Beyond the NCLEX and USMLE

It is easy to get so caught up in studying for your NCLEX or USMLE exam, that you forget the main point...you are learning for the benefit of your future patients and not just to pass the NCLEX or USMLE. Whenever possible, I like to step back and say, 'how does this effect me on the wards or in the unit'. What follows is one of those application blogs, where you look at the whole forest and not just the trees.

Square Man:

Mr. Square Man was born late one night, hours before a practical exam in health assessment. I memorized all of these signs and symptoms and was trying to organize the steps to the history and physical exam and felt pretty confident with my abilities. That was until I stepped into the examination room and saw the standardized patient and stern look of the evaluator. At that moment I had no idea what I was about to do. Luckily, the little stick figure made of graphite and colored dye leaped out in my mind and saved the day-sans a cape of course. Ever since, I have depended upon Square Man to visualize my way through the history and physical. So, without further ado, may I present square man...

The Subjective History

OK, actually before you see Mr Square Man, we need to talk. No I don't mean you and I need to talk, we need to get the history from the patient through an interview. You will be given a hundred different vital portions, and all sorts of acronyms to make it easier, none of which were any aid to me when I drew the blank on standardized patient day. In my humble opinion, the following is the most important part of the History, and what you should drill into your hippocampus:
• AOx3, oriented to person, place and time
• GCS: Look at me, speak to me, shake my hand
• CC: chief complaint (Whats up?)
• HPI:
• P: palliative/provocative (what makes better/worse)
• Q: quality (what does it feel like)
• R: radiation (for pain); region (for pain)
• S : severity (scale 1-10 for pain); symptoms (for non pain complaint)
• T: Timing (when did it start, course of complaint)
• Other vital history parts:
• M: medications (any meds you are on or have taken, i/c OTCs)
• A: Allergies to meds (what happens when you take?)
• D: Diseases (any other health conditions I should know about)
• D: Drugs (alcohol, nicotine, street drugs)
• Other possible history parts (if you have time):
• Social history (smoking, drinking, drugs, sexual partners, etc)
• Family history (of diseases)

The Objective Vitals...Yes they are vital!
• BP, HR, R, Temp, O2 Sats

The Objective Physical...Square Man appears
• Focus on portion of square man containing chief complaint first, or...
• If complaint is general or in head, then go head to toe through the body

1. The HeadStart here for head complaints (h/a), as well as neuro complaints
CNS: (brainstem)
• PERRL, EOMs, Feel face, Move face, Hearing, Ahhh, Shrug/Turn, Tongue
• Snellen chart if vision acuity check required (20 ft, cover one eye, read smallest)
Ears:
• Need more than hearing is ok

• Webber: lateralization...which ear do they hear better in?
• Rinne: To bad ear: conduct defect; To good ear: sensory defect
Nose:
• Patent
• Sinus tap: over, under eyes
Lymph:
• U under chin (sub mand, sub mental)
• U around ears (pre, post auricular)
• Chain down next strap moves you to next part of square man

Issues of note:
• PERRL problem (dilated, nonreactive pupil, etc): brain herniation, meds, midbrain disease
• CN 5: Trigeminal Neuralgia
• CN 7: Bells Palsy or stroke (forehead spared in cva)
• CN 8: Vertigo too? Acoustic nerve disease (neuroma) or Pons
• CN 9/10: What is HR? if tachy you have CN 10 dz and possible Medulla disease
• CN 11/12: Medulla issue


2. The Neck
Rarely start here, though it doesn’t hurt to take a quick look
Lymph:
• Cervical chains down side of neck
Respiratory:
• Trachea deviation?
CV:
• Complaints of syncope? Carotid bruit? Listen before you palpate!
Musculoskeletal:
• Full range of motion of neck

Issues of note:
• Lymph assess: Painless, fixed? CA; Painful? Infection; May be documented as LAN
• Trachea Deviation?: Towards affected side of chest? Spontaneous Pneumo; Towards unaffected side of chest? Tension Pneumo (DECOMPRESS!!!!)
• Bruit?: Atherosclerosis, stroke risk!
• Nuchal Rigid: Can bend back, not forward? SAH or Meningitis


3. The Chest and Abdomen
Start here for complaints of chest pain, breathing issues, abdominal issues, etc
Respiratory:
• I: shape and config of chest; accessory muscle use
• Pa: Symmetry of breathing; Tactile Fremitus
• Pe: Hyperresonance?
• A:
• Listen in each lobe
• Listen bilaterally
• Listen throughout breath
CV:
• I: Heaves
• Pa: Apical impulse, Lifts
• A: Listen with diaphragm and bell; Listen once at apex in left lateral position
• A: 2ICS, RSB (S1, S2)
• P: 2ICS, LSB (S1, S2, split S2?)
• T: 4ICS, LSB (S1, S2, S3/S4?)
• M: 5ICS, MC (S1, S2, S3/S4?)
Abdomen:

• I: Contour, Skin, Venous distribution

• A: One of two places you listen before you touch; Listen in 4 quadrants with diaphragm, then midway between umbilicus and left costal margin, with bell for abdominal aortic bruit

• Pe: You should hear tympany over most of the stomach

• Pa: First light palpate to illicit pain response, then deep to feel for masses

Issues of note:
• Lack of breathing symmetry: Pneumothorax
• Hyperresonance in chest: Pneumothorax
• Adventitious sounds
• Inspiratory, liquid: Crack
• Inspiratory, whistle: Stridor
• Expiratory, liquid: Rhonchi
• Expiratory, whistle: Wheeze
• S3 : Normal in young; Abnormal in older suggests HF as fluid is left in ventricle
• S4: Never normal! Suggests noncompliant, crunchy muscle from Infarction
• Systolic Murmur:
• Mitral: M Regurg
• Tricuspid: T Regurg
• Pulmonic: Stenosis
• Aortic: Stenosis
• Diastolic Murmur:
• Aortic: Regurg from dissection is bad news!
• Lift/Heave: Migrated? HF, CM



4. The Arms
Compare bilaterally; rarely start here except for specific arm complaints
CNS/PNS:
• Strength: Grips (frontal lobe)
• Sensitivity: Light touch (parietal lobe)
• Coordination: Stereognosis or Graphesthesia (cerebellum)
• Reflexes: Biceps, Triceps
CV:
• Radial Pulses: Rate, Rhythm, Strength
• Cap refill: <>

Skin: Temperature, Color, Turgor, Lesions, Clubbing (profile test)

Musculoskeletal:

• Full range of motion? If not possible perform passive ROM

• Special Tests: Phalens, Tinnels; both for Carpal Tunnel

Issues of note:
Neuro deficit: Problem here indicates cortical or nerve tract disease
• Should you have done a stroke screen? Hands raise, smile, Old dog
CV deficit: Weak pulse or slow cap refill suggests low CO; Pulses unequal suggests vascular disease
Skin:
• Turgor prob? Old or dry
Lesions
• Asymmetry
• Borders
• Color
• Diameter
• Elevation/Evolution

5. The Legs
Compare bilaterally; rarely start here except for specific leg complaints
CNS/PNS:
• Strength: Grips (frontal)
• Sensitivity: Light touch (parietal)
• Coordination: Heel Shin/Gait (cerebellum)
• Special Tests: Romberg (spinal disease)
• Reflexes: Quadriceps
• Primitive Reflexes: Babinski
CV:
• DP/PT Pulses: Rate, Rhythm, Strength
• Leg erythema and/or assymetry of legs?
Skin:
• Temperature, Color, Turgor, Hair distribution, Lesions
Musculoskeletal:
• Full range of motion? If not perform passive ROM
• Special Tests: Balottment

Issues of note:
Neuro deficit: Remember reflexes want to be strong and primitive want to come back but are held down by CNS; Disconnect or CNS disease can lead to hyperactive DTRs or Primitive reflexes
CV deficit: No DP/PTs? Try popliteal or femoral
• Arterial disease: pain with elevation, weak pulses, poor healing, loss of hair/nerves
• Venous disease: Varicose veins, edema, Pain on dorsiflexion (Homans)
Skin:
• Hair distribution prob? Diabetes

So I hope that gives you a quick overview of what is most needed in the history and physical examination. The NCLEX and USMLE expect you to easily recognize signs and symptoms, but in the real world, you can never investigate any of these unless you find them. Good luck...

How does the NCLEX Examination work?

Every nursing student has the same questions in regards to the NCLEX examination.

I thought it may be helpful to take a look at some of these questions to help you be ready for what is coming.

Where do I start with the NCLEX?

• Registering: obvious first step is signing up for your NCLEX exam, typically near the end of your senior year of nursing school:
1.Apply to state board through website and pay fee
2.Authorization to Test (ATT) received about 30 days after state receives school verification of degree
3.You schedule a date within 30 days of ATT or you risk expiration of your date

What about how the NCLEX is arranged and how it is graded? What does it take to pass?

CAT: Computer Adaptive Test (i.e. they keep asking you questions from subjects you get wrong, and leave ones you got right)
•75-265 questions possible (15 don’t count)
–I personally know people that have passed and failed at 75, 135, and 265 so don’t despair
•Max time allowed is 6 hours
•Check Results in 48 hours on state website by doing a search for your name as a REGISTERED NURSE!!!

Your NCLEX exam is graded in an adaptive form as well. Check out the following picture while reading this description. You start off with easy questions and are at the midline of the yellow block. If you get an easier question right, you get a point in the positive direction (towards the green), while if you get an easy one wrong you get 5 points in the negative direction (towards the red). If you get the easier one right, you get a harder one that will give you 2 points in the positive direction, and if wrong, 4 points in the negative direction. As you continue to get questions right, you move to harder and harder ones, where eventually you will get 5 points in the positive direction for a correct answer, and only 1 point in the negative direction for a wrong one. For incorrect questions you also move to easier and easier questions, which as stated, are worth less for correct and more for incorrect. At 75 questions the computer does an analysis of your trend line and if you are in the green at this point you are done and have passed your NCLEX exam, usually with greater than 58% correct. If you are in the red at this point you are done and have failed your NCLEX, usually with less than 42% correct. If you are located in the yellow, your NCLEX examination continues until the next random trend checkpoint.

What subjects are covered on the NCLEX?

Question Possibilities (Out of any 12 nclex questions)
•Safe Effective Care:
–Management: (2/12) Med Admin, Dx/Tx procedures
–Safety/Infection Control: (1/12) Precautions (airborne, etc)
•Health Promotion/Maintenance: (1/12) Development, Risk avoidance, recognize alterations in health
•Psychosocial Integrity: (1/12) Stress Coping, Problem solving
•Physiologic Integrity
–Basic Care/Comfort: (1/12) ADLS, Teaching (ie crutches)
–Pharmacology: (2/12) Drug indications, routes, admin, S/E
–Risk Reduction: (2/12) Prevent drug, tx, dz complications
–Physiologic Adaptation: (2/12) Disease s/s, lab values

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What types of questions styles are used on the NCLEX? I mean are they all multiple choice?

Question Types
•Multiple Choice
•Fill in the blank
•Multiple Response
•Ordered Response
•Figure/Illustrations

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How do I study to pass the NCLEX examination?

In short...PREPARE EARLY! I would recommend starting to do NCLEX Review questions at least by the start of your senior year. You can do this in conjunction with your classes, where for example, you study NCLEX Review questions on Pharmacology while studying for your Pharmacology class. Here is a schedule that I recommend to my NCLEX Review students:

Success Plan
•Fall: Use NCLEX review book with good summary section in all classes
–While studying, combine class notes with book review (I built a study guide for all tests out of both resources)
–Do all questions pertaining to that section for each test
–If you study in groups, have different books and quiz each other from these
–Try to answer at least 100 NCLEX book questions before each test.
•Total Questions Completed: 1000
•Spring: During Role Synthesis, make a plan to cover all subjects/systems from a new, mostly questions book
–Plan 25/day
–Mark % correct/incorrect for each section
–Total Questions Completed: 2500
•Summer: 60 days from grad to test
–Focus on weakest sections first
–Take at least 5 comprehensive tests (100 ?s)
–Average 25/day for 1500 total
•Total Questions Taken all year: 5000 +

I would be willing to say that your liklihood of passing the NCLEX is in direct relation to how many practice questions you have done. If you can surpass the 5000 question goal, you have a very good chance of being ready for the NCLEX when it comes your way.

Strokes (aka CVA, aka Brain Attack)

Studying for the neurology section of your NCLEX or USMLE can be overwhelming, but hopefully this review will make it a bit easier. Remember, not all strokes are created equal. But one thing that is, are the deficits from losing a specific section of your brain. One of the more common ways by which you can get these deficits is to lose blood supply to a certain area. Here are some common deficits, depending upon which supply of blood you lose...

· Focal Neurological Deficits: Depend upon area of brain perfused by effected artery
o Internal Carotid Artery/Opthalmic: Amaurosis fugax (transient monocular blindness-retinal ischemia: shade drawn), as well as hemispheric loss mostly from MCA territory
o ACA: Hemiplegia (leg more than arm), Confusion, Incontinence, Primitive reflexes
o MCA: Hemiplegia (arm/face more than leg), Hemianesthesia, Homonymous hemianopia, Drowsiness/Stupor (edema), Aphasia (dominant hemi), Apraxia (nondom hemi)
o PCA: Contralateral Hemisensory deficit, Aphasia, NonMacular Homon Hemianopia
o Vertebral: Ipsilateral face numb, Contralateral limb numb, Diplopia, Dysarthria, Ipsilateral Horners (ptosis, miosis, anhydrosis)
o Basilar: Pinpoint pupils, Quadriplegia, Sensory loss, Cranial nerve/Cerebellar deficit, Locked in state (all paralyzed but eyes)
o Brainstem/Cerebellar: Basilar/Vertebral; Hallmark is crossed deficit-Ipsilateral Cranial nerve deficit and Contralateral Motor deficit, Vertigo, N/V, Nystagmus, Ipsilateral limb ataxia, Rapid deterioration

Specific Stroke Treatment Protocols

Ischemic-ThromboticLarge vesselo Facts:
· Atherosclerosis main cause; Arterial dissection, Hypotension, Homocystinuria, Hyperglycemia (Delayed Calcium recovery in ischemic stroke)
· Common in Carotid bifurcation, MCA
o S/S:
· Progression of deficits over hrs to days with stuttering course
· May have been preceded by TIAs (80%)
· Often has a nocturnal onset (60%)
· Focal deficits depend upon vessel occluded (see above); Usually Carotid, MCA or Basilar
o DX:
· CT w/o contrast to r/o Hemorrhage
o TX:
· HT treated only if severe (more than 220/130) w/Labetalol or Enalapril
· Nimodipine not recommended; HOB elevated; Possible Mannitol and shunt placed

Small Vesselo Facts:
· Lacunar most common thrombotic; Usually caused by Chronic HT or DM
· Most common in small vessels of the Brainstem or Basal Ganglia
o S/S:
· Pure contra-motor hemiparesis/Clumsy hands w/Pons or Internal capsule involvement
· Pure contra-hemianesthesia w/Thalamus involvement
o DX:
· MRI best if small infarct suspected in Cortex/Brainstem
o TX:
· Antiplatelet agents

Hypoperfusion/Watershed: mainly related to low BP, with deficits often seen between the border of the ACA/MCA around the motor strip of the frontal cortex...Volume Resuscitate, Pressors, etc.

Ischemic-Embolic/Cryptogenic
o Facts:
· 50 % of all strokes
· Cardiac source (60%) from AFib/Valve Dz/MI/Cardiomyopathy; Artery source (carotid plaque, DVT w/left to right shunt); Fat/Air embolus; Often in MCA, Vertebral/Basilar
o S/S:
· Rapid onset focal deficit at maximum severity, usually with activity
· May have been preceded by TIA w/breakup of emboli within min-hrs
· May be accompanied by Seizure
· Focal deficits depend upon vessel occluded (see above); Usually MCA or Basilar
o DX:
· CT w/o contrast to r/o Hemorrhage
o TX:
· HT treated only if severe (more than 220/130) w/Labetalol or Enalapril
· TPA if all CI absent; Nimodipine not recommended
· Avoid rhythm conversion; Tx rate only


Hemorrhagic

Epidural (EDH)
o Facts:
· Not always listed as subset of Stroke although presentation often identical
· Usually from a TBI skull fracture that lacerates a meningeal artery. Hematoma puts pressure on brain causing compression, ischemia, and focal neuro deficits.
· Least common intracranial injury; Very uncommon in children/elderly
o S/S:
· Initial LOC, reawakening with clear mentation and then progressive AMS
· Sleepy, NV, Severe HA, dizziness
· Fixed, Dilated pupil on side of lesion w/contra hemiparesis is classic late finding
· Type of Herniation leads to various presentations; Transtentorial (uncal) herniation compresses oculomotor nerve causing ipsilateral fixed, dilated pupil as well as contralateral hemiparesis
o DX:
· Noncontrast CT; Shows lenticular shaped hematoma
o TX:
· Large blood collections are surgically evacuated despite neuro findings
· First step in Pt w/neuro deficit and vomiting is to protect airway by Intubation
· ICP monitor placed post evacuation and artery ligation

Subdural (SDH)o Facts:
· Not always listed as subset of Stroke although presentation often identical
· Collection of venous blood between Dura and Arachnoid
· Often seen in Pts w/Brain atrophy such as alcoholics and elderly
o S/S:
· Progressive neuro decline over days to weeks often w/no deficit initially, May mimic dementia
o DX:
· Noncontrast CT; Shows crescent shaped hematoma
o TX:
· Large blood collections are surgically evacuated despite neuro findings; Post op care in ICU

Subarachnoid (SAH)o Facts:
· 5 % of all strokes (30,000/yr) ↑ in Women (3:2); Peak 50-60 yo
· Usually from a berry aneurysm associated with HT at bifurcation of Circle of Willis
· Also from trauma, vascular anomaly or blood dyscrasias
· 2 % of population harbor aneurysms
· S/S: · Sudden severe Occipital HA with severity never experienced by Pt although a careful history may show minor S/S (NV, HA) from sentinel bleeding · N/V often follow onset of HA · Impaired consciousness and AMS w/Coma common (50%) · Seizures can occur (10%) as can retinal hemorrhage · Nuchal rigidity and other signs of meningeal irritation i/c neck/back pain · Focal neurologic deficits are frequently absent but if present often show a 3rd nerve Palsy
o DX: · CT w/o contrast immediately (faster and more sensitive for early hemorrhage than MRI); If (-)(10% missed by CT) LP for blood or xanthochromia · Cerebral arteriography to determine exact source of bleed if Pt is stable and surgery is a viable option · Bilateral carotid and vertebral arteriography to r/o other bleed source · EKG may show ST Δ, Prolonged QT, or peaked/inverted T waves

o TX: · Medical: · Sedatives to keep Pt calm · HHN Therapy to ↓ vasospasm which is most frequent cause of death for Pts who survive rupture: Hypervolemic (crystalloid or colloid fluids), Hypertensive (Dopamine), Nimodipine (60 mg q4h) · Attempt to keep BP in Pts normal range w/MAP below 100
· Other: · Obtain early neurosurgical consult; Admit to ICU · Bed rest in dark room · Prevent straining or valsalva · Pneumatic leg compression to prevent DVT · Consult physical, occupational, and speech therapists

Intracerebral (ICH)
o Facts:
· Also known as Intraparenchymal Hemorrhage; Most often in Putamen, Thalamus, Pons or Cerebellum; Often in young Pt, smoker, HT
· 25 % of all strokes; 50 % Mortality (depends on Volume/location)
· HT main cause and causes deep bleed; Also from anticoagulation/thrombolysis, Cocaine/amphetamines, AV malformation, Amyloid angiopathy
o S/S:
· Rapid (5-30m), progressive focal deficits depending on site;
· Vomiting (80 %); Headache (50%)
· Gaze deviation (towards paralyzed side = Cerebellum, Down w/unreactive pupils = Thalamus)
o DX:
· CT w/o contrast
o TX:
· Medical: Strict BP control w/MAP below 100
· Surgical: · Urgent neurosurgery consult if bleeding is in Cerebellum · Surgery for bleed elsewhere of no benefit · Other: · Induced hyperventilation to reduce edema and mass effect · Head of Bed to 30o

Other Facts of Interest

· History & Physicalo DDx includes Hypoglycemia/Hyperglycemia, Epilepsy, Tumor, Fever/Infection
o Thorough neurological exam including CN II-XII, Motor/Sensory function, Visual fields, Ability to speak/comprehend/walk, Reflexes (i/c primitive), Cerebellar function, Patient may lose appreciation of dysfunction (anosagnosia)
o Peripheral/Cervical vascular system i/c bruits/murmurs, DVT and EKG rhythm
o Cervical ROM
o Hx of previous S/S; Hx of Medications/Past surgeries/illnesses
· Diagnosticso Labs: CBC w/plts, CMP (i/c LFTs), ESR, PT/PTT, Syphilis serology, Tox screen, D-dimer, Fibrinogen, Urine Homocysteine; ABG, Cardiac enzymes Coags if hypercoag state suspected
o EKG, CXR
o CT: Door to CT interpretation goal is 45 min
· Non Contrast CT first to r/o hemorrhage (sensitivity for ischemic strokes only 50% in 6hrs)
· Next CT angio (arteriography) to evaluate vessel anatomy/patency/perfusion
o MRI: Only helpful in small infarcts in Cortex and Brainstem lesions and is not helpful in acute hemorrhages; should be avoided if Pt is unstable or will delay therapy
o Others: Carotid Doppler U/S, Transcranial Doppler, Echocardiography or U/S (RL shunt)

· Hypothermia is good for coma following cardiac arrest but no data if helpful for Stroke Pt
· Magnesium does not change morbidity/mortality rates
· Hyperglycemia delays recovery from ischemia w/data suggesting Glucose-Insulin-K helpful
· Supine position best for brain perfusion but increases ICP; Use own judgement
· If BP must be treated other acceptable medications include Clonidine, Labetalol, ACEI; Usually wait 3 wks post stroke
· Syncope occurs from stroke only w/hemorrhage, large MCA, or brainstem involvement