typically tender. A common side effect of spironolactone use is the development of
gynecomastia. It works by blocking and displacing androgens, such as testosterone, which allows
estrogen levels to increase.
If a patient presents with breast swelling, breast cancer should be ruled out. It generally presents as
unilateral, fixed, and nontender. Breast cancer may also present with surrounding lymph node
enlargement in the axilla. Another differential diagnosis is pseudogynecomastia, which is the growth of
fatty breast tissue instead of glandular tissue.
Diagnostic tests used to help confirm a diagnosis can include mammogram or breast ultrasound. If the
cause of gynecomastia is determined to be a medication, it will typically resolve by stopping the
medication.
,A 55-year-old man presents to the clinic with fatigue, shortness of breath, and dizziness for 1 day. He
has a history of hypertension. The patient’s electrocardiogram reveals a second-degree
atrioventricular block. Which of the following medications should be immediately discontinued if the
patient is currently taking it? Nondihydropyridine calcium channel blockers, such as diltiazem.
Symptoms of a second-degree atrioventricular (AV) heart block include fatigue, dyspnea, chest pain,
syncope, and even sudden cardiac arrest. Nondihydropyridine calcium channel blockers, such as
diltiazem (C), are contraindicated in patients with second-degree AV heart blocks, as they alter the
conduction through the AV node. Other medications that should be avoided in these patients include
digoxin and beta-blockers.
AV block is defined as an interruption or delay in the transmission of an impulse from the atria to the
ventricles due to dysfunction in the conduction system. This impulse disruption can be transient or
permanent. A first-degree AV block occurs when there is delayed conduction from the atrium to the
ventricle without full interruption in atrial to ventricular conduction (i.e., a prolonged PR interval). A
second-degree AV block occurs when there is intermittent atrial conduction to the ventricle in a regular
pattern (e.g., 2:1 or 3:2), or there can be higher degrees of block that are classified into Mobitz type I
and II. A third-degree AV block occurs when there are no atrial impulses to conduct to the ventricle.
Patients with firstdegree AV block typically have no signs or symptoms. Patients with a symptomatic AV
block typically have at least a second-degree AV block. Patients found to have second- or third-degree
heart block should be immediately hospitalized.
An abdominal aortic aneurysm (AAA) is defined as a widened area of the aorta. It is most commonly
infrarenal in location, which means it occurs below the kidneys. They are typically asymptomatic until
they are close to rupture or with an active rupture. An expanding AAA at risk of rupture can cause back,
flank, and abdominal pain. It can also cause a pulsatile sensation in the abdomen. AAA rupture is a
medical emergency that is fatal without immediate repair. It causes severe pain, often described as
ripping in nature, and extensive blood loss. AAA rupture requires immediate endovascular or open
surgical repair, which is why you should advise this patient to call 911 immediately (A).
A typical infrarenal aorta is 2 cm wide, and any location > 3 cm wide is considered an aneurysm. AAA can
be palpable with physical examination if it is 5 cm wide or larger. Guidelines recommend screening for
AAA in men aged 65–75 years old who have smoked 100 cigarettes or more. The screening is a one-time
recommendation and is completed by ultrasound. Risk factors for developing AAA include male sex,
older age, smoking, and family history of AAA. Cardiovascular conditions such as high blood pressure,
high cholesterol, and coronary artery disease are also risk factors.
The nurse practitioner is reviewing a patient’s comprehensive metabolic panel results. Which of the
following assessments would support a result of hypocalcemia? Carpal spasm or flexion of the wrist
and metacarpophalangeal joints with hyperextension of the fingers upon occlusion of the brachial
artery with a sphygmomanometer is descriptive of a positive Trousseau sign and is a common symptom
of severe hypocalcemia.
Sarcoidosis (D) is not a type of obstructive lung disease. It is a chronic condition that causes collections
of inflammatory tissue, which are called granulomas. Sarcoidosis is a systemic disease and can present
in multiple body systems but most commonly occurs in the lungs. This is considered a type of restrictive
lung disease, which is characterized by reduced lung expansion and decreased amount of air in the lungs
held with inspiration.
, restrictive lung disease include
pulmonary fibrosis,
interstitial lung disease
pleural effusion
The most common symptoms are dyspnea and dry cough. The gold standard diagnostic tool for
diagnosis of restrictive lung disease is a pulmonary function test (PFT). This test measures airflow, gas
exchange, lung volume, and lung capacity. Common PFT results in restrictive lung disease are decreased
lung volume and total lung capacity.
type of obstructive lung disease
Asthma
chronic bronchitis cystic fibrosis are examples of obstructive lung disease, which is
characterized by difficulty with exhalation from obstruction in the airways and lung alveoli.
Hormonal contraception is not recommended for patients with a current breast cancer diagnosis or a
history of breast cancer. A copper intrauterine device (IUD) (B) is the most appropriate type of
contraception for the nurse practitioner to recommend to this patient, as it is an effective and
nonhormonal option.
The nurse practitioner should reasonably exclude pregnancy prior to initiating contraception in female
patients. Routine Pap smears are advised, as warranted. A copper IUD is inserted at any time during the
menstrual cycle and is approved for use for up to 10 years. The efficacy of a copper IUD is comparable to
surgical sterilization. It may cause heavier menstrual bleeding and spotting in between periods, so it
should not be recommended to patients who experience difficulty with these symptoms.
An otherwise healthy 6-month-old girl is brought to the clinic by a parent, who states the patient has
been extremely fussy for the past 2 days and developed a fever of 100.4°F today. On physical exam,
the nurse practitioner observes a well-appearing infant. A screening urinalysis and urine culture are
obtained. Urinalysis results indicate a urinary tract infection. Urine culture results are pending. This is
the infant’s first urinary tract infection. What plan of care is most appropriate for this patient?
prescribing antibiotics to empirically treat the infection and ordering a kidney and bladder ultrasound
Management of febrile urinary tract infection (UTI) in infants consists of prescribing antibiotics to
empirically treat the infection and ordering a kidney and bladder ultrasound (C). Given that this infant
otherwise appears well and has no named kidney anomalies or preexisting kidney disease, amoxicillin or
amoxicillin-clavulanate is a reasonable first-line empiric therapy. Amoxicillin can be flavored by a
pharmacy, making it more palatable for infants and young children. In cases of high risk for antibiotic
resistance to Escherichia coli, the most common organism responsible for UTIs in children, second- or
third-generation cephalosporin therapy may be necessary. Next, the American Academy of Pediatrics
recommends obtaining a kidney and bladder ultrasound for all infants and children aged 2 to 24 months
with a febrile UTI. This test will evaluate for possible predisposing urologic abnormalities, such as
vesicoureteral reflux. Among boys, posterior urethral valves are the most common proximate cause of
recurring UTIs.
Most immunocompetent children ≥ 2 months diagnosed with UTI can be safely managed in an
outpatient setting with close follow-up. The nurse practitioner should follow up once the urine culture
results are available to ensure the patient is being treated with the correct antibiotic for the causative
