Session Number 205

CERTIFICATION REVIEW:
Professional Caring and Ethical Practices (Synergy) and Test Taking Strategies
Barbara Pope, RN, MSN, CCRN, PCCN, CCNS
popeb@einstein.edu
Critical Care Clinical Educator
Albert Einstein Healthcare Network
Philadelphia, PA

Content Description
Synergy has represented 20% of the CCRN exam since July, 1999. The PCCN exam was
developed based on the synergy model; synergy represents 20% of all PCCN questions as well.
The CMC exam was developed with all questions based in synergy. This session will explore
the development of AACNs Synergy Model and how it relates to the CCRN, PCCN, and CMC
exams. It will look at the components of Synergy and present questions that are based on the
Synergy model.
In the second part of this presentation, test-taking strategies for the CCRN, PCCN and CMC
examinations will be discussed. It will review the breakdown of each exam by percentage, and
explore various study methods and the benefits of each. It will present construction of test
questions and distracters.

Learning Objectives
At the end of this session, the participant will be able to:
1.

List the nurse competencies that are described in the Synergy model

2.

Recognize a sample question as representing an area of Synergy

3.

Analyze the construction of a given test question to identify its intent

REFERENCES
NOTE: Please refer to outline for references pertaining to this session.

CERTIFICATION REVIEW:
Professional Caring and Ethical Practices (Synergy) and Test Taking Strategies
Exam Tip: Approximately 20% of both the CCRN and PCCN exams will focus on Professional
Caring and Ethical Practices, approximately 30 and 25 questions respectively.
I. Professional Caring and Ethical Practices (Synergy)
A. What is Synergy?
AACN:
Synergy is an evolving phenomenon that occurs when
individuals work together in mutually enhancing ways toward a
common goal. The Synergy Model creates a comprehensive look at the
patient, putting the patient in the center of nursing practice. It identifies nursings
unique contributions to patient care and allows us to define ourselves within the
context of the patient and patient outcomes.
B. Why Synergy?
Prior to 1999, the CCRN certification exam was systems-based.
All the certification exams are continually redesigned to maintain relevancy
Changes in technology, nursing and consumers required a significant change in
the exam.
Did not look at individual patient needs
Did not consider the family
Did not look at the nurse
Needed to look at practice based on patient and family needs
Needed to look at nurse competencies that matched the needs of the patient
C. More to Synergy than just certification
Synergy a model developed by AACN
Uses include:
Patient Assignment
Acuity system
Development of Competencies
Performance Appraisals
Patient Outcome Assessment
Career Advancement
Utilization by Clinical Nurse Specialists
D. Patient Characteristics
The Synergy Model encourages nurses to view patients in a holistic manner rather
than the body systems medical model. Each patient and family is unique, with a
varying capacity for health and vulnerability to illness. Each patient, regardless of the
clinical setting, brings a set of unique characteristics to the care situation. Depending
on where they are on the healthcare continuum, patients may display varying levels of
the following characteristics:
Stability
Complexity
Vulnerability

Ability to maintain a steady-state equilibrium

Intricate entanglement of two or more systems
Susceptibility to stressors that may affect patient outcomes

Resiliency
Predictability
Resource availability
Participation in care
Participation in
decision-making

Capacity to return to optimal function using compensatory

mechanisms
Able to expect a certain course of events or course of
illness
Extent of resources the patient/family/community bring to
the situation
Extent to which patient and family engages in care
Extent to which patient and family engages in decisionmaking

E. Nurse Characteristics
Nursing care reflects an integration of knowledge, skills, abilities and experience
necessary to meet the needs of patients and families. Thus, nurse characteristics are
derived from patient needs and include:
Clinical judgment

Advocacy/moral
agency

Caring practices

Collaboration

Systems thinking

Response to diversity

Clinical reasoning, which includes clinical decision

making, critical thinking and a global grasp of the
situation, coupled with nursing skills acquired through a
process of integrating education, experiential knowledge
and evidence-based guidelines.
Working on anothers behalf and representing the concerns
of the patient/family and nursing staff; serving as a moral
agent in identifying and helping to resolve ethical and
clinical concerns within and outside the clinical setting.
Nursing activities that create a compassionate, supportive
and therapeutic environment for patients and staff, with the
aim of promoting comfort and healing and preventing
unnecessary suffering. These caring behaviors include but
are not limited to vigilance, engagement and
responsiveness of caregivers. Caregivers include family
and healthcare personnel.
Working with others (e.g., patients, families,
healthcare providers) in a way that promotes/ encourages
each persons contributions toward achieving
optimal/realistic patient/family goals. Collaboration
involves intra- and interdisciplinary work with colleagues
and community.
Body of knowledge and tools that allow the
nurse to manage whatever environmental and system
resources that exist for the patient/family and staff, within
or across healthcare systems and non-healthcare systems.
The sensitivity to recognize, appreciate and incorporate
differences into the provision of care. Differences may
include, but are not limited to, individuality, cultural,
spiritual, gender, race, ethnicity, lifestyle, socioeconomic,
age and values.

Clinical inquiry

Facilitator of learning

The ongoing process of questioning and evaluating

practice and providing informed practice. Creating changes
through evidence-based practice, research utilization and
experiential knowledge.
The ability to facilitate learning for patients/ families,
nursing staff, other members of the healthcare team and
community. Includes both formal and informal facilitation
of learning.

Although all 8 competencies are essential for contemporary nursing practice, each
assumes more or less importance depending on a patients characteristics.
F. Synergy
Need to look at patient characteristics and nurse competencies
Importance of nurse competencies will vary depending on the patients
characteristics
Synergy results when a patients needs and characteristics are matched with
the nurses competencies
How Synergy is used in the exam
Will not be questioned on Synergy terminology
Synergy theory applied to scenarios
Reflects what nurses do
Usually answer is common sense
Example: Professional Caring and Ethical Practice
The greatest family need during a patients first few days in the unit is to
A. Participate in activities of daily living
B. Plan discharge needs
C. Feel that the best possible care is being provided
D. Obtain information focusing on pathophysiology
G. Clinical Judgment: 80% of the both CCRN and PCCN exam
Systems-based
Example: Clinical Judgment
A 20 YO male patient is admitted S/P MVA. He was thrown from his all terrain
vehicle and sustained a contusion of his right temple. He was reported to have
had LOC for 10-15 minutes. The nurse would institute measures to prevent which
potential problem in this patient?
A. Epidural hematoma
B. Concussion and frontal bone fracture
C. Rhinorrhea and potential encephalitis
D. Bilateral cerebral contusions
H. Professional Caring and Ethical Practice (synergy): 20% of both exams
Example: Advocacy/Moral Agency
The nursing staff is resisting being assigned to a disruptive patient. An
appropriate resolution would be to:
A. Request the physician to transfer the patient
B. Rotate the patient assignment among staff
C. Confront the family and demand an end to the disruptive behavior

D. Hold a nursing team conference to discuss possible alternatives

Example: Caring Practices
A patient recalls a near-death experience (NDE) that occurred during resuscitation
and wishes to tell the nurse about it. What is the optimal response by the nurse?
A. Let the patient know that NDEs are often hallucinations
B. Compare the patients story to the actual resuscitation events
C. Encourage the patient to describe the NDE to his family
D. Make time to listen actively while the patient tells the story
Example: Collaboration
A patient with Type I insulin-dependent diabetes mellitus is admitted in diabetic
ketoacidosis (DKA). Since admission to the ICU, the patients glucose levels
have been in the range of 400-500 mg/dl, and regular insulin has been
administered on a sliding dosage scale. Given these findings, the most
appropriate initial nursing intervention is to:
A. Consult with the physician about changing the regimen to regular insulin
via continuous drip
B. Arrange for nutritional consult to enhance adherence to ADA diet
C. Consult with the physician about increasing the maximum dosage of
regular insulin on the sliding scale
D. Request evaluation by the diabetic educator
Example: Systems Thinking
A major trauma victim is transported form a rural hospital. The patient died prior
to the wifes arrival to the ICU. The nurse would best prepare for the wifes
arrival by:
A. Arranging for a physician to speak with her when she enters the unit
B. Planning to escort her to the waiting room to await the physicians arrival
C. Preparing to give her information about the care her husband received
prior to death
D. Planning to escort her to the morgue to see her husband

Three examples of Response to Diversity

1. Diversity related to country of origin
A 55-year-old man from Mexico is admitted to the PCU with hemodynamic
instability related to urosepsis. Which of the following family members would be
most appropriate for the nurse to include in teaching this patient about strategies
to prevent future genitourinary tract problems?
A. 54-year-old wife
B. 59-year-old brother
C. 78-year-old mother
D. 82-year-old father
2. Diversity related to age
Age-related changes found in older patients that may affect oxygenation and
ventilation include which of the following:
A. Increased chest wall compliance
B. Decreased residual lung volumes
C. Increased alveolar surface area
D. Decreased FEV1
3. Diversity related to individual

A patient has just been admitted to the PCU from the Emergency Room with a
diagnosis of gastrointestinal bleeding. She is alert and oriented, however very
nauseated and adamantly about needing to call her son. The nurse says that she
will call the son to notify him of his mothers admission. During the admission
history, the nurse would like to assess the patients belief related to her admitting
diagnosis. What question would provide the nurse with information for
understanding the patients cultural beliefs related to hr diagnosis?
A. When did you experience your first symptoms?
B. Does anyone else in your family have this bleeding problem?
C. Do you consume alcohol on a regular basis?
D. Why do you think youre sick?
Examples: Clinical Inquiry or Innovator/Evaluator
1. Which of the following leads is suggested to help distinguish ventricular
tachycardia from supraventricular tachycardia with aberrant conduction?
A. II
B. AVL
C. I
D. V1
2. The preceptor for a new PCU nurse notices that the orientee is taking a
noninvasive blood pressure measurement using the patients forearm rather than
her upper arm. When questioned about this cuff placement, the orientee states
that he had heard that the cuff could be placed on the forearm. The preceptor has
never heard of using the forearm for this purpose and has no information on this
change from standard practice BP technique. What should the preceptor do?
A. Instruct the new nurse on the standard BP protocol of using the upper arm
B. Take the blood pressure in both the upper and lower arms and then
compare readings
C. Design a research study to compare the relationship between upper and
lower arm BP measurements
D. Review the current literature to identify evidence and recommendations
related to this change in practice
Example: Facilitator of Learning or Patient/Family Educator
A patient with heart failure is being transferred from ICU to telemetry after an
acute episode of pulmonary edema. The nurse is talking to him about signs and
symptoms that should be reported to his health care provider once he is back
home. What should the nurse say to the patient to avoid a readmission?
A. Report a weight gain of greater than 3 pounds over 3 days.
B. Report fatigue and take an iron supplement to prevent anemia
C. Be compliant with all scheduled appointments
D. Limit your fluid intake to prevent shortness of breath
II. Test-Taking Strategies
A. Format of the exam
Multiple choice questions
CCRN: 150
PCCN: 125

CMC: 90
Completion time
CCRN: 3 hours
PCCN: 2 hours
CMC: 2 hours
Computerized
Requires only two keystrokes
Able to change answers
First answer usually the best
Also available by pencil and paper at Trends and NTI
Pass/fail
You will be told at the end of the exam that you passed or failed
Paper and pencil will receive notification from AMP in six weeks
Both include percentages for each section of exam
B. Components of exam

C. Whats the best way to prepare?

Taking a class
Studying from AACN self-assessment exams
Studying from a book
Studying from audio/video tapes
Study groups
D. Getting ready
Preparation the night before

PCCN
80%
36%
14%
5%
5%
5%
5%
4%
2%
4%
20%
4%
4%
3%
3%
2%
2%
2%

CMC
100%
74%
17%
1%
4%
3%
1%

Incorporated
throughout all
questions

A. Clinical judgment
Cardiovascular
Pulmonary
Multisystem
Neurology
GI
Renal
Endocrine
Hematology
Behavioral
B. Prof caring and ethical practice
Caring Practices
Collaboration
Facilitator of Learning
Advocacy/Moral Agency
Systems Thinking
Response to Diversity
Clinical Inquiry

CCRN
80%
20%
18%
8%
12%
6%
6%
5%
2%
4%
20%
4%
4%
3%
3%
2%
2%
2%

Dont drink alcohol

Dont stay up late studying
Dont drink caffeine
Lay out clothes
Preparation the day of
Do not attempt a major review
Dont drink caffeine
Eat breakfast
Wear comfortable clothing
Layered clothing
Arrive 30 - 45 minutes early
D. Taking the exam
Wear a watch
Check that you have answered at least 50 questions in the first hour
Dont spend more than 2 minutes on a question
No penalty for guessing
May be able to eliminate two choices
Read question carefully
Dont read into a question
Dont think of atypical patients
E. Analyzing questions
Look for the answer that has a broader focus
Look for qualifying words
Be careful with negative words
Avoid questions with absolute words
Examples
Broad answer
Two answers are correct; choose the one that provides the most
information
Billy Black is diagnosed with Wolff-Parkinson-White (WPW)
syndrome. When evaluating his EKG, the nurse should note which of
the following characteristics of this condition?
A. PR interval < 0.12 second and wide QRS complex
B. PR interval > 0.12 second and normal QRS complex
C. Delta wave present in a positively deflected QRS complex in
lead V1 and PR interval < 0.12 second
D. Delta wave present in a positively deflected QRS complex in
lead V6 and PR interval > 0.20 second
Qualifying words
All answers may be correct; you need to determine which is most
important. Qualify words: First, best, most, initial, better, highest priority
Mr. Redman is admitted to the ED complaining of chest pain, despite
receiving sublingual NTG. He is beginning to have PVCs and short
runs of VT. What is the most appropriate nursing intervention?
A. Administer another dose of NTG

B. Administer an IV bolus of Amiodarone and start an

Amiodarone C. infusion
C. Evaluate the patients mental and circulatory status
D. Notify the ED doctor
Negative words
Not used in the exam; poor test construction. Changes the nature of the
question. Instead of looking for the correct answer, you are looking for
the only incorrect answer. Examples of negative words: Not, least, except,
inconsistent, all but, atypical, incorrect, false, unlikely, inappropriate,
unrealistic, contraindicated. May also appear as physician orders that you
would question.
Mr. Redman is admitted to the ICU. He is still experiencing mild
chest pain. Which of the following medications ordered by the
physician would you question?
A. Diltiazem (Cardizem)
B. Propranolol (Inderal)
C. Digoxin (Lanoxin)
D. Meperidine (Demerol)
Absolute words
Rarely is anything always the case. Avoid answers using these words:
Always, every, only, all, never, none
Which of the following is an accurate statement about cardiac chest
pain?
A. This pain always is caused by constriction or blockage of the
coronary arteries by fatty plaques or blood clots
B. True cardiac pain is never relieved without treatment
C. This type of pain is relieved only by nitroglycerine
D. Patients generally attribute the pain to indigestion
F. What to do when you havent a clue
Avoid selecting an answer that you also dont understand!
Remember that nursing care is similar in many situations
Select the answer that seems most logical
George Green, age 33, is diagnosed as having a pheochromacytoma.
Appropriate initial nursing care would involve:
A. Administering large doses of xylometazoline to help control the
B. symptoms of the disease
B. Closely monitoring Mr. Greens vital signs, particularly his
blood D. pressure
C. Preparing Mr. Green and his family for imminent death
D. Having the family discuss the condition with the doctor before
informing Mr. Green about the disease because of the protracted
recovery period after treatment
Another example. Look for the one thing thats not like the others.
For several years, Karen Cooper has been treated for severe chronic
emphysema with bronchodilating agents and relatively high doses of

prednisone (Deltasone). Which activity poses the least risk for triggering
an adverse effect of prednisone therapy in this patient?
A. Shopping at the mall on a Saturday afternoon
B. Cleaning her two-story house
C. Attending Sunday morning church services
D. Serving refreshments at her 6 year-old sons school play
G. The wade
Questions with a lot of information that you need to sift through to get to what is
being asked. Dont get caught up in all the info. Ask yourself what they are
asking for.
A young adult patient was found unconscious at home after missing an
important family celebration. The patient had complained of nausea
earlier in the day and had a dry, hacking cough for the previous 5 days.
The family states that the patient has Type I diabetes, but is very
compliant with his regimen. The following were found upon assessment
and receipt of laboratory values: temperature 101.1oF, pulse 110/min,
respirations 26/min, BP 92/64 mm Hg, capillary glucose 304 mg/dL, pH
7.32, PaO2 98 mm Hg, PaCO2 32 mm Hg, and bicarbonate 18 mEq/L, with
a urinary output of 20 ml in the previous hour. The patient is lethargic but
responsive to loud stimuli. Cardiac monitoring reveals a sinus
tachycardia. Lungs are clear. Abdomen is flat with hypoactive bowel
sounds. Skin is hot and dry with poor skin turgor.
Which of the following should the nurse expect to administer at this time?
A. 50 ml bicarbonate IV push
B. 100 units glargine insulin subcutaneously
C. 1000 ml normal saline IV infusion
D. 10 mEq KCL in 100 ml normal saline over 1 hour
H. Levels of testing
Exam tests at different cognitive levels
Level 1 - 36% of exam
Knowledge and comprehension
Level 2 - 39% of exam
Analysis and application
Level 3 - 25% of exam
Synthesis and evaluation
Example: Level 1
William Carlton is admitted to the PCU with acute exacerbation of COPD.
Which of the following is the normal range for the PaO2 value?
A. 10 to 30 mmHg
B. 35 to 45 mmHg
D. 10 to 20 cm H2O
D. 80 to 100 mmHg
Example: Level 2
William Carlton is becoming progressively short of breath. His ABG
results are: pH 7.31; PaO2, 62 mmHg; PaCO2, 53 mmHg; HCO3-, 26
mEq/L

Which problem do these values indicate?

A. Uncompensated metabolic acidosis with moderate hypoxia
B. Respiratory alkalosis with hypoxia
C. Uncompensated respiratory acidosis with hypoxemia
D. Compensated respiratory acidosis with normal oxygen
Example: Level 3
William Carlton has become cyanotic and is experiencing Cheyne-Stokes
respirations. What is the best action for the nurse to take at this time?
A. Call a code blue and begin CPR
B. Call Mr. Carltons doctor and report the condition
C. Ensure that Mr. Carltons airway is open and begin supplemental
oxygen
D. Immediately administer the ordered dose of 200 mg aminophylline IVP
I. Nursing process incorporated into questions
Assessment - 32%
Planning - 15%
Implementation - 40%
Evaluation - 13%
Example: assessment
William Carltons respiratory status continues to worsen. Which of the
following signs and symptoms would best indicate deterioration of his
respiratory status?
A. Increased restlessness and changes in level of consciousness
B. Bradycardia and increased blood pressure
C. Complaints of chest pain and shortness of breath
D. Rapidly dropping PaCO2 and pH values
Example: Planning
William Carlton is diagnosed with acute respiratory failure and placed on
mechanical ventilation with PEEP set at 10 cm H2O. Which of the following
nursing diagnoses would have the highest priority for this patient?
A. Impaired skin integrity related to immobility
B. Decreased cardiac output related to changes in intrathoracic pressure
C. Ineffective individual coping related to anxiety
D. Impaired gas exchange related to decreased lung compliance
Example: Intervention
William Carlton has been on the ventilator for 3 days. He suddenly becomes
extremely restless, and the pressure alarm sounds with each ventilator initiated
inspiration. Which of the following would be an appropriate initial nursing
action?
A. Disconnect the ventilator and call a code
B. Disconnect the ventilator and manually oxygenate the patient for a few
minutes with a bag-valve-mask device
C. Increase the ventilator pressure limit to 50 mmHg
D. Remove the endotracheal tube and reintubate the patient with a tube
one size larger

Example: Evaluation
William Carltons condition has improved and he is preparing for discharge.
He needs to take oral theophylline at home for his lung disease. Which
response indicates he has understood the nurses instructions?
A. I can stop taking this medication when I feel better.
B. If I have difficulty swallowing the time-release capsules, I can crush
or chew them.
C. If I become very sleepy when I take this medication, I need to cut back
on the dosage.
D. I need to avoid drinking coffee and caffeinated soft drinks while Im
taking this medication.

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