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Using Distributed Practice to Prepare for the Foot Care Exam

Trelease, Jill

Journal of Wound, Ostomy and Continence Nursing: November/December 2014 - Volume 41 - Issue 6 - p 609–610
doi: 10.1097/WON.0000000000000090

Jill Trelease, BSN, RN, CWON, CFCN, WOCNCB Board of Directors, Liaison to Foot Care Committee; Nurse Clinician Wound/Ostomy and Lead Nurse Clinician, Center for Wound Healing, Saint Anne's Hospital, Fall River, Massachusetts.

Correspondence: Jill Trelease (

The author has declared no conflicts of interest.

Distributed practice is a method of learning that distributes the learning of material over a period of time, in contrast to concentrated practice otherwise known as “cramming.”1 The distributed practice technique may seem like a commonsense approach to studying, but recent research has demonstrated that distributed practice is also one of the most effective ways to study.2 Dunlosky and colleagues2 examined 10 common study techniques and classified them as possessing high, moderate, and low utility. Techniques characterized as low utility included summarization, highlighting, key word mnemonic, and re-reading; in contrast, distributed practice was classified as a high utility assessment.2 Long-term memory retention is enhanced and testing performance improved when time gaps are scheduled into a learning plan.3,4 Research also suggests that distributed practice techniques result in more effective long-term retention.5

When preparing for a WOCNCB examination, a study plan can be developed using a distributed practice model (Table 1). The plan should be designed using five 60-minute sessions throughout the first week; I recommend including 2 days off. New material is introduced during each daily study session. The second week begins and ends with a practice test. You also may create 3 study sessions in the second week that are a review of any new or difficult material from week 1. Practice tests can be developed using questions from various study materials or a candidate can use the WOCNCB Self Assessment Exam available on the through the WOCNCB Web site. The “Getting Ready for Certification” articles in the JWOCN, archived on the Journal's Web site, may also be used as a study resource. Incorporating principles of distributed practice into a study plan for the WOCNCB certification examinations has the potential to improve test performance as well as enhance long-term memory of key and essential specialty practice knowledge.



1. Benjamin A, Tullis J. What makes distributed practice effective? Cogn Psychol. 2010;61(3):228–247.

2. Dunlosky J, Rawson K, Marsh E, Nathan M, Willingham D. Improving students' learning with effective learning techniques: promising directions from cognitive and educational pscyhology. Psychol Sci Public Interest. 2013;14(1):4–58.

3. Bell M, Kawadri N, Simone P, Wiseheart M. Long-term memory, sleep, and the spacing effect. Memory. 2014;22(3):276–283.

4. Cepeda N, Coburn N, Rohrer D, Wixted J, Mozer M, Pashler H. Optimizing distributed practice: theoretical analysis and practical implications. Exp Psychol. 2009;56(4):1–12.

5. Henetz T. Encouraging distributed practice distributed testing. Published May 2013. Accessed May 15, 2014.

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Practice Questions

1. A 65-year-old woman with a history of peripheral neuropathy presents with discolored white toenails. This finding is most consistent with:

  1. Onychogryphosis
  2. Tinea pedis
  3. Onychomycosis
  4. Acute paronychia

Content Outline: 1 B 10

Cognitive level—Recall

The correct answer is C. Onychomycosis usually occurs in 3 distinct forms: distal subungual, proximal subungual, and white superficial. Onycholysis and subungual hyperkeratosis cause discoloration of the nails and are symptomatic of onychomycosis. Onychogryphosis is characterized by thick, hard nails that curl like a ram's horn. Tinea Pedis is an infection of the feet in which erythema, scaling, and maceration are findings. Acute paronychia is characterized by painful swelling around the base of the nail.

Wolff K, Johnson R. Fungal infections of the skin and hair. In: Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw Hill Medical; 2009. Kindle location 15878.

Wolff K, Johnson R. Disorders of the nail apparatus. In: Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw Hill Medical; 2009. Kindle location 24336.

Howes-Trammel S, Bryant RA, Nix DP. Foot and nail care. In: Bryant RA, Nix DP, eds. Acute & Chronic Wounds: Current Management Concepts (4th ed.). St Louis, MO: Elsevier Mosby; 2012:265.

2. A 25-year-old male patient presents with fusion between his second and third toes bilaterally. This congenital malformation is known as:

  1. Syndactyly
  2. Dyschromia
  3. Dermatofibroma
  4. Melanonychia

Content outline: 1 B 8

Cognitive level—Recall


The correct answer is A. Syndactyly is a common malformation resulting in the fusion of 2 or more digits; it is more prevalent in Caucasian males. Dyschromia is a postinflammatory response, which can result in hyperpigmentation in individuals with darker skin. Dermatofibroma is a benign tumor that can occur on the lower extremities of females. Melanonychia is the linear pigmented streaks that are brown to black that are seen in the toenail.

Vlahovic T, Schleicher S. Skin signs of systemic disease. In: Skin Disease of the Lower Extremities: A Photographic Guide. Malvern, PA: HMP Communications LLC; 2012. Kindle location 1772.

Vlahovic T, Schleicher S. Benign and malignant lesions. In: Skin Disease of the Lower Extremities: A Photographic Guide. Malvern, PA: HMP Communications, LLC; 2012. Kindle location 1275.

Vlahovic T, Schleicher S. Skin of color. In: Skin Disease of the Lower Extremities: A Photographic Guide. Malvern, PA: HMP Communications LLC; 2012. Kindle location 1058.

3. A 72-year-old man presents with a 0.5×0.5-cm yellow ulcer on the distal aspect of the right 5th pedal digit. The toe is edematous and erythematous. Which of the following is an essential element of your initial assessment?

  1. Obtaining a wound culture
  2. Palpating peripheral pulses
  3. Performing an ankle-brachial index
  4. Completing a review of systems

Content outline 1 B 3

Cognitive level: Analysis

The correct answer is B. A clearly palpable pulse is a strong indicator the patient has adequate circulation; diminished or absent pedal pulses are suggestive of lower extremity arterial disease. Wound cultures are best obtained after removal of nonviable tissue. An ankle-brachial index is a noninvasive test that would be performed if the patient lacked palpable pedal pulses. Reviewing comorbidities is an important component of assessment to determine factors that may impede healing and would also be an indication of the need for referral for advanced care.

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Mills J. Evaluation and management of peripheral arterial disease. In: Clinical Care of the Diabetic Foot (2nd ed.). Alexandria, VA: American Diabetes Association; 2010. Kindle location: 1769.
    WOCN Clinical Practice Guideline Series. Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease. Mt Laurel, NJ: WOCN Society; 2008.
      © 2014 by the Wound, Ostomy and Continence Nurses Society.