BOARDS

35 yo F presents w/ c/o bilateral wrist pain. You suspect spouse abuse. You notice a handgun in her purse. What would be your next action?

Call security to ensure safety

Collaboration

Collaboration: "True Partnership" in which all players have & desire power, share common goals, & recognize/accept separate areas of responsibility/activity

A diabetic pt complains of abd pain. Which type of exam do you conduct?

Comprehensive

Your pt voices concerns because he has lost his insurance & worries his children will no longer have coverage for medical expenses. What do you do?

Consult case management

Your pt has refused human blood products based on religious beliefs. He is now rapidly destabilizing. What do you do? a. Administer PRBCs as needed b. Call the ethics committee c. Continue to research alternative tx d. Ask the family to give permission now that he's unconscious

Continue to research alternative tx

A woman of child-bearing age c/o abdominal pain. What level of exam do you document?

Detailed - Problem Focused - a limited exam of the affected body area or organ system. - Expanded Problem Focused - a limited exam of the affected body area or organ system & other symptomatic or related organ system(s). - Detailed: an extended exam of the affected body area(s) & other symptomatic or related organ system(s). - Comprehensive: a general multi-system exam or complete exam of a single organ system. -The # of body areas or systems for the problem-focused exam is one -General multi-system exam must include at least 8 systems. As such, both the expanded problem-focused & detailed exams may be composed of 2 to 7 body areas &/or systems. Nothing specifies that the examination of body areas & organ systems can't be combined, that a detailed exam must include more than two systems, or that more than a statement of "normal" is sufficient for an exam of an area w/o abnormal findings.

Goals set forth in "Healthy People 2020" by the US Department of Health & Human Services include

Elimination of health disparities. Increase quality/quantity of life

T/F: restraining unwilling pt is grounds for malpractice?

False, if they are a danger you can restrain. YOU ARE NOT THE FATHER! Malpractice Insurance: -Claims made: Will cover you so long as insurance is in effect when the claim is made. Have to have exact same insurance policy as when claim was made. - Occurrence Based: As long as the event you're being sued for had that policy in effect, still counts. - Tail Coverage: allows an insured physician the option to extend coverage after the cancellation or termination of a claims-made policy.

What procedure does the AGACNP perform to evaluate cytology, only, in the tumor?

Fine needle biopsy

You notice there have been less favorable outcomes & satisfaction surveys in pts treated for sickle cell anemia. How do you approach this problem? a. Ask the patients treated how care can be improved b. Look back at prior tx given to see how outcomes can be improved c. Form a standardized Tx plans for all pts that can be used by all healthcare staff d. Form individualized Tx plans that can be used by all healthcare staff .

Form a standardized Tx plans for all pts that can be used by all healthcare staff

Pt in ER not doing well, primary MD calls:

Give him info

A RCA of a crisis situation in the ICU identified a lack of clinician-family communication as the basis for the resulting adverse outcome. As part of the performance improvement plan, the NP is asked to develop evidence-based polices to establish clinician-family communication standards in the unit. These policies should include:

Guidelines for having discussions w/ family members that are geared toward establishing tx goals

NP working on ESRD research project . A colleague renal specialist asks for pt info on your pts:

HIPPA Breach! Bee-doo-bee-doo!

Healthcare exchange

Healthcare exchange: health insurance marketplaces = organizations. In each state thru which people can purchase health insurance People can purchase health insurance that complies w/ the Patient Protection & Affordable Care Act at ACA health exchanges, where they can choose from a range of gov't-regulated & standardized health care plans offered by the insurers participating in the exchange

What qualifies pt for HHC:

Home bound, Has a prescription, Requires care services, Wound care, Select care

Adult child of a pt reports that her father has expressed desire to commit suicide & has a hx of EOTH & depression. The best response would be to?

Hospitalize the pt and start psychotherapy

Knowledge deficit in ICU, what would you do for RNs

In-service

Pt presents to ER w/ c/o CP & SOB. NP misinterprets the EKG & admits for further monitoring w/o consulting Cards. Later in the shift, pt decompensates & goes into cardiac arrests. Pt was resuscitated but sustained permanent brain damage. What grounds of malpractice is the NP accountable for?

Lack of Skill

Who ISN'T covered by HIPPA?

Law enforcement/Municipal Offices, CPS/Schools, Employers/Workman's Comp, Life insurance

Difference between advanced directive & living will

Living will provides "POA/healthcare proxy"

Statistical significance:

Look at sample size & p value.

24 yo M has been out hiking on vacation. He shows you the following rash, & thinks he has Rocky Mountain Spotted Fever. What is his dx?

Lyme Disease (Erythema Migrans/Bullseye rash) (both are treated w/ Doxycycline)

Privileging

May be granted in full or part by the hospital. Credentialing committee is made of physicians.

An 80-year-old male pt w/ dementia requires long-term care placement. To which funding agency does the patient apply after "spending down" to qualify?

Medicaid--> This amount is called excess income. Some of these people may qualify for Medicaid if they spend the excess income on medical bills. This is called a spend down. For ex, a person > 65 is denied Medicaid b/c her monthly income is $50 more than the limit for Medicaid eligibility.

Billing--> NP sees a pt for HF & performs an H & P. What % is expected to be paid?

Medicare pays 80% of the total bill, Pt pays 20%. NP is reimbursed 85% of what the MD is reimbursed for physician services, & for procedure is paid 80% of that 85%

Case management

Mobilize, monitor, & control resources that a pt uses during course of an illness while balancing quality & cost ("move pts thru the system appropriately").

Can you tell the pt's wife, for her protection, that her husband has HIV?

No, not w/o his permission

When serving as a nurse researcher, the NP is guided by which ethical principle to ensure that research participants are protected from harm or exploitation?

Nonmaleficence

Who enforces HIPPA?

Office of Civil Rights /Dept. Health & Human Services

Validity of results in an article:

P value. Probability of falsely rejecting the null hypothesis. Want it to be low - Null hypothesis: what you're trying to disprove - Alternative Hypothesis: what you're trying to prove *P value </= 0.05 --> reject the null hypothesis (therefore you accept the alt. hypothesis, which is what you're trying to prove) *P value > 0.05--> fail to reject the null hypothesis

Your pt is worried about insurance coverage & asks you for advice on Medicaid. You instruct the pt that Medicaid:

Pays after insurance & 3rd party payers have paid

The NP program was initiated, primarily, because of what issue in healthcare at the time?

Pediatric physician shortage

How can the NP prepare to get involved in future mass casualty event?

Pre-enroll in disaster volunteer program

A 70-yp pt w/ a hx of DM, HTN, OAs, & a new dx of CAD, is being d/c'd. The AGAC-NP teaches the pt that the 1st point of contact for health care needs is the:

Primary Care Provider

Quality assurance

Process for evaluating the care of pts using established standards of care to ensure quality

80 yo pt has macular degeneration & is seen on the surgical unit for post-op care after repair of a hip fx. To prepare the pt for d/c, the NP:

Provides verbal reinforcement to the pt on how to keep proper body alignment following hip surgery.

51 yo F pt is getting ready to d/c when she tells you she hasn't had a mammogram in 3 years. What do you do?

Refer to PCP for outpatient discharge

32 yo M presented w/ a GSW to the FA. Injuries are negligible & pt is stable. Pt. reports the shot was an accident during hunting. What should the NP do?

Report to the police. ALL GSW must be reported

A pt visits your clinic for sinusitis. She requests a PAP smear since she has not had one in "years." You: a. Refer her to a gynecologist b. Schedule her to come back next week for the PAP at another appt. c. Perform the PAP today d. Do a vaginal exam only, and refer the PAP to a gyno

Schedule her to come back next week for the PAP at another appt

When closing a practice, the NP is required to do all of the following except: a. Give the pt adequate time to find another provider b. Keep all of the pt's records for a minimum of five years c. Send a certified letter w/ a return receipt requested d. Provide names of other providers for future care

Send a certified letter w/ a return receipt requested-->this is for discharging/firing a pt from your practice, boy bye

You have transferred a pt to the SNF. The MD in charge at that facility calls for info about the pt's medical care. What do you do? a. Direct him to look it up in the EMR b. Refuse to share protected health information c. Instruct him to call the department head d. Share the information he requests

Share the information he requests

Pt calls to complain about bills & states he has Medicare, which should cover all costs. You explain:

Since you are healthy, exams are not covered.

You suspect your pt on TPN w/ a PICC has a CLABSI. What is the first intervention? a. Stop the TPN, d/c line, & place new line for TPN b. Start abx c. Send Cx d. Change the guidewire

Stop the TPN, d/c line, & place new line for TPN

You want to get more funding for your hospital's Rapid Response Team. How should you present this issue to the committee? a. Stress importance of the team b. Describe how to improve and expand the team.

Stress importance of the team (answer is worded as looking up evidence about how the team affects outcomes, like a meta-analysis)* Remember: 1) Meta- analysis 1a) Systematic Reviews 2) Randomized Controlled Trials 3) Cohort Studies 4) Case-Control Studies 5) Case Series 5a) Case Reports 6) Editorial 6a) Expert Opinions

CPI (clinical practice improvement) measures what 3 measures to improve nursing?

Structure, processes, & outcomes CPI: Structure, processes outcomes

Based on the individual's culture, ethnicity, & personal choices, NP can optimize the therapeutic partnership w/the pt by:

Tailoring his or her communication style to the pt's preference.

Your pt is not conscious. His advance directive states he wants to be a DNR, but his family says they want him to be a full code. How do you respond? a. Tell her the decision goes to the next of kin b. Call the ethics committee c. Comply w/ her wishes & make him a full code d. Tell her you can't go against the advanced directives

Tell her you can't go against the advanced directives

Pt presents to clinic for routine f/u & passes out. You revive the pt & admit overnight. Which of the following would qualify as incident-to-billing?

Temperature & weight recording

Pt has fully recovered from septic shock due to bacteremia & has been accepted to a LTC facility for continuation of abx. ID hasn't seen pt in 2 days. The NP:

The NP: contacts the ID MD to determine the appropriate abx duration

Pt is getting d/c & needs wound care, pulmonary, & f/u: NP's role is

To coordinate services

A pt has advanced dementia, ESRD, & HF, what do you do for him?

Transfer from acute to palliative care

You are giving a dinner presentation to a group. The pharmaceutical rep calls you the night before & wants you to say that their drug is the only one that works. What ethical principles does this challenge?

Veracity & Fidelity

Reliability

When implementing a new study... tested over & over. The consistency of a measurement, or the degree to which an instrument measures the same way over time

Which of the following is most important to evaluate statistical significance when reviewing the literature? a. Consider the sample size b. Make sure the confidence interval is tight c. See if the p-value is less than the α-coefficient d. Determine the error rate

a. Consider the sample size (Answers are worded differently. "Ensure confounding variables were eliminated" & "P value is less than null hypothesis" were two of them.

Your clinical student breaks the sterile field. How do you handle this situation? a. Discuss it with the student b. report it to the charge nurse c. report it to the unit manager d. inform the faculty in charge of the student

a. Discuss it with the student

Your pt has been taking Thorazine & now has fever, sweating, lethargy, & a temp of 39.4 (102.92): a. Give IVF b. Antipyretic c. Abx d. Ice packs to groin and axilla

a. Give IVF--> flush it out. This is neuroleptic malignant syndrome!! All antipsychotic drugs can cause NMS. Chlorpromazine (Thorazine), Haloperidol (Haldol), Olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone (Risperdal), also...Metoclopramide (Reglan), Prochlorperazine (Compazine), Promethazine (Phenergan)

A former pt of an NP is writing blog posts, sending emails, & distributing false, accusatory statements about the NP's practice. Which of the following forms of defamation is this? a. Libel b. Slander

a. Libel GIRL FIGHT "Slander is spoken."

A 77M pt's wife cares for him at home. Which statement by the wife indicates a need for a SNF? a. My husband needs more help w/ his ADLs b. I can't lift him out of bed anymore c. He has lost 20 pounds d. He has trouble swallowing & I'm worried he will choke on his food.

a. My husband needs more help with his ADLs

Pt has been in a bar fight & has a human bite on his hand. What should you do next? a. Order PO abx b. Order wound culture c. Order IV abx d. Measure the wound depth & width

a. Order PO abx

A pt visits your cardiology clinic. She requests a PAP smear since she has not had one in "years." You: a. Refer her to a gynecologist b. Schedule her to come back next week for the PAP at another appt. c. Perform the PAP today d. Do a vaginal exam only, and refer the PAP to a gyno

a. Refer her to a gynecologist

A pt comes to the ED at a community hospital who is 29 weeks pregnant. She says her water has broken. Her VS are stable. What do you do? a. Transfer her to a tertiary facility b. Contact her OB/GYN for tx advice c. Admit to labor & delivery d. Consult the nurse midwife.

a. Transfer her to a tertiary facility

Which of the following is considered a high acuity role for the AGACNP? a. Primary care clinic b. Cardiology office c. Community health department d. Minute Clinic

b. Cardiology office

Your HIV positive patient is preparing to d/c when he tells you not only that he has passed the virus to his wife, but also that he plans to kill her when he gets home. How do you respond? a. Call the police b. Consult psych c. Consult social work d. Document his statements

b. Consult psych

What is the best way for the AGACNP to get involved in policy making? a. Attend legislative days at the state capitol b. Join a hospital committee c. Write to your local congressman d. Review literature and give more in-services

b. Join a hospital committee

Pt presents to ED w/R wrist pain. She says, "It's my fault; I should have had dinner ready on time." What do you do? a. Tell her not to go home bc it's not safe b. XR the wrist c. Call the police d. Consult psych

b. XR the wrist

How long will it take to begin to see healing in a pressure ulcer that has a clean, well-vascularized bed? a. 7 days b. 2-4 weeks c. 2 days d. 4-6 weeks

c. 2 days

Your pt is a Chinese F immigrant living in the US. You notice she is avoiding eye contact. What is this due to? a. Shame because she feels the illness is her fault b. Embarrassment from the examination c. A sign of respect d. A normal response

c. A sign of respect

Your pt is not doing well & family/wife is at bedside crying. You are preparing to talk to the family. What do you do first? a. Place a social work consult b. Explicitly explain situation, outcomes, & care involved. c. Ask if the pt has an advanced directive d. Set up a family meeting in a room w/ a specific time & date

c. Ask if the patient has an advanced directive

What is the best way for the AGACNP to demonstrate & advocate for full scope of practice? a. Join a hospital committee b. Petition the government c. Bill for independent services d. Start your own practice

c. Bill for independent services

The medical resident obtained consent for an operative procedure. On your visit, the pt is confused/refusing the procedure. a. Cancel the surgery b. Have the wife sign another consent c. Call the resident to clarify the pt was not confused when he signed the first consent d. Consult neurology

c. Call the resident to clarify the pt was not confused when he signed the first consent

What is the strongest predictor of functional impairment prior to d/c of the elderly pt? a. Advanced age b. Incontinence c. Cognitive impairment d. Poor balance

c. Cognitive impairment

Which psychiatric disorder is most commonly diagnosed, yet least commonly treated? a. Bipolar disorder b. Alzheimer disease c. Depression d. Dementia

c. Depression

Pt has developed a fever of unknown origin. What is the next step? a. PO abx b. IV abx c. Do nothing until diagnosis is confirmed d. Tylenol

c. Do nothing until diagnosis is confirmed *Nifedipine, Protonix & HCTZ are all known to cause drug fever

Pt w/PNA is noted to have a heavy drinking habit. 2 days post admit he becomes combative/agitated. What is Tx? a. IV valium b. IV Ativan c. PO Librium d. Lasix

c. PO Librium

D/c planning is underway for a pt who is very debilitated after tx for end-stage liver cancer. His wife is also debilitated & kids live out of state. Best choice? a. Hospice b. Home Health care c. SNF d. Private Duty RN

c. SNF

Your pt has a fever 3 days post op, WBC are 15,000, Blood Cx (-), & Eos 9%. What is the dx? a) Viral infxn b) Bacterial infxn c) Malignant hyperthermia d) Drug fever

d) Drug fever (eos - allergic rxn. Normal is 1-4%) **

Pt is brain dead on the vent. The family wants all possible tx measures done to preserve life, but states that the pt would not want to be on a vent. What should you do? a. Consult neurology to come interview the family b. Document the situation carefully in the chart c. Call a clergy member to offer support d. Call the Ethics Committee

d. Call the Ethics Committee

58 yo Japanese M w/ CP 4/10 for 3 hrs, reluctant to answer ?s. Which of the following in the ED warrant admit? a. Age b. Gender c. Pain level d. Ethnicity

d. Ethnicity (underestimates pain, taught to be stoic. Pain is probably much more severe)

Which of the following components of an evidenced based research process is the most important for NP to participate in? a. Specifying methods of data collection b. Formulating the hypothesis c. Carefully reviewing the literature d. Formulating the research problem

d. Formulating the research problem

A code you are in does not go well, & staff members afterwards are criticizing each other. How do you deal w/ the situation? a. Schedule an in-service to discuss common code mistakes b. Meet w/ each team member individually c. Set up exercises to increase collaboration during a code d. Meet w/ all who participated in the code & have a one-time briefing

d. Meet with all who participated in the code & have a one-time briefing

Pt has a chronic, nonhealing decubitus ulcer. He c/o pain when he moves his leg. What is a potential complication? a. Compartment syndrome b. Decrease in ROM ability c. Septic shock d. Osteomyelitis

d. Osteomyelitis

Best way to make sure a pt will f/u as instructed? a. Instruct the pt to schedule the appointment b. Ask the pt the best time they can go to an appointment c. Have the office manager to schedule the appointment d. Schedule the appointment for the pt

d. Schedule the appointment for the pt

What is the best way to advocate for gay & lesbian population in your area? a. Participate at a high state or national level b. Join a non-profit advocacy group c. Consider lobbying the government d. Start at your facility

d. Start at your facility (answers are worded differently. One of them is "decrease bias in healthcare" & another is "create inservices in healthcare" & another is "obtain funding to increase access."

You are the NP on call for the night. The nurse calls you to report a pt is decompensating. Who do you direct her to call? a. The ER physician b. Anesthesia c. An NP present on another unit currently d. The attending MD who is at home

d. The attending MD who is at home

Now the husband presents to ED w/ drug OD. What is your action? a. Hand him off to another practitioner b. Call the police c. Consult psych d. Treat him w/o prejudice

d. Treat him w/o prejudice BUT HAVE DINNER READY JUST IN CASE

Pt speaks only Spanish & you need to evaluate his pain. What do you do? a. Ask a family member to translate for you b. Utilize the hospital's interpreter service c. Call over the Hispanic housekeeper & ask her to translate d. Use a visual pain scale

d. Use a visual pain scale (less $$ than interpreter)

Pt is refusing care:

let them refuse, educate, & search for alternatives

Nondisclosure

not disclosing pt PHI w/o their permission (confidentiality)

Guy in ER needs refill on Ritalin

research alternatives

4 Roles of a Nurse Practitioner

- Education, - Research, - Clinician, - Consultant/Collaborator

Informed Consent

: a state indicating pt has received adequate instruction/info regarding aspects of care to make a prudent, personal choice regarding Tx. Includes benefits & risks. Includes competence: Pt's ability to CURD: Communicate, Understand, Reason, Differentiate good/bad

NP is asked to provide evidence to the hospital admin about the safety of NP placing CVLs. Which resource provides the strongest level of evidence?

A systematic review (meta-analysis is even stronger) 1) Meta- analysis--> a statistical analysis that combines the results of multiple scientific studies. 1a) Systematic Reviews 2) Randomized Controlled Trials 3) Cohort Studies 4) Case-Control Studies 5) Case Series 5a) Case Reports 6) Editorial 6a) Expert Opinions

You notice that another NP in your group is frequently contacted by pharmacy for prescription errors. How do you handle the situation?

Address it directly with the NP

Government is moving towards being cost effective. What is the best way?

Allow NP to treat a wider variety of pts. Duh.

Which clinical scenario does the NP evaluate for a QI process change?

An increased incidence of postoperative sternal wound infections

40 yo F pt w/no PMH is admitted w/ bilateral PEs. W/U reveals a positive result for lupus anticoagulant, & anticoagulant therapy is planned. Pt verbalizes concern about her ability to manage the appointments & the f/u care. The NPs most effective intervention is to:

Arrange f/u appointments for the pt at the warfarin (Coumadin) clinic & PCP after d/c.

Elderly female pt takes a turn for the worse. The husband is crying when you enter the room & begins telling you what end-of-life care he prefers. What do you do?

Ask him to speak candidly w/ you

Your pt's imaging reveals he has metastatic cancer. The family, in accordance w/ their culture, request that you not share the test results to spare him distress. How do you respond?

Ask the pt what he wants to know about his prognosis

How should the ACNP stay up to date w/ current info?

BUZZFEED! JK. Evidence based guidelines

What legislation allowed NPs to be recognized Medicare providers in all geographical areas w/ their own provider number?

Balanced Budget Act ('97)