ADVANCED PRACTICE NURSING
CERTIFICATION REVIEW:
COMPREHENSIVE EXAMINATION &
CLINICAL RATIONALE
SUBJECT MATTER: Primary Care Medicine, Pathophysiology, Pharmacology, and
Caring-Based Nursing Theory
BASED ON: Primary Care: The Art and Science of Advanced Practice Nursing – An
Interprofessional Approach (6th Edition) Editors: Lynne M. Dunphy, Jill E. Winland-Brown, Brian
O. Porter, & Deborah Holtzclaw
INTEGRATING 2025 CLINICAL UPDATES: American Diabetes Association (ADA) Standards
of Care ACC/AHA Cardiovascular Guidelines (PREVENT Equation) Global Initiative for Chronic
Obstructive Lung Disease (GOLD) Global Initiative for Asthma (GINA) Infectious Diseases
Society of America (IDSA) USPSTF Screening Recommendations
PREPARED FOR: Family Nurse Practitioners (FNP) Adult-Gerontology Primary Care Nurse
Practitioners (AGPCNP) Doctor of Nursing Practice (DNP) Candidates
EXAMINATION OVERVIEW AND THEORETICAL
FRAMEWORK
The following examination is designed not merely to test recall, but to evaluate the Advanced
Practice Registered Nurse’s (APRN) ability to synthesize complex pathophysiological concepts
with the humanistic demands of primary care. This document aligns strictly with the 6th Edition
of Primary Care: The Art and Science of Advanced Practice Nursing, authored by Dunphy,
Winland-Brown, Porter, and Holtzclaw. This text is distinct in its pedagogical foundation: it
rejects the biomedical reductionism often found in medical models in favor of a "Caring-Based"
approach.
The central theoretical construct of this text is the Circle of Caring. In this model, the patient
and family are conceptually positioned at the center, surrounded by the interprofessional team.
The 6th Edition expands this circle to explicitly address the "Science" of new genomic and
precision medicine alongside the "Art" of nursing presence. Furthermore, this examination
integrates the most recent 2024–2025 clinical practice guidelines—such as the shift to the
PREVENT cardiovascular risk calculator , the introduction of DoxyPEP for STI prevention , and
the reclassification of liver disease to MASLD —ensuring that the candidate is prepared for
contemporary practice.
UNIT I: CARING-BASED NURSING — THE ART
Question 1: Theoretical Foundations of Advanced Practice
Clinical Scenario: An Advanced Practice Nurse (APN) is establishing a new community health
,center in an underserved urban neighborhood. The APN intends to structure the clinic’s
workflow around the "Circle of Caring" model, the central theoretical framework of the Dunphy
text. During a stakeholder meeting with physicians, social workers, and community leaders, the
APN explains that unlike traditional medical models which place the provider or the pathology at
the center, this model necessitates a different focal point to improve health outcomes and
patient engagement.
Question: According to the "Circle of Caring" model described in Primary Care: The Art and
Science of Advanced Practice Nursing, which element is conceptually positioned at the center
of the circle, serving as the origin for all therapeutic interventions and interprofessional
collaboration?
A. The Interprofessional Team and Clinical Guidelines B. The Patient and the Family C. The
Advanced Practice Nurse (APN) D. The Electronic Health Record and Health Informatics
Systems
Answer: B. The Patient and the Family
Clinical Analysis & Rationale: The correct answer is B. The "Circle of Caring" is the
organizing framework for the entire Dunphy text, distinguishing it from standard medical
references. In this model, the patient and the family are explicitly positioned at the center. This is
not merely a symbolic gesture but a structural imperative; it dictates that all health promotion,
disease prevention, and restorative activities radiate from the patient's unique context, values,
and lived experience, rather than being imposed upon them by the healthcare system. The
rationale is that primary care is not done to a patient, but with a patient.
Option A is incorrect because, while the interprofessional team is a critical component of the
6th Edition’s expanded focus , the team is conceptualized as orbital—surrounding the patient to
provide a protective and resource-rich environment. The team exists to serve the center, not to
occupy it. Option C is incorrect because placing the APN at the center would represent a
paternalistic model of care, which the text explicitly rejects in favor of a partnership model.
Option D represents a technological tool that supports the circle but is not its focus. The
Dunphy text emphasizes that in the 21st century, despite the rise of informatics and precision
medicine (the "Science"), the "Art" remains grounded in the centrality of the human connection.
Question 2: Health Promotion and Prevention Levels
Clinical Scenario: A 68-year-old male veteran presents to the primary care clinic for a follow-up
of his Type 2 Diabetes and Hypertension. He has a history of a myocardial infarction five years
ago. He currently has no active foot ulcers, but his monofilament test today reveals diminished
sensation in the bilateral great toes. The Nurse Practitioner prescribes therapeutic depth-inlay
shoes and conducts an educational session on daily foot inspection to prevent trauma and
ulceration.
Question: Within the framework of health promotion described in Chapter 3 of the text, this
intervention—prescribing protective footwear and education to prevent complications in a
patient with established pathology—is best classified as which level of prevention?
A. Primordial Prevention B. Primary Prevention C. Secondary Prevention D. Tertiary Prevention
Answer: D. Tertiary Prevention
Clinical Analysis & Rationale: The correct answer is D. Tertiary prevention focuses on
managing established disease to prevent further complications, minimize disability, and restore
or maintain function. In this clinical scenario, the patient already has established pathology:
Type 2 Diabetes and peripheral neuropathy (indicated by the abnormal monofilament test). The
clinical goal is no longer to prevent the disease (which has already occurred) or to detect it in an
, asymptomatic phase, but to prevent the sequelae of the disease—specifically, the development
of diabetic foot ulcers, infection, and subsequent amputation.
Option A (Primordial Prevention) refers to broad, population-level actions to minimize future
hazards to health (e.g., sanitation, green spaces) and inhibit the emergence of risk factors.
Option B (Primary Prevention) involves interventions to prevent the onset of disease in
susceptible individuals, such as immunizations or diet counseling in a pre-diabetic patient to
prevent diabetes. Option C (Secondary Prevention) focuses on early detection and screening
of asymptomatic disease to halt progression, such as the initial A1C screening that diagnosed
his diabetes or a colonoscopy. The Dunphy text emphasizes that primary care providers spend
a significant proportion of their time in tertiary prevention, particularly when caring for vulnerable
populations like veterans , where the burden of chronic comorbidity requires aggressive
management to preserve quality of life.
Question 3: The Art of Diagnosis and Clinical Judgment
Clinical Scenario: A novice Nurse Practitioner is feeling overwhelmed by the volume of data
available in the electronic health record for a complex geriatric patient. The Dunphy text
discusses the "Art of Diagnosis" (Chapter 4) as a synthesis of data, intuition, and evidence. The
text warns against "premature closure" in the diagnostic process.
Question: According to Chapter 4 ("The Art of Diagnosis and Treatment"), what is "premature
closure," and why is it considered a significant source of medical error in primary care?
A. The failure to order definitively diagnostic imaging before starting treatment. B. The cessation
of data collection and hypothesis generation after a single probable diagnosis is identified,
leading to missed alternative diagnoses. C. The discharge of a patient from the clinic before
they have fully verbalized their understanding of the treatment plan. D. The rapid referral of a
patient to a specialist without completing a primary care workup.
Answer: B. The cessation of data collection and hypothesis generation after a single
probable diagnosis is identified, leading to missed alternative diagnoses.
Clinical Analysis & Rationale: The correct answer is B. Premature closure is a cognitive bias
where the clinician accepts a diagnosis before it has been fully verified or before other plausible
possibilities have been ruled out. This is a central concept in the "Art of Diagnosis" chapter,
which integrates the science of clinical reasoning with the art of critical thinking. The text argues
that primary care providers, often working under time pressure, are susceptible to seizing on the
first symptom constellation that fits a pattern (heuristics). For example, diagnosing "migraine" in
a patient with a headache without fully considering "temporal arteritis" because the migraine
features appeared first.
Option A is incorrect because diagnosis does not always require imaging; clinical diagnosis is
often sufficient and appropriate. Option C refers to poor communication or discharge planning,
not the diagnostic process itself. Option D refers to care coordination. The Dunphy text
highlights that avoiding premature closure requires the APN to maintain a "differential diagnosis"
mindset, constantly asking, "What else could this be?" even when the answer seems obvious,
reflecting the comprehensive nature of caring-based practice.
Question 4: Evidence-Based Practice - The "5 As"
Clinical Scenario: A DNP student is leading a quality improvement project to update the clinic's
hypertension management protocols based on the 2025 ACC/AHA guidelines. The student
utilizes the "5 As" cycle of Evidence-Based Practice (EBP) to structure the project. After
CERTIFICATION REVIEW:
COMPREHENSIVE EXAMINATION &
CLINICAL RATIONALE
SUBJECT MATTER: Primary Care Medicine, Pathophysiology, Pharmacology, and
Caring-Based Nursing Theory
BASED ON: Primary Care: The Art and Science of Advanced Practice Nursing – An
Interprofessional Approach (6th Edition) Editors: Lynne M. Dunphy, Jill E. Winland-Brown, Brian
O. Porter, & Deborah Holtzclaw
INTEGRATING 2025 CLINICAL UPDATES: American Diabetes Association (ADA) Standards
of Care ACC/AHA Cardiovascular Guidelines (PREVENT Equation) Global Initiative for Chronic
Obstructive Lung Disease (GOLD) Global Initiative for Asthma (GINA) Infectious Diseases
Society of America (IDSA) USPSTF Screening Recommendations
PREPARED FOR: Family Nurse Practitioners (FNP) Adult-Gerontology Primary Care Nurse
Practitioners (AGPCNP) Doctor of Nursing Practice (DNP) Candidates
EXAMINATION OVERVIEW AND THEORETICAL
FRAMEWORK
The following examination is designed not merely to test recall, but to evaluate the Advanced
Practice Registered Nurse’s (APRN) ability to synthesize complex pathophysiological concepts
with the humanistic demands of primary care. This document aligns strictly with the 6th Edition
of Primary Care: The Art and Science of Advanced Practice Nursing, authored by Dunphy,
Winland-Brown, Porter, and Holtzclaw. This text is distinct in its pedagogical foundation: it
rejects the biomedical reductionism often found in medical models in favor of a "Caring-Based"
approach.
The central theoretical construct of this text is the Circle of Caring. In this model, the patient
and family are conceptually positioned at the center, surrounded by the interprofessional team.
The 6th Edition expands this circle to explicitly address the "Science" of new genomic and
precision medicine alongside the "Art" of nursing presence. Furthermore, this examination
integrates the most recent 2024–2025 clinical practice guidelines—such as the shift to the
PREVENT cardiovascular risk calculator , the introduction of DoxyPEP for STI prevention , and
the reclassification of liver disease to MASLD —ensuring that the candidate is prepared for
contemporary practice.
UNIT I: CARING-BASED NURSING — THE ART
Question 1: Theoretical Foundations of Advanced Practice
Clinical Scenario: An Advanced Practice Nurse (APN) is establishing a new community health
,center in an underserved urban neighborhood. The APN intends to structure the clinic’s
workflow around the "Circle of Caring" model, the central theoretical framework of the Dunphy
text. During a stakeholder meeting with physicians, social workers, and community leaders, the
APN explains that unlike traditional medical models which place the provider or the pathology at
the center, this model necessitates a different focal point to improve health outcomes and
patient engagement.
Question: According to the "Circle of Caring" model described in Primary Care: The Art and
Science of Advanced Practice Nursing, which element is conceptually positioned at the center
of the circle, serving as the origin for all therapeutic interventions and interprofessional
collaboration?
A. The Interprofessional Team and Clinical Guidelines B. The Patient and the Family C. The
Advanced Practice Nurse (APN) D. The Electronic Health Record and Health Informatics
Systems
Answer: B. The Patient and the Family
Clinical Analysis & Rationale: The correct answer is B. The "Circle of Caring" is the
organizing framework for the entire Dunphy text, distinguishing it from standard medical
references. In this model, the patient and the family are explicitly positioned at the center. This is
not merely a symbolic gesture but a structural imperative; it dictates that all health promotion,
disease prevention, and restorative activities radiate from the patient's unique context, values,
and lived experience, rather than being imposed upon them by the healthcare system. The
rationale is that primary care is not done to a patient, but with a patient.
Option A is incorrect because, while the interprofessional team is a critical component of the
6th Edition’s expanded focus , the team is conceptualized as orbital—surrounding the patient to
provide a protective and resource-rich environment. The team exists to serve the center, not to
occupy it. Option C is incorrect because placing the APN at the center would represent a
paternalistic model of care, which the text explicitly rejects in favor of a partnership model.
Option D represents a technological tool that supports the circle but is not its focus. The
Dunphy text emphasizes that in the 21st century, despite the rise of informatics and precision
medicine (the "Science"), the "Art" remains grounded in the centrality of the human connection.
Question 2: Health Promotion and Prevention Levels
Clinical Scenario: A 68-year-old male veteran presents to the primary care clinic for a follow-up
of his Type 2 Diabetes and Hypertension. He has a history of a myocardial infarction five years
ago. He currently has no active foot ulcers, but his monofilament test today reveals diminished
sensation in the bilateral great toes. The Nurse Practitioner prescribes therapeutic depth-inlay
shoes and conducts an educational session on daily foot inspection to prevent trauma and
ulceration.
Question: Within the framework of health promotion described in Chapter 3 of the text, this
intervention—prescribing protective footwear and education to prevent complications in a
patient with established pathology—is best classified as which level of prevention?
A. Primordial Prevention B. Primary Prevention C. Secondary Prevention D. Tertiary Prevention
Answer: D. Tertiary Prevention
Clinical Analysis & Rationale: The correct answer is D. Tertiary prevention focuses on
managing established disease to prevent further complications, minimize disability, and restore
or maintain function. In this clinical scenario, the patient already has established pathology:
Type 2 Diabetes and peripheral neuropathy (indicated by the abnormal monofilament test). The
clinical goal is no longer to prevent the disease (which has already occurred) or to detect it in an
, asymptomatic phase, but to prevent the sequelae of the disease—specifically, the development
of diabetic foot ulcers, infection, and subsequent amputation.
Option A (Primordial Prevention) refers to broad, population-level actions to minimize future
hazards to health (e.g., sanitation, green spaces) and inhibit the emergence of risk factors.
Option B (Primary Prevention) involves interventions to prevent the onset of disease in
susceptible individuals, such as immunizations or diet counseling in a pre-diabetic patient to
prevent diabetes. Option C (Secondary Prevention) focuses on early detection and screening
of asymptomatic disease to halt progression, such as the initial A1C screening that diagnosed
his diabetes or a colonoscopy. The Dunphy text emphasizes that primary care providers spend
a significant proportion of their time in tertiary prevention, particularly when caring for vulnerable
populations like veterans , where the burden of chronic comorbidity requires aggressive
management to preserve quality of life.
Question 3: The Art of Diagnosis and Clinical Judgment
Clinical Scenario: A novice Nurse Practitioner is feeling overwhelmed by the volume of data
available in the electronic health record for a complex geriatric patient. The Dunphy text
discusses the "Art of Diagnosis" (Chapter 4) as a synthesis of data, intuition, and evidence. The
text warns against "premature closure" in the diagnostic process.
Question: According to Chapter 4 ("The Art of Diagnosis and Treatment"), what is "premature
closure," and why is it considered a significant source of medical error in primary care?
A. The failure to order definitively diagnostic imaging before starting treatment. B. The cessation
of data collection and hypothesis generation after a single probable diagnosis is identified,
leading to missed alternative diagnoses. C. The discharge of a patient from the clinic before
they have fully verbalized their understanding of the treatment plan. D. The rapid referral of a
patient to a specialist without completing a primary care workup.
Answer: B. The cessation of data collection and hypothesis generation after a single
probable diagnosis is identified, leading to missed alternative diagnoses.
Clinical Analysis & Rationale: The correct answer is B. Premature closure is a cognitive bias
where the clinician accepts a diagnosis before it has been fully verified or before other plausible
possibilities have been ruled out. This is a central concept in the "Art of Diagnosis" chapter,
which integrates the science of clinical reasoning with the art of critical thinking. The text argues
that primary care providers, often working under time pressure, are susceptible to seizing on the
first symptom constellation that fits a pattern (heuristics). For example, diagnosing "migraine" in
a patient with a headache without fully considering "temporal arteritis" because the migraine
features appeared first.
Option A is incorrect because diagnosis does not always require imaging; clinical diagnosis is
often sufficient and appropriate. Option C refers to poor communication or discharge planning,
not the diagnostic process itself. Option D refers to care coordination. The Dunphy text
highlights that avoiding premature closure requires the APN to maintain a "differential diagnosis"
mindset, constantly asking, "What else could this be?" even when the answer seems obvious,
reflecting the comprehensive nature of caring-based practice.
Question 4: Evidence-Based Practice - The "5 As"
Clinical Scenario: A DNP student is leading a quality improvement project to update the clinic's
hypertension management protocols based on the 2025 ACC/AHA guidelines. The student
utilizes the "5 As" cycle of Evidence-Based Practice (EBP) to structure the project. After
